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Opioids in America: Signs and Symptoms of Malfeasance

In 1980, a letter was published in the New England Journal of Medicine stating, quite correctly, that patients prescribed opiates such as morphine in hospital for acute, serious pain did not become addicts once they left hospital. This was important, because American doctors at the time were reluctant to prescribe such drugs even to patients for whom they were indicated for fear of turning them into addicts. Thus opiates were denied to those dying in severe pain, a cruel absurdity.

The letter had unintended and unforeseen consequences. It was used, more than a decade and a half later, to justify the prescription of strong synthetic or semi-synthetic opioids to patients suffering from chronic backache or arthralgia. Even minimally experienced doctors should have been able to distinguish between patients with acute pain and chronic pain. They should have been able to recognize that the two are very distinct; but, for a number of reasons, many American doctors failed to do so. This failure helped to turn the United States into by far the largest consumer of opioids per capita in the world.  

Last year, 49,000 Americans died of opioid overdose, or (more accurately) opioid-related overdose, since in most cases the opioids were taken in conjunction with other drugs. The opioids were the necessary, if not the sufficient, cause of death, for the other drugs, easily available with or without prescription, would not have caused death if taken on their own. It is therefore reasonable to ascribe the 49,000 deaths to opioids. Since 1999, 350,000 Americans have died of such overdoses.

American Overdose: The Opioid Tragedy in Three Acts is an account of this disaster by the Guardian newspaper’s Washington correspondent, Chris McGreal, with a special focus on West Virginia, one of the states most affected by the epidemic. Indeed, the author takes West Virginia as a microcosm of the United States, the more readily comprehensible due to its small population.

The book is ill-written, reading like an extended but not very carefully crafted newspaper article in the weekend supplement of a serious newspaper. But it is nevertheless interesting both in what it says and what it omits to say.

Where Does Responsibility Lie?  

The author is clear about the many villains of the piece. They are:

  • the Purdue pharmaceutical company, which aggressively and deceitfully marketed its long-acting semi-synthetic opioid, OxyContin, to doctors as being both safe and effective in cases of chronic pain;
  • the doctors who prescribed the drug in vast quantities to patients without regard to their clinical need and as a means of making money for themselves very quickly;
  • the foolish, intellectually irresponsible or downright corrupt pain specialists who promoted opioids as the answer to chronic pain;
  • the drug-wholesaling companies that maintained supplies of the drug to pharmacies that were doling out huge quantities of the drug obviously out of keeping with the pharmacies’ size; the pharmacists who failed to question the prescriptions of doctors who were prescribing the drugs to hundreds of patients a day;
  • the medical licensing boards whose members closed their eyes to malpractice;
  • the local police chiefs and district attorneys, who shielded wrongdoing;
  • the regulatory agencies, especially the Food and Drug Administration, that, as a result of a toxic mix of incompetence and susceptibility to influence-peddling, failed to perform their duty to protect the public;
  • and the U.S. Congress, many of whose members (on both sides of the aisle) were beholden to the pharmaceutical industry for campaign contributions.

Specifically absolved from any responsibility whatever, and therefore absent from the list, are those who took the drug or drugs that killed them.

The author draws an analogy between opioids and tobacco. I think, for number of reasons, that the analogy is unilluminating, inasmuch as the main beneficiary of tobacco sales had for a very long time been the government that licenses its sale, and no one (not even the most ardent consumer) has believed for very long time that smoking is other than extremely harmful to health. By contrast, the government has not been the main financial beneficiary of sales of OxyContin, whose sales benefited from a successful campaign to have pain recognized as the so-called fifth vital sign (along with blood pressure, pulse and respiration rate, and temperature)a campaign that carelessly or dishonestly erased the fundamental distinction between a sign and a symptom, the former being observable to a third party, the latter being a report by the patient of something subjectively experienced.

Of course, all drugs must be prescribed on the basis of risk-benefit to the patient; no drug is entirely safe. But no one would suggest abandoning penicillin because of occasionally fatal hypersensitivity reactions, the medical value of the drug being so obvious. The case of OxyContin is different, however. Its benefits (if any) were grossly exaggerated and its harms grossly underestimated by its manufacturer, and the licensing authority, the FDA, was slack to the point of negligence in seeking evidence of either benefit or harm. The story is a lamentable one of collective failure.

Users Do Have Moral Agency

However, underlying this book is an Animal Farm mentality: that is to say, four legs good, two legs bad. Those with two legsthe manufacturers, the wholesalers, the doctors, the licensing authoritiesare bad, while those with four legs, the people who actually took the drugs, are good. What the author does not see is that this attitude dehumanizes the victims completely, even if his two-legged people were as bad as he says they were (and as I think they were).

Over and over again, McGreal denies any personal responsibility to the people who took the drugs. He regards addiction straightforwardly as an illness, something that strikes in the same way as, say, Parkinson’s disease. (This is the line peddled by the egregious National Institute on Drug Abuse, the federal institution that somehow managed to congratulate itself on its successes and increase its funding while hundreds of thousands died on its watch, an absurdity beyond the range of satire.)

According to the author, the drug is the active partner in the transaction between it and the person who takes it. Hethe personis “hooked” on it and has no choice in the matter. He is assumed to be totally ignorant of the effects of the drug and to be as incapable of resisting its initial siren call as of stopping it once he has started taking it. When he seeks out a clinic where the doctor does not see him and where prescriptions are written without any investigation of his condition whatever, and people are lined up around the block to get in, he is supposed by the author to be so lacking in the attributes of human consciousness as to notice nothing and therefore to conclude nothing. In other words, he is not really a human being at all, but a robot.

It is true that most of the people (by no means all) who take the drug are in difficult circumstances. They are often uneducated, unskilled and unemployed, with very poor prospects. But if difficult circumstances (such as most of us experience in one form or another, at one time or another) excused rather than extenuated our behavior, then we could be held to no standards at all and could rightfully be placed under tutelage for our own good. Those, therefore, who encourage victims to think of themselves as victims and nothing but victims encourage them to remain in a prison of their own construction.

Paving the Way for Fentanyl Dealers

Though McGreal may not realize it, he thinks of the people who take OxyContin as a different species of being from himself. Somehow these are individuals incapable of lying or of special pleading; he accepts uncritically the stories of both victims and their relatives, as if they were the truth, the whole truth, and nothing but the truth.

It seems very difficult for people to hold in their minds simultaneously that corporations, public authorities, and individuals can behave badly. The desire to absolve individuals of their responsibility stems from a reluctance to admit that victims play any part in their own downfall: Victims are either immaculate or they are not victims at all. To recognize this as a false dichotomy is to lack compassion, and we all want to be seen to be compassionate.

Meanwhile, the epidemic has expanded beyond its origins. As prescriptions for OxyContin and other opioids have finally declined in number, so the black market value of these drugs increased and provided an opportunity first for heroin dealers, and then for fentanyl dealers, to take up the baton. American Overdose ends on a pessimistic note: like many others, the author thinks the epidemic will continue or grow worse. I am not so sure. Epidemics such as this, for reasons not always understood, wane as well as wax. But then there is usually something else around the corner.

Reader Discussion

Law & Liberty welcomes civil and lively discussion of its articles. Abusive comments will not be tolerated. We reserve the right to delete comments - or ban users - without notification or explanation.

on June 13, 2019 at 09:40:02 am

"The opioids were the necessary, if not the sufficient, cause of death, for the other drugs, easily available with or without prescription, would not have caused death if taken on their own. It is therefore reasonable to ascribe the 49,000 deaths to opioids"

this could use some clarification. It is not altogether clear WHICH opioids "caused" the deaths. In many instances, the deceased took massive amounts of oxycontin, vicodin, etc in conjunction with heroin or other similarly excessively powerful narcotics.

The number of deaths resulting from a strict regimen of, let us say, vicodin (Norco is the generic) is infinitesimal.

But Dalrymple is spot-on in recognizing the responsibility of the purported *victims*. One always has a choice. For those with severe / acute and chronic ailments (such as myself) these drugs are a blessing, enabling those so afflicted to live what approximates a normal daily regimen.

The trick is to accept that pain will always be a part of one's life; that any attempt to completely alleviate the pain will result in markedly diminished faculties and capabilities. Perhaps, prescribing physicians ought to emphasize the consequences of a "pain-free" dosage and limit the attendant consequences.

The *victims* may find that pain management that reduces discomfort to "aches and pains", not euphoric absence of any discomfort, is far preferable to dependency and oblivion.

And yes, drug companies and "pain specialist" ought to be brought to bar and sanctioned; so too ought those who seek that which is rarely possible or even desirable (given the nature of the ailments) - a pain free existence.

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gabe
on June 13, 2019 at 10:53:23 am

[…] Source: Opioids in America: Signs and Symptoms of Malfeasance […]

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Image of Opioids in America: Signs and Symptoms of Malfeasance – Melvin Charles McDowell, Member of PA Republican State Committee, Representing Bedford County
Opioids in America: Signs and Symptoms of Malfeasance – Melvin Charles McDowell, Member of PA Republican State Committee, Representing Bedford County
on June 13, 2019 at 11:31:10 am

"once they left hospital." Do you mean "once they left THE hospital"?

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Andrew
on June 13, 2019 at 11:31:17 am

then we could be held to no standards at all and could rightfully be placed under tutelage for our own good. Those, therefore, who encourage victims to think of themselves as victims and nothing but victims encourage them to remain in a prison of their own construction.

“[M]aking men smaller and more governable is desired as ‘progress’. ” -- Nietzsche

This social-political imperative is evidenced most impressively in the Seattle homeless crisis. Any action whatsoever to mitigate that crisis is met with derision and militant resistance by Seattle's homeless industry--people, in government and out, whose amour-propre demand that the homeless population of addicts living in tents remain forever in place as a continual problem for them to "solve."

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QET
on June 13, 2019 at 11:39:55 am

While I agree with the author that the user's agency is far too often overlooked in public discussions of the crisis, clarity about the extent of that agency depends on the following question, to which I have not yet heard a clear answer.

To what degree have prescriptions played a role in introducing abusers to their drugs? How many of these addicts developed a dependency after a doctor prescribed an opioid medication after a legitimate injury? How many were abusing other drugs first, or, although first-time users, sought out prescriptions even initially for recreational use?

If prescriptions given for (as far as the patient is concerned) legitimate medical reasons really did lead many or most people in drug use, that's a very different situation than if prescription opiates are just one element in a growing tendency toward drug use within an increasingly permissive society. I admit I am skeptical that prescriptions are at the root of the opioid crisis, but I do not have enough information draw any firm conclusions about this.

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John
on June 13, 2019 at 11:52:20 am

Thank god I did not choose to be a "pain specialist" as I would be a villain to everyone reading the news. Addicts are a common feature of being "on call" for a surgical practice. They call and say they are a patient of the partner who is not available and their prescription has "run out" prematurely, Then we have the ER visitors with classical kidney stone pain. They even will prick a finger to add a drop of blood to the urine sample. The victims are real chronic pain patients whose doctors are afraid to prescribe even weak opioids. Maybe West Virginia is ground zero because so many Democrats are promising to kill off the coal miners' jobs.

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Michael K
on June 13, 2019 at 12:19:31 pm

That is British colloquialism.

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Susan
on June 13, 2019 at 12:21:48 pm

British people often use the term "hospital" without a definite article just as Americans would say that somebody left "college" or "prison" or some other hellish institution.

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Kevin Staudt
on June 13, 2019 at 12:29:13 pm

I hope that Dr. Dalrymple never has to experience long-term, excruciating chronic pain. I hope he never has to struggle to keep from crying while at work because the pain is so terrible. I hope he never knows moments when he would take any pill, do almost anything for just a short period of relief from pain. I pity the trapped people who were under his charge during his tenure as a prison doctor.

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DesertFlower
on June 13, 2019 at 14:05:43 pm

My understanding is that many, or most, of the people who died passed away because their heroin, unbeknownst to them, was spiked with Chinese fentanyl.

The Chinese government shows us all the time that they can control exactly what they want to control, if they really want to, but clearly fentanyl sales to the rest of the world was not something they wanted to stop.

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oak
on June 13, 2019 at 15:52:47 pm

He must be refrring to "The Hospital", a 1970's movie romp starring George C. Scott.

But the Brit's version has a certain flair to it evoking an almost existential sense - So let us all leave hospital.

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gabe
on June 13, 2019 at 15:55:57 pm

:...as a continual problem for them to “solve.”"
whilst simultaneously offering opportunities for the "progressively MAL-educated" to secure lasting employment at the public teat.

Consider in California, housing units for the homeless involved the expenditure of over $350,000 per unit, often no better than a shipping container.

Who says there is no profit in virtue.

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gabe
on June 13, 2019 at 16:03:01 pm

Can not find the article(s) but a study late last year from some government funded group determined that the majority of the new opioid addicts had a history of prior drug abuse.

I agree that prescriptions, at least those emanating from a legitimate medical source, is not responsible for this "crisis"

Anecdotally, I can say that there is (was) much "recreational" resort to opioids having observed this behavior at tailgating parties, golf outings, etc.

The problem, in my experience is that the OVER reaction to this newly manufactured crisis is that legitimate users of these drugs are quite often inconvenienced, overcharged and generally treated as if they too were "addicts."

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gabe
on June 13, 2019 at 17:20:44 pm

What about those of us who suffer from chronic pain, for which there is no (legal) remedy but opioids ? I suffer from degenerative disc disease. Is there a cure? Is there a reasonable (legal) alternative to opioids? I've tried several, but none have been effective. Yet, because of the criminal abuses of some, I have, effectively been criminalized - or, at least, categorized as an "abuser" (for who tends to take a broad overview of the entire situation?), or someone who is, somehow, doing wrong. I'll be on opioids for the rest of my life, and I am an addict. What's the alternative? To accept "that pain will always be a part of one’s life;", or "may find that pain management that reduces discomfort to “aches and pains”, not euphoric absence of any discomfort, is far preferable to dependency and oblivion." That's pure bullshit! Nor is the current drug policy of requiring elderly, sick people, on fixed incomes, with difficulty in obtaining transportation, to visit a doctor every 3 months, and having to hand carry their prescriptions from the doctor's office to the pharmacy, at all just.

We who suffer TERMINAL PAIN (try to understand the implications of the phrase) have a right to have effective medical treatment of that pain - just as much as anyone has any right to any medical procedure. If doctors are abusing the prescribing of certain medications, go after the doctors, and don't try to shift the blame, onus, or responsibility to we who suffer, with ridiculous generalizations, as well as penalties for something we just can't help!

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James Fitzpatrick
on June 13, 2019 at 18:15:55 pm

The fact is, when these opioids were prescribed, most of the people who became addicts abused the prescription. They took way more than the prescribed dosage and/or administered it ways not prescribed, such as crushing the medication.

The users saw the prescription of pain medication as a chance to get high with strong narcotics, all legally prescribed.

The underlying factor in this is the prevalent Drug Culture that inhabits the United States. Drugs are fun. Drugs are normal. Drugs are safe. Everybody does drugs. How are individuals born and bred into this culture supposed to responsibly treat a prescription for medication to manage their pain?

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Mark Liveringhouse
on June 13, 2019 at 18:31:35 pm

"the author takes West Virginia as a microcosm of the United States."
It would be as strange to take Cornwall as a microcosm of England.

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ap
on June 13, 2019 at 18:32:20 pm

Just as the parasite needs its host to remain alive, so too does the "homeless industry" need its homeless population to remain in-place in order that the NGOs and gov't agencies that serve as the homeless industry maintain their parasitical relationship with the taxpayer and other funding sources.

The "homeless industry" is, in essence, a jobs program for social welfare workers, rather than welfare or social insurance for the downtrodden who, apparently, never recover/improve from their socially dysfunctional status, remaining as permanent clients of the social welfare state.

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Forbes
on June 13, 2019 at 18:36:04 pm

Those who ignored history were condemned to repeat it. The opiate pendulum has swung several times from complacency and overuse, to demonization and undermedication. This was covered extensively in a 1972 book by Consumers Union (the publishers of "Consumer Reports" magazine) called "Licit and Illicit Drugs."

This book also noted in a whole chapter on heroin "overdose" that this term is a misnomer, that even large doses of opiates alone rarely cause death (this is slightly less true today due to fentanyl). Fatal overdoses almost always resulted from the use of opiates combined with another depressant, such as alcohol or benzodiazepines such as Valium, or with quinine. The depressants may be taken knowingly or (except for alcohol) combined by the drug dealer, and quinine is added by dealers to cut the product while maintaining the bitter taste of high-purity heroin. The problem with the "overdose" terminology is it leads addicts to think they are at minimal risk as long as they don't take more than their usual dose, when they should also be told of the risks of combining drugs, or of shooting up while drunk.

Fortunately, the full text of this excellent book is available free at:
http://www.druglibrary.org/schaffer/library/studies/cu/cumenu.htm

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David Pittelli
on June 13, 2019 at 19:02:25 pm

As sad as the numbers are, prohibition/criminalization is not the answer. I doubt we would have these numbers of deaths if we did not have a big downturn in employment opportunities for a decade or more.

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gbear
on June 13, 2019 at 19:04:13 pm

Thanks to zealous persecution as outlined above, the number of physicians who diligently attempt to treat pain patients with the objectives of maximizing quality of life and minimizing dose escalation is becoming smaller every day. Those who cast the first stone at physicians should get down on their knees in gratitude that they have have escaped the truly awful conditions that can lead to a life of unrelenting suffering.

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william taylor
on June 13, 2019 at 19:31:07 pm

They also go "to university" in British English.

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William A Befort
on June 13, 2019 at 19:31:43 pm

They also go "to university" in British English.

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William A Befort
on June 13, 2019 at 20:30:55 pm

I don't believe I know any chronic pain sufferers - or anyone else for that matter - who expects to live a pain-free life.

In my experience, most people expect - and I think they are right to expect - to be treated humanely when in pain.

It seems to me that this topic is too often discussed in extremes. The only choice is not doping people to obliviousness vs. forcing them to suffer in agony. There is middle ground, and solutions can & should be crafted for the well being of each individual.

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DesertFlower
on June 14, 2019 at 07:02:25 am

Saying the doctor should have been able to tell the difference in acute pain and chronic pain such as back pain and arthralgia is to discredit the need for opioids for chronic pain. The writer has certainly never experienced the severe chronic pain I and millions of other suffers experience.

I can tell you there is a huge difference in a simple backache and a spine that has 8 herniated discs, 3 in the lumbar area including an annular tear, severe spinal stenosis, severe compression of the cauda equina, radiculopathy, radicular pain and polyarthralgia. The kind of pain that makes you wish for death without opioid medication.

I wonder if the writer knows the difference in a simple headache, a migraine headache or a severe headache from glioblastoma?? Or if he even cares.

The prolem now is that our pain management doctors treat the above spine conditions as a simple backache and reduce our opioids to levels that basically render us bedridden. I am no longer treated as a patient but as a drug addict.

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Cyndi
on June 16, 2019 at 12:05:43 pm

50k people per year is a very big number. If I’m not mistaken, that’s more than are killed in auto accidents yearly.

While the issue of personal responsibility cannot be ignored, obviously, the reality of addiction is that, once you’re hooked, you’ll not get free purely by being a responsible person. So, for the folks who were or are inappropriately prescribed opioids for more than a couple weeks time, maximum, that issue is a bit overstated.

I think the issue that is understated is physician responsibility. These folks are supposed to, first, do no harm. Mis-prescribing opioids for treatment of chronic pain, creating a needlessly addicted patient, ought to be viewed as malpractice. Even in situations where prescribing opioids is warranted (eg, cancer) the adverse health effects of long term opioid use mitigate against using them, unless the patient is at end of life..

The problems with opioid use have long been well known. So how do we now have millions of addicts, of which 50k/yr are now dying? This was caused by drug company marketing? Nonsense.

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RJones
on June 16, 2019 at 19:48:04 pm

How many of you REALLY suffer from chronic pain, for which there is no relief, 24 hours a day, 365 days a year? The "long term effects" of the pain are what's really debilitating, and the prospect of it lasting - and getting worse - to our dying day are completely incomprehensible to someone who is not in the same boat. And to make getting prescriptions more burdensome to the elderly is just adding insult to injury.

So, what is EFFECTIVE besides opioids? Something that can relieve the pain for several hours at a time? Something that is legal? Something that health insurance will pay for? Answer: NOTHING! Those of us who suffer chronic pain, and will suffer chronic pain for the rest of our lives deserve some kind of relief, and not meaningless words and phrases, and sob stories about the "long term effects" of medication that at least takes some of the edge off!

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James Fitzpatrick
on June 17, 2019 at 01:54:31 am

Agree. They are going overboard and hurting the people that do need the meds to lead a productive life along with other methods I.e. PT, exercising and swimming. They take away the meds people will die because who want a life full of unbearable unmanageable pain?

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Linda Derman
on July 03, 2019 at 02:15:34 am

I don't think your comment follows from the article.

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J
on July 03, 2019 at 02:18:37 am

I don't think your comment is correct. There are non-pharmacological interventions that are helpful.

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J
on July 03, 2019 at 02:21:20 am

That number (of deaths) seems nearly unbelievably high?? Is there some artefact here that's causing misattribution of deaths, or miscalculation of numbers? A thousand people a week... I just can't comprehend that being true. At least not from people misusing their legitimately prescribed opiates. Hadn't heard anything about fentanyl from China.

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J
on July 03, 2019 at 09:17:01 am

NO, there are NOT! I've tried everything possible as far as non-prescription medication. I've tried yoga and suspension - which only provide relief when you're doing it - NOT afterwards. Accupuncture? Haven't tried it. Will you pay for it? Because insurance sure won't! Inventions? Specify!

Those of you who don't experience the exhausting, unending pain just have no idea.

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James Fitzpatrick
on July 19, 2019 at 02:11:12 am

No, the numbers quoted refer to ALL deaths, including street drugs (i.e., heroin and fentanyl,) which constitute the vast majority of overdose deaths.

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Sue J.
on August 29, 2019 at 21:37:35 pm

I wouldn't describe it as a colloquialism. It's standard, formal British English.

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James G
on January 15, 2020 at 10:30:17 am

And companies and organizations are often considered (less often than formerly) to be plural. "Purdue are responsible for . . . " "FedEx are offering a new service . . ."

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Flo

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