> Why don’t doctors unions throw out members who would claim to have been hoodwinked by pharmaceutical companies?
If the companies are lying about safety, how are the doctors supposed to know? The only ones with the data necessary to know the dangers of these drugs are the manufacturers and the manufacturers were lying and covering up the dangers.
I think a casual understanding of history has numerous examples of opioids that were prescribed as being safe, and that people then got addicted to, and then we all moved on to the next one. Heroin was one, after all. I find it hard to imagine too many doctors who are unaware of the history. How they have chosen to view that history (psychiatry's triumphant "this time we got it right!" or perhaps simply shrinking away from the issue) is what informs their decisions.
Is it an opioid? Then it is probably addictive for some people.
I know that there is some experimentation involving kappa opioid receptors, trying to essentially neutralize any euphoria or uplift with the k-receptor's dysphoria "bummer," but until that has been ironed out, they're habit-forming for many. Not all, but many.
Asking doctors to decide which research they should and should not trust based on their understanding of history seems like a more dangerous situation.
I dunno, "The history of all opioids we have ever encountered has always been associated with addiction" is not a particularly difficult concept to grasp, nor can I see it taking an inordinate amount of time to cram into their education.
A huge part of most doctors' jobs is balancing the risk of bad things with the benefits of procedures, medications, etc. One of the main reasons we have doctors is so that we can trust their educated judgment. For example, mine noted that guidance had changed on when we should test for some cancers (not as early), because the risk of false positive is higher than the risk of actually having the cancer.
In the case of opioids, doctors know they are addictive. They also unfortunately happen to be _extremely effective_ (for most people) at treating severe pains, and have to balance the benefits of pain relief (both in terms of patient happiness and the healing process) versus the risk of harm. I've definitely seen a shift in doctors' prescribing habits in the past fifteen years, in favor of starting with Ibuprofen or other NSAIDs, with the option to ask for a stronger prescription if pain is too much.
Oh, I am well-aware, as I have been on a somewhat niche Schedule II prescription for over a decade now. It can be quite a hassle.
I am merely pointing out that the idea that medical doctors being unaware of a basic correlation between opioids and addiction, one which has progressed from one medicine to another over the decades, seems ... disingenuous? Preciously naive? Remember, I am replying to "If the companies are lying about safety, how are the doctors supposed to know?"
Here, I think the doctors are supposed to know in the case of opioids because this is an ongoing historical trend. A random new class of medicine? No, they will probably trust the safety sheet, as well they should. The umpteenth opioid? I would be viewing with a gimlet eye anything saying "Nah, no addictive potential."
If doctors only prescribed opioids it would be simple, but they deal in all sorts of constantly evolving drugs where new research may overturn previous assumptions. Trusting the research and heavily punishing those who falsify data seems a lot more sane.
I will counter this one with a hypothetical for you. Monsanto, or Bayer now I guess, trots out a totally safe guys we pinky-swear pesticide. Would you add a little to your drinking water every day? Safety sheets say it can't hurt.
You would probably not do this because you have a historical association with pesticides turning out to be rather broader in impact than was originally let on. You understand that history.
I only suggest that this historical wariness sounds completely reasonable for opioids, whereas a brand new drug class has no history associated with it.
Let me amend your hypothetical. The pesticide presentation is the twentyth such presentation on various topics you've seen today. You see this many every year, and the safety sheets have always been accurate. And, if this pesticide is not used, it is known that the people of your community will suffer and/or die.
Does your understanding of the companies history outweigh your experience of the formats history?
I am not suggesting that they didn't know or would suddenly not prescribe any opioids at all. I have been very careful to say that some, and only some, get addicted.
And I would still not add that pesticide to my drinking water. So I will ask ... would you?
Given that I know people will suffer and die if I don't, yes.
It's a dumb hypothetical though, as my point has repeatedly been that doctors have far too many areas to be concerned about to selectively decide that this one pain killer needs more investigation before I prescribe it regularly.
Exactly, there is a chain of trust involved, and when that trust is broken it makes sense to first look as far up the chain as possible.
Holding doctors responsible for their actions only starts making sense once we are talking about doctors who keep prescribing this long after the risks have become known, which I am sure has happened too. But it's not the root problem.
They are supposed to have learned about it in medical school. If not, that's fine, maybe doctors shouldn't be allowed to prescribe and maybe only pharmacists should be allowed. My point is that it's a very valuable professional quality and we should put the responsibility where the quality is.
This is (well, was) a new drug. Doctors cannot have learned about a drug in medical school when that drug did not exist when they were studying.
My parents are retired Dutch GPs who also ran a small pharmacy[0], so I know a little about how this works, at least in the Netherlands (I admit that this is a pretty big caveat, because (aside from the obvious biases that this introduces) the opioid crisis doesn't exist here - it seems to be a US-only thing. On the other hand, that only gives me more reason to suspect that the problem is systemic, not something to be blamed on individual doctors).
Every year doctors (or any other medical professional as well) have to attend a mandatory amount of lessons to update their knowledge of recent developments in their medical field. In my parents case this also was true for pharmaceutical knowledge. This is where they learn about new medications and their usage. So yeah, they do in fact learn which drug is supposedly safe to prescribe under which circumstances. But you know what is required for all of that to work? An authoritative source of trustworthy information on drug use.
Doctors only start prescribing a drug after it has been approved by the relevant governmental bodies for their usage. So if OxyContin got through the FDA, and was marked as safe for the usage it was advertised for, then I do not understand why you suggest that it's the fault of doctors that they prescribed it in those cases.
Sure, there might have been some stories going around that this drug might not be quite as safe as claimed, but keep in mind that at any given moment hundreds of quack medicine scaremongering stories are making the rounds. When given a choice between believing those, or the official body that is supposed to verify which drugs are safe or not, doctors will usually pick the latter, and in most cases rightly so.
[0] in the Netherlands this is relatively common in small countryside villages that are too small to sustain a pharmacist, who typically needs at least 5000 clients to be sustainable
> Doctors only start prescribing a drug after it has been approved by the relevant governmental bodies for their usage. So if OxyContin got through the FDA, and was marked as safe for the usage it was advertised for, then I do not understand why you suggest that it's the fault of doctors that they prescribed it in those cases.
The caveat is that once a drug is approved for XYZ, doctors can, and do, prescribe it for anything else in their judgement.
Oxycontin wasn’t approved for chronic non-cancer pain, because it’s a poor choice for that, but that’s where the recurring revenue is and somehow accounted for most of its usage.
Short-term post-operative pain and cancer pain just isn’t that big of a market.
> The caveat is that once a drug is approved for XYZ, doctors can, and do, prescribe it for anything else in their judgement. The caveat is that once a drug is approved for XYZ, doctors can, and do, prescribe it for anything else in their judgement.
Yes, but pharmaceutical companies cannot market the drug for non-approved uses or discuss off-label use when promoting or selling the drug. That is illegal.
That illegal activity is exactly what the courts determined Purdue did - bribery, fraudulent marketing, and more. The issue is that Purdue broke the law (and that their sentences for breaking the law were way too light).
Oxycodone was first formulated in 1917, so it's not really "new".
There are lots of FDA-approved drugs that are highly inappropriate for most patients. One of the reasons we tolerate the professional status of physicians is because of their purported expertise in prescribing these drugs safely. If they don't know the function and habit-forming potential of opioids, one might well question that expertise. They aren't regulated in any sense by FDA, and they can't blame FDA for their ignorance.
I agree, go after the deep pockets. I sympathize with patients who became addicted to oxy, while at the same time I'm convinced that opioids should be available to those who need them. I'm glad I got some Demerol when I needed it. I even sympathize with physicians who weighed their patients' needs against the risks of addiction, carefully followed up on their oxy prescriptions, and still had some patients succumb to addiction. I don't sympathize with blanket statements like "doctors just trusted Purdue". Any physician who refilled an opioid prescription without asking the patient some blunt questions and being satisfied with the answers is a piss-poor physician.
>Doctors only start prescribing a drug after it has been approved by the relevant governmental bodies for their usage. So if OxyContin got through the FDA, and was marked as safe for the usage it was advertised for, then I do not understand why you suggest that it's the fault of doctors that they prescribed it in those cases.
Given that the same opioids are approved in the US and Netherlands, with the same warnings and information, why do you think the outcomes are so different between countries?
Before a doctor gets a new drug it should’ve been approved by a government agency and gone through trails. The company selling it trains doctors on its use and side affects. The problem is the company was lying and telling half truths. Not only that they pushed use cases where something as strong as Oxy was not needed.
Pill mill doctors are a different story and they are prosecuted for it.
Purdue kept a database of doctors willing to prescribe their products "for pain relief" and have now switched sides to push a drug that treats opioid addiction under a new marketing campaign and a new industry front.
Doctors who were prescribing medicine at the time that OxyContin hit the market were not in medical school, they had graduated already. If pharma lies about safety there is no way for a doctor to know unless they conduct their own study, which would require lots of extra time and massive funding. Pharmacists didn't know that the safety data was fudged either. Everyone got their oxycontin from a pharmacist after a doctor prescribed it, so having a pharmacist be the only one allowed to prescribe it wouldn't have changed anything.
That does change the interpretation of your earlier statement quite a lot, thank you for clarifying. Together with
Scoundreller's observation it does seem that there are a number of systemic issues working together in the US to create this problem. And one of these seems to be how doctors prescribe medication.
>They are supposed to have learned about it in medical school.
People need to realize that medical school isn't some all-knowing institution where everything knowable about human physiology is imparted unto students.
Consider OxyContin, which the makers claimed worked for 12 hours. 2 things should be red flags here: firstly, I haven't seen an extended release formulation of anything that would work over that period; I'm not even sure if it's physically possible given the human digestion system. Secondly, the many, many patients who complained that it only worked for 6-8 hours.
Any doctor with a basic understanding of pharmacology, and basic bedside manner, should have known something was up there.
"doctors should have known the manufacturers' claims were bogus" is shifting the blame. The real blame should be focused on the manufacturers making false claims in the first place.
It wasn't my intention to shift the blame - clearly the manufacturers should be strung up for making the false claims they did. Absolutely no argument there.
My point is though, that doctors shouldn't blindly trust whatever a manufacturer tells them, if the evidence right in front of their eyes says different.
> My point is though, that doctors shouldn't blindly trust whatever a manufacturer tells them, if the evidence right in front of their eyes says different.
Just to be clear, you're advocating doctors eschewing published clinical data (including data from published trials and the FDA approval) on the basis of nonrandomized anecdotal data?
The issue here is that the manufacturers committed fraud - falsifying and/or misrepresenting clinical data. The courts confirmed this, finding them guilty of fraud, bribery, and more.
Unlike courts, a doctor is in no better position to such sophisticated identify fraud at that scale than a patient is. The pharmaceutical companies and manufacturers absolutely should be held accountable for that, but doctors by and large are not to blame for the fraud committed by pharmaceutical companies.
> The issue here is that the manufacturers committed fraud - falsifying and/or misrepresenting clinical data
This is my point - the claims were BS. A number of doctors should have been raising a number of red flags, because their knowledge contradicted those claims, as did patient evidence right in front of their very eyes.
I'm obviously not saying they should ignore or distrust all clinical data, but if they see such massive discrepancies then they should be speaking up.
> A number of doctors should have been raising a number of red flags, because their knowledge contradicted those claims
Purdue committed fraud, but they never made claims that were so outrageous that they would be prima facie false. (If that had been the case, Oxycontin would never have been approved in the first place). The problem wasn't that the claims were outrageously impossible; it's that the claims were wrong, and Purdue either falsified or misrepresented clinical data in order to convince doctors that Oxycontin was safer than it actually was.
> Patient evidence right in front of their eyes
Encouraging people to rely overly on anecdotal observations is incredibly dangerous, especially when most doctors who prescribe opioids don't prescribe them in such numbers that these issues would be readily visible to them in the first place.
Yes, there were a small number of doctors who did aggressively overprescribe and misprescribe Oxycontin. That was the result of a direct and explicit campaign by Purdue to identify and enable those doctors. Some of those doctors were prosecuted and/or did lose their licenses, but those doctors still only amounted to a small part of the opioid crisis.
> I'm obviously not saying they should ignore or distrust all clinical data, but if they see such massive discrepancies then they should be speaking up.
Most doctors weren't seeing massive discrepancies. We know the discrepancies exist now because there were lawsuits and prosecutions which revealed the specific fraudulent behavior that Purdue and others were engaged in. But without the benefit of hindsight, these issues simply weren't reasonably visible to a typical doctor - they were only visible at large scale to Purdue, who went out of their way to mislead everyone else about it.
There's plenty of blame to go around, both can be at fault. My family doctor, for example, warned me to be very careful of the Oxytocin I was given by the hospital (without any warnings) after my wisdom teeth were removed.
This is the kind of thing I mean - giving someone oxycontin without any warnings is just plain irresponsible.
Furthermore, opioids shouldn't even be used as first line after wisdom teeth removal - across Europe you'd be sent home and told to take paracetamol or ibuprofen, because those medications generally work very well for inflammation-type pain.
If the companies are lying about safety, how are the doctors supposed to know? The only ones with the data necessary to know the dangers of these drugs are the manufacturers and the manufacturers were lying and covering up the dangers.