"Drug courts" don't help addicted people (nor the people around them) -- they're mostly a way for the criminal legal system to whitewash itself and pretend that it cares about drug users in a "medical" way (and not just by slamming them in the clink), and there's a decent article about this: https://psmag.com/news/how-america-overdosed-on-drug-courts
Besides the inherent issue of non medically-trained people coercively prescribing medication for behavioural modification, there's the fact that drug court judges tend to disfavour opioid maintenance therapy and value abstinence from drug use over everything else; which severely increases the risk of fatal overdoses and other bad outcomes. Abstinence-only treatment does not work well for opioid addiction (http://projects.huffingtonpost.com/dying-to-be-free-heroin-t...), and coercive abstinence-only treatment doesn't work well either.
Drug rehab in US is a fucked up industry where degradation, isolation, and humiliation are commonplace and are seen as best practice, and this is the case because, well, their "patients" are literally captive -- it's either that or literal jail.
It seems insane having a Judge prescribe treatment options. Addicts who wish to give up are definitely a medical case and should be treated likewise. Tapering off Opiates does work. Let's not forget that it was prescription meds being pulled away (without support) that caused the huge rise in people turning to heroine. I have quite a strong view that prescribing pain medication should be referred to specialists after six months and/ or stronger medication than co-codamol is needed.
I suffer from Chronic pain and have been prescribed Buprenorphine in the past (Butrans, which don't have the same counter-measures as Subutex), unfortunately they are no longer adequate for me (the patches get pretty big in higher doses).
Interesting fact: the counter measure (naloxone) in subutex is useless. Bupe binds infinitely more than naloxone does to your opiate receptors, and the dose of naloxone is so low that it can't compete anyway.
Even the claims that the naloxone is to deter injection of the drug is suspect at best. It's most likely that this new combination was simply an easy way to get approval and obtain a patent.
This system also invites and funds quack medicine, like "treatment" for non-addictive drug use and non-addicts, while real addicts find a shortage of treatment resources.
This. A non-alcoholic friend of mine got popped for drunk driving, and part of his sentence was counseling for alcoholism. At one point they asked him if he'd ever done cocaine, he foolishly answered yes, and they sent him to a similar program for coke.
On the other hand, since he had to pay the cost it's not like anybody who needed treatment got shorted as a result.
Your black and white thinking does not reflect the truth. I personally know dozens of people who have turned their lives around as a result of drug court. True, the success rate isn't very high, which is the direct result of the variability of whether each individual possesses the tiny bit of willingness to change, which is essential to the recovery process.
> True, the success rate isn't very high, which is the direct result of the variability of whether each individual possesses the tiny bit of willingness to change, which is essential to the recovery process.
"If our process hasn't worked for you, you didn't want it to work enough" is unfalsifiable and can be used to defend any sort of quackery. Indeed, there's no way to generate a counterexample -- of someone who had "willingness to change" but for whom the drug court didn't work -- because the defender of the drug court can always claim that they "didn't want to change enough".
Pseudoscience of this sort has no role in anything as fraught and complex as drug use/addiction.
> "If our process hasn't worked for you, you didn't want it to work enough" is unfalsifiable and can be used to defend any sort of quackery.
Notably, it is routinely used to defend 12-step programs. The standard set of slogans includes the phrase "it works if you work it" (which I've more recently seen applied to cognitive-behavioral therapy).
Sure, some folks get clean using a variety of methods, many with little research. So what? If the success rate isn't very high, it probably isn't the best program.
We could research this stuff and then listen to the research. Use the methods with the best general outcome for the patient, based on medical proceedings. And perhaps use these things with iffy outcomes - AA, for example - as add-ons or options for patients to choose from, with a medical doctor's blessing.
Naltrexone - the active ingredient in this $1000 reformulation of a generic drug - can also be injected as pellets under the skin for the same time-release effect.
It's been a while since I ran across this option. Here's a random site about this therapy:
The active ingredient costs <$2, so Vivitrol is 90% price gouging.
Edit: IMHO, Naltrexone is a good prescription drug that actually helps people physiologically. People's pain receptors get overloaded; naltrexone helps to reset them. Naltrexone helps with alcoholism, and apparently with meth amphetamine [1] too.
With that said, Naltrexone doesn't address the fundamental emotional problems that underlie most cases of addiction. So it doesn't do them a whole lot of good to force them to take it, without also helping them find stability, the lack of which probably led them to self-medicate in the first place.
Then sterilizing the ingredient (which isn't always easy), and formulating a product that is very slow release. Not exactly easy. I give credit to the company for coming up with a useful slow release formulation of a product where nobody else did. Not just a re-hash/evergreening of an existing product for the sake of patent extension (oral Flomax CR, what was the point???)
My bigger concern is with naltrexone itself: If individuals on this need any dental/medical procedure, or have an accident, anaesthesia is very atypical. On-scene EMS won't be able to provide pain management beyond an ibuprofen.
Something like non-opioids that aren't typically used (ketamine, nitrous oxide, other volatile anaesthetics) or sufficiently high doses of short-acting opioids (fentanyl derivative) to overcome the naltrexone blockade (which would need active anaesthesiologist .management)
I'd say that on-scene pain management is a luxury compared to fixing an opioid addiction. (Maybe the desensitization makes pain management harder anyway).
A drug addict seems more likely to suffer from his addiction than to suffer from an accident.
I am basing this on the assumption that naltrexone will only delay pain treatment by a day at most. If it has people in agonizing pain until it wears off things are different.
>With that said, Naltrexone doesn't address the fundamental emotional problems that underlie most cases of addiction. So it doesn't do them a whole lot of good to force them to take it, without also helping them find stability, the lack of which probably led them to self-medicate in the first place.
Could just as easily be exposure and genetic predisposition, there's plenty of "stable" addicts.
The active ingredient's $2 market price includes the markups for R&D, failed previous projects, etc that are inherent in drug development. Repackaging an existing generic hardly merits the same.
> The active ingredient's $2 market price includes the markups for R&D
Not if it's generic, it doesn't. The cost of R&D has to be paid off during the patent period. Also, to call it "repackaged" is disingenuous. The delivery method is what's being charged for.
I felt like he was reframing things to the point where it was no longer true. I think he knows that the new version is an extended release injection (I mean, it was mentioned explicitly in the article), but he said "repackaged" for rhetorical reasons.
It's shocking how confident people are in their understanding of economics when they clearly have never read a book on the subject or taken a 101 course on it. People have some kind of instinct for how much money is "too much" in different contexts and they fully believe they are right without any external frame of reference. Ask them what the "correct" margin should be based on and they'll say something like "the cost plus a little bit more to cover overhead." No understanding of supply/demand whatsoever.
I assume that your studies in economics identified what you are referring to as "cost-plus" pricing...which is not how any drug is priced. At the point of sales, R&D is a sunk cost and is not part of the pricing strategy, in most big modern companies. Companies price their product to maximize profit. That is not always the highest price they could charge, but is a function of total profits.
> Ask them what the "correct" margin should be based on and they'll say something like "the cost plus a little bit more to cover overhead." No understanding of supply/demand whatsoever.
Are you saying that's not the correct price in a competitive market? After accounting for all costs, of course.
Maybe you should read those people as saying "this market is lacking in competition to make prices reasonable".
My primate sense of fairness says that charging 100% of costs is actually a form of charity, 105% of costs is hyper-competitive, 110% of costs is quite respectable and meritorious, whereas 150% of costs is getting to be overly ambitious.
10000% of costs is, quite simply, asking for someone to put a shiv in your kidney.
The only way to achieve such margins is by literally suppressing all competition with armed force, with an unquenchable, non-substitutable demand. In the case of pharmaceuticals, the feds provide that force.
Feds provide force sometimes, but other times it's just a matter of time. When you produce a new product or service, you have a 'monopoly' on it until other people move in. Thus, margins start high and quickly lower even in a maximally competitive environment. Just wanted to share that concept in case others didn't make that connection!
There is a difference between the price that balances supply and demand, and the price that is 'fair' to ask.
Specifically, when demand is very inelastic because things are plain necessary the balance point is no longer fair.
Normally, the balance point is the fair point. By making it cheaper, you get people who don't need it still buying it, leaving no supply for others that do need it. At the same time, making it more expensive leaves people who need it not being able to get it.
This reasoning is why we say the market price and fair price coincide. This breaks down when demand is inelastic. (It also breaks down when income inequality gets to be huge). Specifically, when there are no people that want something but don't need it, the argument breaks down. In this situation, the market price is called price gouging.
There are some cases where responding to the market makes sense. I.e. when there is a flood incoming, make flashlights and batteries a bit more expensive to discourage hoarding and encourage more supply. Don't charge the market price mark-up of 10x though.
Yeah, dude, totally! Like, people are stupid for not trying to price gouge every stranger they encounter.
Who doesn't think like that? If demand is high, it's the perfect excuse to exploit people. Why would anyone try to rationalize a reasonable exchange, when they can rip desperate people off?
It is shocking how many people will ignore the fact that health care and pharma in the U.S. are nothing like the toy models taught in econ 101, or an actual free market for that matter, but pretend that they are in order to defend rent seeking.
I haven't seen anyone arguing that health care in the U.S. is in anything resembling a free market... Have you actually ever seen that, or did your fingers/heart get ahead of your brain there? ;-)
Your first comment is clearly calling those toy models (of supply/demand in free markets and econ 101) relevant to this situation, which is healthcare in the US. Don't play games with wording.
Especially when you can remove the clause containing the words "free market" without changing the meaning of the comment. "It is shocking how many people will ignore the fact that health care and pharma in the U.S. are nothing like the toy models taught in econ 101, but pretend that they are in order to defend rent seeking."
Judges are essentially prescribing medication without an MD for behavioral modification. Who will be liable when a patient/defendant experiences a complicated reaction as a result? You would think judges would be aware of their exposure to the legal risks of their actions, so maybe they have insurance.
> Who will be liable when a patient/defendant experiences a complicated reaction as a result?
The defendant. The same person who is liable when corrections bunks them with a prison rapist, or a psychopath who ends up building a guitar out of their vocal chords.
The justice system is a deep pit that we toss people into, without any care for what happens after. If we made anyone in on the side of the prosecution accountable for the consequences, the entire system would grind to a halt.
Only monetary damages. But they have effective immunity from prosecution because it's (as far as I know) never happened that a prosecutor has pressed charges against a judge for his ruling, outside of corruption.
Almost. It takes a lot to go after a judge. The big case that comes to mind is the Cash for Kids Scandal, where Honest Services Fraud was one of the charges used.
I didn't know there was even such a thing as honest service fraud until recently. It appears to have a lot of problems as a charge, but it certainly feels like it should be used a lot more to simply prevent some of the Machiavellian screw-jobs modern business (and politics) inflict on people. I know, I'm getting a little "ranty", but doesn't the term "honest service fraud" seem to fit so many of the problems caused by big organizations today?
I may be being overly pedantic, but I believe there is a little submeaning in your post. I believe judges have immunity from retaliation within the judicial system. As far as I am aware, state medical boards are non-judicial and do have the authority to issue fines for such things as practicing medicine without a license.
I take Low Dose Naltrexone for chronic fatigue. It was an instant fix. A return to an almost forgotten normal. I do get crazy vivid dreams that I remember well and they can be a little disturbing but it is a small price to pay for my life back. I buy the 50mg pills from overseas and dose it down to 4.5mg. It's the only thing that worked for me after years of trying practically everything else. It is super cheap. I think the world would benefit from more people knowing about it.
There's two parts of addiction, and chemical dependency is only a small part of it, imo. This might resolve that problem, but it doesn't do anything about people who just like to be high all the time. There are lots of people who have addictions to drugs or just activities that don't have any chemical dependency associated with them at all.
Psychology's discovery of the relationship of neurotransmitters to behavior was a huge breakthrough, but trying to treat every problem with drugs is like trying to fix a broken Office install by replacing RAM. Sometimes the problem is software, not hardware.
The most insidious effect this has, with drugs like Suboxone or Subutex, the courts are basically mandating prolonged opioid use by the defendants, all on some Doctor's opinion that this is better.
They should also seek the opinions of addicts who have sought or been forced into this treatment regime. Though I have not experienced it myself, the general consensus from the people whom I have spoken to who have, is that withdrawal from these drugs is much more severe than Heroin.
If the point is to help the addict through the withdrawal process so they can get clean, it seems rapid detox protocols would be more expedient. But of course, as we all here on HN know, the real money is in a monthly subscription, not a one-time payment.
And that's what Drug Replacement Therapy (or as pharma PR prefers, "Medically Assisted Treatment") is. It's switching to a dope man who wears a lab coat and uses a prescription pad instead of balloons. And a huge payola scheme for pharma and practitioners.
So what you're saying is there is no benefit to person from switching from impure, potentially fatal street drugs to a pharmaceutically pure drug, free of charge that lets them live a relatively normal life?
I take it your a proponent of drug abstinence rather than harm reduction?
I wonder why the street drugs are impure? I wonder why you can't get pharmaceutically pure heroin? I wonder why you think that opioid recovery is free of charge, is that just near you?
I think what GP was trying to say was that trying to treat people in opioid recovery programs with opioids that can be abused in the same way as dirty street drugs is ineffectual and their use isn't being proscribed for recovery as much as it's being proscribed because it's profitable to someone.
I agree with them. I don't think I interact with many opioid dependent people, but I've heard good anecdotes about Kratom, Marijuana, and Narcotics Anonymous for recovery. Two vilified plants and an organization that rejects outside help(or how ever the local chapter interprets their traditions) versus a potential goldmine of profits and feel-goods, I think I know which way the government is going to enforce their minimal efforts at drug rehabilitation.
God if you think NA is a good successful program, I've got a bridge to sell you. I was a junkie for six years. Abstinence only doesn't work (where that's defined as working for a sizeable percentage of people who go through it). ORT does, and the facts and numbers back this up.
Anecdotally, Suboxone saved my life. And I've got a number of dead friends to prove it (some of which had gone through NA multiple times, and two had the damnable Vivitrol injections). So I'm a bit biased here, but I find your comment quite naive, albeit typical for those who have an opinion on this life without having had much interaction with it, much less lived it.
Success is relative. The recovery programs that have sprung up from the ideals of Alcoholic Anonymous are not perfect, but the US Government has done very little to actually support those with substance issues. Quantitatively AA and NA are far more successful than all the money we throw at drug enforcement, and our drug enforcement policies actually harm the programs and the users, i.e. mandatory AA attendance in response to alcohol related offences and the danger to an NA individual's recovery when they do fall off the wagon and are picked up by law enforcement.
I've seen the local success rate for AA, and I imagine that the NA programs are worse, but they are better than the alternatives we, the United States, present them.
I won't dismiss your testimonial of your experience with DRT. But it is not the universal truth.
I would ask, are you on long term therapy presently? Or was it a short term assist through withdrawal?
We've got plenty of studies showing how a few Oxy sends every day people to the streets looking for heroin. The studies haven't caught up for Subs yet. I know I'm projecting, but I'm pretty sure when the studies come, they will tell the same story. Why am I so confident in that? This story has repeated itself since Heroin was introduced as DRT for Morphine addiction. Then Methadone for Heroin. It's a vicious cycle across generations of the cure is worse than the problem.
Suboxone has been around for decades. You are definitely projecting, and you do understand that buprenorphine is not a regular opiate, right? Partial agonist and also an antagonist. I was on it for 4 years, as I had a 2 gram a day heroin habit for six years prior. Please be careful making assumptions about things you do not understand.
The truth is, opiate receptors are a lot more binary in reality than this analog "theory" proffered by the purveyors of opioids. As with either substance, controlling the dosage obviously changes the level of effect on the recipient. In the U.K. they treated heroin addiction very similarly, with heroin. They'd give you enough to prevent withdrawal but not so much that you'd get high.
PS working the 12 Steps would likely help you with that self-righteous condescension issue that has survived your chemical addiction.
You most definitely can get pharmaceutically pure heroin, it's used in many countries in hospitals every minute of every day, just not in the US because of its scary name.
Some countries even give it to addicts instead of buprenorphine/methadone.
When they state mandates this type of treatment, it is an increase in harm, to the addict.
In general though, I'm ok with real harm reduction programs like needle exchanges, free condoms, and safe using zones. I'm not present in this life to stop anyone from using, far from it. But state mandated opiate use, that quite simply is a Chemical Holocaust.
I despise vivitrol. Two people I knew back when I was an addict used it to try and get clean, they're both dead due to trying to "break through" as it does nothing for your cravings, or the reasons you started using in the first place.
Buprenorphine was much more effective for myself, and I broke my six year heroin addiction using it, legally from my government for a nominal cost of a few dollars per day.
America seems hung up on abstinence and "cold turkey" as if it's the be-all end-all of treating addiction. Just use willpower, right? Vivitrol seems "perfect" in that environment, as it should stop you chemically from using, but the thing is that people don't want to be junkies, they want to live their lives and be happy, without the noose around their neck that is addiction. But if you don't deal with why they started using, how can you expect someone to heal?
Besides the inherent issue of non medically-trained people coercively prescribing medication for behavioural modification, there's the fact that drug court judges tend to disfavour opioid maintenance therapy and value abstinence from drug use over everything else; which severely increases the risk of fatal overdoses and other bad outcomes. Abstinence-only treatment does not work well for opioid addiction (http://projects.huffingtonpost.com/dying-to-be-free-heroin-t...), and coercive abstinence-only treatment doesn't work well either.
Drug rehab in US is a fucked up industry where degradation, isolation, and humiliation are commonplace and are seen as best practice, and this is the case because, well, their "patients" are literally captive -- it's either that or literal jail.