How Much Did Physicians Drive the Opioid Crisis?

It’s well known that the opioid crisis started with prescription abuse but how much abuse was driven by patients who fooled their physicians and how much was driven by physicians who responded to monetary incentives with a nod and a wink? Molly Schnell provides some evidence which even a hard headed rationalist like myself found startling.

In August of 2010, Purdue Pharma replaced old OxyContin with a new, anti-abuse version of OxyContin. The new version was just as good at reducing pain as the old but it was more difficult to turn it into an injectable to produce a high. If physicians are altruists who balance treating their patient’s pain against their fear of patient addiction and downstream abuse then they should increase their prescriptions of new Oxy. From the point of view of health, the new Oxy is simply a better drug and with less abuse to worry about altruistic physicians should be more willing on the margin to prescribe Oxy to reduce pain. So what happened? Prescriptions for Oxy fell immediately and dramatically when the better version was released.

Now, to be fair to the physicians, patients who wanted to abuse Oxy stopped demanding it after the new version was released and physicians might not have realized how many of their prescriptions were being abused or sold on the secondary market. The aggregate data, which is a combination of supply and demand shifts, can mask individual physician behavior. Schnell, however, has data on the prescribing behavior of about 100,000 individual physicians who prescribed opioids.

Schnell finds that nearly a third of physicians behaved exactly as the altruism theory predicts. Namely, when new Oxy was released these altruistic physicians increased their prescriptions of Oxy and they maintained or reduced their prescriptions of other opioids. In fact, the median altruistic physician doubled their prescriptions of the new and improved Oxy. But almost 40% of physicians in Schnell’s sample behaved in a decidedly non-altruistic manner. Beginning in August of 2010, these non-altruistic physicians halved their prescriptions of new and improved Oxy and increased their prescriptions of other opioids. It’s difficult to see how attentive and altruistic physicians could decrease their demand for a better drug.

Schnell also finds that some parts of the country had fewer altruistic physicians and the consequences are evident in mortality statistics:

…. these differences in physician altruism across commuting zones translate into significant differences in mortality across locations…a one standard deviation increase in low-altruism physicians is associated with a 0.33 standard deviation increase in deaths involving drugs per capita. While this association is reduced conditional on observable commuting zone characteristics (including race, age, education, and income profiles), a significant and large association between the share of low-altruism physicians and drug-related mortality remains. Furthermore…this relationship persists even conditional on the number of opioid prescriptions, suggesting that the association is driven by the allocation of prescriptions introduced by low-altruism physicians rather than simply the quantity.

The less-altruistic physicians increased prescriptions for other opioids after new Oxy was introduced but perhaps even this was better than the non-prescription alternatives like heroin and street fentanyl. Indeed, Alpert, Powell and Pacula show that the introduction of improved Oxy led to more deaths because people switched to more dangerous, illegal alternatives. So was it a bad idea to introduce a better drug? Maybe, but if new Oxy had been introduced earlier perhaps fewer people would have been addicted, leading to less demand for illegal markets later. Thus, static and dynamic effects may differ. The economics of dual use goods is complicated.

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Out of curiosity, how is it lucrative for a doctor to prescribe the medicines? Do they sell them?

A few ways. Some docs have maintained, legally or otherwise, their own supply they sell or have a deal with a pharmacist. Some were getting paid directly by the pharmaceutical companies for speaking engagements or appearing on panels. (Device manufacturers and drug companies can pay pretty well for doing this stuff.) Also by an increase in pt volume. If the pt is just coming in to get an Oxygen script it doesn't take much time to do that, much less time than seeing a complicated diabetic pt for whom you get paid the same amount for a visit.

So overall, for the unethical docs running pill mills Oxy was a godsend. For most docs it really wasn't a money maker. It did make it easier to take care of pain patients. Looking back it is a blot on the profession that we bought into the Purdue propaganda so readily.

Steve

But how many of these truly unethical doctors were there? 1% 2%. However it could have been that they drive most of the demand. On that point despite the nice chart admittedly there is no incentive identified here (aside from the above comment). The patients still need to come in and ask for painkillers. Given that each pill can be worth I think up to $10 on the resale market that is an awfully good reason to feign pain. So I still do not see how this at all implicates the doctors who are mere intermediaries (with the exceptions noted).

The top prescribers cover a wildly disproportionate percentage of scripts. Some of this legit specialization, when you specialize in pain patients, they all need pain treatment.

But there were also docs who were churning a script every five minutes. Billing even 25 bucks per is $300 an hour and $2400 a day. Inevitably these sorts of jackasses, prescribed huge amounts of drugs, were investigate by medical associations and the DEA with many losing licenses or doing jail time.

What really made things work for these bad apples was the pain crusade of the 90s. Addiction fears were literally described as Puritanical remnants of religious taboos. It became medical dogma that addiction risk was low, patients were wise enough to self manage without paternalistic oversight, and the harms of dependence were overstated. Anyone who reported these physicians were actively denigrated as “dinosaurs” and the like.

As always changing culture, in this case prescribing culture, is risky and we only ended up with a few million dead people.

+1 the above is definitely not postmodern bullshit

I?m amazed, I must say. Rarely do I come across a blog that?s both
equally educative and interesting, and without a doubt, you have hit the nail on the head.
The issue is something too few people are speaking intelligently about.
Now i'm very happy I stumbled across this during my hunt for something
regarding this.

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I can ot imagine Brazilian physicians trying to make money ny addicting patients.

That's because well over 60% of Brazilian physicians are monkeys from the Amazon. They are paid in bananas instead of money. Facts.

What most people who dont follow this issue won't realize is that Purdue, and IIRC some other pharma companies, were the ones actually pushing the idea of the pain scales. They had a nifty product they were willing to lie abbot, and they helped create demand.

We now still use pain scales, but we dont push large amounts of narcotics. We dont blindly trust studies published and paid for by pharma anymore, at least when it comes to narcotics.

So what was titled altruistic should have been labeled naive.

Steve

& don't let sociologists misdefine empathy

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'Addiction fears were literally described as Puritanical remnants of religious taboos'

Purdue really covered all the bases, didn't they? Or is that too cynical, though likely all we need to do is wait for more court cases to provide documented evidence.

'It became medical dogma that addiction risk was low'

Purdue really covered all the bases, didn't they? Court cases, etc.

'patients were wise enough to self manage without paternalistic oversight'

Purdue, court cases, etc.

'and the harms of dependence were overstated'

Purdue, court cases, etc.

'Anyone who reported these physicians were actively denigrated as “dinosaurs” and the like.'

Well, hard to blame Purdue for that one, assuming one ignores just how regulatory (self-) capture works.

'in this case prescribing culture'

Well, Purdue was active in saying that their products were perfectly fine to prescribe.

Here is an introduction involving a court case - 'When Purdue Pharma started selling its prescription opioid painkiller OxyContin in 1996, Dr. Richard Sackler asked people gathered for the launch party to envision natural disasters like an earthquake, a hurricane, or a blizzard. The debut of OxyContin, said Sackler — a member of the family that started and controls the company and then a company executive — “will be followed by a blizzard of prescriptions that will bury the competition.”

Five years later, as questions were raised about the risk of addiction and overdoses that came with taking OxyContin and opioid medications, Sackler outlined a strategy that critics have long accused the company of unleashing: divert the blame onto others, particularly the people who became addicted to opioids themselves.

“We have to hammer on the abusers in every way possible,” Sackler wrote in an email in February 2001. “They are the culprits and the problem. They are reckless criminals.”' https://www.statnews.com/2019/01/15/massachusetts-purdue-lawsuit-new-details/

A bit more detail - 'The new filing also reveals how Purdue aggressively pursued tight relationships with Tufts University’s Health Sciences Campus and Massachusetts General Hospital — two of the state’s premier academic medical centers — to expand prescribing by physicians, generate goodwill toward opioid painkillers among medical students and doctors in training, and combat negative reports about opioid addiction.'

Interesting to see that now, the next 'criminals' are the physicians. Though for some apparently, Purdue remains simply an innocent victim of reckless criminals.

How does pointing put the actual experience of patients being denied pain relief in a previous decade absolve Purdue?

Purdue stepped in and took advantage of that situation. Purdue misled doctors. That doesn't change the basic problem of how we manage pain switching between too puritanical - where prescriptions become expensive, short-term, and specialists refuse to specialize - or too permissive where we make no effort to police over-consumption and presume we can make pills with their own inherent locks.

Need a better pill. Or as I sang back in the 80s, I Want a New Drug

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I'm going to assume that this is misplaced - I certainly am not absolving Purdue of anything, particularly as Oxycontin's marketing followed an already successful strategy to sell MS Contin.

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The issue isn't that it is lucrative directly (most primary care offices don't make money off prescriptions since they're filled at outside pharmacies), but it can be difficult for a primary care physician to maintain a panel of patients if they don't prescribe opiates (i.e. patients will "doctor shop" for a physician who will give them what they want). To have a profitable practice, a doctor needs to keep their schedule pretty full... From what I've heard from colleagues, this is more rampant in rural areas (e.g. one doc from Alabama ended up switching specialties because she couldn't maintain a profitable practice without prescribing opiates)

Interesting, and another layer of the ugliness of this situation.

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This makes sense. To a large degree, at least in the US, there are regulatory frameworks in place to disincentivize pharma and device manufacturers and physicians from engaging in kickback activities (e.g. manufacturers have to report direct expenditures to physicians to the government who then provides this data, searchable by physician, to the general public. If I work for a manufacturer and buy a cup of coffee for a physician at a trade show, I have to report that. There are anti-kickback statutes in place as well that limit how manufacturers can incentivize sales performance, so this addresses things at the corporate/practice level. So while these may not be 100% effective, they do introduce risk that could prove costly long-term for physicians (i.e. if a journalist picked up on the fact that a given physician was taking a lot of favors from manufacturers and ran with that story, it could be damaging to their reputation, which in today’s world is a non-trivial concern). So this post above makes more sense to me, as the doctor’s primary incentive is to keep their practice as full as possible and get as many from-patient referrals as possible.

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This ignores what was going on in the medical world at the time. By 2010 people were worried about narcotic use. A lot of us had already become pretty skeptical about Purdue and their claims that THIS narcotic is better. Remember that when they released the original Oxycontin it was with the claim that it was much less likely to lead to addiction, and they had (made up) proof it was better. However, it was around 2009-2010 that people started doing their own research and finding that Oxycontin was addictive.

So let's replace the word altruistic with naive or trusting. Let's replace the word less-altruistic with suspicious. The very fact that they brought out a new version that was supposedly less likely to have addiction issues after having promoted Oxy as the drug that did into have addiction issues set off alarms for a lot of people.

Steve

^-- This. Most doctors are surprisingly likely to believe drug company slogans. I don't think Purdue ever published made up studies on Oxy abuse rates. Everyone who looked into it in any detail knew from the 90s that Oxy abuse was common.

Also, if you put the two papers together, its not that clear what an altruistic doctor should have done in 2011 with a patient who was using old Oxy 80s but now wants Dilaudid as a substitute. You refuse and say take the new Oxy, its the same. They say "no," leave and ... buy Perc 30s and die? Did you help? Maybe you should offer Subs and some counseling but they refuse (or you can't prescribe subs) so it might be better (and easier) to let them have the Dilaudid. Who knows?

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The paper deals with this by looking at the fact that non-altruistic doctors also increased their prescriptions of more easily addicting alternatives to oxy. Only the non-altruistic docs both decreased scrip for the new version AND increased prescriptions of substitutes.

You are, again, taking the word or Purdue that their new product was less addicting. At that point many of us didnt believe Purdue at all. If you didnt believe Purdue, ie you were skeptical, then it logically follows that you would order less of the Purdue product and more of the alternative.

Steve

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My question is then, why weren't these "non-altruistic" docs prescribing the good stuff regardless? I mean if you want to be a strict pill pusher in it just for the money and damn the lives of your patients, you could write for far more lucrative crap.

For instance Desoxyn is medical grade methamphetamine. It is approved, with caveats, for treating ADHD and obesity. It is vastly easier to hook patients and in is much harder for your addicts to substitute. Yet docs did not prescribe it.

But suppose your addicts only want opioids. Okay, why not just quit prescribing Oxy and skip straight to the riskier stuff before the reformulation? After all the author is basically arguing that docs are just writing scripts for the money, but they don't maximize profit before the change. Seems odd to me.

Frankly I expect that even the bad docs (though not the outright criminals) were not writing just for fun and profit. They swapped with oxy changed because their patients' demands changed and if you are writing scripts just to get along the new path of least resistance becomes what patients want that docs are comfortable writing. Part of the calculus may well be that docs don't care if their patients are addicts or high, part might be that Purdue was deemed untrustworthy (particularly when the single largest claim - that oxy lasted all day - failed in real life), and part might be some profit maximizing carpe diem ... but it sure reeks on not being solely profit maximization in a completely amoral setting.

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There's another problem in all of this. I'm one of (apparently hugely many) who used oxycontin without issue (for treating post-surgical pain.) I feared addiction and a laborious process to break off, but no, one day it just wasn't needed anymore.

In other words, when used *appropriately* it's just fine. (Same is true of Morphine, Fentynal, etc., no?)

So given the rather blunt mechanisms available to government, how to thwart these destructive side tangents?

Who knew though ? Who knew if you chopped up pills and snorted them, the delay mechanism to prevent the opium high would not work?

This is some combination of “back massager” type selling with a wink and a nod, physicians catering to drug addicted patient demands, and a general breakdown of societal norms regarding prescription drug abuse.

What I'm not seeing here is the relation to the ethnicity/nationality of the doctors. A significant percentage of those who run the worst pill mills are foreign doctors.
But, just as that same situation exists with food stamp fraud, we're not supposed to notice.

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Bryan,

I had the same experience, 3 months of morphine followed by 12 months of Oxy. I just needed it less and less and stopped. I _did_ need it though, when I needed it.

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I love it when a single, perfect chart explains everything and can't possibly hide other information or be interpreted in any other way

Hello Armin, you are right to always question data and analysis. You are also free to provide your own analysis of the data or provide alternative data sources.

Just because someone says the moon is made of cheese, doesn't mean I need to do my own analysis and prove what it's really made of. All I have to do is call bullshit on the obviously false moon-cheese hypothesis.

This is what I'm doing here: Calling obvious bullshit when a single plot is presented as evidence of something as complicated as the behavior of multiple humans interacting with each other and within a complicated regulatory and financial landscape.

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Couldn't it be considered altruistic to help a drug addict get high? Certainly someone with a libertarian orientation should be inclined to think so. Especially if you are helping them get high in a relatively safe and inexpensive way.

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>It’s well known that the opioid crisis started with prescription abuse

And also false.

Like many other things lefties post on blogs.

+1 the meme that the opioid crisis started with prescription abuse
is narrative public radio postmodern bullshit

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So what did cause/start the crisis then?

postmodern social constructs from people
who never took pharmacology (a science)

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Heroin.
Abundant and cheap.
From poppies.
Grown in......
Afghanistan.

Are you getting the pattern?
The Law of Unintended Consequences
Run rampant

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strange how the narrative falls out from under you one day and some convenient Devil is found.

https://www.mdedge.com/ccjm/article/109138/drug-therapy/fifth-vital-sign-complex-story-politics-and-patient-care

In the mid-1990s, the American Pain Society aggressively pushed the concept of pain as the fifth vital sign.
... Half a decade later the Joint Commission and others hopped on this train, emphasizing that pain needs to be regularly assessed in all patients, that pain is a subjective measure, unlike the heart rate or blood pressure, and that physicians must accept and respect patient self-reporting of pain. Concurrent with these efforts was the enhanced promotion of pain medications
... Step forward in time, and pain control has become a measure of patient satisfaction, and thus potentially another physician and institutional rating score that can be linked to reimbursement.

Perverse incentive + no patient accountability + obese/unhealthy population

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I failed to see the chart where we, the voters, decided to most of this addiction with federal health insurance. And. oddly in contrast, the prescriptions fell upon the onset of Obamacare.

So there is still a lot of contradictory stuff to sort out. The research imperiled by this huge wedge of government payments.

By the time the ACA became active, the dangers of opioid abuse were already being trumpeted and prescription rates were dropping. So yes, blaming the ACA is absurd. Something to bear in mind though: while oxycontin didn't go generic until quite recently, generic Vicodin and Percoset have existed for a while, and they're dirt cheap.

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Over-reliance on prescription medications is a reflection of over-reliance on medical doctors and other health care providers. Given the overwhelming amount of data for bad outcomes from both prescription medications and medical services, one wonders why people continue to herd like sheep to doctors' office or hospitals and pharmacies. Okay, am I blaming the victim? Doctors respond to the expectations of their patients; and if the expectation is for doctors to do something, whether it's prescription medications or surgery, that's what the patients will get. Cowen and Tabarrok often blog about the role of economists in different businesses and sectors, but I don't recall many blog post about the role of economists in health care. My view is that incentives need reform, both the incentives of the patients and the incentives of the doctors. In health care, less can be, and often is, more. That's health care reform everyone should support.

Me too.

At my age, I'm at the point where the next time I go into a hospital, I'll come out feet first. I never thought I would mirror former generations.

When I was released, in 2007, from bilateral knee replacement surgery, I asked the nurse (want medical advice, ask a nurse) what to take besides the prescription morphine-based stuff I was on the whole time I was in hospital. She said, extra-strength Tylenol has all the analgesic properties without the narc stuff. I opted for that. It hurt at night in bed, but easy trade off to me, a little pain never hurt anybody - offer it up.

Some seem to believe personal responsibility is too puritanical.

Telling orher people they should just enjoy their pain is disgustingly sadistic. Narcotic abuse is a huge problem, sure, but the vast majority of people who have been prescribed these drugs do NOT become addicted. You're like the old Temperance folk who thought the problems of alcoholism should be solved with a one size fits all total ban on booze and never mind the majority of people who weren't drunks.

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I hope you have 30 more years of acerbic ornery posting, skewering idiocy, left in you.

Get a room

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"Telling orher people they should just enjoy their pain is disgustingly sadistic. "

He said he took Tylenol instead of a narcotic. You are bizarrely strawmanning his post.

Or just reacting to this - 'It hurt at night in bed, but easy trade off to me, a little pain never hurt anybody - offer it up.

Some seem to believe personal responsibility is too puritanical.'

But then, one would have to read the comment all the way to the end.

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These comments show just how little the general public understands the underpinnings of the prescription drug crisis in this country. These drugs were pushed on physicians, marketed as lower risk alternatives for addiction. Pain scores were added to every medical encounter. I work in an emergency department and still field complaints of pain medication is not administered right away to anyone who subjectively rates their pain highly (and basically everyone does).

To label prescribing the newest brand of long acting narcotic as “altruistic” is laughable and misleading. The makers of OxyContin care about one thing only and that’s making a profit. No drug comes out without evidence being pushed to suggest it’s phenomenal. Good doctors read the evidence and can see that the study authors are paid by the manufacturers of the drug being studied. There is nothing commendable about being the early adopter of a brand new narcotic.

u sed
"there is nothing commendable about being the early adopter of a brand new narcotic."
actually there is something commendable when the early adoption of the narcotic ameliorates metastatic bone cancer pain

I had that for a while; it's not so bad.

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That is absolutely ridiculous. You have no idea whether the newer formulation of OxyContin was better for treatment of the pain of metastatic cancer. To just blindly assume that would be the case is absurd. That sort of thinking is how we landed in this mess with opiates to begin with.

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I am a bit skeptical about the sole driving force being physician character. 2010 is right about when the major articles trashing Purdue started to get published.

This was also right around when people were finding that oxy was not a actually able to cover 12 hours of analgesia without withdrawal symptoms. I know many docs who decided they just did not trust Purdue to honest about reformulation and swapped prescriptions rather than trust that they were not being lied to, again.

I have no doubt that a minority of docs were just cashing out. Thanks suspect a large number of docs just go along with whatever moves the patients through in fifteen minutes or less. But there were a lot of issues beyond just basic package that insert information.

Correct. The paper from MGH came out about that time, but the rumors started circulating well before that. When Purdue released the second drug it acted as confirmation that the rumors were true.

Steve

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As you note, old-Oxy was a dual use product. The new version allegedly doesn't satisfy one of those uses, so demand is lower. Why is this startling?

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They overlook the role of the federal government in the crisis- in 2001 doctors were warned that they had better treat pain more aggressively-the fifth vital sign etc

Yep, and the nurses started asking when you went to the doctor if you were in any pain and then to rate it from 1-10, as if there was the possibility that you were in agony but keeping it a secret from everyone.

We still use the pain scale. We still use narcotics sometimes. We dont use massive amounts of narcotics anymore because some drug company told us their drugs were not addictive. Physicians bear some responsibility for not questioning the claims of Purdue vigorously enough, but lets not forget they out and out lied.

Steve

I defer to you on the subject of Purdue, since I've not followed it closely. I just wanted to point out that there was a definite change in procedure at my doctor's office at some point, and part of it struck me as a little bit silly.

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'but lets not forget they out and out lied'

And given enough time, the Bartley J. Madden Chair in Economics at the Mercatus Center will be able to explain why, in the end, the FDA is actually at fault, and how the answer is to reduce the FDA's regulatory role so at to allow the market to work its magic..

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". . . almost 40% of physicians in Schnell’s sample behaved in a decidedly non-altruistic manner."

(What coincidence: on-time public high school graduation rates in the US hover at about 60%, too.)

If ONLY 60% of US physicians can properly be deemed "altruistic" (even after millennia of Hippocratic Oaths and decades of professional training and credentialism, even though "philanthropy" remains the cherished motive of US medical care delivery, sigh), we have yet another metric by which to begin measuring the extent of professional corruption in the US. (What might we learn from Big Pharma convictions, political pay-to-play, regulatory kickbacks, et cetera?)

Nota bene: even our most earnest and caring philanthropists are helping to kill us, what consolation! (How much coursework dedicated to philanthropy is a part of contemporary medical training? [for that matter how much pharmacology were these corrupt physicians ever exposed to in their professional training and credentialing?])

That's because, again, the choice of altruistic is wrong. Naive or trusting is much better. At that time most docs were getting pretty skeptical about Purdue's claims. Then they came out with another drug which was supposed to be even less likely than the first one, about which they lied? Fool me once......

Steve

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Per Tabarrok, "Beginning in August of 2010, these non-altruistic physicians halved their prescriptions of new and improved Oxy and increased their prescriptions of other opioids. It’s difficult to see how attentive and altruistic physicians could decrease their demand for a better drug."

Was there a significant price difference between old Oxy and new Oxy? If there was a substantial price increase, then doctors mindful of their patients' budgets might've shifted to a less expensive product. Could some of those purportedly non-altruistic doctors have been looking out for their patients' financial well-being?

+100 That is the first thing I thought when I read the post.

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Just want to take this chance to say that the comments on this blog are awesome. Good job Tyler and Alex, I bet the large majority of people would not put up with all the disagreements (many not being very polite) but it is definitely worth it.

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"Beginning in August of 2010, these non-altruistic physicians halved their prescriptions of new and improved Oxy and increased their prescriptions of other opioids. It’s difficult to see how attentive and altruistic physicians could decrease their demand for a better drug." It's not difficult at all. In 2010 the news was that Oxy is bad and Tramadol is good because it is "non-addictive." That probably proved not true but that is what they were told. Only an empirical economic study makes it "difficult to see."

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My understanding is the root cause is largely what I would call lower-level blue collar workers (people working in warehouses, etc.) getting relatively minor injuries on the job, going to the doctor to get pain killers so they can "work through the injury" because they cannot take time off from the job. Many of these people juggle two jobs (part time) and are financially struggling to begin with. I find this argument credible.

OTOH, I read the book "Dreamland" a few years ago, which depicted the opioid crises of being nothing more than just another drug craze where people were using just to "catch a high" and became addicted.

Since I don't know anyone personally who has died from this, I am in no position to comment on the veracity of any of these scenarios.

You do know someone who died from this:
Prince,Tom Petty dude from counterfeit hydrocodone, contaminated by illicit fentanyl.
Be like Portugal.
Prohibition has never worked.
Harm reduction works. Deaths almost zero in Portugal.
Less than 1% of patients with pain developed addiction.

https://www.facebook.com/markmusheribsen/videos/10218008742785527/

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I watched Will Farrell and John Reilly in "Holmes and Watson" the other night. (A movie terrible in new ways.) But Holmes' introduction of Watson made me smile:

Homes: "Fortunately, we have a real doctor in the house."

Watson, gallantly extending his hand: "Would you like some heroin?"

I am surprised, someone upthread saying they found Oxycontin quite manageable. Following surgery to remove a ruptured ladypart, the night I spent alone in the hospital, on Oxycontin - I must be honest - ranks as the only time in my life I have felt purely happy. I sometimes turn it over in my mind to try to relive it - but what is there to relive? - I sat serenely on a hospital bed tangled up in tubes after a confused attempt to remove my hospital gown, looking at a square of black sky.

Mistrusting that feeling, the rest of the bottle remained in the cabinet for years, untouched.

Actually, maybe it was hydrocodone, now that I think about it. So nevermind.

*Drugs played a part.*

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Reading over all o chris it is very disappointing that a paper like this would even be published. It is so ignorant of what was going on in the medical world at that time. This reads like the paper of some grad student who was too young to know what was going on in health care during that time period. She is too ignorant of health care issues to know that she has identified a problem, but does not recognize the problem. We need physicians to be more skeptical of studies published by drug companies. Self interest really does matter, something which you think an economist would recognize. What should have been pointed out in this study is that 40% of physicians continued to blindly believe whatever Purdue published.

Steve

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I’m wondering if the terminology usage of low-altruism and high-altruism is best representative of the trade-offs being made in the spectrum of physician care described here, whether these words best boxout the surface over which the transactions occur.

First off, altruism is a word charged with moral implications. The high-altruism physicians are quickly labeled by commentators as good, and the low-altruism physicians are automatically unethical. As Steve noted above this does not necessarily paint out the scenarios in their true light. The dimensions of the choices are not quite so one dimensional but exist in a spectrum of multidimensional choices.

As Steve also mentions the power of a pricing mechanism is, by most every reader of this blog, considered ‘good’, very good in fact. The dimension of pecuniary price should not be thrown out with the bath water. I’d suggest the opposing force in not some type of self-constraint against self-interest, but rather a proclivity to reduce a pecuniary incentive to achieve at some level a group or public object.

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interesting post, but around 2010, perhaps as AlexT says, there was a spike in heroin and fentanyl deaths, as you can see from any chart Googling it. AlexT: "The less-altruistic physicians increased prescriptions for other opioids after new Oxy was introduced but perhaps even this was better than the non-prescription alternatives like heroin and street fentanyl. " Indeed. Some poor "Dr. Feelgood" doc got a life sentence in the Midwest when one of his patients died. Malpractice premiums must be going up.

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One of the reasons physicians were so readily made gullible to the marketing of Oxy was the lack of education in pain science when they were in medical school. It was therefore easy for a drug company to feed them whatever nonsense was drummed up to help them sell a product. Combined with the 1990's withdrawal of Vioxx from the market and opioids seemed like a good idea. But they weren't, at least not in the frequency or amounts prescribed. Getting back to the original question, "Why were doctors so gullible about pain treatment?" Let's take a look at a main driver in medical school education: The USMLE aka US Medical Licensing exam... the one test all med students must past to become doctors. ALso the one test that if a school's graduates don't past, they lose accreditation. Take a look at the USMLE website and what they test on. Neither "chronic pain" nor "addiction" is on there. Go figure.

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As one other has commented above, the analysis is lacking any mention of price. If you can say that the price of the old oxy and the price of the new oxy are equal, then everything you are saying about the behavior of physicians and patients makes sense. But to ignore it as a possible explanatory factor is puzzling on an economics blog/website.

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