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Comment by alkonaut | Hacker News Reader

I trust this guy will get what he deserves, but surely there should be other people falling here?

Usually it's the taker of bribes that is the biggest criminal. Any doctor who can be shown to have given addictive opioids to people that aren't terminally ill should be investigated.

This is completely regardless of whether it was the "standard practice" at the time, or whether some pharmaceutical sales rep told them it was a good idea.

If just a couple of hundred doctors would lose their license and a few dozen end up in jail, that would make some headlines and perhaps make other doctors think twice before prescribing oxycodone to someone with normal back pain. Doing that is like amputating someone at the hip for toenail fungus.

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> Any doctor who can be shown to have given addictive opioids to people that aren't terminally ill should be investigated.

This is a terrible idea. All opioids are theoretically addictive. They're also the most effective painkillers. Even cocodamol is an opiate. Escalating the War on Drugs like this is just going to leave a whole load more people in treatable pain.

It's a complex problem, but I think this Vice article is a good summary of how the UK has avoided a comparable crisis: https://www.vice.com/en_uk/article/ppm5eg/the-truth-about-ox...

No, I still agree. If a doctor is giving someone painkillers when they aren't necessary, then that's not much different from drug dealers on the street. Just because they are doctors doesn't mean they should get a free pass. Even more so, the opposite should be true, because we expect doctors to have integrity. If there is nuance to a specific case of this, then let that be determined in court.

The OP said no opioids should be prescribed unless the patient is terminally ill - since you say you agree, are you saying that opioids are only necessary for terminally ill patients?

What I meant was very rare and exceptional cases where the side effects aren't that important. Cancer patients was one such example.

> If a doctor is giving someone painkillers when they aren't necessary, then that's not much different from drug dealers on the street.

Well, you're not wrong. However, this isn't limited to opioids. If a doctor is not following the standard of care, according to their peers, and a patient has an adverse outcome then the Doctor is subject to board review and they may have their license revoked and/or be prosecuted. This is already in place and has been for some time. This is why most Doctors are generally extremely conservative in the treatments and interventions they recommend for their patients.

You assume that there's a quantitative definition of necessary. Pain is subjective.

The main difference is that a doctor supposedly has a higher interest in your well being than your dealer does.

My understanding is that a doctor isn't going to be making more money because they're prescribing you opiods or not. But they do it anyways because it can help you through pain. Just like you can get stuff to help with your cold, even if it's not necessary

Airlines aren't the same as pillow manufacturers just because they lend you one on a flight.

I think the doctors we are discussing here are the ones that took a higher interest in the bribe than their patients.

That article makes a curious argument: that the UK won't have an oxycodone problem because they already have 2.5x more heroin users per capita than the US — so potential demand is already saturated. I mean, right, they probably won't have any more trouble from oxycodone than they already have from heroin and tramadol, but they already have a big opioid problem. (Maybe they're better at preventing overdose deaths than we are; I don't know.)

"Already have 2.5x more heroin users per capita than the US" Based upon what data ?1

I don't know the article's sources, but it says "America has five times the general population of Britain, but only twice the number of heroin addicts." You can research this as easily as I can.

2 doctors who prescribed the 10,000x more potent than morphine that is only approved for late stage terminal cancer, note this is far far more potent than any other opioid. The doctors prescribed it for knee pain, minor injuries, headaches, minor Joint pain, any and everything and they owned their own pharmacy which essentiallY just sold that and one other opiodmillegally. 81 witnesses came forward showing how addicting themselves to this insanely worse than opiod substance ruined their lives.

Meanwhile one doctor had 23 Lamborghinis, many beach front condos and 2 doctors prescribed 1/3 of the total prescriptions in the world. Both serving 20+ years sentenced last year, NPs who pushed all this got 3 years, almost every executive has been charged and trial 2018

Links?

https://www.justice.gov/usao-sdal/pr/dr-couch-and-dr-ruan-se...

Thanks!

This is the back-story that makes the whole thing make sense. This isn't a War on Drugs over zealous prosecution, this was a brazen attack on the healthcare system to extract millions through illicit prescriptions which also destroyed lives due to the dangerous nature of the drug. Unreal!

All opioids are addictive. Doctors have to weigh the risks against the benefits, just like they do for any other treatment.

Do they err in the direction of over-prescribing? Probably. But to say that opioids should never be given to anyone who is not terminally ill would be to err in the opposite direction.

The normal practice in most other places (which doctors should be automatically investigated for, if systematically diverging from) is to only prescribe the most potent opioids in exceptional cases such as to terminally ill cancer patients.

This seems to work pretty well.

EDIT: added "exceptional cases" - this can be other cases than just cancer, see e.g reply

Medicine is not so black-and-white.

It's not. But the practice of prescribing opioids is wildly different in other countries. So the base assumptions when weighing the benefits and drawbacks (addiction) need to change. Basically, doctors should try more alternatives and doctors need to tell patients that the pain may be the lesser evil compared to opioids. This also requires changed expectations from patients, about what doctors can do about pain.

I agree that the most powerful opioids should be used very sparingly. But that's quite different from restricting the use of addictive opioids -- which is to say, all of them.

Yes, this is only really a discussion about the most potent opioids like oxycodone, and only for long term prescription use.

Use of opioids in an IV in a hospital after a major surgery isn't what's discussed. That happens everywhere and doesn't seem to cause addiction problems.

My wife had to have a full spinal fusion. You probably don’t even have the mental tools necessary to start thinking about that kind of pain. The sort of pain that causes people to consider suicide as a preferable alternative.

Because of the intense back pain leading up to the surgery she was already taking high opiate doses. After the surgery she was taking doses of hydromorphone (5x as strong as morphine) that would kill you or me with a single dose.

I would appreciate it if the HN peanut gallery would take a moment to stop and consider others before spouting off. Take this opportunity to do some research into the humiliating procedures the war on drugs has visited upon patients and doctors, then ask yourself if we really need more of the same.

For example: did you know my wife had to hobble into the pain management office and pee in a cup on several occasions? Just to make sure she was taking the drugs (the torso-length scar on her back being insufficient). The fact that someone selling the pills could have simply taken some the morning of the test made the farce even more absurd.

I think this example would be one of the cases where the most potent opioids would be prescribed in any country. I'm not advocating never prescribing them - only to do it in exceptional cases.

Then that differs from what you'd said of "terminally ill"

Right - that wasn't the correct formulation. The formulation used is of course "exceptional cases", and terminal cancer is just one such example.

I edited that my post above (sorry if your reply looks odd after the edit)

The scar really isn't sufficient. There have been many cases of relatives (usually spouses, but sometimes children or parents) stealing pain medication which was prescribed for post-operative pain, and then coercing their victim into not reporting the theft. As horrible as it is, the drug testing was there to protect your wife.

"many case" [citation needed]

Seriously?

The industry term for this is "drug diversion," and it happens pretty frequently and is very under reported. The patient may not even be aware it's happening because a health care employee, real estate agent, teenager child, nanny, guest, etc may be stealing the medicine. It even happens in a hospital setting, with deadly results - https://www.medscape.com/viewarticle/825801

That's why if you have drugs someone may want to steal it's recommend you keep them locked up.

Not even dying in hospice care stops family: https://www.washingtonpost.com/national/health-science/dying...

People here get their pain medication in quantities which have to suffice for a specific time, so if they need new medication before that time has run out this leads to questions and checks. No painful hobbling, no peeing, simple math.

> You probably don’t even have the mental tools necessary to start thinking about that kind of pain.

As I don't know your story, you don't know mine. Get off your high horse before you lecture the peanut gallery.

With great sympathy to your wife, to those who've had lives taken and families destroyed by an addiction which started with a doctors over prescription, maybe hobbling to pee in a cup doesn't sound so bad.

I think one of the problems is that the medical and legal community seem to be incapable of doing anything but extremes. About 5 years ago I went to the doctors for headaches and was given a subscription for 90 pills every month of fioricet and expected to only take it when I needed it and not more than 3 a day. About a year and a half ago after I got a new doctor who was appalled, asked me if I would consider going down to 30, and was surprised when I told him I had no problem with that because it was unneeded and I was already only refilling it 1-2 times a year anyway. Now in the past year I hurt my shoulder pretty badly, to the point where I was having difficulty using it due to the pain and was dropping light weights. I was told physical therapy and aspirin and if it still hurt too much to use I could try more aspirin. We seem to swing wildly between giving out a ridiculous amount of drugs(90 a month no questions asked) to giving out none, even when people are in pain.

Why can doctors not prescribe something like 3 pills a month to someone? Its not nearly enough to get addicted on, but can help someone experiencing severe but temporary pain. Is it something in our legal framework that only allows doctors to prescribe a months worth at a time with the assumption that its taken every day? Is it some pressure from insurance companies who don't want to deal with paying out small claims like for 3 pills?

There's two issues here. The first is that "as needed" is really hard for pharmacies and insurance companies to handle; the only way they can avoid arguments (and potential lawsuits) is to dispense the maximum allowed. So even if your doctor expects that you're only going to need an 1 pill/day on average, if he writes "as needed up to 3 polls/day", you're going to be given 90/month.

The second issue is deliberate overprescription. Most insurance companies have rules on the amount of medication which can be dispensed -- 100 days is a common limit, but some limits are as low as 30 days. The justification for this is that they don't want you to end up with lots of unneeded medication if your needs change; but usually the real reason is that they don't want to end up covering costs which can be offloaded to your next insurance company if you change insurers. In response, some doctors will deliberately inflate prescriptions -- e.g., if your doctor thinks you need one pill/day and trusts you not to abuse the medication, he might write a prescription for 3 pills/day so that your insurance company will approve an amount which will last you for longer.

> Any doctor who can be shown to have given addictive opioids to people that aren't terminally ill should be investigated.

Opioids are a good choice for end of life care, but they're also useful in other situations, such as acute (short term) pain - post operative pain for example.

They're not a great choice for chronic (long term) pain, but even then they can be used carefully.

Right. Morphine drugs given for short durations after e.g surgery isn't at all uncommon in the countries where potent opioids are almost never prescribed for longer term use. That would probably not change.

> I trust this guy will get what he deserves,

Aren't you a little bit concerned that he might be guilty yet go unpunished? Or that he's innocent but goes down anyway?

There's a lot of money involved here, and a lot of political prestige as well. The opioid crisis is pretty big, and there's huge interest in both outcomes.

Plus the justice everyone deserves is swift and not expensive. What's the chance this doesn't get stretched out to years and years, with huge legal fees racked up?

> Any doctor who can be shown to have given addictive opioids to people that aren't terminally ill should be investigated.

No, they should have their license revoked. Those people are not doctors, they are opportunistic capitalists in the medical sector that should have no right to practise medicine.

In fact, this scheme could only work if doctors complied. I would say what they did was much worse than what the billionaire did. They're bad actors.

This permeates the whole system of education. Apparently, for a long time (And I sure hope this changed), doctors were taught opioids aren't addictive if the patient is in pain. See e.g

http://edition.cnn.com/2016/08/25/health/us-surgeon-general-...

This makes you wonder how many professors at medical schools also go on nice holidays paid for by pharma companies or lobbyists.

>Those people are not doctors, they are opportunistic capitalists in the medical sector that should have no right to practise medicine.

You can’t change these incentives without moving the US to a nationalized health care system, including public financing of education for doctors and much harsher regulation of the pharma industry. As long as you have doctors going into massive amounts of debt to finance their education and a drug industry with obscene wealth and power, you’re always going to arrive at this outcome. Capitalism is fundamentally opportunistic, which is why it has no business in healthcare.

Speaking as an American medical resident currently in training, please realize that opioids are the only pain medication aside from nerve modulators like gabapentin or pregabalin that have any serious effect after NSAIDs have been exhausted. We routinely use it appropriately for patients with gallbladder, kidney and very run-of-the-mill problems.

> Any doctor who can be shown to have given addictive opioids to people that aren't terminally ill should be investigated.

About ten years ago I had two teeth removed. The next day I received a phone call from the dentist office. They wanted to know how I felt. I felt fine and I was curious why they would call me about it. They told me that often after a tooth removal, patients were complaining about pain. Again I told her I was fine and that was it.

I can understand that sometimes people complain about pain, but that's the thing : they are supposed to complain about it, I mean they must be actively demanding treatment.

Never ever had I received a phone call from a doctor or her staff. I can't help thinking that they wanted me to complain about pain so that they could prescribe me pain relief medication.

Am I being paranoid?

I think you're looking at it from the wrong end.

Usually a dentist prescribes painkillers without finding out if you'll need them. Most people go "Oh, hey, vicodin", and take it because they have the prescription.

This dentist was, by the sounds of it, actually taking an opt-in route - you have to say "Yes, I am in pain" to receive painkillers. Seems more responsible to me.

> Usually a dentist prescribes painkillers without finding out if you'll need them.

That would be absolutely unacceptable, imho.

And I thought being in pain was not enough to be prescribed opiods anyway? Isn't the pain supposed to be chronic or the patient incurable?

Episodic pain should not be treated at all, imho.

Fast forward 10 years. Top story on HN is "I'm in excruciating pain and my doctor is refusing to prescribe me a painkiller because he's afraid of losing his license". Top comment: "This is ridiculous! Why are all these regulations preventing people from getting proper health care instead of actually helping them?"

No, the solution is not putting doctors in jail. No, the solution is not piling regulations on top of more regulations. Only thing that's needed is educating people and providing less addictive alternatives. If the pack of pills has "Warning: this is highly addictive! Use only in emergency!" in big bold letters, then people will think twice about taking them.

Once you take kickbacks, your "professional judgment" is clouded. Are you giving that because it's better for me or because you'll get a bonus for prescribing that?

Kickbacks/bribes are absolutely despicable, there is no argument about that. I'm just against some elaborate set of rules that is going to regulate what doctors can prescribe or not. These decisions should be left to the doctors' discretion. And bribe cases should absolutely be prosecuted.

They tried this with cigarettes. It did not really work: https://www.rand.org/blog/2014/09/graphic-warning-labels-on-...

The cigarette warning labels are working just fine. The point is to warn people of the dangers and practically every smoker is already aware of those and yet they choose to smoke anyway. That's perfectly fine in my book - as long as one is making an informed decision, they should be able to pick the poison that kills them.

I don't know about the US, but in the UK at least I reckon it's the taxes that work better than the labels (the price of a pack of cigs has risen dramatically over the past 15 years or so)

They also banned small 10 packs, and 7.5g pouches. This seems to really stop people from buying a small pack for a night out, at least it stopped me.

That is until you buy a larger pack and have some.left over the next day that is.

At least they could no longer pretend surprise at the damage cigarettes did to them.

I say "pretend" because it was no great revelation in the 1960s that smoking was bad for you. My father said they were called "coffin nails" back in the 1930s, and the first thing doctors routinely advised their patients was to quit smoking.

And, of course, the black, scarred lung of a smoker was ridiculously obvious to any person who did an autopsy or operation on a smoker.

Putting doctors in jail isn't a solution to the problem, but it is legal justice for the crime of prescribing dangerously inappropriate medication for financial benefit.

Warning labels is one part of the solution. Limiting kickbacks and tightening those regulations can be another.

Making sure teachers in medical schools don't tell their students that opioids aren't addictive is another.

Information to the public about what pain and pain treatment is, and what treatments are effective compared to their side effects is yet another.

This sidesteps the fact that informed and responsible citizens should have access to opiates even if they are not ill, much less terminally so.

I get that it's a compromise, but it is still a morally reprehensible position to believe only terminally ill patients should be allowed the choice to put opiates in their body.

The real problem is a mixture of Big Pharma propaganda, kickbacks, lack of proper education, deep socio-economic troubles, depression, and need for escapism. The solution is not to limit the freedoms of responsible citizens but to address each of those concerns in turn.

>Any doctor who can be shown to have given addictive opioids to people that aren't terminally ill should be investigated.

Yep. Investigate all of us. High quality understanding of medicine right here..

>normal back pain

I assume, definition of this phrase would be the point of contention .

Yes. And the definitions taught in medical schools and passed from the SGs office should probably be approximately that if the back pain comes from your late stage cancer then it's fine to prescribe opioids. If it's not then don't.

I'd prefer the government NOT be in the doctor's office (a private space where a service is being rendered).

it's a person giving a service under hippocratic oath. The fact that the person is an MD at all is because he took training that is carefully outlined by government. He prescribes only medication that is legal to prescribe under rules set by government. He's probably paid by some insurance scheme that is either directly government (where there is public healthcare) or at least mandated and controlled by government (e.g. ACA).

So I think it's fair to say that the doctors office is one of the offices where government is very present.

I know and I think we're much worse for it. No matter the intentions, when the government gets involved the services become poorer quality and more expensive. I definitely think we'd be better off if we stopped disadvantaging that services relative to other services.

This is just objectivity wrong.

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