经济学人社论 || 仅靠立法难以解决美国阿片类药物危机

Opioids

阿片类药物

Avoidable pain

可免之痛

Legal settlements alone will not solve America’s opioid crisis

仅靠立法难以解决美国阿片类药物危机

This week saw a landmark reckoning in court for a drugmaker involved in America’s opioid disaster. A judge in Oklahoma ordered Johnson & Johnson (j&j) to pay $572m to fund a state plan to combat opioid addiction. Whatever the outcome of j&j’s legal appeal, this is a milestone in a public-health calamity that cost 47,600 American lives in 2017 and could well claim a further 500,000 over the next decade (see article). Faced with such devastation, states, counties and municipalities have served firms with roughly 2,500 lawsuits.

本周法庭上出现了一场里程碑式的审判，清算了一家牵涉阿片类药物泛滥危机的制药商。俄克拉荷马州的一名法官裁定强生公司支付5.72亿美元，以资助该州一项抗阿片类药物成瘾的计划。无论强生公司上诉结果如何，这都是2017年公共卫生灾难的一个里程碑。这场灾难导致47600名美国人丧生，并很有可能在未来十年造成50万人死亡。面对这样的灾难，美国各州、郡和市已向相关企业提起了约2,500起诉讼。

注:

1. 强生公司因阿片类药物案被罚5.72亿美元，成美国首例

https://news.sina.com.cn/c/2019-08-27/doc-ihytcitn2234550.shtml

2. 2017年抗击阿片危机 川普宣布公共卫生紧急状态

https://www.voachinese.com/a/trump-opioids-20171026/4087839.html

The roots of the epidemic lie in the marketing of prescriptions by pharma firms almost 25 years ago. Opioids have long been known to be highly addictive and easy to overdose on. Almost one in five addicts dies within a decade. Yet newer versions of the drugs were sold as having lower risks. Firms also worked hard to promote the idea that doctors were undertreating chronic pain.

这场大灾难源于约25年前制药公司对处方药品的营销方式。长期以来，人们都知阿片类药物极易上瘾且容易过量服用，近五分之一的上瘾者会在十年内死去。然而新型药物以风险更低为卖点进行售卖，各大公司也大力宣扬医生对慢性疼痛治疗不足的观念。

Drugmakers involved in mis-selling opioids could begin to make amends by shouldering their share of the blame and settling quickly. That way the money will arrive sooner, and less of it will go to lawyers. There are encouraging signs that Purdue Pharma, which lies at the origin of the epidemic, may settle a batch of lawsuits for up to $12bn. Yet it is vital not to lose sight of why the opioid crisis struck America so much harder than anywhere else. The blame lies partly with the incentives woven into its health-care system.

参与不当销售阿片类药物的制药商可以做出补偿，承担自己的责任，并迅速解决问题。这样一来，资金就可以快速积累，支付的律师费也会变少。有令人鼓舞的迹象表明，作为此次疫情源头的普渡制药(Purdue Pharma)，可能会以高达120亿美元的价格了结一批诉讼。然而，重要的是，不要忽视为什么阿片危机对美国的影响比对其他任何地方都要严重，其部分原因在于美国医疗卫生体系中的利益驱动。

注：

1. 普渡制药：

https://www.zhihu.com/question/269382961 “90年代一个叫Purdue Pharma的无良药厂，号称他们家的OxyContin不容易成瘾，派出了大量的医药代表推销他们家的止痛药，改变了整整一代医生的处方习惯，结果呢，现在美国使用了全世界85%的阿片类止痛药。用的人多了，滥用的人也多了，成瘾的人就多了，死的人也多了。Purdue Pharma的罪孽并不是秘密，The New Yorker发过长篇报道The Family that Built an Empire of Pain（The Family That Built an Empire of Pain）”

2. 为何说与医保体系有关？
http://www.modernweekly.com/hots/27461 

1980年代中期联邦政府将阿片类止痛药纳入了医保范围，原意是给予贫困人群福利，结果间接促使无数中产阶级美国人下海“贩毒”。

3. 世界卫生组织简报：遏制阿片类处方药物依赖

https://www.who.int/bulletin/volumes/95/5/17-020517/zh/

1995年之前，美国阿片类止痛药的处方仅限于为晚期癌症、严重受伤或大手术后患者缓解疼痛。这种限制是基于对患者可能成瘾的担心和两种阿片类药物流行病的惨痛经历：1900年代初，海洛因可合法销售，用于治疗各种病痛，而1960年代，在越南战争时期，非法海洛因依赖流行一时。

4. 阿片类药物是一类用于减轻疼痛的药物。它们包括海洛因、以及处方止痛药，如羟考酮、氢可酮、可待因、美沙酮和吗啡。

For a start, many drug distributors and pharmacies, mesmerised by growing sales, failed to take action, as they are obliged to, when signs emerged that opioids were being diverted for illicit use. Doctors and hospitals, eyeing the bottom line, also veered towards incaution when handing out pills. The system put sales and “customer” satisfaction before patients’ well-being. Medical-professional societies were at best supine, and in a few cases complicit in encouraging overuse. Regulators fell short, too. States could have limited prescription volumes, or set rules for how opioids were to be prescribed. The Food and Drug Administration (fda), the federal regulator, failed to take account of the public-health impact of opioids when it deemed them safe. It has since not done enough to reform its approval regime, and it has still not properly reassessed the opioids already on the market to determine whether they need to be removed from  sale.

首先，当有迹象表明阿片类药物被转用于非法用途时，分销商和药店被不断增长的销售额所迷惑,未能采取应有的行动。医生和医院瞄着财务报告的最后一行（净利润），在开药时也变得轻率、不审慎。他们把销售和“顾客”满意度置于病人的健康前。医学的专业团体基本上无所作为，在少数情况下，它们甚至助长了药物的过度使用。监管者也没有履行监管的责任。各州本可以限制处方量，或就阿片类药物开具情形制定规则。联邦监管机构食品与药物管理局（FDA）在评定阿片类药物为安全药物时，并没有考虑到它们对公众健康的影响。FDA一直没有采取足够的措施来改革其审批制度，也未重新评估市面上的阿片类药物，以确定它们是否需要停止销售。

Keen to signal they mean business, some states have introduced laws to tighten supply. Paradoxically, perhaps, they need to be careful. Prescription opioids are no longer the main cause of death from addiction. Efforts to cut off people who are addicted risk sending them onto the black market for supplies. Regulators need to focus instead on medically assisted treatment for addicts, which has been scandalously neglected. This would save thousands of lives a year.

为了表明他们认真的态度，一些州政府出台法律缩紧阿片类药物的供应。但矛盾的是，以当前的形势看来，或许他们得谨慎为上。如今处方阿片类药物已不再是成瘾死亡的主因。贸然切断瘾君子的货源可能令他们铤而走险，去找黑市货源。相反，监管机构需要把重点放在为瘾君子提供医疗辅助治疗上，可惜的是，这一点被忽视了。辅助医疗服务每年本可以挽救上千条性命。

注:

mean business:  to be serious in your intentions 没有在开玩笑

The full cost of dealing with the crisis will run to hundreds of billions of dollars, which is why legal redress is needed—and why, unlike in tobacco settlements, the damages from pharma companies should go directly into alleviating the harm from opioids rather than into general government spending. Unfortunately, even then, generous settlements with drug firms and distributors will not foot the entire bill. Large sums will thus have to come from taxpayers.

彻底解决阿片类药物危机的成本将高达数千亿美元，因此需要借助法律救济手段。另外，处理阿片类药物危机又不同于烟草解决方案，因为药企的损失将直接用于减轻阿片类药物造成的伤害，却不会影响一般政府开支。不幸的是，尽管如此，药企和药品经销商大笔的罚款也不足以为全部危机买单。这笔开销的大头最终还是得由纳税人支付。

All this should be a warning to governments everywhere. In most parts of the world there is a shortage of pain relief. But as governments expand access to drugs, they should heed the lessons from America. Opioids need to be dispensed according to properly enforced rules. Regulators have a role in supervising how they are marketed. Doctors should be vigilant and inform patients of the risks. None of this is to absolve the companies that mis-sold drugs or looked the other way. Patients have a right to expect high ethical standards from those who supply their medicines. But making sure that opioids are a gift to humanity and not a curse is a job for the entire health system.

这对其他国家政府来说也是一个警示。世界大多数地区都缺乏止痛药物。但随着药物获取渠道得以扩展，各政府需从美国这起案件中吸取教训。阿片类药物需按照适当的执行规则进行发放；监管机构有责任监督药品如何被销售；医生应保持警惕，并告知病人服用该类药物的风险。但这不是帮那些错卖药品和装无辜的公司开脱。病人有权利要求提供药品的人拥有高的道德水准。但，最终还是整个医疗体系来让鸦片类药物变成人类的福音，而非梦魇。