Drug Dealers Inc.
May 9, 2012 10:35 AM   Subscribe

US Senate probes painkiller makers and their advocates. Improper relationships between pharmaceutical companies and organizations that promote their drugs helped usher in an epidemic that's killed 100,000 people through misuse of opioids. Sales of the powerful drugs have risen 300 percent since 1999 and opioids were involved in 14,800 overdose deaths in 2008, more than cocaine and heroin combined.
posted by binturong (75 comments total) 13 users marked this as a favorite
The streets are awash in pills. Prices are like a quarter of what they were a few years ago. I just keep saying "qui bono?"
posted by telstar at 10:37 AM on May 9, 2012 [1 favorite]

Where's William Burroughs when we need him? I would love to hear his angle on all of this.
posted by philip-random at 10:40 AM on May 9, 2012

Most of the recent increase in sales is attributable to Rush Limbaugh gearing up for election season.
posted by Fritz Langwedge at 10:41 AM on May 9, 2012 [2 favorites]

If this also came with a sensible attitude towards pain management in this country I'd welcome it, but it's probably just going to add ammunition to the kind of shitbirds who recommend you "offer your suffering up to god."
posted by Lentrohamsanin at 10:41 AM on May 9, 2012 [30 favorites]

I have a huge problem with the way this data is presented in the article. Are the deaths from the opioid or from kidney or liver failure due to overdosing on the NSAIDs/analgesics included in the pills? It's very, very easy to overdose on tylenol. It's not very easy to overdose on hydrocodone.
posted by TheNewWazoo at 10:43 AM on May 9, 2012 [27 favorites]

an epidemic that's killed 100,000 people through misuse of opioids.

...which seems like the expected outcome of unnecessarily adding near-lethal amounts of acetaminophen to addictive drugs that are likely to be abused, right?
posted by almostmanda at 10:45 AM on May 9, 2012 [41 favorites]

"an epidemic that's killed 100,000 people through misuse of opioids"? "involved in 14,800 overdose deaths in 2008, more than cocaine and heroin combined"?

Bullshit. Official statistics credit damn near any death of a person with opioids in their system to the painkillers, regardless of circumstances of death. They're worthless for any actual discussion on addiction and the prosecution of pain patients/doctors.
posted by Holy Zarquon's Singing Fish at 10:46 AM on May 9, 2012 [11 favorites]

Will Rush Limbaugh be testifying?
posted by ZenMasterThis at 10:47 AM on May 9, 2012

E.R. Doctors face quandary on painkillers -- “Almost all dental patients request a prescription for narcotic pain pills,” Dr. Lobitz said. “ ‘I just need something to tide me over until I can see a dentist’ — that’s the classic line.”
posted by wikipedia brown boy detective at 10:48 AM on May 9, 2012

As much as I don't like the pharma-industry pushing drugs of questionable use on people who don't need them, the current crackdown on opiate painkillers drives me up a wall. My newly-retired father has multiple injuries and ongoing conditions that cannot be fixed, only managed with ever increasing pain medication.

Not too long ago, he could have simply phoned or visited his nearby GP who would check the date of his last refill and write him a new one if the dates matched the number of pills prescribed. Now he has to be driven about an hour away to a specialist pain clinic every month or so just for the pleasure of being told "Yes, that stuff you have that isn't going to ever get better still isn't better. Have you tried relaxing in a hot bath? Every day you say? Gentle stretching? Oh, ok, I guess you can have some more pills. " Every month, I think.

Has to be driven because they are required to report him to the DMV who are going to confiscate his driving license.

As sales of the powerful drugs have boomed — rising 300 percent since 1999 — so, too, have overdose deaths. Opioids were involved in 14,800 overdose deaths in 2008...

I'm sure this has nothing at all to do with the baby-boomer generation getting older and requiring more pain-killer prescriptions to be written. Nothing at all.
posted by K.P. at 10:50 AM on May 9, 2012 [8 favorites]

US Senate probes painkiller makers and their advocates.

"Does it hurt here?"
"How about here?"
"What do you feel now?"
"Not much."

I mean, what do they expect?
posted by gauche at 10:52 AM on May 9, 2012 [4 favorites]

I was just talking to one of my friends about this - she was prescribed Vicodin for back pain even though she is sensitive to Tylenol. They're a lot more reluctant to prescribe vicoproufen be ause of its higher potential for (or really, survivability of) abuse. So, trained chemist that she is, she went to some pretty methy lengths to separate the hydrocodone and aceitominaphen.
posted by modernserf at 10:54 AM on May 9, 2012 [3 favorites]

mmmm. opoids. say it with me: oooohpoooooiiiiids.
posted by quonsar II: smock fishpants and the temple of foon at 10:59 AM on May 9, 2012 [2 favorites]

K.P., bear in mind that your fathercan still be arrested for taking those pills.
posted by Holy Zarquon's Singing Fish at 10:59 AM on May 9, 2012

Of course that's the classic line. I wonder if Dr. Lobitz has ever had serious oral pain. I was practically suicidal over the pain from the dry sockets after my wisdom teeth got done and they'd prescribed me only enough Percocet for the first 3 days, and hadn't warned me I might need more. I can't even come up with words to describe what it felt like. I'm not even totally sure the first oral surgeon I saw would have even given me more; the followup was thankfully done by someone else, who took a look in my mouth, immediately put some numbing stuff on the area, and babied me excessively before writing me another two weeks' worth.

I think there's a dual problem here. There's a lot of abuse. There's also a lot of people who aren't getting adequate medical care (or dental care) in some other fashion, and therefore are in quite a lot of pain, and it is cheaper to prescribe painkillers than to actually treat the underlying causes. So making it harder to get painkillers essentially tortures part of the population in order to prevent abuse by another part of the population.

If we had adequate substance abuse treatment available to the poor in this country, I would say that the Tylenol additive--I almost want to say 'adulteration', given how dangerous it seems to be--would make sense. Given that it's not, that just makes it seem like we're on the one hand depriving people legitimately in pain, and on the other hand attempting to kill the people who have an addiction, and I cannot figure out where any of this fits into the rubric of "do no harm".
posted by gracedissolved at 11:00 AM on May 9, 2012 [17 favorites]

Re: Tylenol, it's adulteration, plain and simple. It's basically the same as adding salt to cooking wine; it doesn't do anything to make the product more effective at its primary purpose, but if you try to use it to get high/drunk, the additive chemical will make you miserable, and then you'll be sorry. Or dead.
posted by Holy Zarquon's Singing Fish at 11:03 AM on May 9, 2012 [5 favorites]

wikipedia brown boy detective: E.R. Doctors face quandary on painkillers -- “Almost all dental patients request a prescription for narcotic pain pills,” Dr. Lobitz said.

In a long, weird evening, I found out that it's not that hard to get a few painkilles from the E.R. I wasn't in the room, so I don't know what the guy said to the doc, but the guy came out half an hour after I he went into the E.R. with 10 pills of something, of which he took 3 in the next hour. I'm guessing it was the easiest way out of an awkward situation. How can you tell someone that they really aren't in pain, that they're just lying?
posted by filthy light thief at 11:04 AM on May 9, 2012

I'm with K.P. Prescription pill abuse is real, but so is the complete and utter cluelessness of traditional medicine on the subject of chronic pain. My wife has chronic pain, and most of the time they just look at her dumbfounded; they have no idea what it is, and they're not particularly interested in finding out. Most of them don't even believe it's real. the ones that do dole out the pills on autopilot; my own experience with back pain has been that the prescription appeared to have been already written before I got there. And they were worthless, too -- made me high but didn't alleviate the pain at all, let alone get it to go away. A visit to the chiropractor did that -- literally a five second treatment and it was gone.

I have a friend with chronic headache pain who depends more than he should on Excedrin, and I have watched him OD on acetaminophen before, which was absolutely terrifying. I don't understand why that stuff is legal; the difference between an effective dose and a fatal overdose is incredibly small. And yet they stuff it in EVERYTHING -- go down the cold and flu aisle sometime and see how many products have it. Shocking. Even a normal dose of Nyquil with a couple tabs of Tylenol to back it up can put you in the hospital.
posted by Fnarf at 11:06 AM on May 9, 2012 [4 favorites]

E.R. Doctors face quandary on painkillers -- “Almost all dental patients request a prescription for narcotic pain pills,” Dr. Lobitz said.

Our big trauma center ER has helped to address this problem by having a 24-hour emergency dental clinic onsite. If people come in with dental pain, they're numbed up with lidocaine and sent across the hall for the dental folks to deal with. If people are seeking, they usually bug out before they're seen in the dental clinic; if they aren't, then their issue is dealt with in a timely and appropriate fashion. Either way, it takes the dilemma off the shoulders of the ER doc.
posted by KathrynT at 11:13 AM on May 9, 2012 [10 favorites]

Tired of sourcing opiates from health-blind industrial giants? Try the natural route, explained in Jim Hogshire's Opium for the Masses.
posted by telstar at 11:13 AM on May 9, 2012 [3 favorites]

Prescription pill abuse is real

But so what? If it weren't for the adulteration, the crisis wouldn't exist, and the "abuse" would be about as a big a deal as people who play their music too loud.
posted by spaltavian at 11:19 AM on May 9, 2012 [5 favorites]

Holy Zarquon's Singing Fish, it's also similar to the US government's 'federal poisoning program' of industrial alcohol during Prohibition
posted by the man of twists and turns at 11:19 AM on May 9, 2012 [4 favorites]

similar to the US government's 'federal poisoning program' of industrial alcohol during Prohibition

Are they going to have a cute coloquial name for a horrible symptom again like 'Jittery Jake'?
posted by Slackermagee at 11:32 AM on May 9, 2012 [2 favorites]

This is a hugely complex issue that tends to be oversimplified by the media. As TheNewWazoo pointed out, there's no information in this article about the percentage of deaths or overdoses attributed to acetaminophen, which is present in large quantities in most of the narcotics that are prescribed for moderate pain.

In the past few years, the recommended maximum daily dosage of acetaminophen has fallen from 4000mg to 3000mg to 2700mg, and new research indicates that sustained use at near-maximum dosage levels can cause liver failure (previously on mefi).

I have suffered from debilitating migraine headaches for over 20 years. There are meds for migraines, but they're very expensive, and they don't always work. Narcotic pain killers are generally inexpensive and fairly effective at either dulling the pain or simply knocking me out. For instance, commonly-prescribed triptans like Imitrex or Maxalt cost anywhere from $15 - $100/dose, whereas generic hydrocodone is usually $0.30 - $1/dose. When the triptans work, they are amazing, and have a tolerable side effect/risk profile. Unfortunately, they only work for about 50% of my headaches, so I always wonder whether I'm about to flush $100 down the toilet when I use an Imitrex injector.

I've also moved many, many times over the past 15 years, which makes it difficult to establish a long-term relationship with a doctor. Over the past few years, I've found that it has become increasingly difficult to obtain narcotic analgesics from any doctor that hasn't known me for several years. In my experience, asking for narcotics will generally cause the doctor to assume that you are an addict engaged in "drug-seeking behavior."

I fill a prescription for Lortab roughly every 2 - 3 months, and I have to jump through ridiculous hoops every time. Even though I no longer live there, I do this through my old family doctor in Indiana, because I haven't found any new doctor who is willing to prescribe anything other than triptans and various prophylactic anticonvulsants (like Topamax) which have nasty side effects. I'm lucky to get even the few that I do, though they are limited in terms of utility due to the obscenely large amounts of acetaminophen in each dose.

One other thing worth noting: withdrawal from narcotics is not a fun experience, but is nowhere near as bad as withdrawing from, say, benzodiazepines. In fact, there are a lot of folks who experience more severe withdrawal symptoms from various SSRI antidepressants like Zoloft. Withdrawal from any drug is highly individual and related to the quantity and duration of dependency, but moderate withdrawal from narcotics is shorter and less dangerous than many other common drugs on the market today. The maximum recommended daily dose you're likely to see for hydrocodone is probably 60 - 80mg, which will put you at the maximum dose of 3000 - 4000mg of acetaminophen. If you take that much every day for a month and stop cold turkey, you'll experience gastrointestinal problems, insomnia, and flu-like symptoms for several days, likely peaking about 48 hours after the last dose. By comparison, there are a substantial number of people taking Xanax XR (or a similar benzodiazepine) for anxiety at anywhere from 2mg - 6mg per day. If you stop taking Xanax XR after taking 2mg per day for a month or two, you will be in for at least a couple of weeks of hellish withdrawal and are at serious risk of seizure or death.
posted by drklahn at 11:32 AM on May 9, 2012 [3 favorites]

This paper has several estimates for total accidental deaths per year due to overdose of acetaminophen from any source; the upper bound I see is 250. Lots of people are injured by acetaminophen overdose but don't die from it (and would probably not have overdose listed as their eventual cause of death), so I don't think that's explaining these statistics. Also worth noting that FDA already did lower the acetaminophen dose in combined acetaminophen-opioids (that change is still phasing in).
posted by a robot made out of meat at 11:44 AM on May 9, 2012

Of course that's the classic line. I wonder if Dr. Lobitz has ever had serious oral pain.

No kidding. I had to have a tooth removed last year, and the days leading up to the appointment were completely dominated by pain management. If I screwed up by so much as half an hour, I ended up laying on the floor whimpering, feeling like my skull was cracking apart, just trying to breathe while I waited for the next batch of whatever to kick in. I went through most of my stock of Canadian codeine pills, piles of ibuprofen, a few scavenged oxycodone (which were the only thing that let me sleep) and several bottles of whiskey - it was not a good time for my liver.

I've been in pain before due to injuries, but this was a pain that pre-empted all other needs. "I just need something to tide me over" indeed!
posted by Mars Saxman at 11:45 AM on May 9, 2012 [3 favorites]

There seems to be a misunderstanding here that Congress is targeting legitimate pain prescriptions. The epidemic got particularly bad in jurisdictions where doctors are allowed to both prescribe and dispense pills in the same office, creating conditions that attracted flagrant abuse of the law and medical ethics. There are many moments of head-shaking disbelief in the following tale from Florida, but one moment in particular stood out for me: when they couldn't be bothered handling the crumpled dollar bills from people, so they just burned them. That tells you something about the overall cash flow from the operation.

How Florida brothers' 'pill mill' operation fueled painkiller abuse epidemic

After Florida clamped down on the same-office rule, dispensations fell by 97%.
posted by dhartung at 11:58 AM on May 9, 2012

There seems to be a misunderstanding here that Congress is targeting legitimate pain prescriptions.

I don't think they're specifically singling out legitimate prescriptions; I just don't think they care.
posted by Holy Zarquon's Singing Fish at 12:07 PM on May 9, 2012 [2 favorites]

Of course that's the classic line. I wonder if Dr. Lobitz has ever had serious oral pain.

Two years ago, when I had back surgery, the only pain meds that did anything to quell the blinding pain were Avinza and, later, good old hydrocodone. Even today, two years on, I still have to resort to a 5mg hydrocodone at night on those days when I've over-stressed my back.

Sounds like I better get a new prescription before the opioid witch-hunt goes full-court-press.
posted by Thorzdad at 12:09 PM on May 9, 2012

First off, I have ranted on this subject multiple times. Fuck tylenol! Get that shit out of my scripts. Its useless, and doesn't aid in pain reduction, otherwise I would just take fucking tylenol.

Second of all due to my age (mid twenties) and having arthritis, my doctor is hesitant to script me anything strong enough to adequtly deal with my pain. So I am stuck in three different scenerios.
1. I run out of my pain medication early
2. I am in fucking pain, lying on a heatpad like an invalid.
3. Trading drugs for other drugs.

I hate being in this situation and when I discussed this with my PCP, she practically told me to doctor shop more or less. Direct quote " if you were older, I would give you the medication that would better deal with your pain, but I dont want you to be an addict nor get grief from the government"

Seriously!?!? So I am stuck in a shit situation? Besides I would rather be dependent, which is different from addiction to pain medications than feeling like complete and utter shit every single day for the last decade.
posted by handbanana at 12:19 PM on May 9, 2012 [1 favorite]

Read (or maybe don't read) the article, Dhartung posted handbanna, those crooked motherfuckers made it harder for you to manage your pain. It's a damn shame and a pure example of the how useless the war on drugs is. Addiction is a medical and social problem, not a criminal problem.
posted by Divine_Wino at 12:24 PM on May 9, 2012

I'm glad to see that the mefi consensus (so far) is contrary to the bullshit anti-opiate propaganda of the linked article (and post).

Besides the very salient point that many OD deaths attributed to opiates are actually the result of OD from acetaminophen (though this should not be overstated, as it's pretty much very easy to die from an opiate OD when alcohol or another central nervous system depressant is involved — which is far too common), the really important point that is being either suspicious elided or obscured in such articles is that the vast majority of ODs, abuse, and addiction occur as the result of illicit use of opiates by people for whom they were not prescribed. The rate of abuse, addiction, and OD by patients prescribed the drugs is a very small fraction of the total number.

Nevertheless, articles and viewpoints like this consistently represent this as a crisis of lax overprescribing of opiates by doctors to patients, when it simply is not the case. It's a lie to claim that it is.

Far be it from me to defend the pharmaceutical companies and their improper relationships to pain advocacy groups and the like. Indeed, I very strongly blame the pharmaceutical industry (particularly Purdue Pharma) in conjunction with the FDA for the majority of the present opiate abuse epidemic because of the (naive or criminally negligent) approval of OxyContin as a new opiate that would be difficult and unlikely to be abused (it includes a buffer to greatly slow the onset — the quickness and intensity of the high is extremely highly correlated to opioid abuse) when it was obvious to anyone who has a brain and/or wasn't on the take that this could be easily circumvented by crushing the pills and taking them orally or nasally. OxyContin built the contemporary cultural phenomenon of widespread opiate abuse — once it became popular, it fed a growth of street opiate abuse that pulled in all the other available prescription opiates.

Nevertheless, I don't blame any pain patient advocacy groups for accepting pharma money because, frankly, when we live in a time and place when such advocates are targeted by prosecutors (no, really, it happens) and pain patients are almost universally suspected and scorned by physicians, pharmacists, and almost always undertreated as a result, it's hard to argue against taking whatever help is available, even from sources with questionable motives like the pharma industry.

And, in any event, what's happening here is just a particular manifestation of the anti-drug hysteria that has gripped the US for forty years. Other countries don't restrict and adulterate opiates to the degree to which the US does and yet they don't have crisis of abuse that's worrying people here. Furthermore, there's as much reason to be worried about abuse of and ODs from antianxiety meds such as Xanax, but that doesn't get the same press. Opiates have the peculiar distinction of being particularly vilified by the puritanically-minded in our culture. This isn't a problem with the prescribing of opiates for pain and a resulting abuse. This is a problem of drug abuse and the illegal drug trade, in general, and the social conditions (and regulatory and legal regimes which do more to support it than eliminate it). The victims of this hysteria are the pain patients who don't get the treatment they need.
posted by Ivan Fyodorovich at 12:41 PM on May 9, 2012 [2 favorites]

This is a subject very close to my heart and I am scared to see that things may get even more difficult for people who need opiate prescriptions.

My mother, who is in her 50s, has been on the same level of daily percoset+naproxen for over 3 years due to debilitating chronic pain. Every other fucking appointment is an argument about the fact that there are more than 30 days in some months (Don't get me started that she had to pay for an office visit every single month to get her refill until I accused the office of taking advantage of my mother. Now it's every three months). She must submit to random urine tests, blood tests every 3 months, and a constant barrage of "Lyrica-this, Lyrica-that". It is MINDBLOWING and I have completely lost all respect for this doctor. All of this is apparently due to "the rules" for an GP with fewer than 5 chronic pain patients in her entire practice (I asked).

Now my mother has been suffering from the beginning of arthritis and a collapsed disk. The breakthrough pain has almost completely sapped her of any of the spark she had for life. Her kidney function finally started to suffer from the buffet of NSAIDS that she is taking to try and manage the pain because she knows as well as I do that the doctor will never approve a larger dose.

If things get any harder, I don't know what we will be able to do for her.
posted by Vysharra at 12:44 PM on May 9, 2012 [2 favorites]

Apparently, even in this Internet world, 100,000 people had never heard of CWE.
posted by Bathtub Bobsled at 12:53 PM on May 9, 2012 [1 favorite]

Thanks I will have to check out that article!a

Vysharra, fuck Lyrica. Gabapentin is great for nerve issues with few side effects and is generic. It certainly is a life saver for me.

Re: Oxycotin, for those of us in pain its a life saver. Yet it was marketed wrongly as safe and less addictive than other opiate drugs. I have a stash for when pain gets really bad. I could see people falling into trouble with it, but it has certainly been useful for bad days. For regular pain days, its a bit over kill for me. I always try to stay aware of my frequency, dose, and tolerance to avoid getting myself into trouble.
posted by handbanana at 12:54 PM on May 9, 2012 [1 favorite]

CWE is awesome, but time consuming.

Plus I dont think the average patient, user,or abuser may be aware of opiate derived medication as being water soluble
posted by handbanana at 12:57 PM on May 9, 2012 [1 favorite]

"This is a subject very close to my heart and I am scared to see that things may get even more difficult for people who need opiate prescriptions."

I've said before that the things you describe are the primary reasons why I don't take the opiates I need for the genetic illness that has disabled me and causes constant chronic pain. The truth is that for every one physician out there who contributes to the problem of illicit diversion (via pill mills or the like) there's twenty who either refuse to prescribe opiates at all (no, really, there's lots of physicians out there now who simply won't under any non-hospital circumstances) or vastly under-prescribe them in combination with humiliating and onerous conditions such as you describe.

And the main reason for this extreme over-caution (as exemplified by the "rules" you mention) is because of hair-trigger FDA sanction against physicians and aggressive prosecutorial action against physicians for supposedly overprescribing opiates. Physicians are naturally paranoid and this has translated into a culture of paranoia that's entrenched by conventional (and usually merely community) opinion in medical school about fears of prescribing opiates. It's the med school grads of the last ten years that are most inclined to refuse to prescribe opiates at all. They've been told, over and over, that there's a enormous host of patients just waiting to take advantage of them and that if they allow this, they will lose the medical license and possibly be sent to prison.

The whole idea that it's trivially easy to be prescribed opiates is mostly a lie and only partly true — that is, it's only true if you're an actual addict who knows how to and is willing to obtain opiates under dubious circumstances, such as knowing which are the actual pill mills and to doctor shop and all that. For the vast majority of us who look for pain relief responsibly and for legitimate reasons, it's difficult to get it.
posted by Ivan Fyodorovich at 12:57 PM on May 9, 2012 [2 favorites]

The War on Drugs is a symptom of why this situation exists: political meddling in medical affairs. Legal and illegal cartels both thrive on this shit.

My type of pain is complex, nerve pain and a couple of different problems with bone pain, plus neuropathy related to a stem cell transplant. Early on I used oxycodone and Tylenol, plus mscontin. I ruled out hydrocodone (and Vicodan), because I wanted to monitor the amount of the stuff in tylenol that I had to ingest...tylenol is pretty much an ambusher, while oxycodone is more incremental in its debilitating effects, and you can more easily deal with it until you approach Limbaugh levels of intoxication. A major problem with oxycodone, of course, is resetting your tolerance for it by quitting--this is sort of like voluntarily having a case of the flu for about a week. It's a bitch, and if you don't know what to expect it can be frightening. I have recently dropped the oxycodone completely, but increased my mscontin level by a third. This doesn't work as well as weed.

I can use marijuana in tea, or smoke it, as an analgesic for chronic pain. This is especially effective during the night, when the pain seems to spike as I try to drift off to sleep. Sometimes I soak in the hot tub for for an hour or so, and gain a few hours of relief from pain. I can't afford to buy marijuana, even though I am elegible to get a card (Oregon is one of those states). I'd rather use marijuana than the opiates. It's more effective than timed-release mscontin, because it acts immediately--I can take it for the infrequent spikes of pain I just mentioned, rather than loading up on a 12-hour pill. I don't want to increase the amount of mscontin I take, for the same reasons I didn't like to take increasing amounts of oxycodone. Federal law prohibits the VA from prescribing marijuana, but I get the morphine (and all it's children) from them for free.

Go figure.
posted by mule98J at 1:05 PM on May 9, 2012 [1 favorite]

handbanana, you and I are in complete agreement. I had to direct the doctor to switch her from Lyrica to Gabapentin after doing some research (above, when I wrote neproxen I meant Neurontin) due to Lyrica's horrific side effects. The doctor acted as if they had never even heard of gabapentin for nerve pain.

Apparently the Lyrica advertisement campaign was exceptionally effective.
posted by Vysharra at 1:05 PM on May 9, 2012 [1 favorite]

i use marijuana as well, and its odd. When I smoke, I use less pain meds and generally dont feel as bothered by my pain. The neurochemistry for the mechanism of action of cannabis is interesting.
When studying or writing for class, it really helps in a way that is less mind numbing than opiates.

Perhaps you could make some grower friends. They seem to always have a surplus and generally one can haggle for good prices if you dont have a grower friends. Fortunately in a medical marijuana state it is a buyers markets, not a sellers as it seems to be the case in nonmed states. At least thats how MI use to be until our compassionate care voter intiative was passed into law.
posted by handbanana at 1:21 PM on May 9, 2012 [1 favorite]

If things get any harder, I don't know what we will be able to do for her.

Have you heard of poppy tea?
posted by futz at 2:22 PM on May 9, 2012

so I always wonder whether I'm about to flush $100 down the toilet when I use an Imitrex injector.

Imitrex, or as it is known over here in the Netherlands, sumatriptan, isn't cheap. I checked a few databases I have access to, and one injection would set you back 51.93 euro. But then again, 48.85 euro of that would be covered by your health insurance.
posted by DreamerFi at 2:45 PM on May 9, 2012

An interesting and so sadly true bit from the piece that homunculus linked to (bolding mine):
Lenhart’s story has been making its way around the web the past few days, and has been generating the appropriate outrage. But it shouldn’t be all that surprising. This is the perfectly predictable outcome of all this painkiller hysteria of late. It’s bad enough coming from the usual drug warriors. But because there’s a big evil pharmaceutical corporation to play the villain, we now get progressive outlets like ProPublica, and Alternet and Salon spitting out the government’s hype without the least bit of skepticism—or concern for pain patients.
I've seen it here (this post itself is a perfect example of the bolded part) and I've seen it elsewhere in places where you'd not expect it. It's like there's a sort of blind spot for people who are otherwise skeptical of typical anti-drug hysterical bullshit.
posted by Ivan Fyodorovich at 3:26 PM on May 9, 2012

Telstar's comment is fairly convincing regarding possible pain med availability. It just seems so Puritan to me. If an effective medication can be used recreationally, i.e., Adderall, Morphine, Oxycodone, pot ,etc., then people mustn't have access to it, we have to restrict production, add toxins, and limit availability to people in genuine need. Thankfully, my brother got as much morphine as he needed when he was dying. But people are forced to have urine tests to prove they really take their meds (yeah, so you could just take the meds the day you go see the doc, duh), and have to get their meds every month in person, costing more, and some people can't get prescriptions filled because the pharmacy runs out, and can't get more.

Yes, there are pill mill docs who over-prescribe. Yes, there are people who waste ER time, money and energy seeking recreational drugs. But if you balance the bad stuff, much of which should be manageable, against people in serious pain, how can you really ignore the people in pain? Offer it up to Jesus? Be tough? This country (I'm in the US) just gets more Puritan and weird-religious-y-conservative all the time.
posted by theora55 at 4:25 PM on May 9, 2012

And yet safe & effective marijuana is illegal. Never once, in the history of mankind, has anyone died from an marijuana overdose. It's physically impossible. And yet it's illegal because... it's illegal. Ridiculous.
posted by LordSludge at 4:48 PM on May 9, 2012 [5 favorites]

Perhaps it's also an issue for the right to die. People could be overdosing on purpose, you know, although Valium (and others) and alcohol is more effective (see Kinkaid).
posted by semmi at 6:48 PM on May 9, 2012

One of my housemates needs to go to her doctor's soon to get a refill on one of her medications.

Which is an anti-psychotic. And yet still, the 'rules' say they can't give her more than one month of the stuff, and there's usually a six-week wait for appointments, so she regularly is four weeks on, two off. These aren't painkillers, these are brain-adjusters, and they still have ridiculous requirements.

This is idiocy.
posted by mephron at 7:01 PM on May 9, 2012

those who have never sufferedr from intense cronic pain just don't know how lucky they are. i did suffer it for a few uinterrupted days, and that's enough already to crush one's will to live, trustme you don't want any of it. i'd even excuse rush limbaugh for his being a malignant hypocrite bastard if it was caused by that kind of pain.

i wonder: do neuroscientist know enough about pain, as perceived by the brain, to measure its intensity, say by sticking a person in a MRI or other machines able to assess how much pain is being perceived?
posted by elpapacito at 7:05 PM on May 9, 2012

"i wonder: do neuroscientist know enough about pain, as perceived by the brain, to measure its intensity, say by sticking a person in a MRI or other machines able to assess how much pain is being perceived?"

I don't think what you're considering actually exists. There certainly is some quantifiable signal going to the brain. But that's only a part of the story. And how the brain interprets that signal, especially in the case of chronic pain, is complex and extremely variable. So I feel certain that there's not the sort of quantification you're looking for.

However, I suspect that you could quantify in some way that would be actually meaningful, such as finding ways to quantify how brain functioning in general is altered by pain loading. You could either compile a bag of things which are quantifiable and create a composite quantification, or you could just find one measurable thing that is a reliable proxy for the peoples' subjective experience of pain. I'm skeptical about the latter; however, I suspect that some combination of both approaches would be best because I think that even if you found a nice bag of brain functioning characteristics that are reliably and proportionately altered under varying pain loading, this still would deviate from too many peoples' subjective experience of any given pain loading at any given time. So you'd want something where some rough subjective measurement is balanced against your neurochemical measurement and they inform each other well enough to produce something that would be meaningful and useful.

But it might not be that much more useful than the subjective one-to-ten self-reporting that is already used in medicine. And all of us who live with chronic pain know that these subjective self-reporting pain measurements are very, very sloppy and varying. But they're better than nothing.

At the sensory level of description, pain is fairly straightforward. But that's very misleading because what happens in the brain is very not straightforward and varies greatly between people and over time in individuals and by circumstance.

Which is all one way of explaining just why it is that most of us who live with chronic pain will tell you that the pain itself, in the sense that we all think about the experience of pain, is actually the smaller part of the problem of living with chronic pain. My ability to live with the direct sensation of pain varies greatly and, because I've lived with it constantly for more than a decade, I actually mostly just don't really experience it at all, at least consciously. At the very least, I "tune it out". But it's all the other things that happen in the body and brain as the result of pain that I can't tune out. Inflammation and pain has all these systemic, cascading effects and those are ever-present. Fatigue is an obvious example. Mood is another. There's many. What chronic pain does, more than anything else, is vastly reduce one's quality of life in general. It's not one particular thing. And it's not really what most people think of as pain (even though when there's a spike, it is) because the brain naturally adapts to ever-present pain, not unlike how it adapts to ever-present odor. The experience of pain tends to be relative to past and continuing experience of pain. So absolute measurement is not really possible, at least in the sense that relates to anything that people experience subjectively. Yet, as I am trying to explain, it may well be very meaningful and helpful to quantify all these things that pain does to the body and brain.

Opiates are very weird and examples of how weird this all is because they pretty much (as far as we know) or (more speculatively) mostly just affect the pleasure center of the brain. It's revealing that this causes a big reduction in the experience of pain — it doesn't in any sense reduce the nervous system's signalling of the pain, nor of course the inflammation and other physiological things which either cause the pain or are intimately related to it. So this just demonstrates how complex the subjective experience of pain really is and how much it's dependent upon a complicated relationship of different brain functioning.
posted by Ivan Fyodorovich at 8:15 PM on May 9, 2012 [2 favorites]

"i wonder: do neuroscientist know enough about pain, as perceived by the brain, to measure its intensity, say by sticking a person in a MRI or other machines able to assess how much pain is being perceived?"

The US army is looking for a way to objectively measure pain

So it looks like that right now, the answer is no.
posted by Iax at 11:06 PM on May 9, 2012

>> CWE is awesome, but time consuming.

Plus I dont think the average patient, user,or abuser may be aware of opiate derived medication as being water soluble

Plus, if some goody-two-shoes-government-knows-best type relative or acquaintance knows you're doing that and takes it upon themselves to inform your employer or doctor, you are labelled a drug-abuser and fucked for life.
posted by K.P. at 6:08 AM on May 10, 2012

For the record, if you have a tylenol/hydrocodone prescription, and you go to a compounding pharmacy, instead of a "deal it out from a big jug o' pills" pharmacy; you can have it made with aspirin instead of ibuprofen or acetaminophen. That way you don't run the potential issues with CWE.
posted by dejah420 at 9:25 AM on May 10, 2012

Are you sure? Because that doesn't make sense. It's not as if there aren't hydrocodone/aspirin and hydrocodone/ibuprofen combos available, because there are. And, regardless, acetaminophen is a very different drug than the two NSAIDs of aspirin and ibuprofen. There are people who very much should not be taking an NSAID for various reasons and subsituting an NSAID for acetaminophen would be bad. What you're describing is a pharmacist giving a patient something quite different from what the physician prescribed, and not in a trivial sense.

I'm not disagreeing that for many people it would be better to have one of those two combinations instead of the acetaminophen. But they should just ask their physician to actually prescribe one of them.
posted by Ivan Fyodorovich at 10:26 AM on May 10, 2012 [1 favorite]

Compounding pharmacists do exist but from what I've read you don't simply take a prescription in and ask for ibuprofen instead of acetaminophen with your opiates. That still needs to be negotiated between you, your prescribing doctor, and what the FDA will allow. If you can't handle NSAIDs but don't want to burden your liver with too much acetaminophen you're possibly/probably out of luck in today's world.
posted by K.P. at 5:21 AM on May 11, 2012

Even some big chains like Walgreen's have units which are compounding pharmacies. They can do cool things.
posted by Ivan Fyodorovich at 10:20 AM on May 11, 2012

The research now shows that opiates are not an effective treatment for chronic back pain. While they give short term relief, they make the nervous system more sensitive which in turn increases the pain over time. As the pain increases, the medication use increases, leading to a spiraling effect. I work in an outpatient clinic for people with chronic pain. Our nursing staff works with our clients to taper they're medication while our psychologist, physical therapist and nurses help them to develop non-pharmaceutical ways to decrease the pain. After 6 weeks most of our clients have decreased their medication use, many completely eliminating their narcotic use, decreased their pain level and improved their function. While these drugs do have their place, they are overused when there are safer, more effective ways to deal with chronic pain. They do take time and effort, and are not reimbursed as generously by the insurance companies.
posted by Lost at 9:44 AM on May 12, 2012

Chronic back pain is a very poor and prejudicial choice to use as an ailment representing chronic pain in general. Back pain is a difficult, often intractable, condition that is best treated primarily with physical therapy and behavioral adjustment. A palliative-centric approach is definitely sub-optimal.

But there are many conditions where there is no alternative to placing the emphasis on palliative treatment. There are many, many conditions where pain management through opiates is the only effective treatment, both in the short and long terms.

Also, I'd like to see some citations for your claim that (specifically with regard to back pain, or generally?) opiates "make the nervous system more sensitive" and therefore "increases the pain over time".

All things being equal, a pain clinician's perspective and judgment on this topic would be among the most informed and most valuable available. And, it should be emphasized, the more holistic approach of pain management in pain clinics is superior. However, all things are not equal and pain clinicians are in the regulatory spotlight with regard to opiates and thus have a powerful incentive to err on the side of excessive caution and to rationalize this with dubious science. Primary care physicians are most frequently targeted and prosecuted, but a big part of that is that pain clinicians and similar bear the greatest constant scrutiny and are very aware of it.
posted by Ivan Fyodorovich at 12:52 PM on May 12, 2012

There are many types of chronic pain, and I don't mean to to imply that they all are the same as chronic back pain. Unfortunately the research regarding effective treatment of pain is lagging behind in all areas. I chose chronic back pain because many of the studies narrow the field. in my experience working in this field, back pain is one of the most frequent complaints of people on opioids. I also find that many of the approaches that work with low back pain also work with other types of pain. I don't know what you're experience is, and I certainly can not say that I know what anyone with pain is experiencing, as everyone experiences pain differently. I do know that alternatives to medicating for pain are underused, and that many physicians are not well versed in other alternatives to supplement or opioid therapy.

Citation for hyperalgesia(nervous system becoming sensitive):Anesthesiology. 2006 Mar;104(3):570-87.Opioid-induced hyperalgesia: a qualitative systematic review.Angst MS, Clark JD.

You are right- there are people who require opioids for short or long term use. There are doctors who prescribe appropriately. Unfortunately there are physicians out there who do not do so and there are people out who are misusing the drugs. I've run into some physicians who over-prescribe and some who under-prescribe. Unfortunately, it is the patient who is frequently paying the price.
posted by Lost at 3:06 PM on May 12, 2012

Your citation and other, more recent, surveys show that while OIH exists, its clinical prevalence isn't known and that the apparently categorical statement that opiates "make the nervous system more sensitive" and therefore "increases the pain over time" should be rephrased to include either a can or sometimes. And, from what my brief perusal seems to show, it's not clear that it's the opiate receptors which are involved with OIH, but possibly that it from activation of NMDA receptors.

Anyway, I agree that patients are the ultimate losers in all this. But I think that your perception, and that of many other people, has a great deal to do with combined bias effects — opiate abuse is a high-profile and (for whatever reasons) emotionally provocative problem. The examples of it one encounters weigh disproportionately heavily. And then, from that, comes selection bias. You're finding what you're looking for.

I'm not denying that opiate abuse exists and is a problem. But I'm arguing that under-prescription is a much bigger problem with a much bigger personal and social cost.

It's not as if the US is the only place in the world where these issues exist — the simple truth is that much of the rest of the world serves as an example that the problem of opiate abuse and policies about prescribing opiates are not the only two factors involved. You can have opiate abuse with extremely tight control of opiates, and you can lack abuse with loose control of opiates.

As I wrote earlier, opiate abuse is largely a product of a culture of recreational drug abuse and the associated large-scale organized criminal industry that satisfied this appetite, not physicians over-prescribing opiates to pain patients. That exists, too, but it's a small part of the larger problem of opiate abuse. Meanwhile, there's a very large problem of limited availability of opiates to the patients for whom they are the only truly effective therapy. Again, the irony is that for every person like myself who doesn't take opiates (though every physician I've ever seen has adamantly agreed that I need them — just not every one of them wants to be under the scrutiny of prescribing them to me) because of the hassle involved, there's twenty recreational abusers out there who know exactly where and how to relatively easily acquire their opiates for abuse. This is a perverse outcome of this situation. The paranoia about prescribing opiates does far more to limit the clinically-appropriate prescribing of them than it does to reduce abuse.
posted by Ivan Fyodorovich at 3:45 PM on May 12, 2012

The amount of opioids prescribed has sky rocketed. In some cases they are under prescribed, in many cases they are over prescribed, such as in the pill mill cited above. Despite the increase in the use of opioid prescription in use, there is unclear evidence that it truly is effective in chronic pain.

Patients on opioids for chronic pain are much more likely to abuse and become addicted than those without. Of people with addiction, most of them received the prescription form one doctor, or from a friend or relative who got them from one doctor.

Do you have reference regarding your statement that many deaths attribute to OD from opiates are due to acetaminophen? I have been unable to locate anything regarding that.
posted by Lost at 3:04 PM on May 13, 2012


"In the United States, the United Kingdom, Australia, and New Zealand, paracetamol is the most common cause of drug overdoses."


"On June 30, 2009, a U.S. Food and Drug Administration (FDA) advisory panel voted by a narrow margin to advise the FDA to remove Vicodin and another painkiller, Percocet, from the market because of "a high likelihood of overdose from prescription narcotics and acetaminophen products". The panel cited concerns of liver damage from their acetaminophen component, which is also the main ingredient in commonly-used nonprescription drugs such as Tylenol.[10] Each year, acetaminophen overdose is linked to about 400 deaths and 42,000 hospitalizations"

Not sure where to go to find out how many of acetaminophen overdoses were from Vicodin etc. But I do recall reading about this problem before from reputable resources. For chronic pain sufferers who have developed a tolerance to opiates, it may be quite easy to OD on acetaminophen before suffering from respiratory failure, especially when you consider that the effects of acetaminophen are far more cumulative than respiratory depression from opiates.

"Despite the increase in the use of opioid prescription in use, there is unclear evidence that it truly is effective in chronic pain."

Is there any clear evidence that any one particular therapy is truly effective for chronic pain? Like most medical problems, the best solution combines various forms of therapy -- something that many people don't know or ignore. I know I've been feeling better ever since I got a prescription for oxycodone, but that's because it allows me to get out of the house and do things, which can also a form of therapy.

Drug abuse is usually a symptom of another problem. In cases of opiate abuse, prescribed for chronic pain, it could be the symptom of a more psychological problem, like anxiety or depression, or it could be a symptom that the non-drug therapy isn't working or not being done. There are many possibilities, but the point is that when people focus on drug abuse they are taking focus off of what may be causing the abuse, which can often be the bigger problem.
posted by Soupisgoodfood at 8:01 PM on May 13, 2012

"Of people with addiction, most of them received the prescription form one doctor, or from a friend or relative who got them from one doctor."

The latter example is nothing like the former example.

I categorically deny your explicit claim that most opiate addicts began as patients prescribed opiates and I very emphatically deny your implicit claim that prescribing opiates generally leads to opiate addiction. Of course prescribing opiates to an addictive personality when they otherwise are not easily available will increase the chance of that person becoming an addict. But what you're not making clear is that it is a tiny portion of patients who are prescribed opiates who become addicted and there are decades of studies that make this clear. The vast majority of patients are not at risk of developing opiate addiction as a result of being prescribed opiates. It is the minority of people who are already inclined to addiction who are at risk, and they are generally at risk and likely to become addicts of some form or another, whether it's opiates or alcohol or something else.

It is grossly misleading to imply that prescribing opiates to the majority of patients leads to or even increases the likelihood of addiction for those patients. Of course prescribing opiates to addiction-prone persons vastly increases the chances that those persons will become addicted to opiates. Those people are the small minority and are not representative.
posted by Ivan Fyodorovich at 12:32 AM on May 14, 2012 [1 favorite]

mephron: One of my housemates needs to go to her doctor's soon to get a refill on one of her medications.

Which is an anti-psychotic. And yet still, the 'rules' say they can't give her more than one month of the stuff, and there's usually a six-week wait for appointments, so she regularly is four weeks on, two off. These aren't painkillers, these are brain-adjusters, and they still have ridiculous requirements.

This is idiocy.

I agree, that's idiotic.

But you might want to let your your friend know that it is possible-- hypothetically, of course--that compassionate doctors realize this is a common problem because of the rules.

Hypothetically, compassionate doctors might even have figured out ways to avoid the problem, if patients actually bring up the issue with them.

For instance, say your friend went in today, May 14. Her doctor would give her a 30-day Rx, right?

Suppose--hypothetically- the doc also wrote your friend an additional 30-day Rx for the same medication, but on the second one he wrote, "Not valid prior to June 14, 2012" or "Fillable only after 6/14/2012"? Something like that.

Your friend does not have multiple months of the same Rx. She does not have twice the dosage of the meds. That would be against the rules!

But she would be covered until she can get in to see that doctor again.

posted by misha at 4:37 PM on May 14, 2012

"{Suppose--hypothetically- the doc also wrote your friend an additional 30-day Rx for the same medication, but on the second one he wrote, 'Not valid prior to June 14, 2012' or 'Fillable only after 6/14/2012'? Something like that."

Yes, this is a good way to solve that problem. But, unfortunately, it's only a piece of a puzzle where other, similar problems continue to crop up.

Before I stopped taking opiates at the end of last year, the doctor I saw would do this. She'd print out three months of prescriptions with the "don't fill before" dates and such. However, there's also the problem with the pharmacy. Those don't fill before dates are, by their nature, written to satisfy such technical requirements and have razor-thin margins. Oxcodone has a shorter half-life than hydrocodone, and much shorter than codeine, and so my own experience was that I'd begin withdrawal after just 12 hours of my last dose. Getting a pharmacy to fill one of these prescriptions within the proper window was often difficult and on numerous occasions either a mistake at the pharmacy (which I couldn't agitate too strongly about, lest I brand myself "drug-seeking") or, you know, a weekend or a holiday would force a situation where I'd be in withdrawal for several days until I got my prescription filled, through no fault of my own. And then, too, there's the case that I'm disabled and in chronic pain and it's often difficult for me just to leave the house and so there's other times where not getting my scrip filled and going into withdrawal for days at a time happened because, technically, it was my fault but really just has to do with how difficult it is to function with a serious disability.

I've been in withdrawal many more times than I can count and this is also relevant to my previous comment because, despite this, I've never even considered alleviating it through illegitimate means. Avoidance of withdrawal is a strong motivating force involved in addiction, though it's certainly not the strongest, and there's many, many patients like myself who have endured it numerous times without behaving badly in the way that Lost and others like to imply most opiate users will naturally, eventually, behave because we're all going to be addicts, sooner or later. This just isn't true.

But it is true that I am willing to live without the medication every doctor I've ever seen agrees I need, and live in greatly increased pain, simply because anti-drug anti-opiate hysteria has created barriers that I've decided are not worth continually surmounting compared to experiencing greatly increased chronic pain. That should say a lot about how screwed-up the status quo is.
posted by Ivan Fyodorovich at 5:03 PM on May 14, 2012

Soupisgoodfood, thanks for the reference, but I was really looking for some evidence that OD attributed to opiates are due to acetaminophen, not that acetaminophen is a cause of OD. Can anyone help me out with this?

There is evidence of other therapies being effective in chronic pain including physical therapy, exercise, CBT, pain neuroscience education, Tai Chi, acupuncture, and graded motor imagery. There is not one therapy which is superior as chronic pain is variable is its presentation, although pain neuroscience education has some promising research coming out. A combination of therapies is most effective. Unfortunately, in many cases physicians focus on pharmaceutical interventions disregarding other options.

It has been my experience that some doctors will continue to prescribe increasing doses of opioids as tolerance increases, or because it is not effective in the first place, and they are under illusion that more will solve the problem. Then one they look up, realize that someone has become addicted, or the patient ends up with a different doctor, who sees the same thing and labels them as drug seeking. While it is sometimes the patient asking for more medication, I frequently they frequently say they looked for other alternatives, but all they were offered were narcotics. In either case tapers ensue. the best case scenario is other alternatives are offered, the taper is slow and the patient has others ways of managing the pain. The worst case scenario, the taper is quicker than is reasonable, the physician ends up firing the patient who is left in no man's land.

Ivan Fyodorovich, I do not claim that most addicts start out as patients being prescribed opiates. While the majority of patients being prescribed opiates will not become addicted, more than an insignificant will become addicted. The numbers vary according to study and population, but between 25-30% is typically what I am coming across in my review of the literature. That is not an insignificant number. Approximately half of addicts report that they are received the drugs form one physician, or that they received the them from a friend or family member who9 obtained them from one physician. What this says to me is there are doctors out over prescribing these drugs.

Which begs the question- how do ensure that these medications are prescribed appropriately? how do we ensure that those people who need and would benefit from this type of therapy receive it appropriately, that those who would benefit form something else receive it, and that those who are abusing the system (doctors and patients) are weeded out? I don't know the answer to this. Our current system is broken- on the one hand it, insurance reimbursement and the way the system is set up favors a medicating model, on the other hand, we make people jump through hoops for medication they need. There remains a poor understanding of pain control throughout the medical community.
posted by Lost at 8:21 PM on May 14, 2012

Lost: While the majority of patients being prescribed opiates will not become addicted, more than an insignificant will become addicted...[somewhere] between 25-30%

That sounds very high to me. Is that people becoming physically dependent (for example, a person taking 4 Vicodin per day to manage pain keeps taking 4 per day indefinitely to avoid withdrawal even when not in pain)? Or actually addicted (increasing their dose to unsafe levels, seeking additional sources, exhibiting repeated poor judgement, damaging relationships and job, and all that)?
posted by K.P. at 4:05 AM on May 15, 2012

Oh, and getting back to the original inked article, it looks like part of the rise in deaths may have much to do with substituting riskier methadone for other painkillers to treat chronic pain.

"It is implicated in more than twice as many deaths as heroin, and is rivaling or surpassing the tolls of painkillers like OxyContin and Vicodin....Between 1999 and 2005, deaths that had methadone listed as a contributor increased nearly fivefold, to 4,462, a number that federal statisticians say is understated since states do not always specify the drugs in overdoses....Insurance plans embraced methadone as a generic, cheaper alternative to other long-lasting painkillers like OxyContin, and many doctors switched to prescribing it because it seemed less controversial and perhaps less prone to abuse than OxyContin."
posted by K.P. at 5:17 AM on May 15, 2012

It is very high. Yes, this is as in keeping addicted behavior, not physical dependent as in staying on the same dose to avoid withdrawal or to manage their pain. I'm sure the numbers would be higher if we were to include these people. Unfortunate, but that is the nature of these substances.
posted by Lost at 6:12 AM on May 15, 2012

Is there a source for that number (that one can read online, more than just an abstract/summary)?
posted by K.P. at 8:33 AM on May 15, 2012

I can give you sources, but the full articles are not accessible online w/o paying. Generally studies published in medical journals are not available for free, except for abstracts. Let me know if you're interested.
posted by Lost at 2:28 PM on May 15, 2012

I can give you sources...Let me know if you're interested.

I am, actually.
posted by K.P. at 3:36 PM on May 15, 2012

A couple of references:

J Gen Intern Med. 2002 March; 17(3): 173–179. Use of Opioid Medications for Chronic Noncancer Pain Syndromes in Primary Care

J Addict Dis. 2011 Jul-Sep;30(3):185-94. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. Boscarino JA, Rukstalis MR, Hoffman SN, Han JJ, Erlich PM, Ross S, Gerhard GS, Stewart WF.
posted by Lost at 4:44 AM on May 17, 2012

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