What About This? By Wayne William Cipriano

I heard that the big pharmaceutical company Johnson and Johnson (J&J) got whacked with a fine of over a half-billion dollars the other day. J&J is one of the larger companies that produce these opioid pain medications that have been reported to be killing so many people who have overdosed while using the drugs.

I haven’t read the judgment, just got my information from the hysteric media, so you might want to check the “facts” as I relate them. What I heard is that the judge decided J&J shared a large portion of the blame for those overdoses because, I think, J&J marketed those drugs to prescribers as a very effective pain control (which is true) with very little potential for addiciton (which is not).

As I said, I do not know the particulars of the judgment, so I am going out on a limb by saying I disagree with the decision.

Unlike, for example, tobacco, prescription drugs cannot be purchased by the individual consumer over-the-counter once having reached legal age.

The basis for the tobacco settlement was essentially that the industry not only knew of the ill effects of tobacco on human beings for decades, not only kept those ill effects secret, not only added compounds to tobacco to make it even more addictive than the industry knew it to be, but intentionally marketed tobacco to underage potential users. I am sure there were other problems, but those are the ones I recall, and serve, I think, to make the settlement just. We can argue about some of this if you wish, but the main point is that customers were hustled on the sly – and that is where the two cases of tobacco and opioids share some similarity. In the beginning, the customers, users of tobacco and prescribers of opioids, were deceived as to the addictive qualities of each. 

On the one hand, the guy buying a pack of smokes every day for decades slowly, or perhaps not so slowly, using into an addiction; on the other hand, the guy using opioids, gradually increasing the dosage, also using into addiction. But here, I think the liability trail diverges. Tobacco companies offered their products to anyone (of legal age or not) with no warning initially and then with a series of warnings that were, for the most part, ignored by tobacco users. And, I’d say, that was the users’ perogative. Besides, who didn’t know smoking caused cancer? Ever heard the phrase “Cancer Sticks”? Or respiratory difficulty? Ever heard of “Coffin Nails”? Ask anyone, not just users, anyone at all, if smoking causes cancer or a multitude of other health problems and the overwhemling response will be, “Sure it does.” And many, if not almost all users, would say, “So what?” or “That’s the price I pay,” or “You gotta go somehow and I like tobacco,” and so on.

You are right in saying that tobacco users may not have gone into much detail, but everyone “knew.” Maybe the really hidden facts of adding compounds to tobacco to make it more addictive and marketing to minors are what did in the industry, but the dangers were generally known by everyone. And they used tobacco.

Call it a liberterian opinion. Once you know the facts (cigarettes will kill you!) and you choose to use the product freely available to you, you are on your own. As long as you know the facts.

Opioids are different in one clear way – they are not freely available. You can’t buy them out of a machine, at the corner newsstand, from a candy store, or grocery outlet. You need a prescription from a licensed person specifically because these drugs are so dangerous and so addictive when used without proper instruction and supervision.

Let’s forget about stolen opioids (from patients, highjacked trucks, pharmacies) and those received from friends who perceive our “need.” These come to a piddlingly tiny percentage of opioids consumed. The huge majority of opioids used and misused are “legitimately” prescribed and dispensed.

The difference between tobacco and opioids is simply that. To buy tobacco there is no third entity standing between the manufacturer and the user. And, as I said, once the user is in possession of the facts, it’s up to the user. I believe that is why tobacco is not contraband after the huge settlement, still available to the legal-aged consumer, because we all know, finally, how dangerous tobacco is, we are all “trained” and “experienced” and the decision to use or avoid is ours.

Opioids, on the other hand, can only be obtained legally from that third entity, the “trained” and “experienced” person who understands how dangerous opioids can be, how addictive they are, and thus serves as a bulwark against overuse and overdosing by controlling the amount of opioids one can purchase and has the periodic opportunity to explain in a clinical setting the proper use of the drugs and the potential damage that accompanies improper use.

Indeed, prescribers of opioids even have a built-in safeguard that is denied to tobacco users. Even when we learn of the dangers of tobacco, that knowledge may “dull” over time, seem less significant, maybe even sound overly dramatic and alarmist. With continued use over time, we acclimate to and eventually ignore the warnings we have learned.

Opioids cannot be purchased routinely, over and over, once a prescription for a legitimate malady has been procured. The number of pills or tablets or capsules cannot be repurchased unless a brand new prescription is written, again limiting the number of pills and the time.

It seems that prescribers of opioids are escaping responsiblity by stating that the manufacturers lied to them regarding the potential for addiction of the “new” opioids. And, if that is the case, if manufacturers made such assertions as to the lack of addictive potential of these drugs, then the manufacturers deserve the lion’s share of the responsiblity for these addictions in the beginning.

But, after weeks and months, and even years of opioid use by patients, even the most incompetent of prescribers realized, or should have realized, that the initial reason for the use of these opioids has faded and addiction has taken place.

These prescribers are not you and me. They are infused with many privileges and resonsiblities that you and I do not have. And that infusion is granted on the basis of their training and their experience. In the present example, the training and the experience to determine when opioids should no longer be prescribed even when desired, addictively desired, by their patients. It is the prescribers’ duty to turn off that opioid faucet because it is hurting and may someday kill their patient. Recall the first precept of the Hippocratic  Oath: Above all, do no harm.

Only the most crass of us would suggest that the income streams provided by addicted patients returning month after month for a “checkup” and a new prescription for opioid medication means more to prescribers than the obvious danger such behavior manifests for their patients. And haven’t these prescribers supported state-wide, if not nation-wide clearinghouses to detect and prevent opioid overprescription?

Yes, I agree that if and when prescribers were deceived by manufacturers suggesting certain opioid compounds comprised little or no addictive danger, those manufacturers should be held responsible for those deceptions. But, as time goes by and anyone, formally “trained” or not, “well-experienced” or not, can easily observe that addiciton, not therapy, is occurring, the manufcaturers’ assertions of no addiction proven false, the liability protection manufacturers seem to be giving prescribers by this recent judicial decision must evaporate.

Prescribers have a duty to their patients that must supercede immense income streams, short clinical interactions, manufacturers’ assurances, even patients’ deceptions. 

What About This?

By Wayne William Cipriano