“Got any of dem Zoh’s?”
June 11, 2014 8:31 AM Subscribe
How Much Does It Hurt?
Zohydro is the new FDA-approved painkiller that some doctors think the FDA had no business approving. And in ERs across America, they’re anxiously awaiting the fallout.
Zohydro is the new FDA-approved painkiller that some doctors think the FDA had no business approving. And in ERs across America, they’re anxiously awaiting the fallout.
Cheese matured on a slab of wood? Gotta keep Americans safe from that. High-octane heroin derivatives? *shrug*
In 2014, for example, the DEA total is 326,000 kilograms of opioids, including just under 100,000 kilos of hydrocodone. Put another way, that’s about 700,000 pounds of ersatz heroin usually doled out in 5 milligram or 10 milligram doses.
Christ, guys, just legalize weed already.
posted by mhoye at 8:46 AM on June 11, 2014 [11 favorites]
In 2014, for example, the DEA total is 326,000 kilograms of opioids, including just under 100,000 kilos of hydrocodone. Put another way, that’s about 700,000 pounds of ersatz heroin usually doled out in 5 milligram or 10 milligram doses.
Christ, guys, just legalize weed already.
posted by mhoye at 8:46 AM on June 11, 2014 [11 favorites]
The current paranoia around prescription opiates is really unfortunate for those of us for whom these meds are affordable lifesavers in controlling severe pain. Doctors are literally afraid to write a script for the things, due to the watchful eye of the government.
posted by Thorzdad at 8:52 AM on June 11, 2014 [49 favorites]
posted by Thorzdad at 8:52 AM on June 11, 2014 [49 favorites]
Doctors are literally afraid to write a script for the things, due to the watchful eye of the government.
Doctors are literally afraid to write a script for the things, due to the fact that some people abuse them and die from overdoses and rob from their mothers to get money for them.
posted by Melismata at 8:55 AM on June 11, 2014 [2 favorites]
Doctors are literally afraid to write a script for the things, due to the fact that some people abuse them and die from overdoses and rob from their mothers to get money for them.
posted by Melismata at 8:55 AM on June 11, 2014 [2 favorites]
Ersatz heroin? All the scare articles in the world aren't going to stop me from believing that people who need pain medicine should get it. Including Zohydrone where appropriate, and cannabis where appropriate. If our attitude towards drug addiction and abuse is that the solution is to deny medicine that's needed by people who are suffering, we've fucked up. It's like suggesting withholding insulin to prevent overeating.
posted by Cookiebastard at 8:55 AM on June 11, 2014 [29 favorites]
posted by Cookiebastard at 8:55 AM on June 11, 2014 [29 favorites]
If the drug that cures cancer is something that also makes you feel absolutely amazing and also sometimes light yourself on fire if you're not restrained when it's given to you, then I think we're supposed to be able to trust the medical profession to not prescribe it to people who don't have cancer and to ensure adequate supervision to prevent self-immolation. Some people are really hurting in an entirely non-metaphorical way. Having questions about whether it's a good idea for an individual patient, I totally get, but any idea that the FDA should have withheld approval is ridiculous.
posted by Sequence at 8:58 AM on June 11, 2014 [5 favorites]
posted by Sequence at 8:58 AM on June 11, 2014 [5 favorites]
Doctors are literally afraid to write a script for the things, due to the watchful eye of the government.
Doctors are literally afraid to write a script for the things, due to the fact that some people abuse them and die from overdoses and rob from their mothers to get money for them.
Yes, that's a totally fine standard to make medical decisions. I won't give you what you need, because some other people might like it without needing it.
The fact that even on Metafilter someone thought that "bad people" was a perfectly coherent response to an issue of how we classify drugs, deal with addiction and regulate personal decisions shows how entrenched the prohibition mindset is. Who care's how we got here, people are being bad!
posted by spaltavian at 8:59 AM on June 11, 2014 [39 favorites]
Doctors are literally afraid to write a script for the things, due to the fact that some people abuse them and die from overdoses and rob from their mothers to get money for them.
Yes, that's a totally fine standard to make medical decisions. I won't give you what you need, because some other people might like it without needing it.
The fact that even on Metafilter someone thought that "bad people" was a perfectly coherent response to an issue of how we classify drugs, deal with addiction and regulate personal decisions shows how entrenched the prohibition mindset is. Who care's how we got here, people are being bad!
posted by spaltavian at 8:59 AM on June 11, 2014 [39 favorites]
explosion: "The US has a huge problem with being unable to exercise moderation, or see shades of gray instead of black and white."
Maybe I'm reading your comment wrong, but there's a few things we should think about here. I believe that Zohydro is just hydrocodone, right? I think given opioid tolerance combined with how addictive those drugs can be might be worth considering the wisdom of churning out 50mg pills of the stuff. I say this as somebody who's had chronic pain, both from back surgery and arthritis and who has had reason to be grateful for how hydrocodone helped manage that pain.
I'm totally down for America becoming a more thoughtful and compassionate country in terms of prescription painkillers, but there's still adverse effects of the drugs that have to be managed.
Melismata: "Doctors are literally afraid to write a script for the things, due to the watchful eye of the government.
Doctors are literally afraid to write a script for the things, due to the fact that some people abuse them and die from overdoses and rob from their mothers to get money for them."
My father had a very... complicated... end of life, and he was on many different pain killers, including a large dose of hydrocodone. Shortly before he entered hospice care, his doctor, who had treated him for years without issue, told my mother and father that he could no longer treat him because he had the FBI contact him repeatedly about my father. He looked, on paper, like a "shell patient" that the doctor was using to sell painkillers on the black market. He was afraid that his practice was in jeopardy, and it was easier to stop serving my father than to prove the case that he was a real patient in real need.
posted by boo_radley at 9:00 AM on June 11, 2014 [17 favorites]
Maybe I'm reading your comment wrong, but there's a few things we should think about here. I believe that Zohydro is just hydrocodone, right? I think given opioid tolerance combined with how addictive those drugs can be might be worth considering the wisdom of churning out 50mg pills of the stuff. I say this as somebody who's had chronic pain, both from back surgery and arthritis and who has had reason to be grateful for how hydrocodone helped manage that pain.
I'm totally down for America becoming a more thoughtful and compassionate country in terms of prescription painkillers, but there's still adverse effects of the drugs that have to be managed.
Melismata: "Doctors are literally afraid to write a script for the things, due to the watchful eye of the government.
Doctors are literally afraid to write a script for the things, due to the fact that some people abuse them and die from overdoses and rob from their mothers to get money for them."
My father had a very... complicated... end of life, and he was on many different pain killers, including a large dose of hydrocodone. Shortly before he entered hospice care, his doctor, who had treated him for years without issue, told my mother and father that he could no longer treat him because he had the FBI contact him repeatedly about my father. He looked, on paper, like a "shell patient" that the doctor was using to sell painkillers on the black market. He was afraid that his practice was in jeopardy, and it was easier to stop serving my father than to prove the case that he was a real patient in real need.
posted by boo_radley at 9:00 AM on June 11, 2014 [17 favorites]
Relief from pain is one of the greatest things modern medicine affords us, and it's unfortunate that we've got to walk a fine line between improving quality of life and preventing or at least mitigating dependence. I listened to an interview yesterday with an athlete who had developed an opiate problem in his early 20s by the usual route: nagging injuries. He realized it when he went off the pills for a long-weekend vacation, since he wouldn't be aggravating his injuries, and got dope sick. He eventually became an IV heroin user when the pills got too expensive and difficult to get and snorting heroin wasn't doing it anymore. That seems to be the trajectory of a lot of modern addicts (which isn't, of course, to say that all chronic pain patients wind up shooting dope).
Treating chronic pain is important; living with pain is miserable and doctors shouldn't be afraid to help their patients. There are probably a lot of cases where cannabis would be a more appropriate treatment than opiates, though, and it will be interesting to see in the coming years how that shakes out when it becomes legal on the federal level. I hope it means we'll see a lower incidence of opiate dependence and overdoses, but maybe I'm naive.
posted by uncleozzy at 9:01 AM on June 11, 2014 [11 favorites]
Treating chronic pain is important; living with pain is miserable and doctors shouldn't be afraid to help their patients. There are probably a lot of cases where cannabis would be a more appropriate treatment than opiates, though, and it will be interesting to see in the coming years how that shakes out when it becomes legal on the federal level. I hope it means we'll see a lower incidence of opiate dependence and overdoses, but maybe I'm naive.
posted by uncleozzy at 9:01 AM on June 11, 2014 [11 favorites]
The fact that even on Metafilter someone thought that "bad people" was a perfectly coherent response to an issue of how we classify drugs, deal with addiction and regulate personal decisions shows how entrenched the prohibition mindset is. Who care how we got here, people are being bad!
And you'd think that our more conservative sect would be all over the "why should a fine upstanding citizen be forced to live in pain just so that a worthless junkie might not overdose" angle of it.
posted by Talez at 9:01 AM on June 11, 2014 [11 favorites]
And you'd think that our more conservative sect would be all over the "why should a fine upstanding citizen be forced to live in pain just so that a worthless junkie might not overdose" angle of it.
posted by Talez at 9:01 AM on June 11, 2014 [11 favorites]
Maybe I'm reading your comment wrong, but there's a few things we should think about here. I believe that Zohydro is just hydrocodone, right?
If that's true, it's safer than a lot of other painkillers. It wouldn't have the unneeded non-opiod painkillers that destory your liver.
But we're not really trying to prevent people from dying because they use a drug recreationally. They're bad people who "rob their mothers". They deserve it.
That seems to explain the media's "reefer madness" storyline on this. A drug that's less likely to kill you, heaven forbid!
posted by spaltavian at 9:05 AM on June 11, 2014 [3 favorites]
If that's true, it's safer than a lot of other painkillers. It wouldn't have the unneeded non-opiod painkillers that destory your liver.
But we're not really trying to prevent people from dying because they use a drug recreationally. They're bad people who "rob their mothers". They deserve it.
That seems to explain the media's "reefer madness" storyline on this. A drug that's less likely to kill you, heaven forbid!
posted by spaltavian at 9:05 AM on June 11, 2014 [3 favorites]
I assume that I can search for "tamper resistant" and replace it with "laced with acetaminophen as an intentional poison?"
posted by ROU_Xenophobe at 9:07 AM on June 11, 2014 [19 favorites]
posted by ROU_Xenophobe at 9:07 AM on June 11, 2014 [19 favorites]
Oh, and I am disappoint that the street names they are coming up with are pretty lame. "Zorros"? "Zoh's"? Meh.
The obvious choice should be "Zombies". Get with the program, Drug Slang Arbiters.
posted by Cookiebastard at 9:11 AM on June 11, 2014 [9 favorites]
The obvious choice should be "Zombies". Get with the program, Drug Slang Arbiters.
posted by Cookiebastard at 9:11 AM on June 11, 2014 [9 favorites]
Mod note: Couple comments removed, let's maybe focus on the substance of the linked article.
posted by cortex (staff) at 9:12 AM on June 11, 2014
posted by cortex (staff) at 9:12 AM on June 11, 2014
I assume that I can search for "tamper resistant" and replace it with "laced with acetaminophen as an intentional poison?"
I suspected this, too, but it's actually addressed directly on the second page of the article:
posted by muddgirl at 9:12 AM on June 11, 2014 [8 favorites]
I suspected this, too, but it's actually addressed directly on the second page of the article:
If there was a modest bright spot, it was that Purdue Pharma introduced a tamper-resistant formulation of OxyContin in August 2010; anyone trying to crush the pills to abuse the drug would end up with a gooey, uninjectible gel.Tamper-resistant seems to literally mean tamper-resistant, not "poisoned."
posted by muddgirl at 9:12 AM on June 11, 2014 [8 favorites]
ROU_Xenophobe: "I assume that I can search for "tamper resistant" and replace it with "laced with acetaminophen as an intentional poison?""
from Guidance for Industry Abuse-Deterrent Opioids — Evaluation and Labeling
from Guidance for Industry Abuse-Deterrent Opioids — Evaluation and Labeling
1. Physical/Chemical barriersposted by boo_radley at 9:13 AM on June 11, 2014 [1 favorite]
2. Agonist/Antagonist combinations
3. Aversion
4. Delivery System (including depot injectable formulations and implants)
5. Prodrug
6. Combination
I assume that I can search for "tamper resistant" and replace it with "laced with acetaminophen as an intentional poison?"
No, Zohydro is pure hydrocodone in an extended release formula.
The issue that has people worried is, like OxyContin was before last year, it's trivial to break the med out of the time release cap and consume it as an instant dose. 50mg of hydrocodone is a pretty steep dose if taken at once. The concern wasn't about the pure hydrocodone, it was about the fact that they didn't make it a tamper-resistant package like OxyContin is now, which makes it very difficult to take the entire dose at once.
Basically, people saw the problems we had with OxyContin, which is oxycodone in an extended release formula. The FDA mandated a tamper-proof formulation of OxyContin, which is why people are agog that they would then approve a temperable formulation of hydrocodone.
posted by eriko at 9:18 AM on June 11, 2014 [11 favorites]
No, Zohydro is pure hydrocodone in an extended release formula.
The issue that has people worried is, like OxyContin was before last year, it's trivial to break the med out of the time release cap and consume it as an instant dose. 50mg of hydrocodone is a pretty steep dose if taken at once. The concern wasn't about the pure hydrocodone, it was about the fact that they didn't make it a tamper-resistant package like OxyContin is now, which makes it very difficult to take the entire dose at once.
Basically, people saw the problems we had with OxyContin, which is oxycodone in an extended release formula. The FDA mandated a tamper-proof formulation of OxyContin, which is why people are agog that they would then approve a temperable formulation of hydrocodone.
posted by eriko at 9:18 AM on June 11, 2014 [11 favorites]
1 - yes, tamper-resistant in this case means that it cannot be crushed — for snorting or injecting.
2 - This is not the strongest formulation available, the lack of tamper-resistance is the concern.
Source: the article.
posted by Dark Messiah at 9:22 AM on June 11, 2014 [10 favorites]
2 - This is not the strongest formulation available, the lack of tamper-resistance is the concern.
Source: the article.
posted by Dark Messiah at 9:22 AM on June 11, 2014 [10 favorites]
I assume that I can search for "tamper resistant" and replace it with "laced with acetaminophen as an intentional poison?"
I have actually done a bit of marketing work for a major pain relief drug, and its new formulation's alterations to reduce abuse potential are an anti-crush mechanism (you cannot, no matter how hard you try, turn it into a powder), hydrogelling (any combination with moisture turns it into a thick, viscous gel; makes it impossible to inject, but also causes issues with older patients who can't swallow quickly), and a controlled-release formulation designed to reduce "drug liking" among abusers (the payload of the drug is given out at an even interval over time, so no matter what you do to it, you can't front-end all the narcotic effects in a quick burst).
posted by Shepherd at 9:24 AM on June 11, 2014 [4 favorites]
I have actually done a bit of marketing work for a major pain relief drug, and its new formulation's alterations to reduce abuse potential are an anti-crush mechanism (you cannot, no matter how hard you try, turn it into a powder), hydrogelling (any combination with moisture turns it into a thick, viscous gel; makes it impossible to inject, but also causes issues with older patients who can't swallow quickly), and a controlled-release formulation designed to reduce "drug liking" among abusers (the payload of the drug is given out at an even interval over time, so no matter what you do to it, you can't front-end all the narcotic effects in a quick burst).
posted by Shepherd at 9:24 AM on June 11, 2014 [4 favorites]
Not all of that goes into domestic prescription medicine (some is used for research, some is shipped overseas), but since 2004, total amounts for oxycodone, hydrocodone, hydromorphone, and oxymorphone have basically tripled.It's interesting to note that Vioxx was taken off the market in 2004 - this was when my Uncle had to have the morphine pump installed. Vioxx really was a miracle drug for those in constant pain (with one little side effect that destroyed your heart, basically) - I have to believe the wave of pain pill addiction that followed was a result of those who were on Vioxx desperately trying to avoid going back to a life of constant, crippling agony. Successors to Vioxx are not available in the US, which understandably is gun-shy on the whole family of COX-2 anti-inflammatories.
posted by Slap*Happy at 9:28 AM on June 11, 2014 [1 favorite]
Sorry all. I got so annoyed with the article, and my own assumptions, that I stopped reading before I got to the goods.
posted by ROU_Xenophobe at 9:31 AM on June 11, 2014 [3 favorites]
posted by ROU_Xenophobe at 9:31 AM on June 11, 2014 [3 favorites]
Hydrocodone? Sheesh, that's the bottom of the list for any opiate/pain killer given a choice.
Good old methadone, morphine, fentanyl, dilaudid, propofol, or the anesthesia drugs are what medical professionals get hooked on. Hydrocodone is just about the bottom of the list. And time-release usually means covered in wax or some substance that does just that: releases over a period of time in the requisite dosage.
If you take more of *any* drug than recommended, you chance addiction, overdose, etc.
I had also had the "we don't Rx narcotics!" reaction from MDs when I ask for Vicodin or Norco. And I'm old, post surgical, and have a Dx for debilitating stuff.
It's strange how something that alleviates pain is such a huge issue in this country. I guess I need to wait for a bathtub drug like crack/meth or something that grows like pot that I can buy on about any street corner.
posted by CrowGoat at 9:35 AM on June 11, 2014
Good old methadone, morphine, fentanyl, dilaudid, propofol, or the anesthesia drugs are what medical professionals get hooked on. Hydrocodone is just about the bottom of the list. And time-release usually means covered in wax or some substance that does just that: releases over a period of time in the requisite dosage.
If you take more of *any* drug than recommended, you chance addiction, overdose, etc.
I had also had the "we don't Rx narcotics!" reaction from MDs when I ask for Vicodin or Norco. And I'm old, post surgical, and have a Dx for debilitating stuff.
It's strange how something that alleviates pain is such a huge issue in this country. I guess I need to wait for a bathtub drug like crack/meth or something that grows like pot that I can buy on about any street corner.
posted by CrowGoat at 9:35 AM on June 11, 2014
Successors to Vioxx are not available in the US,
Celebrex is still on the market. I don't know of any other COX 2 inhibitors marketed in the US.
posted by Mister_A at 9:42 AM on June 11, 2014
Celebrex is still on the market. I don't know of any other COX 2 inhibitors marketed in the US.
posted by Mister_A at 9:42 AM on June 11, 2014
I have actually done a bit of marketing work for a major pain relief drug, and its new formulation's alterations to reduce abuse potential are an anti-crush mechanism (you cannot, no matter how hard you try, turn it into a powder), hydrogelling (any combination with moisture turns it into a thick, viscous gel; makes it impossible to inject, but also causes issues with older patients who can't swallow quickly), and a controlled-release formulation designed to reduce "drug liking" among abusers (the payload of the drug is given out at an even interval over time, so no matter what you do to it, you can't front-end all the narcotic effects in a quick burst).
Honestly while this is much, much better than lacing the pills with toxic things it does present similar problems because there's a certain kind of addict who will burn pills, add acid, not back down from the challenge until they get them in their veins somehow, and that guy is going to kill himself. Definitely seen case reports of bad things happening to people shooting up MS Contin gel, for example.
Good old methadone, morphine, fentanyl, dilaudid, propofol, or the anesthesia drugs are what medical professionals get hooked on. Hydrocodone is just about the bottom of the list. And time-release usually means covered in wax or some substance that does just that: releases over a period of time in the requisite dosage.
It's true 50mg of hydrocodone isn't going to impress a truly seasoned opiate user but everybody's got to start somewhere, and it is worth 10 regular vicodin so I'm sure these will be quite popular.
posted by atoxyl at 9:47 AM on June 11, 2014
Honestly while this is much, much better than lacing the pills with toxic things it does present similar problems because there's a certain kind of addict who will burn pills, add acid, not back down from the challenge until they get them in their veins somehow, and that guy is going to kill himself. Definitely seen case reports of bad things happening to people shooting up MS Contin gel, for example.
Good old methadone, morphine, fentanyl, dilaudid, propofol, or the anesthesia drugs are what medical professionals get hooked on. Hydrocodone is just about the bottom of the list. And time-release usually means covered in wax or some substance that does just that: releases over a period of time in the requisite dosage.
It's true 50mg of hydrocodone isn't going to impress a truly seasoned opiate user but everybody's got to start somewhere, and it is worth 10 regular vicodin so I'm sure these will be quite popular.
posted by atoxyl at 9:47 AM on June 11, 2014
I'm allergic to NSAIDS and cannabis, and have other medical issues that preclude tylenol usage. My only analgesic choices are opiates - fortunately my preferred one is not a CNS depressant. The last prescription I was able to get is when my long-time GP retired. 4 years ago. I dread even minor exertion injuries, much less dental work or surgery.
posted by Dreidl at 9:51 AM on June 11, 2014 [1 favorite]
posted by Dreidl at 9:51 AM on June 11, 2014 [1 favorite]
I wonder how much chronic pain could be prevented by better working conditions, earlier and better access to medical care, better access to mental health care and better pay which could provide better food, gym memberships, etc. All the younger-than-sixties people I know with chronic pain basically got there either from bad working conditions and no downtime or a spiral of depression/poverty/poor life choices/untreated injury/weight gain/inability to exercise/more injury. Now, obviously there are plenty of people whose chronic pain wasn't preventable - and everyone with chronic pain should be able to treat it! - but when I see "umpteen gazillion people on opiates for chronic pain in the US" my first thought is "why are so many people in so much pain in such a rich country?"
posted by Frowner at 9:57 AM on June 11, 2014 [33 favorites]
posted by Frowner at 9:57 AM on June 11, 2014 [33 favorites]
Good old methadone, morphine, fentanyl, dilaudid, propofol, or the anesthesia drugs are what medical professionals get hooked on.
I still don't get how somebody could possibly get hooked on propofol. There's a reason anesthesiologists call it "Milk of Amnesia" - it's basically boredom in a syringe.
posted by fifthrider at 10:34 AM on June 11, 2014
I still don't get how somebody could possibly get hooked on propofol. There's a reason anesthesiologists call it "Milk of Amnesia" - it's basically boredom in a syringe.
posted by fifthrider at 10:34 AM on June 11, 2014
Seriously. This is what the FDA is up to. Approving this rubbish, and banning the use of wooden cheese aging boards. I'll retire to Bedlam.
posted by town of cats at 10:48 AM on June 11, 2014 [2 favorites]
posted by town of cats at 10:48 AM on June 11, 2014 [2 favorites]
So, it's dangerous because it'll get abused, because our culture doesn't teach or allow people to enjoy recreational drugs responsibly?
You're going to have to point me to those countries that have happy, healthy populations of long-term recreational opioid users.
posted by RobotVoodooPower at 10:59 AM on June 11, 2014 [4 favorites]
You're going to have to point me to those countries that have happy, healthy populations of long-term recreational opioid users.
posted by RobotVoodooPower at 10:59 AM on June 11, 2014 [4 favorites]
...but when I see "umpteen gazillion people on opiates for chronic pain in the US" my first thought is "why are so many people in so much pain in such a rich country?"
There's a sadly locked New Yorker article on a doctor convicted and jailed, as, the court determined, he irresponsibly prescribed heavy-duty opiates and a whole lot of people overdosed.
It's a really complicated set of circumstances, especially among the impoverished, and the article, while not at all minimizing what he did, made it clear that he was just trying his best in a dangerous and narcissistic way, and, on top of that, he was being constantly rewarded both monetarily and through the esteem of his patients for helping them with problems no other doctor wanted to treat.
Anyway, there's a point in the article where someone who has some sort of authority on the subject says the reason for the massive amount of opiate prescription and abuse among poor and marginalized people can basically be summarized as "shitty life disease": mental health problems are incredibly stigmatized, physical health problems can be treated with highly-addictive (but working!) substances and people either consciously or unconsciously (as mental health problems can easily surface in physical symptoms) present their mental health problems as physical health problems to an MD who is unscrupulous, apathetic or, like the guy in the article, just trying his best in a particularly destructive way. They get a prescription for an opiate, feel better, get hooked and and the ball keeps rolling down the hill.
Prescription opiate abuse in this country is a honest-to-god hydra. You can jail all the doctors you want, poison or tamper-proof the medication, enact stricter laws, whatever. And some of this stuff may work, plenty of it will backfire -- there was a letter to the editor in the next issue of the New Yorker with someone saying that he would pay any sum of money to just get someone to prescribe pain medication to his wife, who suffers from chronic pain and can't get treatment -- and the overdoses still go on. God knows we now have a fucking heroin resurgence in NYC because synthetic opiates are getting too expensive.
posted by griphus at 11:01 AM on June 11, 2014 [10 favorites]
There's a sadly locked New Yorker article on a doctor convicted and jailed, as, the court determined, he irresponsibly prescribed heavy-duty opiates and a whole lot of people overdosed.
It's a really complicated set of circumstances, especially among the impoverished, and the article, while not at all minimizing what he did, made it clear that he was just trying his best in a dangerous and narcissistic way, and, on top of that, he was being constantly rewarded both monetarily and through the esteem of his patients for helping them with problems no other doctor wanted to treat.
Anyway, there's a point in the article where someone who has some sort of authority on the subject says the reason for the massive amount of opiate prescription and abuse among poor and marginalized people can basically be summarized as "shitty life disease": mental health problems are incredibly stigmatized, physical health problems can be treated with highly-addictive (but working!) substances and people either consciously or unconsciously (as mental health problems can easily surface in physical symptoms) present their mental health problems as physical health problems to an MD who is unscrupulous, apathetic or, like the guy in the article, just trying his best in a particularly destructive way. They get a prescription for an opiate, feel better, get hooked and and the ball keeps rolling down the hill.
Prescription opiate abuse in this country is a honest-to-god hydra. You can jail all the doctors you want, poison or tamper-proof the medication, enact stricter laws, whatever. And some of this stuff may work, plenty of it will backfire -- there was a letter to the editor in the next issue of the New Yorker with someone saying that he would pay any sum of money to just get someone to prescribe pain medication to his wife, who suffers from chronic pain and can't get treatment -- and the overdoses still go on. God knows we now have a fucking heroin resurgence in NYC because synthetic opiates are getting too expensive.
posted by griphus at 11:01 AM on June 11, 2014 [10 favorites]
You're going to have to point me to those countries that have happy, healthy populations of long-term recreational opioid users.
Yo, Holland representing.
posted by MartinWisse at 11:16 AM on June 11, 2014 [10 favorites]
Yo, Holland representing.
posted by MartinWisse at 11:16 AM on June 11, 2014 [10 favorites]
You're going to have to point me to those countries that have happy, healthy populations of long-term recreational opioid users.
Countries that have decriminalized drug use and that have instituted evidence-based harm-reduction measures - including supervised use spaces - have fewer people dying from overdoses, getting hepatitis and HIV, and ending up in the criminal justice system. In the US we keep doing what we've been doing for decades, which doesn't work, but we won't admit it doesn't work if that means we have to talk about drugs and the people who use them in terms that doesn't demonize them.
posted by rtha at 11:17 AM on June 11, 2014 [7 favorites]
Countries that have decriminalized drug use and that have instituted evidence-based harm-reduction measures - including supervised use spaces - have fewer people dying from overdoses, getting hepatitis and HIV, and ending up in the criminal justice system. In the US we keep doing what we've been doing for decades, which doesn't work, but we won't admit it doesn't work if that means we have to talk about drugs and the people who use them in terms that doesn't demonize them.
posted by rtha at 11:17 AM on June 11, 2014 [7 favorites]
Yeah, harm reduction is the name of the game. Heroin-assisted treatment has a track record of being able to work, just as wet houses (assisted living for chronic alcoholics where alcohol is provided in measured, regular doses) do.
In the US, "use" and "abuse" are conflated for basically any substance save for alcohol, and many drug policies are made based on that conflation. But that strategy is demonstrably wrong and the policies that stem from it oftentimes cause more harm than good.
posted by griphus at 11:26 AM on June 11, 2014 [4 favorites]
In the US, "use" and "abuse" are conflated for basically any substance save for alcohol, and many drug policies are made based on that conflation. But that strategy is demonstrably wrong and the policies that stem from it oftentimes cause more harm than good.
posted by griphus at 11:26 AM on June 11, 2014 [4 favorites]
Interesting factoid - Naltrexone, which is used to treat opioid addiction, also treats Crohn's disease (unofficially and off-label). How is this known? Crohn's disease is a funny autoimmune disease that gets pounded into remission by various immunosuppressors and immunomodulators, but after years on one (cheapish) medication, it may suddenly stop working and your GI will prescribe something else like, say, Remicade (about $1500US/mo) or Humira (about $1200US/mo) and if you can't afford it (with or without insurance), you go without until you get incredible gut pain that you treat with opioids, to which you then get addicted, but hey! Oxy is cheaper than Humira! And when you go in for your addition and are given an Rx for Naltrexone (about $32US/mo), you go into remission for Crohn's disease.
Hooray! The system works!
posted by plinth at 11:27 AM on June 11, 2014 [14 favorites]
Hooray! The system works!
posted by plinth at 11:27 AM on June 11, 2014 [14 favorites]
My experience of medical care in the US is - we'll do these tests, you should take these pills, go see this specialist, who will repeat the loop of some tests, pills, referral, maybe a procedure. When I've had docs who were personally acquainted with me and my life, and who took the time to sort through symptoms, test results, prescriptions, I had better results. But there's no corporate model for profiting from that. My current doc, new to me since I changed insurance, seems to care. But I may end up seeing some other provider on any given visit. The US healthcare system is driven by profit and a desire for efficiency, and while every individual health care provider I know wants to do good, the system as a whole is not serving people well.
posted by theora55 at 11:57 AM on June 11, 2014 [4 favorites]
posted by theora55 at 11:57 AM on June 11, 2014 [4 favorites]
You're going to have to point me to those countries that have happy, healthy populations of long-term recreational opioid users.
not gonna say it's a great time being an opiate addict but you can certainly keep people a lot healthier with clean paraphernalia and better yet clean drugs. And being on methadone or buprenorphine maintenance is indefinitely sustainable as long as you or somebody can pay and basically like being any ordinary person with a very important daily appointment. But I guess that may not count as recreational use anymore.
posted by atoxyl at 12:10 PM on June 11, 2014
not gonna say it's a great time being an opiate addict but you can certainly keep people a lot healthier with clean paraphernalia and better yet clean drugs. And being on methadone or buprenorphine maintenance is indefinitely sustainable as long as you or somebody can pay and basically like being any ordinary person with a very important daily appointment. But I guess that may not count as recreational use anymore.
posted by atoxyl at 12:10 PM on June 11, 2014
a) Good Lord, it's not poison, it's Vicodin minus the poisonous adulterant (Tylenol). As a chronic pain sufferer, I'm in favor.
b) Generally, I think non-fatal deterrents are better.
c) Why Propofol abuse: dissociation and sexual hallucinations
posted by j_curiouser at 12:13 PM on June 11, 2014
b) Generally, I think non-fatal deterrents are better.
c) Why Propofol abuse: dissociation and sexual hallucinations
posted by j_curiouser at 12:13 PM on June 11, 2014
So, it's dangerous because it'll get abused, because our culture doesn't teach or allow people to enjoy recreational drugs responsibly? Gotcha.
Though for sure opiate addiction is not particularly a matter of teaching people the wrong things or a culture of immoderation.
posted by atoxyl at 12:20 PM on June 11, 2014 [3 favorites]
Though for sure opiate addiction is not particularly a matter of teaching people the wrong things or a culture of immoderation.
posted by atoxyl at 12:20 PM on June 11, 2014 [3 favorites]
When I've had docs who were personally acquainted with me and my life, and who took the time to sort through symptoms, test results, prescriptions, I had better results. But there's no corporate model for profiting from that.
5 minutes more attention (instead of testing for everything under the sun to prevent liability) can safe billions in health care cost, simply by getting the first line of defense, your GI, doing a better job and preventing expensive down the line care.
When what society needs from a system (good health for as many as possible) and what society gets from a system (profit) are at odds, society is doing something wrong.
I mean, I can imagine "there's no profit model to give me what I need" when you're in a small niche market and it's just not feasible for the 3 potential customers, but when it's a multi-trillion market, and something as simple as 5 minutes extra attention can make a difference... priorities need to move away from "profit".
posted by DreamerFi at 12:27 PM on June 11, 2014
5 minutes more attention (instead of testing for everything under the sun to prevent liability) can safe billions in health care cost, simply by getting the first line of defense, your GI, doing a better job and preventing expensive down the line care.
When what society needs from a system (good health for as many as possible) and what society gets from a system (profit) are at odds, society is doing something wrong.
I mean, I can imagine "there's no profit model to give me what I need" when you're in a small niche market and it's just not feasible for the 3 potential customers, but when it's a multi-trillion market, and something as simple as 5 minutes extra attention can make a difference... priorities need to move away from "profit".
posted by DreamerFi at 12:27 PM on June 11, 2014
(it really comes down to certain percentage of people being particularly susceptible)
but it also would in many ways be drastically less harmful (not that somebody won't fuck up fatally but come on that goes for everything) if the drugs weren't artificially scarce so don't think I'm on the side of underprescription
posted by atoxyl at 12:31 PM on June 11, 2014
but it also would in many ways be drastically less harmful (not that somebody won't fuck up fatally but come on that goes for everything) if the drugs weren't artificially scarce so don't think I'm on the side of underprescription
posted by atoxyl at 12:31 PM on June 11, 2014
Celebrex is still on the market. I don't know of any other COX 2 inhibitors marketed in the US.
I don't think it's the same as it used to be, though? It doesn't seem to have the same benefits although I wholly admit that it is just as likely that my arthritis is just a whole fucking lot worse now.
i'm not allowed to take it anyway, sob
posted by elizardbits at 12:33 PM on June 11, 2014
THe active ingredient is the same; I don't know if they've altered the dose or whatever. I think, unfortunately, that your second hypothesis is likely the correct one; you have my sympathy.
posted by Mister_A at 1:29 PM on June 11, 2014
posted by Mister_A at 1:29 PM on June 11, 2014
This whole area is so distressing. If you were planning an advertising campaign to sell a drug to users, you could not do better than the current hysteria around Zohydro. And if you were planning to enmesh doctors and pain patients in a distressing mesh of overregulation and criminalization that does nothing to prevent addiction, you couldn't do better than what we are doing now.
The New Yorker piece and this were so enraging— Are We Too Good at Treating Pain? Um, that could have been answered in the negative by speaking to chronic pain patients, which, although I am not going to read the darn thing again to check unless someone pays me to write about it, I think he did not do much of. Which, if true, is horrifying: how can you write about pain without talking to people in pain? The whole reason opioids are an issue is that we don't have many options for chronic pain.
Regarding the New Yorker, it basically attempted to destroy the legacy of Siobhan Reynolds, the only major pain activist who *didn't* take drug company money. It painted her as though she made things worse for the doctor she tried to help, when, in fact, she was one of the few people who, by hiring lawyers who understood the issue, actually gave these guys a teeny weeny chance of not going to prison. The piece basically supported the criminalization of pain treatment, failing to recognize that malpractice isn't drug dealing: you can't be an "accidental drug dealer" if you are a doctor. If you think you are practicing medicine, even if you are doing so badly, you are not a dealer. You might be a bad doctor, but that isn't a criminal matter.
ARRHGHGHGH... this makes me so upset I can't even write about it.
posted by Maias at 1:52 PM on June 11, 2014 [8 favorites]
The New Yorker piece and this were so enraging— Are We Too Good at Treating Pain? Um, that could have been answered in the negative by speaking to chronic pain patients, which, although I am not going to read the darn thing again to check unless someone pays me to write about it, I think he did not do much of. Which, if true, is horrifying: how can you write about pain without talking to people in pain? The whole reason opioids are an issue is that we don't have many options for chronic pain.
Regarding the New Yorker, it basically attempted to destroy the legacy of Siobhan Reynolds, the only major pain activist who *didn't* take drug company money. It painted her as though she made things worse for the doctor she tried to help, when, in fact, she was one of the few people who, by hiring lawyers who understood the issue, actually gave these guys a teeny weeny chance of not going to prison. The piece basically supported the criminalization of pain treatment, failing to recognize that malpractice isn't drug dealing: you can't be an "accidental drug dealer" if you are a doctor. If you think you are practicing medicine, even if you are doing so badly, you are not a dealer. You might be a bad doctor, but that isn't a criminal matter.
ARRHGHGHGH... this makes me so upset I can't even write about it.
posted by Maias at 1:52 PM on June 11, 2014 [8 favorites]
Even before a single doctor in the United States had written a prescription for Zohydro [...] potential users were already dreaming up possible street names. “How many times will this be said in the future,” someone posted on Opiophile, an online forum for people who like to share their drug experiences and expertise. “Got any of dem Zoh’s?” There were other possibilities: Zs, Zodros, and Zorros. Another voiced chimed in: “I like Zorros … Yeah, has a ring to it.” This was on October 26, 2013, less than 24 hours after the FDA announced its decision.
Less than 24 hours later, people talked about it on the internet?! This was such a gross and unnecessary opening for this article and should have been cut. Such a shame, because the part that follows, the depiction of the ER docs "glumly" browsing the online forums to forecast the arrival of Zohydro-related overdoses -- that would have been a good, evocative mental image right up front to represent the concerns over the abuse of Zohydro.
Instead, it was apparently irresistible to start out by conjuring up an image of those degenerate pill-heads and their anticipatory glee...as if this is all FUN AND GAMES! See how dangerous this drug is?!
The most dramatic moment of these hearings often happens when the panel debates, and votes on, the merits of a new drug. And the simple explanation for how the FDA wound up approving a high-dose, non-tamper-resistant version of a highly addictive narcotic came out in that final discussion and boiled down to a single philosophical question: What is more important, adhering to an equitable regulatory framework for drug approval (and maintaining what the FDA called “a level playing field” for the company) or considering the larger issue of public health?
I was taken aback a bit by the confidence of this assertion. This "simple explanation" which "came out" of the FDA discussion...this was according to whom? What exactly is simple about this question? What issues in public health are included in the "larger issue of public health?"
posted by desuetude at 2:59 PM on June 11, 2014
Less than 24 hours later, people talked about it on the internet?! This was such a gross and unnecessary opening for this article and should have been cut. Such a shame, because the part that follows, the depiction of the ER docs "glumly" browsing the online forums to forecast the arrival of Zohydro-related overdoses -- that would have been a good, evocative mental image right up front to represent the concerns over the abuse of Zohydro.
Instead, it was apparently irresistible to start out by conjuring up an image of those degenerate pill-heads and their anticipatory glee...as if this is all FUN AND GAMES! See how dangerous this drug is?!
The most dramatic moment of these hearings often happens when the panel debates, and votes on, the merits of a new drug. And the simple explanation for how the FDA wound up approving a high-dose, non-tamper-resistant version of a highly addictive narcotic came out in that final discussion and boiled down to a single philosophical question: What is more important, adhering to an equitable regulatory framework for drug approval (and maintaining what the FDA called “a level playing field” for the company) or considering the larger issue of public health?
I was taken aback a bit by the confidence of this assertion. This "simple explanation" which "came out" of the FDA discussion...this was according to whom? What exactly is simple about this question? What issues in public health are included in the "larger issue of public health?"
posted by desuetude at 2:59 PM on June 11, 2014
Interesting factoid - Naltrexone, which is used to treat opioid addiction, also treats Crohn's disease (unofficially and off-label). How is this known? Crohn's disease is a funny autoimmune disease that gets pounded into remission by various immunosuppressors and immunomodulators, but after years on one (cheapish) medication, it may suddenly stop working and your GI will prescribe something else like, say, Remicade (about $1500US/mo) or Humira (about $1200US/mo) and if you can't afford it (with or without insurance), you go without until you get incredible gut pain that you treat with opioids, to which you then get addicted, but hey! Oxy is cheaper than Humira! And when you go in for your addition and are given an Rx for Naltrexone (about $32US/mo), you go into remission for Crohn's disease.
Thank you very much for this, plinth; you've crystalized something I've been puzzling over for awhile now.
We know that opioids tend to be quite constipating, and if Crohn's, like many auto-immune diseases, can be triggered by an infection or even the mere presence of an organism, couldn't it be in the best interests of such an organism living in the bowel of a Crohn's sufferer to produce something which would bind to the relevant opioid receptor in order to keep the bowel from moving and thereby getting rid of a source of nutrients for it?
In this scenario, the naltrexone would work by displacing the ligand produced by the organism from the opioid receptors (which is exactly what it does to the Oxy), allowing the bowel to move normally, clearing its contents and preventing the organism from building up to levels which trigger an immune response.
posted by jamjam at 6:06 PM on June 11, 2014 [2 favorites]
Thank you very much for this, plinth; you've crystalized something I've been puzzling over for awhile now.
We know that opioids tend to be quite constipating, and if Crohn's, like many auto-immune diseases, can be triggered by an infection or even the mere presence of an organism, couldn't it be in the best interests of such an organism living in the bowel of a Crohn's sufferer to produce something which would bind to the relevant opioid receptor in order to keep the bowel from moving and thereby getting rid of a source of nutrients for it?
In this scenario, the naltrexone would work by displacing the ligand produced by the organism from the opioid receptors (which is exactly what it does to the Oxy), allowing the bowel to move normally, clearing its contents and preventing the organism from building up to levels which trigger an immune response.
posted by jamjam at 6:06 PM on June 11, 2014 [2 favorites]
Some comment by some Jones guy I saw there:
I know the difference between hydrocodone (a prodrug like codeine that has to be converted in the body and is pointless to inject, which is a more addictive route of administration) vs. heroin (diacetylmorphine, an incredibly potent bioavailable "instant drug" that is very effective through injection or insufflation) and can only conclude that the "PhD researcher" did a shoddy job of factoring in route of administration and the actual real-world preferences of drug addicts. Any pharmacist or pharmacologist with the slightest understanding of kinetics and the metabolism of these drugs would concur. It's total sensationalist bullshit to say "an opiate is an opiate" let alone "an opioid is an opioid" (opiates are opioids, not all opioids are opiates, some have higher receptor affinity, some are pro-drugs that some people convert into real drugs better than others, etc). Terrible article for giving zero perspective on the legitimate pain patients or pharamacists who know what the hell they're talking about.
Edit (in 4 minutes)(whoops)
posted by aydeejones at 8:23 PM on June 11, 2014
I know the difference between hydrocodone (a prodrug like codeine that has to be converted in the body and is pointless to inject, which is a more addictive route of administration) vs. heroin (diacetylmorphine, an incredibly potent bioavailable "instant drug" that is very effective through injection or insufflation) and can only conclude that the "PhD researcher" did a shoddy job of factoring in route of administration and the actual real-world preferences of drug addicts. Any pharmacist or pharmacologist with the slightest understanding of kinetics and the metabolism of these drugs would concur. It's total sensationalist bullshit to say "an opiate is an opiate" let alone "an opioid is an opioid" (opiates are opioids, not all opioids are opiates, some have higher receptor affinity, some are pro-drugs that some people convert into real drugs better than others, etc). Terrible article for giving zero perspective on the legitimate pain patients or pharamacists who know what the hell they're talking about.
Edit (in 4 minutes)(whoops)
posted by aydeejones at 8:23 PM on June 11, 2014
Naturally the article does this thing where it weaves oxycodone and hydrocodone and heroin and morphine all together and then the research mentioned focuses on similarities between oxy and hydrocodone, which are both going to be less crazy-potent than morphine, heroin, dilaudid, etc. My response was more focused towards a comment specifically addressing the "equivalence" between hydrocodone and heroin. It's true that high doses of less potent substances will keep a user happy for a long time, and it's usually the expense that drives an otherwise "never would I inject" typical personality to using heroin. But that's a more complicated thing to talk about than saying "IT'S ALL HEROIN YO!"
posted by aydeejones at 8:29 PM on June 11, 2014
posted by aydeejones at 8:29 PM on June 11, 2014
Sometimes I think we should rename the US to "Malaisia" but it sounds too similar to another country. Maybe "Nucynta" or "The Ennui-ted States of America."
posted by aydeejones at 8:32 PM on June 11, 2014
posted by aydeejones at 8:32 PM on June 11, 2014
Heroin is also a prodrug, as are lots of opiates that are quite worth injecting if you are so inclined. If I recall hydrocodone probably "works fine" by this ROA - the reason it's not done often is that it can produce a severe and potentially dangerous reaction. I know for sure that's true of codeine. It's also just pretty weak in the grand scheme of things. But for a lot of people who don't have a tolerance snorting one of these would get them well beyond high.
Incidentally I have always been nearly impervious to hydrocodone. Presumably one of those differences in metabolism.
oxy and hydrocodone, which are both going to be less crazy-potent than morphine, heroin, dilaudid, etc.
taking the drug pedantry further, morphine isn't super potent- less so than oxycodone orally (about equivalent to hydro, morphine's low oral availability is kind of famous) and about twice as parenteral. then H is two or three times that and from there of course synthetics and semi-synthetics really run away with it
posted by atoxyl at 10:27 PM on June 11, 2014
Incidentally I have always been nearly impervious to hydrocodone. Presumably one of those differences in metabolism.
oxy and hydrocodone, which are both going to be less crazy-potent than morphine, heroin, dilaudid, etc.
taking the drug pedantry further, morphine isn't super potent- less so than oxycodone orally (about equivalent to hydro, morphine's low oral availability is kind of famous) and about twice as parenteral. then H is two or three times that and from there of course synthetics and semi-synthetics really run away with it
posted by atoxyl at 10:27 PM on June 11, 2014
yeah, i got some fentanyl in my iv last month and it was really very nice.
posted by elizardbits at 10:32 PM on June 11, 2014
posted by elizardbits at 10:32 PM on June 11, 2014
i thanked the nurse so effusively that she gave me a frysquint of suspicion
posted by elizardbits at 10:34 PM on June 11, 2014 [1 favorite]
posted by elizardbits at 10:34 PM on June 11, 2014 [1 favorite]
yeah, i got some fentanyl in my iv last month and it was really very nice.
this is the real don't try this at home category. i'm sure you know but if anyone is actually interested in/learning from this discussion, fentanyl is 100x as strong as morphine. and there are derivatives 100-1000 times stronger, one of which is the likely candidate for the disastrous "incapacitating" agent used in the 2002 russian theater siege
posted by atoxyl at 10:42 PM on June 11, 2014
this is the real don't try this at home category. i'm sure you know but if anyone is actually interested in/learning from this discussion, fentanyl is 100x as strong as morphine. and there are derivatives 100-1000 times stronger, one of which is the likely candidate for the disastrous "incapacitating" agent used in the 2002 russian theater siege
posted by atoxyl at 10:42 PM on June 11, 2014
Why are patients shut out of the debate over prescription pain medicine?
posted by homunculus at 10:57 PM on June 13, 2014
posted by homunculus at 10:57 PM on June 13, 2014
Why We Must Not Let Addiction Hysteria Kill Off Zohydro: As a chronic pain patient, a misdirected crusade against opioids has significantly added to my suffering. I'm even afraid to ask my doctor about taking Zohydro. Let's go with the science, not the scare tactics.
posted by homunculus at 11:02 AM on June 14, 2014
posted by homunculus at 11:02 AM on June 14, 2014
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This thread has been archived and is closed to new comments
Maybe if we had better ways for people to get help and support, if we didn't demonize people for enjoying drugs, or for becoming addicted, we might not have to worry about this?
The US has a huge problem with being unable to exercise moderation, or see shades of gray instead of black and white.
posted by explosion at 8:44 AM on June 11, 2014 [19 favorites]