> The on-ramp from minor pain or surgery to a massive, blindly-renewed, over-prescription of Oxy to an opioid addiction that spirals into street drugs

This is mostly not a thing. I have known hundreds of current and former opioid addicts. I don't think I know a single one that was "on-ramped" from Vicodin or Percocet in any truly meaningful sense. It is the case that people almost always use these first. But it is relatively rare to become an opioid addict as the result of a one-off, acute vicodin prescription, per se.

> is still mediated by doctors. Until these doctors start losing their licenses for their clear and obvious breaches in their duty of care, this on-ramp will remain open.

I hope that is true! It doesn't seem like that to me, but I admit to not having carefully studied the data. Casually, there are 1.6 million opioid addictions currently in the US [1]. There were ~50,000 overdose deaths in 2019. That is, 1/1600 opioid addicts died in 2019 alone. To a first approximation, 0 people overdose annually from vicodin/percocet and other short term acute pain treatments.

It would be fairly surprising to me if (much) more than 1/1000 strong opioid users (per year) dies from an overdose. If the numbers were substantially higher than this, the epidemic would burn itself out in the population rather quickly. We can infer from this that most active opioid addicts are users of strong opioids, which are basically never prescribed for acute use. Hence, the overwhelming majority of current addicts are users of strong, non-acute opioids.

This doesn't mean there can't be some gateway effect (I do in fact think there is), but it does mean that "the problem" is mostly the presence of the strong opioids, not the Vicodin prescription for your wisdom teeth.

I'd be open to contrary data on the matter, though.

> The fact that medical boards allow these doctors to retain their licenses is the core of the issue

It is an issue, and we should absolutely try to improve it. It's just unlikely to materially dent the larger issue.

> I am only aware of a handful of the most obvious, blatant, and egregious pill mill operators being prosecuted. Regular doctors who simply cannot be fucked to care for their patients, and prescribe them pills so they leave their office, have yet to be held accountable.

I can personally attest to this being false. It was really quite annoying - I had to find new doctors on a number of occasions as a result, and that was ~15 years ago. Things have gotten much, much tighter on the pharmaceutical side since then. Every doctor who wrote me something was in prison
or dead (from suicide, in prison) within 2-3 years of the last time I saw them, and I didn't even turn them in.

It is true that at any given time the Oxycontin prescriptions are power-law distributed, with most of the scripts being written by a small number of doctors. But this is a little bit like looking at the profits in the high frequency trading industry, or the cartels in Mexico (not to morally equate these things). Yes, there are a small number of them and they seem to make a lot of excess profits, but that does not mean you can knock them off and change anything. Nature abhors a vacuum, as they say.

1. https://www.hhs.gov/opioids/statistics/index.html