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PaperclipPerfector  10mo ago (text post)   29058 thread views

Culture War Roundup for the week of June 24, 2024

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I mean, obviously, I was being flippant in a parenthetical. But yeah, there are people in this very thread who are saying that pharmaceutical drugs have nothing to do with overdose deaths, at least. I haven't gotten them down to the nitty gritty of other types of dangerous use, but most advocates of drug legalization generally don't want to talk about any type of dangerous use.

In any event, would you praise the Sackler family for at least trying to flood the market with pharmaceutical drugs (whether they succeeded in this endeavor or not, would you praise the endeavor)? Would you say that the only real problem is that they didn't manage to sell billions more pills through millions more doctors looking the other way to millions more straw purchasers? That if only they had flooded the market enough that the street price of pharmaceutical drugs dropped to rock bottom, then it would have positively helped the opioid crisis?

In any event, would you praise the Sackler family for at least trying to flood the market with pharmaceutical drugs (whether they succeeded in this endeavor or not, would you praise the endeavor)?

Absolutely not - I come at this from the "smelly hippy" angle rather than the libertarian one, and I think that what they did was actually monstrous. I'm a proponent of drug legalisation, but I think that legalisation should be accompanied with responsible education and policies with regards to addiction and the like. The Sacklers were ultimately responsible for and made substantial profits from a legal and corporate structure that heavily encouraged and even induced addiction in cases where it wasn't necessary. I absolutely think that drugs should be legal, but I think that part of that liberalisation should include responsible management of them. Encouraging addiction because those ruined lives are extremely profitable is the part of what the Sacklers did that I object to, not so much the distribution of the drugs themselves.

The Sacklers were ultimately responsible for and made substantial profits from a legal and corporate structure that heavily encouraged and even induced addiction in cases where it wasn't necessary.

How so?

Someone else has already written this up for me, so I'll just quote them.

https://web.archive.org/web/20201004103052/https://www.newyorker.com/news/news-desk/the-sackler-familys-plan-to-keep-its-billions

With the launch of OxyContin, in 1995, Purdue unleashed an unprecedented marketing blitz, pushing the use of powerful opioids for a huge range of ailments and asserting that its product led to addiction in “fewer than one percent” of patients. This strategy was a spectacular commercial success: according to Purdue, OxyContin has since generated approximately thirty billion dollars in revenue, making the Sacklers (whom I wrote about for the magazine, in 2017, and about whom I will publish a book next year) one of America’s richest families.

But OxyContin’s success also sparked a deadly crisis of addiction. Other pharmaceutical companies followed Purdue’s lead, introducing competing products; eventually, millions of Americans were struggling with opioid-use disorders. Many people who were addicted but couldn’t afford or access prescription drugs transitioned to heroin and black-market fentanyl. According to a recent analysis by the Wall Street Journal, the disruptions associated with the coronavirus have only intensified the opioid epidemic, and overdose deaths are accelerating. For all the complexity of this public-health crisis, there is now widespread agreement that its origins are relatively straightforward.

...

Her filing was studded with damning internal company e-mails revealing that, even in the face of a skyrocketing death toll from the opioid crisis, members of the Sackler family pushed Purdue staff to find aggressive new ways to market OxyContin and other opioids, and to persuade doctors to prescribe stronger doses for longer periods of time.

eventually, millions of Americans were struggling with opioid-use disorders.

This is an absolutely magic sentence that tells us nothing about how any of this works. There is no model here. At least, there is no model that can be stated in words, in public. My suspicion for why is because the model that is implicitly being used violates the claims of people who are pro-legalization.

Did you actually click the link? I didn't include the sordid details but they do actually explain what happened and how it worked. A magic sentence like that is totally fine when you include the explanation in another part of the text.

I did click the link. I read the whole thing. They don't explain any sort of model for the intermediate steps. If you need to convince yourself of this, just try. Try on your own to reconstruct a model of how it's supposed to work from the article. Use your own words. See if you can do it.

Uh, sure? They used a variety of financial incentives to encourage doctors to prescribe higher and higher doses of Oxycontin even when it wasn't necessary, because that made them more money. They were directly(and indirectly) paying doctors to hand this stuff out even when it wasn't strictly necessary, taking advantage of the prestige and respect rightfully given to medical professionals in order to generate vast profits while directly fostering opioid addictions.

Maybe I'm missing your point, because I don't know what kind of intermediate steps you need to get from "Inducing doctors to unnecessarily prescribe high doses of opioids" to "Opioid usage epidemic".

prescribe higher and higher doses of Oxycontin even when it wasn't necessary

There is literally only one sentence in the article that refers to dosing, and that's just repeating a claim from a plaintiff. It's pretty weak even from that plaintiff. I guarantee that you, the plaintiff, the FDA, nobody has any sort of rigorous line on when it is "necessary". Their "titration" stuff is basically the same damn thing that Scott talks about doing all the time with other drugs.

But in any event, I don't think the legalization folks have premises that allow saying things like, "Oh, we'll just set it up so that people are magically only allowed to go from having 20mg pills to 40mg pills when it's strictly necessary (according to some magic definition of necessary). That'll totally be a part of how complete legalization will be an utter boon to society and not a disaster!"

Instead, I think the complete legalization folks will say that all that shit is meaningless. We should just make them all legal. The 20mg pill, the 40mg pill, hell the 10mg pill and the 80mg pill, too. That people can just buy whichever one they want. Maybe they'll choose to get a doctor's recommendation. Maybe they'll even use your yet-to-be-published, magic definition of "necessary". But they think that people will somehow be responsible in their usage, substituting away from dangerous street drugs like heroin and fentanyl and toward, I don't know, whichever of the 10mg/20mg Oxy pill your magic chart says is "necessary". They might try a higher dose, like how some people try hard liquor instead of wine or beer, but for the most part, folks will prefer to objectively and responsibly move to a reasonable dose. And it's not like their marketing is ever going to be like, "Hey doctors, you should prescribe a higher dose even when your patient responsibly wants a lower dose," or, "Hey doctors, here is @FirmWeird's objectively correct definition of 'necessary'; don't use that."

But in any event, what does your magic, yet-unknown line of "necessary" have to do with addiction? What's the model connecting this completely unknown thing to rates of opioid addiction?

More comments

That pro-legalization people refuse to endorse your strawman is still not a point against legalization. The Sacklers were not trying to flood the streets with pharmaceutical drugs; they were trying to sell more drugs through already-legal channels. And charge more for them than generic pharmaceutical drug producers were charging, too. Insisting on misrepresenting the Sackler's actions as somehow the ideal of what drug legalizers would want, and then attacking drug legalizers for not endorsing them, proves nothing outside your own mind.

The Sacklers were not trying to flood the streets with pharmaceutical drugs; they were trying to sell more drugs through already-legal channels.

Where is the daylight between these things? If they sell more and more drugs through already-legal channels, especially if they can use doctors who will look the other way and straw patients who will then put them on the streets, then the latter helps accomplish the former.

Insisting on misrepresenting the Sackler's actions as somehow the ideal of what drug legalizers would want

Nope. I don't think at all that it is the "ideal" of what drug legalizers would want. But it sure as hell helps the world, helps the situation, helps the opioid crisis, under the commonly-stated model of how the world works. It's a completely beneficial work-around, rather than the ideal, but isn't it absolutely a work-around that has positive impact? Shouldn't someone at least remark on this wonderful positive impact, that it's one of the very few ways that people are helping, rather than hurting?

Where is the daylight between these things? If they sell more and more drugs through already-legal channels, especially if they can use doctors who will look the other way and straw patients who will then put them on the streets, then the latter helps accomplish the former.

Where's the evidence that the Sacklers were using unethical doctors and straw patients to get their product out to recreational users?

One example. Fundamentally, the claim is that Purdue/FDA believed that, with non-abusive use, extended release was less likely to result in addiction. This is probably true for some value of true (interesting discussion to be had about RCTs, selection effects, ideal/typical use/abuse, with connections to things like obesity/alcoholism/etc.), which then led to physicians being much more nonchalant about prescribing them. Thus, the pipeline was born, and there have been plenty of profiles of 'kingpins' running straw patient networks to siphon as many pills as they could into the streets. (The Sacklers didn't need to personally set up networks of doctors/patients.) This entire chain worked together to accomplish the important final outcome: more pills on the streets.

Given the beliefs about this pipeline, its mechanism of operation, and its final outcome, one can pretty much take the entire proposition to be, "This is a way to get pharma-quality opioids onto the streets." It's a work-around, yes. But any utilitarian consequentialist, who also believes the preliminaries about making pharma-quality opioids, should think that this work-around is an absolute utilitarian Good (TM). They could agree to quibbles on many edges, but they should absolutely endorse the project as a whole.

But really, we can divorce ourselves from any specifics. Let's just assume a hypothetical world, and it's purely questions about the pipeline that are in play. It's like the Underground Railroad, but for pharmaceutical opioids. Sure, it's not the abolitionists' ideal world; it's a kludgy work-around, but it gets more pharmaceutical opioids into the streets (gets more slaves away from slavery). Different abolitionists might quibble with different details, but at least somebody would be willing to stand up and say, "Getting slaves out of slavery is a Good, and if we could get more slaves out of slavery via the Underground Railroad, it would be Better." Similarly, somebody should be willing to say, "Getting pharmaceutical opioids into the streets is Good, and if we could get more pharmaceutical opioids into the streets, it would be Better." Would you agree with that?

Yes, there were people running straw patient networks and unethical doctors to prescribe to them. But the Sacklers weren't doing this; not personally and not through proxies; it was a side-effect. This was not, so far as I can tell, a goal of theirs, and that would be required to satisfy your idea that drug legalizers should somehow lionize the Sacklers.

Your AMA Journal of Ethics column, BTW, is crap. It claims "patients became dependent on the prescription drugs and moved on to cheaper and readily available illicit drugs, including heroin and fentanyl." with a footnote that makes no such claims. May as well cite Porter and Jick.

Similarly, somebody should be willing to say, "Getting pharmaceutical opioids into the streets is Good, and if we could get more pharmaceutical opioids into the streets, it would be Better." Would you agree with that?

I would agree that pharmaceutical-quality opiods displacing low-quality opiods on the streets would be a good thing. Pharmaceutical-quality opioids adding to low-quality opiods would be a bad thing. (I think recreational drug use is most often a bad idea, though I do not think it should be illegal). We can see that when pharmaceutical-quality opiod supplies dry up, low-quality opiods substitute for them, but I think strictly speaking there has not been strong evidence for the reverse; I would expect it to happen under true legalization but for it to be caused by the entry of high-quality suppliers into existing black markets seems less certain.

I would agree that pharmaceutical-quality opiods displacing low-quality opiods on the streets would be a good thing. Pharmaceutical-quality opioids adding to low-quality opiods would be a bad thing.

I don't know what you mean by this. I don't think this is a knob we can tune, even in our hypothetical model. In our hypothetical model, we can basically just turn up/down the quantity of pharmaceutical opioids that make it to the street. We can't really determine whether they displace low-quality opioids or add to them. The market would decide this, right? Unless you're saying that the project of pumping more pharmaceutical opioids into the streets is only Good if it's combined with some other form of crackdown on low-quality opioids?

I think the fundamental claim underlying a lot of positions is that if we just turned the knob of increasing pharmaceutical opioids on the street, then the market will totally, definitely, automatically treat them as a substitute, and they will displace low-quality opioids. This is like, the basic claim that allows people to continue on a chain of reasoning that legalization -> pharmaceutical opioids become widely available -> substitution of pharmaceutical opioids for low-quality opioids -> unmitigated win. I think if you're saying that this chain of reasoning just doesn't hold, because we just have no idea whether they'll substitute or add, then I would view that as being a pretty generic argument against the type of drug legalization reasoning that I've been saying all along doesn't go through. Like, it would appear that we actually agree?

In our hypothetical model, we can basically just turn up/down the quantity of pharmaceutical opioids that make it to the street. We can't really determine whether they displace low-quality opioids or add to them. The market would decide this, right? Unless you're saying that the project of pumping more pharmaceutical opioids into the streets is only Good if it's combined with some other form of crackdown on low-quality opioids?

I expect that a drug user given the choice between, at equal price per dose, pharmaceutical opiods and shit put together in Mexican lab with random Chinese ingredients and cut with God-knows-what, would choose pharmaceutical opiods. However, I would not expect a black market to reliably give that choice. Black markets tend to have a major problem with fraud.

I think the fundamental claim underlying a lot of positions is that if we just turned the knob of increasing pharmaceutical opioids on the street, then the market will totally, definitely, automatically treat them as a substitute, and they will displace low-quality opioids.

I think that is not actually the claim of those who want legalization, and does not follow from the claims of those who want legalization.

I expect that a drug user given the choice between, at equal price per dose, pharmaceutical opiods and shit put together in Mexican lab with random Chinese ingredients and cut with God-knows-what, would choose pharmaceutical opiods. However, I would not expect a black market to reliably give that choice. Black markets tend to have a major problem with fraud.

Has there been a whole lot of fake Oxy pills? I imagine it would be a bit challenging to make high-quality counterfeits. I imagine there would probably be some fraud around the edges; hell, people can go on Amazon today, a totally white-looking market, and order regular products from China that turn out to be fraudulent. But my sense is that if we truly turned up the dial on dumping pharmaceutical opioids into the streets, then the prices would plummet, and we'd only have small amounts of fraud around the edges (why go to great lengths to make counterfeits when supply is plentiful and prices are cheap?). Why wouldn't that be the case?

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