np,

> Follow-up Q for you. What is the realistic way to prescribe opioids routinely and safely?

The simple answer is "less and with better monitoring". The first half of that was the equilibrium that Purdue intentionally shifted in the medical establishment. The cascading effects of that are what caused the modern day opioid crisis. Unfortunately, the modern-day opioid crisis as I understand it is mostly no longer related to pharmaceutical availability. So, while we should improve and lock down that supply chain route, unfortunately I don't expect it to make a large dent in the overall problem.

> Are there certain formulations that have been or should be removed from the market?

Take-home fentanyl is probably unnecessary, but again, I wouldn't really expect this to be a silver bullet. The DEA/FDA has gotten much tighter on their prescribing rules for powerful opioids, but their doing so has largely coincided with the expansion of the illegal heroin, and then fentanyl markets. It is now too late to fix by choking off supply, because the market has mostly moved outside of the regulatory regime (though we should still do that, to the extent we can).

> How do we reinstate the taboo on prescribing them?

These answers keep getting worse but we largely already have. We could probably do more, but if you are an MD and you are not "opioids are dangerous actually"-pilled, I think you need to go back to medical school. There was a short period in the mid 2000s where doctors were convinced otherwise by Purdue among others. Doctors who "think otherwise" today are almost without exception just outright criminals.

> For EG: I got a vasectomy recently and was told to expect a day or two of pain. I was prescribed a month's supply of opioids without a single comment from the doctor on their addictive nature. My understanding is that this is how people get introduced to opioids; the pathway goes "legal scrip -> addiction -> illegal supply -> fentanyl -> death" and that's the engine of the epidemic.

Overprescription like that (which that definitely is) is bad and unfortunately common. It's hard to say exactly how much addiction is caused by that variety, though. Most serious opioid addictions that I am aware of didn't get that way from a one time moderate overprescription of things like Vicodin or Percocet. It is possible to get "mildly" addicted from a month's supply of that and when you run out you might have a slightly unpleasant day or two, but not worse than that. If the illicit market wasn't there, that 30 day supply would be the end of any binge, and that would be "mostly fine", as such. That is not an endorsement or to say that it is at all a safe thing to do, but the risk comes primarily from not wanting to quit when you run out, and having other options available.

Two things changed with the introduction of Oxycontin:

1. It started being prescribed for chronic, not acute pain. This meant that people had permanent, ongoing prescriptions for them. Which meant that people built up a very large tolerance, which led to..

2. Oxycontin is pure oxycodone, it is not formulated with an NSAID (like Percocet is). The presence of an NSAID limits the amount you can take before you get sick, and prevents you from (straightforwardly) consuming it via non-oral routes of administration, which is exponentially more addictive.

> Should it be legal for the doctor to prescribe pain meds like this? (Or, should it be legal but discouraged? Is there a well-understood way to do this?) If it should be legal, should we expect the epidemic to continue? And if so, is post-bankruptcy Purdue a good thing or a bad thing?

Legal but discouraged, definitely. They are an important tool in the treatment of acute pain. They can, more rarely, be an important tool in the treatment of chronic pain (cancer / chemotherapy being a good example of a sufficiently serious condition). And finally, they are absolutely worthwhile for palliative care. For these reasons and what is now the magnitude of the illicit market, I don't think there is a lot of value in a total restriction.