Hacker News Reader

Comment by JDulin | Hacker News Reader

These court-cases have two worthy objectives: Correcting this behavior in pharmaceutical co.s in the future and compensating the states & people harmed in the past.

Incentivizing restraint and honest advertising is only possible by punishing executives, personally [1]. Especially those in sales.

And fair compensation is many, many times this number. So I fail to see how this is anything other than an injustice, and fear that it will take the pressure off of other court cases against opioid sellers.

Reading the book "Dreamland" [2] on the opioid crisis changed my life. Even as someone from a part of Ohio hurt by opioids, it's hard to imagine the venality of these people, the callousness of the Mexican drug dealers who swoop in behind them, and the magnitude of suffering their perfect storm concocts.

[1] https://news.ycombinator.com/item?id=19669453 [2] https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidem...

View on HN

There can be no "honest" advertising of drugs. We need to start banning ads for drugs completely. It probably wouldn't hurt to do the same for alcohol, etc. It's not like people still won't drink or asking for drug X but it stops the patients from demanding it. We've already made some strides by banning the pharma reps from sending super models to doctor's office to flirt and convince them to push drug X but we need to push further.

Instead we should be spending more money at the FDA level. The surgeon general should have the resources that say that condition X, the approved drugs are A, B, C, D and E. You can also do in a phased fashion. You always prescribe A. Only if that fails do you prescribe B, etc. There are lots of treatment plans like this already (usually driven by insurance costs) but these could be built by leading physicians in each specialty. There are providers that have the knowledge of what works and doesn't but we do an awful job of capturing it. Most doctors just know what they learned in school 30 years ago or what they can google. We need better codification of successful treatment options for each condition X.

With liability for deviating from the plans?

Having experienced a vaguely diagnosed condition that the doctor treated with intuition, I hope you don't get put in charge.

Am confused by this whole thing, As someone who grew up in Australia I've never seen drug advertising, the closest would be supplements / vitamins that you can buy over the counter

Is the idea that a user sees a drug advertised then goes to their doctor to ask for that specific one? Wouldn't the doctor give you a yay or nay for needing it then perscribing it?

Do doctors in the US let the patient decide whether they should be perscribed the drug despite not agreeing with it?

I'm in the US, I see drug commercials all the time, but I don't understand how they work.

Am I just supposed to go to my GP and ask for a drug I saw on TV? Are there really that many drugs so that any decent GP doesn't know most of them?

I think that's exactly how its meant to work. I'm sitting at home, and I have a bad stomach, an advert comes on the TV: "Do you have a bad stomach? Ask your GP about engorgolate today!". So I do. 2% of GPs then end up prescribing it

Ah that makes sense, thanks for writing this out

Doctors in the US generally won't prescribe medications they deem unnecessary, but there's a few issue that reduce the effectiveness of that. Two big ones are:

1. If an individual sees drug advertisements with particular symptoms they might think that they have them, which would make their concerns sound more probable to doctors when they complain about it.

2. In the US medical malpractice suits are a big issue, so that fear often causes things that might be considered on the edges of unnecessary in most countries to be converted to "maybe, I don't want to get sued if something does happen". This is magnified by point 1.

Take more people thinking they are sick, multiplied by multiple conditions, multiplied by doctors effectively excessively afraid of false negatives in diagnosing, and you have one big public health concern and some big marketing bonuses.

"Doctors in the US generally won't prescribe medications they deem unnecessary"

I'm not sure about this statement. Pharma is literally paying doctors to push their drugs. Obvious conflict of interest no?

E.g. https://www.abcactionnews.com/news/full-circle/pharmaceutica...

The sibling comments cover advertising to the general public, which is allowed in the US. And yes, many of us in the US find it just as strange as those of you in other places.

There is another problem, and I don't know how it is resolved elsewhere. Pharma companies have paid sales rep that travel to medical offices, and push their product directly to doctors. This is ostensibly in the name of educating the MDs, but they hand out free samples. The hope is to convince the MDs that this drug is better than its predecessor.

Free samples is just the start. Big prescribers get cushy dinners, "educational" retreats at resorts, "speaking fees", and the like.

I know several people who have been diagnosed with, say, fibromyalgia, Crohn’s disease, PCOS, or some other chronic problem and would be happy to know about new, potentially more effective medication. In theory, they’re the primary audience for these commercials.

Additionally, some commercials are targeted at people who have undiagnosed problems, who may not even realize that what they have is unusual. Those commercials start with a list of symptoms, a recommendation to talk with a doctor, and a note that if you do have a particular condition a new drug could potentially help.

And, of course, there are ads for things that people can readily self-diagnose, like erectile dysfunction.

In practice, the ads leave a lot to be desired. Probably the worst marketing campaign I remember was Nexium, which ran ads for several years encouraging people to talk with their doctors about “the purple pill,” without ever mentioning what it could treat. The tag line — “little, purple, different” — didn’t help.

> Probably the worst marketing campaign I remember was Nexium, which ran ads for several years encouraging people to talk with their doctors about “the purple pill,” without ever mentioning what it could treat. The tag line — “little, purple, different” — didn’t help.

IIRC, this trick lets them avoid the big list of disclaimers and side-effects, as they're not making any medical claims in the ad. Nasty, IMO.

The other issue is that sometimes the new, more-expensive, under-patent medications are less effective than something that already exists. But they don't say that in the ad. Or to doctors when they're wining and dining them.

It took a while for me to remember, but let me correct something: Nuprim’s tagline was “little, yellow, different” ( https://youtu.be/kPYACe8I-T8 ). Nexium was just the purple pill with mysterious ads.

Keep in mind that the magnitude of the fine cannot be known ahead of time. These Fight Club-esque arguments that corporate civil liability can not possibly curtail bad corporate conduct ignore the fact that killing people carries an almost unbounded punitive penalty in front of a jury. The confidence interval on the damages is very large, which makes doing things with practically unbounded civil liability actually dangerous for companies, and actually deters behavior which might appear otherwise profitable.

Considering the A) relative minor role that J&J played compared to the other original defendants, B) the relatively small size of the aggrieved population compared to the potential population with a cause of action, and C) the particular law they brought suit under... this is in fact a pretty spectacular result overall for the State.

Really the bigger question is why the State settled with the other defendants for so little. That tells you all you need to know about whether the State thought this verdict was likely, and what they thought the scale of damages might be for the major players, let alone the side-show that was J&J.

I realise this might sound like a circular argument, but: Any fine imposed on a rational company for criminal conduct must be insufficient, because had the fine been sufficient, a rational company would not have engaged in the criminal conduct.

In other words, if a company gets hit with an $X fine for Foo, the options are:

1. The company determined the profit from Foo was greater than $X multiplied by the probability of getting caught.

2. The company's governance meant decision-makers on Foo received bonuses for its profits, but were insulated from the costs/fines, and acted in their personal interests but against the company's interests.

3. The company underestimated $X or the probability of getting caught.

4. The company or its employees were irrational.

And if you're the efficient-market-Homo-economicus type that believes 3 and 4 are impossible, that only leaves 1 and 2 - requiring fines larger than $X irrespective of what $X is or personal executive liability respectively.

Of course, the downside to this argument is the results if you transfer it elsewhere in the justice system; by this logic, every crime should have infinite punishment - but an automatic death penalty for speeding is an absurd result.

> Of course, the downside to this argument is the results if you transfer it elsewhere in the justice system; by this logic, every crime should have infinite punishment - but an automatic death penalty for speeding is an absurd result.

But, the penalty for a crime isn't set by logic, it's set by legislative process, which prevents the absurd result.

Right, which sadly means it is not bound by any logical structure and will likely be very unbalanced.

Ex, Enron execs went to prison for years, yet no one died due to their actions. Big Pharma knowingly oversells a highly addictive substance that results in people's death....and yet the corporate veil is not pierced (where's the 10+ year prison sentences).

You just need to change the probability of getting caught.

Efficient market theory in no way claims that all companies must always act rationally.

And even more so, you can attempt to make a rational decision, and still be wrong.

It’s also often said about the market, that it can remain irrational longer than you can remain solvent.

The parent comment doesn't just say "efficient market". It also explicitly mentions "Homo economicus" and "rational company". A rational company makes rational decisions, pretty much by definition.

The saying that the market can remain irrational longer than you can remain solvent directly contradicts the efficient market hypothesis.

> These Fight Club-esque arguments that corporate civil liability can not possibly curtail bad corporate conduct ignore the fact that killing people carries an almost unbounded punitive penalty in front of a jury. The confidence interval on the damages is very large, which makes doing things with practically unbounded civil liability actually dangerous for companies, and actually deters behavior which might appear otherwise profitable.

Your argument ignores the fact that when this "unbounded liability" hits the company, it might bankrupt the company, but that is completely irrelevant to the responsible people, who usually get to keep the fat bonuses they earned and go on to work in another company, doing the same things. A company has, in principle, a strong incentive to prevent this, which is why there are CCOs and compliance departments. But in practice, this too often loses out to the stronger incentive to maximise profits.

The shareholders certainly consider bankruptcy to be relevant. One would think they would find the hiring of "responsible" people who bankrupted their previous company to be relevant also.

While the number seems small (still much bigger than what Purdue and others ended up paying by settling early instead of dragging it), it's worth noting that it's only in one state. They could potentially all go through the same process in all states, as this was a widespread issue. But even then I agree that it still doesn't come close to the amount of pain and suffering they caused.

I wonder if it's limited to all states. Feels like a door is open for individuals, and perhaps other things like cities, counties, etc. I'm imagining some sort of J&J all-hands-on-deck meeting tommorow.

And yet somehow opioids are still legal.

They've had a Opoid conference in Boston the past few years.

http://opioidconference.org

This seems to be an attempt by the states to reign in egregiously bad behavior by these businesses/ doctors that are supposed to be federally regulated (which frankly seemed to be lacking). Opioids things seem addictive enough to warrant some review on if there aren't other pain-killers that can replace them completely perhaps excepting in a few exceptional circumstances.

Because making a substance illegal has worked so well!

Opeoids work when used correctly. No one is arguing that they should be banned. Doctors just need to not be lied to so that they don't prescribe highly addictive substances thinking they aren't.

Why would you want to make them illegal? What do you plan to give terminally ill cancer patients or people with extensive burns for example?

1. Everyone should read Dreamland. Even if you think you know the Opioid story, you don't know half of it. And completely aside from that, it's really well written.

2. One thing I took away from Dreamland was that there wasn't one factor to blame. Instead it was 4-6 separate factors that came together in a nightmarish perfect storm vortex to create this crisis.

Which means the pharmaceutical companies have plenty of blame here, but still only 20-30% of the total.

4-6 sounds like it could be summarized without reading an entire book. :)

Sure, but where is the fun in that :) Also, I don't think I can do it justice from memory.

The war against illegal drug makers has had no effect. All you'll do by punishing pharmaceutical companies is have them exit the opiod business, and pray that you don't acquire a very painful condition.

The opioid business is only a subset of the analgesic business. If this forces pharma companies to target their research on non-addictive painkillers, that’s a good thing.

Future research is not available now. Pray you don't get an extremely painful condition.

Europe seems to manage this fine. There are plenty of companies manufacturing opioids, and they are widely available for people with severe pain.

But companies are not allowed to advertise them. Same rules as we have for cigarettes and politicians, and it completely bypasses the question of whether a given advert is biased / truthful.

How casually prescription meds are advertised on TV in the US was really shocking to me being from Europe.

Only OTC medications seem to be advertised here in Eastern Europe. This includes NSAIDs. They are more harmful than opioids due to the risk of virtually everything, such as: myocardial infarction, stroke, erectile dysfunction, gastric ulceration/bleeding, kidney failure (incl. hypertension). They also cause raised liver enzymes, and so on.

None of the aforementioned side-effects exist for opioids. The only major concern is constipation (especially in the elderly), nausea, aaaaand euphoria. Yes. That is it. Respiratory depression and other severe adverse effects are not really an issue if you are taking therapeutic doses, especially if taken orally. If you are taking it intravenously, then you are properly under medical supervision anyway. There is a reason for why the elderly usually receive opioids instead of NSAIDs. It is more effective, and it has a better safety profile. The issue is with questionable products with adulterants and unknown purity. Harm reduction policies, and the end on the War on Drugs can improve the situation tremendously. Portugal is a great example of this.

https://en.wikipedia.org/wiki/Nonsteroidal_anti-inflammatory...

https://en.wikipedia.org/wiki/Opioid#Adverse_effects

As for addiction: https://global.oup.com/academic/product/addiction-and-choice...

An excellent book, it is worth reading. According to my experiences many people have lots of misconceptions regarding addiction.

Non-addictive? The elderly commonly receive opioids. They are not addicted to them, only physically dependent. You can get physically dependent on almost all medications, even, say, beta-blockers or proton-pump inhibitors.

There is nothing wrong with opioids, we do not need a replacement. The issue stems from questionable products from the black market. Plus, why should we ban X or look for a replacement of Y just because there are people who consume it recklessly? This hurts everyone, and is a terrible "solution". If anything, we need harm reduction policies. I would rather not deprive people from the legal access of effective painkillers because some reckless people overdosed on them. There will always be reckless people. Always. This is not a reason to hurt innocent and non-reckless people.

Considering nobody can get these drugs unless a physician prescribes them, when are we going to see a wholesale round up of doctors?

So far it’s been a few high profile cases, but obviously the problem runs deeper than that.

And J&J is by no means a major opioid manufacturer. As the article states, their drugs were less than 1% of all prescription opioids.

I think J&J got hit because they have deep pockets.

Doctors already are being rounded up. That's like going after the atreet dealer. Have to go for the head.

They are scapegoats. I just read majority of case files - there is not much of a proof that JJ did anything more than what law allowed them to do! Tune as old as Congress itself - you think a corporation acts immorally? Change the damn law! Don’t expect for-profit corporation to have a soul.

Finally - the reasoning here should he similar to gun and a murderer. If guns don’t pull triggers but people do, then similarily here only responsible people should be these that abused said drug, especially when it was manufactured and sold accordingly with laws and doctor’s prescription.

Guns are a public policy aberration in this regard.

Lawn darts killed one kid and got banned. Cars got forced to be safer with seat belts and airbags, with the industry kicking and screaming throughout.

You right and to contextualise this - do gun shops who sold the guns that did the crime make them as guilty when the gun shop followed the law. Case with most (sure some exceptions) Doctors, they prescribe the drugs, the patient abused them or what has transpired is the patient did what the doctor said, just couldn't get off those drugs and that is were doctors may well be foul. Equally they may not have the tools or resources to cater for such instances. After all addiction treatment is often a waiting list a World away for many in that position.

But would banning opioids have more positive than negative - who knows. Hence your gun analogy fits this situation perfectly. Though some would say banning guns would be easier than banning opioids.

Equally most things banned, end up shifting them into criminal distribution and quality. Though I've yet to find a lawn dart dealer, I dare say that somebody somewhere sells them illegally - nature of banning something alas. Hmm, just had a quick look and Amazon has many lawn darts for sale :(.

> do gun shops who sold the guns that did the crime make them as guilty when the gun shop followed the law

That depends. We had a case locally where a shop was repeatedly robbed, made little effort to improve security, and wound up shut down for it.

https://www.democratandchronicle.com/story/news/2018/08/16/d...

> As a result, MCSO investigators obtained a court order to close down the business and take control of its inventory, which Baxter described as "hundreds of guns and pallets of ammunition."

> "For more than a decade, the Monroe County Sheriff’s Office has attempted to work with the owner to improve security for his facility, Baxter said.

For clarity: Metal-tipped lawn darts were banned. You can get a foam Nerf one now, sure.

Ah I looked at the UK site: https://www.amazon.co.uk/Unibos-Garden-Outdoor-Family-Tradit...

Thought they were banned in the UK as well, seems not so...yet.

[edit add] https://www.crowndarts.com/ sells them (metal tips) and will ship to the USA and Canada! that was just a quick look, so guarantee more avenues to procure them.

> Cars got forced to be safer with seat belts and airbags, with the industry kicking and screaming throughout

Where can I read more about this?

He's exaggerating.

Car companies want to sell cars and therefore they want to minimize the overhead spent on regulatory compliance. It's really easy to sit here in 2019 and clutch your pearls about the evil car companies not wanting air bags in everything but the reality is that those car companies were catering to consumers (or at least a fairly accurate approximation of consumers). Consumers regarded airbags and seat-belts as minor incremental safety improvements in their day (the way we would think about something like blind spot detection today) and generally cared more about price than they did about the presence of those specific features and would gladly forgo airbags in exchange for several hundred dollars of the purchase price.

1st gen airbags also have a well deserved reputation for turning accidents you could have walked away from with bruises into a trip to the hospital so many people actively didn't want them.

Edit: Yes, I'm totally wrong and everybody in 1965 was tripping over themselves to buy a new car specifically for the seat-belts and everyone in 1985 could not get enough airbags and the car companies totally misread what consumers wanted. <eyeroll/>

Seat belts: https://www.pewtrusts.org/~/media/assets/2011/03/industry-cl...

> Automakers objected, contending that manufacturing costs would rise, seat belts would imply increased accident rates and safety wasn’t a selling point with customers.

Decades later, they did the same with airbags, ironically trying to get out of it by pushing mandatory buckle-up laws to shift responsibility from the industry to consumers.

https://www.latimes.com/archives/la-xpm-1985-02-19-mn-546-st...

Cars kill 40,000 people every year in the USA. Nothing is done about that number.

Things are being done, but the most effective one would be to reduce speeds and number of cars.

Since USA is big distances, 1 has strong opposition, and 2 even stronger.

They could also make the drivers license short time, like 2 years requiring a refresh exam, but that'd be a real pain in the rear.

You could mandate built in breathalyzers, but they would routinly be failing or bypassed... Though it's a good attempt.

Ultimately getting rid of reducing number of unsafe human drivers would be good.

Bypassed? Unlikely. Breathalyzers are all about tamper-detection. If you know of a way of bypassing one, contact a lawyer. Somebody will pay you boatloads of money as an expert witness.

> "Cars kill 40,000 people every year in the USA. Nothing is done about that number."

Nothing? Much has been done and continues to be done to make roads and cars safer. US road deaths, per population, have fallen by almost 2/3 since their peak in 1969. By miles travelled, deaths have fallen almost 80% since the 1960s.

This has largely been a result of regulation, including:

- Standardized crash testing

- Compulsory seatbelts

- Compulsory electronic traction/stability control

- Compulsory airbags

etc

Automatic Emergency Braking (AEB) is currently in the process of being adopted, and will be fitted in all new US passenger vehicles by 2022. Further significant improvements from things like lane keeping and self driving technologies can be expected in the coming years/decades.

> And J&J is by no means a major opioid manufacturer

The had the non-hospital fentanyl market cornered for a while. Their patches were only for chronic use by patients already tolerant to opioids.

Even if they had less than 1% of the market, they would have had a much larger proportion of the high-dose market, where mortality risk ramps up.

You can arrest the dealers all you want, but to actually stop the problem you need to stop the suppliers/cartel.

Sorry, this is nothing more than a shake down. There is no demonstrative connection between prescription use of opioids and non medical use. prescription use has come down only to see abuse go up.

since it has become so much more difficult to divert prescriptions those seeking them have resorted to fentanyl and heroin which is not the fault of J&J or any other company.

The real cause it the drug war that too many nations practice. this has led the over dose issues we have seen. it is not legal sellers of drugs or their advertising. quit buying into this sham sold by politicians and the media, the reason it exist is to simply redirect blame and shake down the companies by relying on ignorance

Just started listening to Dreamland, already hooked, thanks for the recommendation!

> Incentivizing restraint and honest advertising is only possible by punishing executives, personally [1].

Catch it early, give warnings and fines before you have a national health crisis in your hands.

Reply on news.ycombinator.com