The opioid epidemic is directly caused by the OxyContin manufacturer's desire to sell a pain drug that "lasts twelve hours". These patient instructions almost couldn't be better designed to foment addiction. The big selling point was the "twelve hour" length of action. OxyContin was often not effective for the full twelve hours, causing a whiplash between under-treating pain and taking the medication at the prescribed time. This lead patients to be in pain for several hours every day, watching the clock as they waited for their next dose to alleviate said pain. If they take their medication early to combat this, they run out and have to deal with untreated pain until they get more. If they increase the dosage - as suggested by the manufacturer - then they now over-medicate at the start of the curve, build tolerance, and eventually become under-medicated again nearing the end of the twelve-hour period.

Psychologically, the risk of addiction comes from the brain getting trained that taking a substance causes a stark and rapid change in psychological state. If you have a consistent level of a medication, you tend to not become addicted to it. You can develop tolerance and physical dependence, but the addictive behavior doesn't get trained. To do that, you'll want a sharp and dramatic onset of effect associated with the drug-taking behavior, and negative reinforcement of the drug-taking behavior via the unpleasant effects of withdrawal.

This makes a lot of sense and definitely applies to more than just OxyContin. I am currently experiencing this with Vyvanse. Luckily, it's way easier to reverse compared to opioids, but still pretty damn hard.

Vyvanse is a prodrug, which means that dosage largely controls duration of effect rather than intensity. I suspect you eat a high protein breakfast or otherwise have a physiology that turns the prodrug into dextroamphetamine more quickly than expected. If Vyvanse doesn't last as long as the manufacturer assumes and comes on more intensely than you need, it's likely a good idea to switch over to dextroamphetamine with an actual extended release mechanism (and don't defeat the mechanism, of course). The combination of the effect being too intense and not lasting long enough is pretty rough to deal with, psychologically.

No way to PM you, but I just want to say thank you for your reply :)

There's a control group in the form of Europe where overdoses are an order of magnitude lower and have remained relatively stable over the last 10 years at least.

I had a medical issue with incredible pain in France, I have not been given an addictive pain killer, they started with the most common (Tylenol), then went one notch up (Acupan) when it became ineffective (I think I am very receptive because I rarely take medicines).

But doctors have to be willing to spend the time to follow the patient and do the gradation instead of going straight for the strongest thing in the toolbox and avoiding coming back to the issue (which I feel would be a given in the country where they have the highest pay).

> But doctors have to be willing to spend the time to follow the patient and do the gradation instead of going straight for the strongest thing in the toolbox

I know in the U.S. addicts/dealers will sometimes go "doctor shopping"[1]. Most U.S. doctors don't track or even realize when a chronic pain patient (or any patient, for that matter) doesn't follow up and a doctor wouldn't typically be told if a patient decided to seek treatment from another physician.

I would guess "doctor shopping" would be more difficult in France under the single-payer healthcare system? Do you mind explaining how your system works? Is it difficult to change doctors? Or to get a second opinion? If a patient doesn't follow-up with the doctor will someone from the doctor's office check in?

[1]https://en.wikipedia.org/wiki/Doctor_shopping

In the US it is very similar. I’m in my 30s and never had the option to use painkiller for neck and back pain. In fact, the only time I ever received it was after a dental operation which removed an impacted and painful wisdom tooth.

A lot of people will just doctor shop until they find one who will prescribe painkillers.

That doesn't match my experience.

Both times I've dislocated my shoulder I've been sent home from the ER with percocet that I didn't need (and never took). They wouldn't even let me opt-out, and sent it home with me "just in case."

I know my American mother in law got oxycotin on first intention without specific instructions or recommendation after an operation.

Europe generally has decent mental and physical health treatments as well as decent social security nets which results in less people having to self medicate with legal or illegal drugs.

perhaps you have brought your own Biases to the table.

"too pat" means its too simple, how does that work out when applying occam's razor?

Its easy to say "Junkies will be junkies", you are propagating this mentality and leaning on the crutch of the fallacy of single cause to iterate your own biases. The research is very clear.

Mayo Clinic: "Anyone who takes opioids is at risk of developing addiction. Your personal history and the length of time you use opioids play a role, but it's impossible to predict who's vulnerable to eventual dependence on and abuse of these drugs. Legal or illegal, stolen and shared, these drugs are responsible for the majority of overdose deaths in the U.S. today"

Us National Library of Medicine: "Opioid addiction is characterized by a powerful, compulsive urge to use opioid drugs, even when they are no longer required medically. Opioids have a high potential for causing addiction in some people, even when the medications are prescribed appropriately and taken as directed."

These reputable institutions havent tried to determine "future" addiction because the present data is loud and clear. Opioids are incredible addictive. I wonder why you are completely willing to ignore this data and instead blame the victims and sanctify the distributors. I think it speaks volumes for your position.

Perhaps you chose it pre-emptively and dont want to ratify the easily available data. (come on friend. its a simple google away https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3674771/)

Instead of playing devils advocate, and vocalizing what you "dont buy". Rather analyse the query and ask people in the field. Your biases might give you comfort but it is not the truth and the truth deserves pursuing.

While there will be some overlap there was also a lot of perverse behavior. Basically the drug company creates a drug that it wants to sell, drug reps travel to doctors explaining the drugs, when the doctor does the prescription, the doctor and sales rep get cash.

Now you have an incentive structure where doctors are prescribing drugs to patients that may not need them, may not need the dose prescribed, and so forth.

That combined with how addictive any opioid can be leads along with the trust common people put in doctors, assuming that what they are being prescribed is safe, leads to the problem.

The more of the drugs that get prescribed the more everyone makes in the process.

Same thing that happened with all of the shady loans during the housing crisis. All you have to look for is the financial incentive and lack of punishment and you get the same cycle repeated.

It's kind of nuts to me that we even allow the concept of a "pharmaceutical sales rep" to exist. Especially one that's paid on commission. That doesn't seem like the incentive alignment that works best for society. There's only one thing I want influencing my doctor's prescriptions: science. And I'm sure I'm not alone in feeling that way.

>Has anyone tried to demonstrate that OxyContin addiction, for example, might not have been heroin addiction if OxyContin wasn't available?

The facts on the ground are that a pharmaceutical company actively encouraged and massively profited off the sales of a product they fully knew to be addictive, leading to a severe public health crisis. If we want to argue that these people would have just turned to illegal substances instead, then the logical conclusion is that the company should be prosecuted like any other common purveyor of controlled drugs would be. That wouldn't end well for Purdue.

Heroin hasn't been marketed as "virtually non-addicting" or actually non-addicting for quite some time, although that's pretty much the exact tagline it had when it first came out. It doesn't take a genius to see that marketing something so incredibly addictive as OxyContin as non-addictive will lead people to take it and get addicted unnecessarily, regardless of any other circumstances. It's simply impossible that this was a mistake. I can buy it may have been a mistake in the late 1800's when heroin first came to market, but in modern times, this was a calculated effort to make money off of people's misery and deaths. "People will die and their lives will be ruined, but we'll make a ton of money off them, so fuck them," is likely what was said before going ahead with this plan.

This was pushed by doctors at the behest of the companies, doctors who the patients trusted had their best intentions in mind. The drug companies knew from history that the US government would not do anything to stop them, but instead would help to promote their drugs over the illicit substances sold on the street that had the exact same effect. To claim that all the advertising, pushing, and money spent on promoting OxyContin had no effect on anyone and that people would have taken heroin regardless without being pushed by the drug companies' machine into first taking something they claimed was benign is fucking absurd and flies in the face of both logic and current research in psychology, advertising, and marketing.

Heroin addiction rates & related deaths have also been increasing at the same time, so it's not that Oxy has been cannibalizing heroin sales. However, the fact that heroin addiction has increased at the same time would speak to aggressive Oxy sales not being the whole problem. Although I've also seen in mentioned that Oxy addiction has lead to increased heroin use as addicts turn to the illegal market when their legal outlet runs dry.

No, not mostly.

If you're not in a city large enough to support street dealers, and aren't connected to the local illicit scene wherever you are, you're not just going to be able to go out and get heroin or fentanyl or whatever. That is not how these things work.

Purdue encourages GPs to overprescribe Oxycontin, including for period pain and headaches. 13% of those patients who took Oxycontin for headaches became addicted.