Another Way In Which Patents Contributed To The Opioid Crisis: Hospitals Ordered Not To Use Better, Less Problematic Medicines

from the this-is-fucked-up dept

Two years ago, we wrote about a stunning (and horrifying) study that explained how patents deeply contributed to the opioid crisis. It described the lengths that drug companies — including OxyContin maker Purdue Pharma — went through to block any and all generic competition. It was quite a story.

However, on a recent episode of Terry Gross’s “Fresh Air” she interviewed medical bioethicist Travis Rieder about his new book, In Pain. It tells the story of how, even as a “medical bioethicist,” Rieder himself got addicted to opioids after being in a severe motorcycle accident — and then was shocked to find that none of his doctors either knew how or cared enough to help him get off the painkillers. The story is fascinating — and harrowing.

Deep into the discussion, however, one part caught my attention. Rieder tells a story about how, rather than putting him on opioids, they could have just given him acetaminophen:

GROSS: One of the pain killers that you were given when you were in the hospital was intravenous acetaminophen. And you thought that that was really, surprisingly effective as a painkiller, but you were only given a few doses, even though you kind of begged for more more because it was effective and not habit-forming. So why couldn’t you get more of it?

RIEDER: Yeah, this is such a wild story. I didn’t know for a long time, and so all I had was this immediate experience where, after that fifth surgery, when I was really behind the pain, the pain management team upped all of the doses of everything I was on, but then also gave me three doses over 24 hours of IV acetaminophen. And for me, the way I described it at the time, it was as good as morphine in the short term, but it didn’t knock me out. It didn’t sedate me. I didn’t have to worry about my breathing. And so I really liked it for that reason, and I asked for more.

And I remember one of the residents being kind of hesitant – you know, one of these young doctors in training – and kind of mumbling something about, I don’t think you can have more because of your liver, or something. I didn’t question it.

But, turns out, it’s got nothing to do with his liver:

Months later, I’m an invited speaker at an anesthesiology conference, and I’m hanging out with some of the docs over a coffee break. And I’m telling them the story because I’m like, hey, I’ve got these, you know, really smart people. I’m going to pick their brains. And I get to the point where the resident mumbles this excuse to me, and they all chuckle. And I look at them, and I say, what? Is that not the reason? And I can tell in that moment that they all know something and that they all know that they all know. And one of them looks up at me and says, they’re not giving it to you because it’s too expensive.

(Laughter) And my mind was blown. I was like, wait a minute – what do you mean it’s too expensive? It’s just Tylenol, right? They said, yeah, but the IV form is still on patent. And so once it goes off patent, it’ll be standard of care because it works great. But, you know, for now, it’s too expensive, so most of us have hospital orders not to use it.

So, let’s get everyone hopped up on addictive and destructive opioids, because this form of Tylenol is still on patent. That’s just great. He continues:

I think what it started for me was a dive down the rabbit hole of, how does money play a role in how we treat pain and how we overutilize opioids for pain, right? Because what it made really clear is that opioids are dirt-cheap because a bunch of them have been off patent for decades, and that these other sorts of therapies can be really expensive.

For all the talk of how patents create incentives for new life-saving medicines, it’s important to recognize that they create some pretty fucked up incentives at times as well.

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Comments on “Another Way In Which Patents Contributed To The Opioid Crisis: Hospitals Ordered Not To Use Better, Less Problematic Medicines”

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Goo Of Unknown Osmolality says:

Re: Re: Yes, I've noted that I'm more "socialist" than YOU, "Stone"!


Why don’t you join me on that BASIC, instead of attacking me false claims of racism?

Why don’t you join me against corporations as persons as Masnick and Mitt Romney believe?

Why not join me against what Masnick claims that corporations having gov’t-conferred power to totally and arbitrarily "deplatform" people for views which are okay by common law?

Can’t you see where Masnick’s views lead? To Nazi-like gov’t-corporate control.

But no, you support "capitalism" even while it eats you alive!

Stephen T. Stone (profile) says:

Re: Re: Re:

Why don’t you join me on that BASIC, instead of attacking me false claims of racism?

Because (a) you’re an asshole regardless of whether you’re racist and (b) you won’t denounce filthy rich corporations using copyright to censor legally protected speech.

Why not join me against what Masnick claims that corporations having gov’t-conferred power to totally and arbitrarily "deplatform" people for views which are okay by common law?

Because (a) people are not entitled to the use of someone else’s platform and (b) “common law” says a corporation that owns a platform can ban someone for breaking the rules of that platform even if the speech that someone uses to do so is legally protected.

Scary Devil Monastery (profile) says:

Re: Re: Re: Yes, I've noted that I'm more "socialist" than YOU, "Sto


…which then leads us all right back into the dead valley which is old-style soviet-style communism.

Karl Marx was a genius when it came to economy analysis and his book "Das Kapital" is still taught in modern finance classes all over the world. His ability to predict globalization – and how our modern economy works – a century after his lifetime is uncanny.

And at some point in the far off future when we’ve come to a point where human flaws are mitigated or no longer exist, communism may be viable and even desirable on scale. But today? Not a chance it’ll work. A theoretically perfect system needs practically perfect people if it’s to work in real life.

But with humanity as we know it today the rule will remain that supply will meet demand by allowing the markets to govern.

We could go on a very long debate around the tacit understanding that todays "capitalism" has devolved into a free-for-all unregulated mess of monopolization and artificial profit inflation where the consumer – the other side of the algorithm – is increasingly left helpless…
…but at the end of the day "TAX THE RICH" isn’t going to work. Crippling corporations ability to make money won’t work. Telling people making copies or repairing their own stuff is unlawful won’t work.

What might work is simple. Regulate the banks. Ensure the system can’t create worth out of nothing by fiat. Ensure the concept exponential growth gets killed off as the catchphrase of the modern age. And while doing all of that ensure government gets pared down to the arbiter role it was originally envisioned to hold. But don’t kid yourself – in order to accomplish ANY of that you need the power and authority to make it happen. Which of course means some entity backed by the violence monopoly. Which means government authority.

Your view, Baghdad bob, of having some magical power swoop down and dethrone government and corporation alike isn’t realistic. You want private platforms to be forced to allow a 3rd party to tell them what they must or must not carry? By whose authority? That "nazi-like gov’t" you keep harping on, is the only answer.

The answer to every one of your demands can only be practically found in a dictatorship. And a not very enlightened one at that.

Sure, things are shit. Your suggestions, though, are just so much worse.

Anonymous Coward says:

Re: Re: Re:2 Re:

Your view, Baghdad bob, of having some magical power swoop down and dethrone government and corporation alike isn’t realistic.

blue’s rant about how he wants government and corporate control removed is instantly disproved by his constant blind faith support of the Trump administration. As in, the administration who continues to benefit corporations above all else. Which is something you’d think blue would be against, but try to point out how Trump is a racist, backroom-dealing asshole and he’ll act like you suggested nuking a baby.

David says:

Re: Re: Re:2 Yes, I've noted that I'm more "socialist" than YOU,


…which then leads us all right back into the dead valley which is old-style soviet-style communism.

Communism is not about downscaling the rewards for people controlling the resources but about communalising the control of resources. An increase of taxation makes the capitalists work harder for their rewards, the other puts a stop to the kind of work capitalists are good at.

Completely different things. Even in the extreme limit of a differential taxation of 100% this is a far cry from taking control from the capitalists and criminalising and vilifying them.

It’s popular in the U.S. to decry any degree of trying to taxate some of the benefits capitalists derive from state-supplied social and technical infrastructures as communism, but it just doesn’t match the underlying realities of the difference between the systems’ governing principles.

David says:

Re: Re: Re:4 Yes, I've noted that I'm more "socialist" th

If the company derives its value from the state-supplied social and technical infrastructures it is formally based in, having those countries proscribe the taxation code and rates seems like a fair deal.

The problem is when taxation and value creation are located in different countries. The solution cannot be to try undercutting the countries who do not significantly contribute to a company’s value.

James Burkhardt (profile) says:

Re: Re: Re:4 Yes, I've noted that I'm more "socialist" th

This boogyman of taxation just doesn’t happen. Despite changes in state level taxation, corporations appear to rarely move to a new state or city on the basis of changes in tax law. They may set themselves up in tax advantaged states to begin with, but few companies move to other jurisdictions for the tax benefits. And tax laws

Apple doesn’t appear to be moving their IP holding company out of Ireland despite the immanent closure of the Double Irish loophole. And they didn’t move their headquarters out of the Bay Area, in fact bringing jobs in Texas back to the Bay Area with the opening of the new campus, despite the strong taxation regime preventing most Domicile location shenanigans. Despite the fear mongering, relocation for tax benefits just isn’t a widespread thing, something we can see in the number of companies not moving to more tax advantaged states.

Crayola (profile) says:

Re: how harmful is IV acetaminophen?

I am not a Dr, but I Google:

The maximum blood concentration (Cmax) of Ofirmev is higher than with oral or rectal administration; however, it is important to note that the Cmax with Ofirmev (29 mcg/mL) remains far below the 150 mcg/ mL concentration considered potentially hepatotoxic.

Ofirmev exposes the liver to approximately 50% less acetaminophen compared with equivalent doses of oral acetaminophen. This lack of first-pass metabolism and resultant decrease in liver exposure likely play a role in the low incidence of hepatic damage reported with Ofirmev thus far.

So it’s safer than taking pills, at least from what I’m reading.

Kumouri (profile) says:

Re: Re: Re: how harmful is IV acetaminophen?

The big difference between oral and intravenous administration is that intravenous administration generally avoids the liver. That’s (generally) why intravenous preparations use significantly less of the drug than oral, as they don’t lose nearly as much active ingredients to filtering by the liver.

Scary Devil Monastery (profile) says:

Re: Re:

"Not trying to minimize the harm that patents like this cause, but I’m not completely sure about this story — which seems to be a matter of "dueling anecdotes"."

Normally urban myth or dueling anecdotes would be the way to dismiss any single case…
…but looking at the court history of the American Medical Association there’s plenty of reason to believe the OP, sadly. There was a multi-state lawsuit regarding the way AMA-associated medical practitioners conspired to bilk patients out of the maximum allowable insurance amount using the most costly (and not rarely unnecessary) treatment while taking pains to feed the patients well over the recommended limit in medication, usually painkillers.

The AMA is primarily a business association. If someone tells me they bend ethics to ensure maximum profit to the direct detriment of patients then I’m inclined to say that story defaults to being credible.

Paul Brinker (profile) says:

Re: Patented?

Your talking about Compounding, this exists, but due to cost it’s uncommon unless the drug is very exotic or requires dosing that is incompatible with standard available drugs.

Compounding acetaminophen may have risks, it may not be water soluble when simply crushed, It may react with salt, binding agents may need to be removed as its not commonly found in powder form. Almost anything going directly to blood requires an extra level of care as your body cant filter it.

All of the above is why it was re-run through clinical trials etc.

So no, this is not as simple as crush it up and mix.

Anonymous Coward says:

Re: Re: Patented?

All of the above is why it was re-run through clinical trials etc.

Why what was re-run through clinical trials? I don’t know enough about medicine to know whether the linked patent is novel or is the bog-standard way to make an IV-dose of anything. Whether the hospital staff or the manufacturer puts it into solution shouldn’t make a difference, because it’s all the same idea of "put an existing drug in IV form". And while it’s a good idea to run clinical trials, putting money and work into something doesn’t automatically mean it’s patentable.

Robert Beckman (profile) says:

Not just patents

A large part of this isn’t just the patents, but also downstream liability for later complications. Paracetamol (Tylenol) IV is safer than other routes because it bypasses first pass metabolism, but unlike opiates there’s also a ceiling effect.

If you have a patient with severe pain, you can start with low dose morphine and just keep titrating up until the patient gets enough relief. You can’t do that with paracetamol, so for a patient for whom you think it won’t be enough, you just start with morphine.

Where this gets more interesting is that there are drugs that cause neither addiction nor dependence, and are much stronger than anything other than an opiate, but that have their own potentially negative effects. Toradol is a commonly used example of that, but which can fry your liver if used too frequently (and the “too frequently” dose is pretty close to the effective dose).

So from a hospitals perspective, the real driver is ease of administration. You can give a mix of many different drugs to optimize effect, or you can use only OTC and morphine, which has the benefit of being easy to administer, easy to monitor, and cheap.

But if you try to do the best for each patient you’ll inevitably give a patient too much toradol and pay out millions after litigation.

Shaun Wilson (profile) says:

Don't throw pain patients under the bus

I suffer from ongoing pain due to arthritis and about the only thing I’m offered any more is oral acetaminophen (or paracetamol as we call it here is Australia). Unfortunately for me it doesn’t seem to have any effect while opiates work well and have negligible side effects – but because of political and media grandstanding I’ve been almost completely weaned off them.

When I was on a reasonable dose of opiates I had a life and a (part time) job, now I have no life, no job and I barely make it out of the house most days. While some so called "pill mills" actually involved fraud the majority are just good doctors, some of the few still willing to buck the public pressure and actually care for their patients. By being one of the few not scared away from treating pain they therefore get a good reputation for helping and end up seeing more patients in need.

TRX (profile) says:

Re: Don't throw pain patients under the bus

In America the modern attitude is "suck it up, pain is good for you." So you have people with terminal cancer, multiple compound fractures, or open-heart surgery given Tylenol or placebos and told "that’s all we’re allowed to give you."

There’s also the problem that for surgery, American anesthetists may be trained to use various drugs, but in practice they only use IV Demerol or morphine and are very reluctant to use anyting else, even when a patient has a documented history of bad reactions from them.

Anonymous Coward says:

Re: Re: Re:

Try using internet searches to investigate medical trials in the US and Canada to determine the efficacy of IV acetaminophen administration as a primary, preferred approach versus oral administration. Not only is the cost of the former procedure significantly higher, such studies were unable to sustain that as a general rule IV administration was superior to conventional approaches.

As for doctor gossip about hospital directions to use other approaches, there is nothing in the article even remotely lending credence to the headline assertion that patents contributed in any way to the opioid crisis. As you have correctly noted on multiple occasions, correlation is not causation.

tom (profile) says:

I have no issue with Doctors earning a profit. But from TFA, the issue here wasn’t the Doctors, it was the hospital administration issuing medication orders. I am becoming more and more convinced that the solution to the ‘Health Care Crisis’ is banning insurance and government programs and returning to the patient directly paying the doctor/hospital. Many report say somewhere between 30 to 50% of health costs are administrative including insurance admin cost + profits, cost of complying with government mandates and compliance reporting, etc. Eliminate that cost and health care becomes affordable for a large number of people. Sure, some will get hit with bills for complex treatments they can’t pay but I doubt the number will be much different then what we get today.

Mason Wheeler (profile) says:

It’s not just patents; the monetary incentives are bad all the way around. If you do a bit of research, you’ll find that drugs like Methadone which are used to treat opioid addiction are made by the very same companies that make opioid painkillers. In other words, they have very little incentive to do anything to help people not become addicted because addiction is good for business.

Anon says:

Why Are You Surprised?

As earlier comments show, it’s not just "crush aspirin and dissolve it to add to IV". There are many additional checks and balances about what the effects are, proper doses, etc. Someone had the idea and did the research and has the patent. When it expires, it will be cheaper – but clinical trials are not free, especially when the usual "free research" from the assorted government agencies is cut way back.

It’s nothing new. Even here in Canada, you heard disputes about why our universal health care does not cover this or that new drug because it costs thousands a month (or per dose). There’s a limit to what any health care provider should spend for a person, unless you’re willing to pay significantly more inn taxes or health care premiums. In fact, we have the reverse logic for drugs – my pharmacare plan mandates the pharmacist automatically substitute a generic if available, unless the doctor explicitly says "not the generic". Save money, does the job.

I’m against restrictive patents too, but the logic is unassailable – some things won’t be developed or researched if there’s no profit to be made. The question is, what’s a reasonable price to pay back that research? That’s what needs to be legislated, if necessary.

Patents are limited monopolies, are for good ideas, developed and produced. That little container with the magnet near the rim for holding paper clips – that was someone’s bright idea and was patented. It looks obvious now. Xerox dry copying was a bright idea developed and sold as a monopoly for decades.

I suppose the question not answered for the author is – when does the patent expire?

Wendy Cockcroft (profile) says:

Re: Why Are You Surprised?

I’m against restrictive patents too, but the logic is unassailable – some things won’t be developed or researched if there’s no profit to be made.

Unless the development is done on a non-profit basis. The fly in the ointment is the expectation of making a profit when it ought to be of making a useful product. If you were right, generics makers would fail.

The question is, what’s a reasonable price to pay back that research? That’s what needs to be legislated, if necessary.

Much of the research is publicly funded and carried out in universities. Given the savings the government would make if it funded all of the R&D as a public good V paying out huge sums to companies owned by party donors…ah, there’s the problem.

dickeyrat says:

Because this is What Matters in Amerika: 1) Promotion, Preservation and Proliferation of anything and everything Fascist, for the Praise and Glory of Our Respected And Beloved Leader Donald Trump, anointed by God to be our Dictator-for-Life, and the Glory of his Divinely Blessed Progeny, the precious Jr., Eric, Ivanka, and The Donald’s son with his own daughter Barron, who are Divinely Entitled to continue the White and Wisened absolute Trump rule over whatever Amerika will inevitably decay into. And 2) The Continued Profits and Enrichment of those charged with promoting and providing the public "Health", whose duties include cleansing the chronically infirm and diseased hordes out of our preserved and esteemed White population, as chosen and anointed by our White Republican God. Sieg Heil MAGA!!

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