Chronic pain management, opioids and addiction
May 4, 2016 8:40 PM   Subscribe

We should seek an understanding of the drugs of concern: how they work to relieve pain, how they kill in overdose, how deaths might be prevented & how we should respond as a society. A professor of pharmacology and therapeutics writes in Slate about the undertreatment of pain, discussing how to manage the conflicting risks of inadequate pain relief, physical dependency, overdose and addiction. (Written in response to Prince's suspected overdose before his death, but covers the known facts with respect.)
posted by ambrosen (67 comments total) 26 users marked this as a favorite
 
People are hypocritical when it comes to pain meds. They see nothing wrong with prescribing drugs like Neurontin, Cymbalta, or Lyrica, drugs with horrific side effects that are hell to wean off of. Doctors prescribe them like they're jelly beans. But ooooh no, can't prescribe opiates, even if they help people, because some people abuse them.

Seriously. I would take opiate "addiction" any day over the living hell that was Cymbalta. Sadly, opiates don't help me very much either. But they certainly help some people, and I would never look down upon anyone for seeking out the medicines they need.
posted by panama joe at 9:23 PM on May 4, 2016 [24 favorites]


It's extraordinary to me that, for all this talk of an epidemic, we don't have a reliable notion of (a) how many people progress from their own prescription painkillers to addiction and (b) which groups among those treated with prescription painkillers are most at risk for thus progressing. I don't see how we can make policy without a solid notion of either. Well, I do see it: the shotgun blast approach that means cutting off pain relief to those who need it without necessarily much helping the most vulnerable to addiction.

It's also not clear to me how much of an improvement for anyone it is going to be to have the anecdotal current oxy addict, the late-middle-aged un- or underemployed man, drinking away his despair instead. To the extent that opioid addiction is at all different from it was in the past, it's at least in part the symptom of something we don't want to think about, much less treat: the sadness of the disposable human being. Blocking his access to Percocet doesn't make the despair go away, and there are plenty of avenues of self-destruction still available.

But, by all means, let's have another moral panic. It's been like a decade since meth.
posted by praemunire at 9:25 PM on May 4, 2016 [23 favorites]


Oh, but don't you know? Only zombies use meth! I've watched Breaking Bad, I know what I'm talking about. Look at them, they're all zombies! Totally different from anyone who uses Adderall, which we all know is a completely different drug, completely different in every different way.

Anyone who uses a "hard drug" is destined to go down in flames. I've watched Requiem for a Dream! That's what happens. You use hard drugs, you lose an arm! No exceptions.

Unlike the multitudes of functioning alcoholics that riddle our popular culture. They just like a strong drink! Nothing wrong with that. I like a good drink from time to time. Jessica Jones drinks a bottle of whiskey a day, and can still fight off like five badguys at a time! She's awesome!

Likewise, someone who takes a drug like Cymbalta for pain? Not an addict! Sure, they may have to tolerate a few life-destroying side-effects. And yes, if they ever, ever, ever want to get off it, they may have some horrific withdrawal symptoms (like brain shocks!) and maybe they might just contemplate a little bitty bit of the 'ole suicide, but, you know, totally better than regular, managed painkiller use, right? Has to be. Nobody takes Cymbalta for fun, so it has to be okay, right?

Right?
posted by panama joe at 9:34 PM on May 4, 2016 [10 favorites]


The research we have indicates that opiates are not effective at treating chronic pain. Anyone with chronic pain can probably attest that the best they are likely to get from opiates is some reduction in pain. And other interventions, such as a combination of physical therapy, cognitive interventions, physical activity, and alternative pharmaceuticals may offer more long-term relief.

Opiates are also life-threateningly dangerous and people who take them for pain can and do certainly have physical dependence on them that makes discontinuing them extremely challenging. It's a little bit parsing to try to separate that wholly from the concept of addiction.

I do think we should be cautious about moral panics and drugs, but I don't think that caution should necessarily lead us to conclude that opiates are good medicine for chronic pain. They seem to be very problematic medicine for this problem.

I read the article, but I'm not totally clear what the message is: don't conflate dependance with addiction? I mean, OK I guess. I think it is reasonable for prescribers to use more caution in administering opiates than they did in the 90s and early 00s. Yes, let's not go too far in restricting their use (but no one is actually proposing that), and importantly, let's also change federal policy to allow much wider access to methadone, suboxone, and other drugs that may save the lives of opiate-dependent people.
posted by latkes at 9:40 PM on May 4, 2016 [10 favorites]


I stopped taking opioids for my chronic pain (associated with my genetic illness) four years ago primarily because, even then, the suspicion and paranoia about opioids became both prohibitive in practical terms, and also just emotionally unpleasant. I couldn't get a scrip for more than 30 days at a time and my doctor's office wouldn't send a new scrip to the pharmacist more than two days in advance of the end of the 30 day period. At that time I was taking oxycodone, which has a short half-life, and so I'd began to feel withdrawal symptoms beginning about 12 hours after my last dose. What would happen about three or more times a year was that either the doctor's office or the pharmacist would somehow not renew/fill my prescription. I wouldn't know that something was wrong immediately because maybe the doctor's office hadn't called it in yet that day. And I had a rule about not making repeated phone calls to either the pharmacy or my doctor about this so as to not have someone make a note that I was behaving as "drug seeking". So I'd only call twice a day. Sometimes, the refill should have been made on a Friday and so, by Saturday, when the doctor's office hadn't sent the prescription over, it was too late for it to be done before Monday. I'd spend the weekend in withdrawal. And let me tell you -- withdrawal is horrible.

Even during the worst experiences of withdrawal, I never considered doctor shopping or otherwise relieving the discomfort with anything that would amount to either opioid abuse or something far too close to it. I have a bit of experience with addicts, mostly alcoholics, and addictive behavior is pretty clear and obvious to me. I've never felt in danger of being addicted to opioids, but that's probably because I'm not inclined to be and/or I'm extremely wary of it. But for nearly ten years I took a regular and high enough dosage of opioids to be physically dependent. Physical dependency is not addiction.

And let's be clear -- my pain is absolutely now not managed. I take a very strong NSAID (and did along with opioids) that helps, but my primary "management" of the pain is to be less and less active. I rarely leave the house -- in fact, I rarely walk or am physically active at all. Washing some clothing and putting it away will put me in bed for a while. The NSAID + opioids together managed my pain pretty well, but I'm willing to forego the opioids because of all the trouble with them. All my doctors are unanimous in the fact that opioids are appropriate for my illness, it's not that they don't want to prescribe them. It's all the crap that goes along with taking them. It's my understanding that a lot of pain clinics that prescribe opioids now require regular urine testing -- since everyone's freaking out about all the addiction, they now assume that everyone is at least a potential addict. And addiction in our culture still it thought to have a moral component -- to be an addict is to be shamed and under the current regime, being a pain patient taking opioids means being constantly scrutinized as someone possibly deserving shaming.

And the thing is, all these articles about the rise of opiate deaths never distinguish between patients taking opioids as prescribed by their doctors, patients who are addicts and doctor shopping and taking a higher dosage than any of their individual doctors have prescribed, and people who are addicts who procure opioids on the black market. The statistics and articles don't mention the typical involvement of other central nervous system depressants, like alcohol. They all just discuss the problem as if it's the inevitable result of doctors prescribing opioids for chronic pain. It's often implicit that there's no distinction between physical dependency and addiction, and that almost all those who are prescribed opioids long-term will become addicts. This infuriates me.

I don't believe that the explosion of opioid abuse is directly the result of the push to be more willing to use opioids for pain management in the 90s. That's been the main argument of many papers and articles in the last few years on this topic. It's obviously a factor, it can't not be a factor. But I think the real culprit in this is Oxycontin. Oxycontin was designed and heavily marketed as an opioid that is resistant to being abused, because of its buffer. The likeliehood of a substance being addictive is inversally proportional to its onset of action -- the more quickly you feel the effect, the more likely that you will abuse it and become addicted. So the buffer was supposed to disrupt the potential for abuse. But, of course, you can just crush the pills. Somehow, this possibility escaped Purdue Pharma and the FDA. Purdue took advantage of the loosening of restriction on opioid prescription and with its claim of being difficult to abuse, Oxyxontin began to be extremely widely prescribed. And because it is actually easily abused, it was. And because many people involved had a financial incentive to not recognize this was happening, it became a huge industry -- pill mills and doctor shopping and, most importantly, diversion. Only a small number of people will become addicts, but if you make a very potentially addictive substance available to many people, you'll get more addicts. And those addicts will, in turn, sustain an industry of illegal drug use that will involve recreational use and the creation of yet more addicts. And those prescription opioid addicts will look to other opioids, like heroin. And a whole lot of this abuse will involve other drugs, particularly other CNS drugs. You'll get lots of overdose fatalities.

And then everyone will begin talking about how we shouldn't be prescribing opioids for chronic pain sufferers -- just, say, cancer patients -- because apparently treating the pain of people like me is the problem.
posted by Ivan Fyodorovich at 9:41 PM on May 4, 2016 [87 favorites]


Opiophobia. Last month, I tripped and faceplanted while walking my dog and broke my fucking face. Right under my left eye. Tons of facial swelling and a broken bone. I conservatively ranked my pain level at an eight. Urgent care and the ENT refused to give me opiate painkillers, because of drug seekers. I went to urgent care because I thought I broke my nose and the xrays clearly showed a facial fracture. My patient history at both places was for recurring sinus infections, so I didn't have any sort of record of drug seeking behavior. My FIL gave me some leftover Percocet from a recent surgery, and I feel zero guilt about that. Breaking a bone really hurts.
posted by Ruki at 9:47 PM on May 4, 2016 [16 favorites]


Anyone with chronic pain can probably attest that the best they are likely to get from opiates is some reduction in pain.

I think some reduction in pain is pretty much the whole idea.

And other interventions, such as a combination of physical therapy, cognitive interventions, physical activity, and alternative pharmaceuticals may offer more long-term relief.

So ... ever damaged a nerve? Physical therapy and physical activity? Not applicable. Cognitive interventions? Yeah, it's all in my head, I should try "mindfulness" some more. Alternative pharmaceuticals? After my Cymbalta experience? Yeah, no thank you.

As I said, opiates don't help me, which is why I don't take them. But if they did help me? Even if they only offered "some reduction in pain?" You'd better believe I'd take them. They have side effects (like many other drugs), and they're hard to get off of (like many other drugs), but the only reason we're even having this conversation is because some people enjoy them, and because some people enjoy them, we feel okay about denying them to the people who actually need them.
posted by panama joe at 9:49 PM on May 4, 2016 [42 favorites]


Opiates clearly have benefits and risks. But research does not show them to be effective for long term chronic pain.

Personal stories are important and given how crushing chronic pain is, this topic invariably feels personal. But it makes sense for prescribers to be guided by the best available research.

It's a complicated topic. To me there are no obvious policy conclusions except that we need much more evidence based substance treatment and providers need time, training and commitment to treat everyone as an individual. I appreciate the people sharing their experiences in this thread.
posted by latkes at 10:06 PM on May 4, 2016 [3 favorites]


Those looking for a good summary of the current evidence may wish to read this 2014 paper from the journal 'Neurology'

There's a good discussion of the evidence (or frankly the lack of evidence) surrounding the efficacy of opiates in chronic pain (ie > 6 weeks)

They conclude

Over 100,000 persons have died, directly or indirectly, from prescribed opioids in the United States since policies changed in the late 1990s. In the highest-risk group (age 35–54 years), these deaths have exceeded mortality from both firearms and motor vehicle accidents. Whereas there is evidence for significant short-term pain relief, there is no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence, or addiction
posted by DrRotcod at 10:08 PM on May 4, 2016 [4 favorites]


Anyone with chronic pain can probably attest that the best they are likely to get from opiates is some reduction in pain.

Yes, yes they will.

None of the items you listed will fix the metal in my joints, the rods in my hands, the missing muscles in my back, the damage to my optic nerves and retinas. No amount of exercise will make my joints regrow their cartilage and meniscus.

I am not allowed to use aspirin/NSAIDs because my idiot father gave me multiple Clotting Factor VIII genes and the strokes will kill me dead. The other stuff is my fault because I was a big brave fire fighter (dumb) / MMA fighter (really dumb) / and then I got run over by are really big truck. And then a car. And then another car. And another. (bad luck and a sad insistence on pedestrian transportation)

I do not use opioids because I am rough and tough and I eat pain. Also, doctors will not give me effective pain treatment due to my perceived youth and health.

I use alcohol and caffeine as substitutes. It is pretty awesome! (<- Snark! Not actually awesome)

The advice to use physical therapy/exercise/woo is meant well. It may even apply to those with garden variety boo-boos. I'm not sure it applies to people with chronic pain.

no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence, or addiction

Sure, but we want the pain relief. The overdose concern is real and doctors can manage that. The dependence part is an unfortunate fact of life. The addiction part is the zombie war on some drugs promulgated by well meaning yet, in my opinion, misguided individuals.
posted by pdoege at 10:12 PM on May 4, 2016 [33 favorites]


but the only reason we're even having this conversation is because some people enjoy them, and because some people enjoy them, we feel okay about denying them to the people who actually need them.

qft.

seriously, f*** all puritans and their narrow, narrow vision.
posted by philip-random at 10:19 PM on May 4, 2016 [21 favorites]


but the only reason we're even having this conversation is because some people enjoy them, and because some people enjoy them, we feel okay about denying them to the people who actually need them.

We're also having the conversation because people are dying from them, in those aged 35-54 years prescribed opiates kill more people than car crashes or guns. The debate is over how freely opiates should be prescribed, with the trade-off being between overdose deaths versus under-treated pain. This debate is made more challenging by a disparity in evidence quality, whilst the harms of opiates are clear, their benefits in the management of chronic pain are not.

And for all that people may dismiss psychological and physical therapy, it works and it doesn't kill people
posted by DrRotcod at 10:26 PM on May 4, 2016 [2 favorites]


Heh. I think Mark Sandman may have said it best : show me a cure for pain, and I'll throw my drugs away.

The fact is, modern medicine doesn't know what the fuck to do about chronic pain. What do you do when the neurologists send you to foot-and-ankle surgeons, and the foot-and-ankle surgeons shrug their shoulders and send you back to the neurologists? You've fallen into a black hole of medicine, and nobody can help you.

Neurologists will give you drugs like Cymbalta, Lyrica, and Neurontin. Hope you don't plan on eating, sleeping or fucking ever, ever again. And say goodbye to your energy level! And possibly even your will to live. Even if these drugs can be effective (which Cymbalta certainly wasn't for me), it's entirely possible their side effects can be so devastating as to make your chronic pain preferable in comparison.

Which is why I say, if you find something that works, fucking use it.
posted by panama joe at 10:27 PM on May 4, 2016 [15 favorites]


One way to reduce overdoses from opioids is to deny people who need pain management anything that might help, like opioids.

Another way is to educate people on an ongoing basis by, like, talking with them - about their substance (prescribed and not) use, about their pain, about other issues in their lives that may be hindering their healing or interfering with other pain management techniques - and by educating their family members and by handing out naloxone even more freely than we hand out ignorance and judgement.
posted by rtha at 10:33 PM on May 4, 2016 [25 favorites]


We're also having the conversation because people are dying from them, in those aged 35-54 years prescribed opiates kill more people than car crashes or guns.

So ... why don't we have a War On Heart Disease? Or a War On Cancer? Or a war on, I dunno, preventable medical errors (like the kind that ruined my foot) which are now postulated to be the third leading cause of death in America?

We're not talking about these things because they're not sensational. But oooh drugs! Drugs are BAD! But just some drugs. Not alcohol. Not Adderall. And certainly not drugs like Cymbalta, Lyrica, and Neurontin.

Maybe we should just work on helping people who are in bad places in their lives so they don't want to abuse prescription medication. To my mind, that makes more sense then denying medicine to the people who need it.
posted by panama joe at 10:36 PM on May 4, 2016 [24 favorites]


Long life of shadows, silence and loss as pain distances me slowly from the world, or a shorter and richer life as I can function enough to work, cultivate relationships, exercise, eat healthily and seek medical care?

Sorry, liver. Short and sweet for me.
posted by dorothyisunderwood at 10:43 PM on May 4, 2016 [17 favorites]


I have been taking Percocet for pain for a few years. It makes me not care about the pain but it also makes me short tempered. I just sent an email to my PCP and Neurologist about my concern over my increase in dosage over the past year. Either my tolerance has increased or my pain has, or both. I asked them how they would feel about me trying Medical Marijuana in place of the Percocet. My PCP is completely supportive and I am waiting to hear from the Neuro. I am very concerned that he is going suggest something like the drugs mentioned above. I am not willing to take them.

I was pleasantly surprised that Kaiser had a policy that addresses the use of pot for pain. I was not expecting a supportive response.

I don't believe anyone knows what do with people and chronic pain. All of the current options have downsides. It really is a matter of picking the downsides that a person and the provider can live with. I wish it was different for both sides.
posted by cairnoflore at 10:46 PM on May 4, 2016 [11 favorites]


why don't we have a War On Heart Disease? Or a War On Cancer?

The US does have an official War on Cancer. It's kind of a Forever War. And the Surgeon General is pretty down on smoking and heart disease, and that's from a General, so that's kind of a war thing.
posted by meehawl at 10:55 PM on May 4, 2016 [5 favorites]


And for all that people may dismiss psychological and physical therapy, it works and it doesn't kill people

I believe that your statement "doesn't kill people" is false, or perhaps not reasonable given the problem domain.

I read the linked article. It reports moderate success in treating lower back pain. Eg, some success at one type of pain. It appears to be silent about other causes of pain (???).

The article is silent about how to move that pain treatment methodology into the sizable population of individuals who are too poor to purchase the treatment. Or how to deal with pain sources that require more than moderate success.

It is also silent on the results of self medication with alcohol, heroin, meth, and suicide. I did not see any mention of the costs of missed job and life opportunities.

My thesis is that although nonpharmacologic therapies may have some benefit for some patients and
1. that is not sufficient to treat the actual patient population due to financial and physical reasons
2. lack of access to nonpharmacologic therapies will drive patients to opiates
3. lack of access to legal access to opiates will drive patients to self medication with illegal opiates, alcohol, suicide, etc.
4. the self medication above is driving the death rate
5. the current fiscal, political, and moral climate will block all application of 1 and 2 above to a substantial minority of the population and that population will see a high death rate due to 4 above

I believe a reliance on nonpharmacologic therapies will not solve the issue of higher morality given the unfortunate facts on the ground and saying otherwise is an error.

I believe that we need to have a better harm reduction strategy that incorporates opiates and other pain killers, I believe that we should cease pushing back against it, and I think that we should actively work to make it policy.

I would be happy to revise my conclusions if my reasoning is shown to be faulty.
posted by pdoege at 11:02 PM on May 4, 2016 [14 favorites]


It's pretty telling when various sources unthinkingly include "dependence" as a serious risk. A vast number of drugs taken for chronic conditions involve physical dependency. Physical dependency is not inherently a problem except insofar as availability is a problem -- which, surprise, it is with opioids and therefore dependency itself is used as a reason to disfavor opioids.

I've weaned off of opioids numerous times. When I stopped at the beginning of 2012, it was after six weeks of slowly reduced dosages. I felt zero withdrawal effects.

As for the arguments about the effectiveness of opioids in managing chronic pain, I'm confident that none of the alternatives in isolation are effective by the same standards or even as effective. Truly effective management of chronic pain requires comprehensive treatment, involving all the things mentioned. Opioids are not a panacea and it's definitely true that they are far more effective for acute pain than they are for chronic pain. In my own experience, the NSAID + opioid combination worked well because the NSAID lowers the level of the constant background of pain, and probably reduces the average peak level of pain, while opioids are effective at treating those acute peaks -- which are frequent. And we're also talking about different kinds of pain. Opioids are an important, irreplaceable component of effective treatment. Only within the context of judging them alone against an ideal result do they fare badly, because of course they do. Anything would, because we don't have a silver bullet for chronic pain relief.

There is absolutely a moral panic component to the discussion about opioids. You can see it just in the above comments, which only begrudgingly admit a distinction between physical dependence and addiction. You can see it with how the discussion conflates the (past) standard for prescribing opioids for pain management and the entirety of the opioid abuse epidemic and overdose fatalities. There is almost invariably at least as much bias and distortion in the discussion in these ways as there is from the other side. I've read posts on web forums where doctors talk amongst themselves, there's a tremendous bias against opioids which basically now sees every single patient who ever requests opioid pain relief as a dirty drug-seeker who is wasting their time.

But I don't think you can understand what's going on here without taking into consideration the medical history about pain relief (medicine was long extremely hostile to it and has been only grudgingly accepting of it every step along the way, right up to the present) and the moral stigma that attaches to the recreational use of drugs in our culture, most especially the stereotypical drug fiend heroin addict. This is the underlying social context that is very easily and quickly leveraged into a moral panic when a genuine problem -- because there is presently a genuine problem with opioid abuse -- becomes apparent.
posted by Ivan Fyodorovich at 11:02 PM on May 4, 2016 [32 favorites]


So ... why don't we have a War On Heart Disease? Or a War On Cancer?

We do, vast amounts of money is spent on preventing and treating these conditions, and as a result the number of people dying from ischaemic heart disease has fallen since 1990, and whilst cancer is more common, for any given cancer you've got a better chance of survival today than you did in 1990.

As an aside, the 'preventable medical errors' story that's in the news is based on a BMJ article which used a definition of 'medical error' which would include opiate overdose as a medical error...

Maybe we should just work on helping people who are in bad places in their lives so they don't want to abuse prescription medication. To my mind, that makes more sense then denying medicine to the people who need it.

I totally agree, and one of the ways you can do that is with cognitive behavioral therapy and physiotherapy. And to be clear, a lot of the people overdosing on the opiates are doing so accidentally with the opiates they've been prescribed by their doctor. This is partly because the opiate dose required to control pain increases faster than your tolerance to the respiratory depressant effects of the drug, so people using them long-term get closer and closer to an over-dose threshold
posted by DrRotcod at 11:03 PM on May 4, 2016 [4 favorites]



We're also having the conversation because people are dying from them,


if we really wanted to save people from accidental overdoses (particularly young people who really are kind of dumb about drugs and such), we'd have public service announcements wherein it was made clear:

A. yes, injecting heroin directly into your veins can kill you,
B. but so can snorting it (this is how most rookies blow it -- seriously, watch Pulp Fiction again)
C. if you must partake, smoking's probably the safest way to go, but it's still not that safe.
D. do you really want to mess with a drug that can kill you just because you made a rookie mistake with dosage? (seriously, watch Pulp Fiction again)

And for all that people may dismiss psychological and physical therapy, it works and it doesn't kill people

it works for some people. it's worked for me in the past. but I can easily envision a future where the old methods just aren't working as well anymore. please don't deny me meds based on some unexamined puritanism.
posted by philip-random at 11:10 PM on May 4, 2016 [8 favorites]


Physical therapy isn't helpful for many things. Such as nerve damage, for which it is often useless. Various forms of psychological therapy may be helpful, but they won't take away your pain.

Prescription painkiller abuse should be seen as a separate issue from prescription painkiller use. Personally, I think if we want to address drug abuse and overdoses, we need to radically reconceptialuze the problem. Let's take the law out of it completely. Police officers have no place in a doctors office. People with a legitimate need should be able to get painkillers from their doctors. Drug addicts should be able to get their drugs from safe, legal sources where things like counseling and clean needles are available. Treat addiction and overdoses like a medical problem, which is what it is. Not a legal problem.

We've been treating drug abuse as a legal problem for generations, and the problem has only gotten worse. That right there is the root of the real problem, not a few doctors being a little too free with their prescription pads.
posted by panama joe at 11:17 PM on May 4, 2016 [24 favorites]


there is no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence, or addiction

let's just parse that carefully - to be sure we get it right...
there is no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence, or addiction
so there is some evidence for pain relief over time. sweet. i'll just reformulate it:
there is no substantial evidence for maintenance of pain relief or improved function over long periods of time with without incurring serious risk of overdose, dependence, or addiction
good. so in exchange for some relief and improved function, there is a risk.

I agree to this deal.
posted by j_curiouser at 11:27 PM on May 4, 2016 [22 favorites]


3. lack of access to legal access to opiates will drive patients to self medication with illegal opiates, alcohol, suicide, etc.
4. the self medication above is driving the death rate


I'm not sure this is correct, evidence suggests a dose-dependent relationship between opiate prescription and overdose risk; prescription of higher doses of opiates increases the risk of over-dose.

phillip-random: I'm not talking about people overdosing on heroin, I'm talking about people overdosing on prescription opiates, that's the think that's killing more people in their 30-40s than cars or guns. Certainly there's a lot of people misusing prescription opiates which are 'diverted' from legitimate prescriptions, but a fair portion of people are dying from drugs that their doctor has prescribed for them. Its not only drug addicts who are overdosing, its people using the drugs as prescribed by their doctor.
posted by DrRotcod at 11:27 PM on May 4, 2016


its people using the drugs as prescribed by their doctor

yeah, no. i'm pretty sure the ld50 wasn't on the script. probably something more reasonable.
posted by j_curiouser at 11:34 PM on May 4, 2016 [3 favorites]


j_curiouser: The problem is that under the current legal system in the USA the responsibility for making that risk/benefit analysis is not only on the patient, but on the doctor. A doctor in California was recently convicted of murder for the deaths of several patients who overdosed on opiates she had prescribed. One could certainly argue that people should be allowed to decide whether or not they want to take opiates, but with that you would have to absolve doctors of all responsibility for any adverse outcomes
posted by DrRotcod at 11:37 PM on May 4, 2016 [2 favorites]


"Its not only drug addicts who are overdosing, its people using the drugs as prescribed by their doctor."

What proportion of opioid fatalities are the result of use as prescribed and without involvement of another CNS depressant? I'd like to see evidence that it accounts for more than a very small portion -- and yet, the debate is centered around use as prescribed, which should not involve other CNS depressants.
posted by Ivan Fyodorovich at 11:37 PM on May 4, 2016 [11 favorites]


phillip-random: I'm not talking about people overdosing on heroin, I'm talking about people overdosing on prescription opiates, that's the think that's killing more people in their 30-40s than cars or guns.

sorry, the pain must have blurred my vision. Unfortunately, my personal experience of opiate related death has been almost exclusively black market stuff. So I tend to go off in that direction.
posted by philip-random at 11:44 PM on May 4, 2016 [1 favorite]


Unfortunately we can't do anything in moderation. When opium was discovered- awesome! Opium all around! Put it in everything! Everybody have some! When some people had bad outcomes - run away, shut the box, nobody can have any. You get 7 pills if you break your arm. You get 2 pills for a tooth extraction. Still in pain? Need more? Not a white man? Well that doesn't line up with what my prescription-writing robot says you're feeling therefore you must be lying, go die in a gutter you filthy addict. If doctors want to be treated culturally like all-knowing gods then why don't they have the authority to make decisions based on what their actual patients are saying.

The article is absolutely right that how we use this stuff must be thoughtful but we as a culture apparently aren't capable of that.
posted by bleep at 11:48 PM on May 4, 2016 [9 favorites]


under the current legal system in the USA the responsibility for making that risk/benefit analysis is not only on the patient, but on the doctor

and there it is. provider liability. not really centering on effective pain relief, then.
posted by j_curiouser at 11:48 PM on May 4, 2016 [14 favorites]


Saying that opiates aren't effective for long-term relief therefore they just shouldn't be prescribed for people in long-term pain just doesn't make any sense. They don't hand these things out like candy, you must have failed everything else. So you fail everything else, then what? Just let people suffer? Because research?
posted by bleep at 11:53 PM on May 4, 2016 [16 favorites]


But research does not show them to be effective for long term chronic pain.

It would help if you cited some of that research. The excerpt that DrRotcod posted actually supports the thesis of the article - that long term pain maintenance can lead to dependence, but if done correctly, that's sometimes an acceptable tradeoff.

My anecdata is a friend that had the combination of a degenerative back condition with a spinal injury. He was absolutely dependent on opiates but they also made the difference between lying in bed all day unable to move from the pain and having a semblance of a normal life. Dependence and even the possibility of a reduced lifespan were worth it to him.
posted by Candleman at 1:07 AM on May 5, 2016 [12 favorites]


I've had chronic pain for 15 years. For 6 years or so I've taken a low dose of hydrocodone daily. Same amount the whole time (haven't felt any noticeable change in tolerance). If I stop taking it for a few days, the pain gets worse but otherwise no big change.

Before that, I did physical therapy for years, CBT, massage, all sorts of things. Nothing worked well, and certainly not as well as the drugs. It doesn't make all the pain go away (possibly a higher dose would, but that would have other tradeoffs). But I can work and have a normal life thanks to it.

It has gotten considerably more difficult to obtain in the past few years (30 days at a time, have to go get physical prescription from doctor every 30 days, etc). And I worry that it will just become impossible at some point. I really don't think the government should be stopping people who can benefit from taking these drugs if they wish. Maybe the research shows that for most people, or in many situations, something else is better. But I do know its either helping my pain or, I don't know, causing me to hallucinate that it helps my pain? I haven't read this research but my experience clearly says it can help.
posted by thefoxgod at 1:55 AM on May 5, 2016 [22 favorites]


They don't hand these things out like candy, you must have failed everything else.

The past 4 times I have been to the doctor's office for an injury (one fall-related back injury, one case of 5 cracked ribs, one overly-strained shoulder, and one activation of an old ruptured L5), the only thing the doctor seemed to want to do was to prescribe me some hydros and get out the door. I can't take opiates because they make me suicidal, and it takes some convincing to get them to prescribe me some decent (and hopefully not stomach-eating) NSAID, which usually will help with my pain for enough days in a row for it to reduce to where I can deal with it using naproxen or something.

When I fell in Jan 2015 and did what I thought was serious damage to my back (turns out it was all just soft-tissue damage), I explained to the doctor that I couldn't take opiates because they make me suidical, and he wrote me a prescription for a thing. That I got filled, and then came home and took the recommended dose. And THEN sat down and looked at the wikipedia page for Tramadol. Wrong order in which to do things. That was a pretty horrible night. I've learned to ask more questions.

So, yeah, they DO seem to hand them out like candy. Even when you insist you don't want them.
posted by hippybear at 1:59 AM on May 5, 2016 [1 favorite]


This is partly because the opiate dose required to control pain increases faster than your tolerance to the respiratory depressant effects of the drug, so people using them long-term get closer and closer to an over-dose threshold

This is frequently stated but I'm not sure it's all that well substantiated. Or at least I have seen mixed things. There might be dangerous parts of the curve but tolerance to respiratory depression and tolerance to analgesia can both get very very high.

I was just thinking reading this actually that I would like to see more research into how exactly opioid overdoses happen because it shouldn't be that hard not to OD on a known dose. I suspect mixing in other downers accounts for a lot but I feel like there may be factors that aren't fully understood.
posted by atoxyl at 3:05 AM on May 5, 2016 [3 favorites]


Also I have pretty strong hopes for buprenorphine (or other weird modulators to come) to deliver some of the benefits of opioids while limiting the downside.
posted by atoxyl at 3:14 AM on May 5, 2016 [1 favorite]


This is frequently stated but I'm not sure it's all that well substantiated. Or at least I have seen mixed things. There might be dangerous parts of the curve but tolerance to respiratory depression and tolerance to analgesia can both get very very high.


I should say I don't know that much about whether this eventually comes into play as a limiting factor with very high doses used for pain management - just that I've tried to look it up but seen different things. It's a story that gets told a lot about why recreational users OD though - that they use more and more trying to get high until they die - and that's pretty inconsistent with my personal experience and observations. Except again when people get too comfortable throwing in booze and benzos.
posted by atoxyl at 3:22 AM on May 5, 2016


Maybe, just maybe, more middle aged white people are medicating themselves to death because life fucking sucks more and more for them every year.

It's kind of like China during the heyday of opium abuse. Western press loved to talk about the unique moral degeneracy of "the heathen Chinese." Less remarked upon was the utter collapse of the social order and civil war. Oh and imperialism. That too. Maybe that had something to do with the willingness of people to check the fuck out of life? Nah.
posted by wuwei at 5:03 AM on May 5, 2016 [12 favorites]


Taking up flower gardening might help.
posted by Jacqueline at 5:09 AM on May 5, 2016 [1 favorite]


Yet another symptom of the US culture's "life at all costs" mandate. Doesn't matter if your pain, whatever the cause, is making life a living hell. We won't let you manage it because you might become addicted to the palliative and die! Doesn't matter if you have a fatal disease and it is a medical fact that your pain and quality of life will greatly deteriorate: you gotta live until your body gives out.

I fully support people making informed choices about their lives. Some may not wish to risk treatment of chronic pain with opioids due to the risks of dependence which could theoretically lead to addiction and abuse. But to take the choice away from everyone else, including those who have been informed, done the mental math and decided that the risks are worth the possible benefit? Not everyone out there believes suffering is a virtue.
posted by smirkette at 5:26 AM on May 5, 2016 [19 favorites]


So, yeah, they DO seem to hand them out like candy

I had a wicked cough a few years ago that just wouldn't quit. I coughed up a little blood one morning and my wife insisted I see the doctor. They gave me a Z-pak and a giant bottle of hydrocodone syrup. I think I took one dose and noped right out; sure, I stopped coughing, but I also kept waking up wondering why I hadn't been breathing.

But yes, freedom from pain is one of the most important things medicine can provide. It's a tough line to walk, though, when there is a real risk of harm (for some people) from the medications that could let them live their lives without pain; the puritan-tinged tut-tutting over the possibility of useful drugs being used for pleasure definitely doesn't help.
posted by uncleozzy at 5:33 AM on May 5, 2016


I went looking to see if I could find evidence on PubMed about the number of overdose deaths linked to people taking medications that were actually prescribed to them for pain (versus prescriptions obtained for access to opiates.) I couldn't find anything at all. I saw that about 19000 people die per year from overdoses of prescription opiods, but that says nothing at all. I'd appreciate a link to any breakdowns of that number.
posted by OmieWise at 5:44 AM on May 5, 2016 [2 favorites]


We're also having the conversation because people are dying from them, in those aged 35-54 years prescribed opiates kill more people than car crashes or guns. The debate is over how freely opiates should be prescribed, with the trade-off being between overdose deaths versus under-treated pain.

Most of the pharmaceutical ads on TV list death as a possible side effect of the medication being advertised. Shouldn't it be up to the doctor and patient to weigh the potential risks of a particular treatment against its potential benefits? I, for one, can easily imagine becoming suicidal if I didn't have access to adequate medical pain management.
posted by The Underpants Monster at 6:17 AM on May 5, 2016 [3 favorites]


Seriously. I would take opiate "addiction" any day over the living hell that was Cymbalta. Sadly, opiates don't help me very much either. But they certainly help some people, and I would never look down upon anyone for seeking out the medicines they need.

Cymbalta and neurontin are incredibly useful drugs, and when effective can be used indefinitely with zero concern for misuse, addiction, or toxicity and your kids won't steal it and get high. And for some people they don't work or have unpleasant side effects. As well, they work for pain that can't always be addressed with opiates, and can help sleep and mood. Your hyperbole just makes it that much harder to bring all available options into the discussion.
posted by docpops at 6:36 AM on May 5, 2016 [6 favorites]


Shouldn't it be up to the doctor and patient to weigh the potential risks of a particular treatment against its potential benefits?

That's a given, but is it sufficient or possible in today's exploding possibilities of drugs matched with today's economic restrictions that give a good 12 minutes of patient/physician consultation time?

Perhaps when "smart" medicines and "IoT" medical interfaces monitor a persons condition 24/7 with genetically matched sensors and high encryption interaction with a Wilson-like monitor? Yep and if pigs had rocket belts.
posted by sammyo at 7:09 AM on May 5, 2016


So, yeah, they DO seem to hand them out like candy

Man, not to me they don't! Acute back injury and years of resulting chronic pain treated with what I guess is the recommended anti-drug SOP : PT (until my insurance company cut me off, which is an extra awesome layer of added stress--get better in 15 sessions or less or else you are SOL for the next calendar year!) and... that's it, just PT. The only pill I was ever prescribed for that was a course of steroids. Also on my list of things I didn't get: any kind of imaging in order to, idk, diagnose my injury?

The only time in my life I've ever been prescribed opioids was when I went to the ER with a dog bite. They gave me like 20 oxys which is actually kind of absurd but given my chronic back pain, I was kind of thankful because it meant I could keep some around as a rescue med for when my back had a particularly rough day. I hoarded those things for over a year.
posted by soren_lorensen at 7:14 AM on May 5, 2016 [9 favorites]


Cymbalta and neurontin are incredibly useful drugs, and when effective can be used indefinitely with zero concern for misuse, addiction, or toxicity and your kids won't steal it and get high. And for some people they don't work or have unpleasant side effects. As well, they work for pain that can't always be addressed with opiates, and can help sleep and mood. Your hyperbole just makes it that much harder to bring all available options into the discussion.

My pain and life experience are not hyperbole. They are pain and life experience.

Maybe Cymbalta works for some people. Great. Let them have it. But denying people an effective medication because this country has an ass-backwards attitude towards substance abuse is not just unwise, it's cruel and immoral.
posted by panama joe at 7:14 AM on May 5, 2016 [14 favorites]


So opiates kill more people than guns or alcohol. But we have an extremely powerful, well-funded political machine that not only successfully prevents any restrictions on firearms but continues to produce increasingly deadly upgrades. And the idea of limiting driving is not just impractical for much of the country but also unthinkable. Drugs and cars are embedded in our American identity.

But mitigating pain in people who either have a chronic condition or who have broken their face - that's apparently not worth the collateral damage. I don't mean to handwave any addiction or death, but we've already decided that guns and cars (as well as processed food, alcohol, and environmental pollution) are totally worth the repercussions. Because drugs. And because sucking it up is the American way.

I am fortunate not to live with chronic pain, but holy shit - I have suffered some periods of agony over temporary conditions. Maybe I'm just a wuss, but I cannot ignore the pain of, say, a ruptured disc or a broken bone, and until I can get some pain relief, I am aware of every second - no sleep, no conversation, no distractions. Does wonders for my depression, which I understand also a large number of lives each year. I am terrified of the next time I get hurt and just have to deal with a period of agony - I can't imagine how I would feel if pain was my default state.

Thank god I live in a state with legal marijuana.
posted by bibliowench at 7:42 AM on May 5, 2016 [8 favorites]


I went looking to see if I could find evidence on PubMed about the number of overdose deaths linked to people taking medications that were actually prescribed to them for pain (versus prescriptions obtained for access to opiates.) I couldn't find anything at all. I saw that about 19000 people die per year from overdoses of prescription opiods, but that says nothing at all. I'd appreciate a link to any breakdowns of that number.

They don't exist. That was my point further up. Until we understand that, we can't effectively address a legitimate problem without huge collateral damage. If 50% of people treated with prescription pain killers become addicted--not just dependent, addicted--then we need to approach the problem one way. If 10% of them do, another. In either case, if we can figure out which subgroups are most at risk for addiction (e.g., people with substance abuse histories?), then we can even more effectively evaluate the risks of prescribing to any particular patient and make sure the most vulnerable get better support to avoid that result.

That's why a statement like this:

We're also having the conversation because people are dying from them, in those aged 35-54 years prescribed opiates kill more people than car crashes or guns.

is careless, lazy, and dangerous. "Prescribed" is not the same as "prescription." "Prescribed" embraces the person who was prescribed the medication for legitimate pain AND the kid who buys them on the street. And everyone in between. (About the only thing it excludes is medication straight-up stolen from a doctor or pharmacy.) The proper policy response to the death of each of those individuals is different. Lumping them all together and demanding that "something must be done!!!" is exactly how you end up hurting a lot of bystanders.

Honestly, I'm not even sure that that statement is true for "prescription opiates." I've been poking around looking for data and I'm not seeing breakdowns that clearly show this (though they may well be out there, I didn't devote my life to it). There is absolutely a risk to opiate use, but good data is the first victim of any moral panic.
posted by praemunire at 8:15 AM on May 5, 2016 [7 favorites]


neurontin are incredibly useful drugs, and when effective can be used indefinitely with zero concern for misuse, addiction, or toxicity and your kids won't steal it and get high

Neurontin does get abused. I don't know who these people are who find Neurontin such a pleasant experience, but apparently they exist.
posted by praemunire at 8:17 AM on May 5, 2016 [1 favorite]


In terms of units sold, hydrocodone/APAP was the second highest selling drug in America in 2014, beating out antihypertensives, statins, insulin products, and everything other drug aside from levothyroxine. Sales have no doubt fallen somewhat since it was moved to Schedule II in October 2014, but it's still a big seller.

The number of prescriptions written annually for hydrocodone and oxycodone products has steadily risen for the past twenty years. The number of overdose deaths involving prescription opioids has also steadily risen over that time period. The upward trend preceded the recession but was accelerated somewhat by it. Overdose deaths from heroin remained fairly flat over most of that time period but has started to trend upward over the last few years.
posted by dephlogisticated at 8:39 AM on May 5, 2016 [1 favorite]


the graph missing - and the part of the discussion that keeps slipping into the background is - "pain relief reported by chronic pain sufferers".

graph that, bitches.
posted by j_curiouser at 10:28 AM on May 5, 2016 [11 favorites]


The number of prescriptions written annually for hydrocodone and oxycodone products has steadily risen for the past twenty years. The number of overdose deaths involving prescription opioids has also steadily risen over that time period.

That's nice, but it says absolutely nothing about diversion rates or indeed factors that may be increasing death rates beyond the mere existence of the drug (e.g., the increased [though now somewhat cut back on] use of acetaminophen combinations as a supposed deterrent to abuse : "[Acetaminophen] Overdose from prescription combination products containing acetaminophen account for nearly half of all cases of acetaminophen-related liver failure in the U.S., many of which result in liver transplant or death." Did those people die of the hydrocodone or the acetaminophen in their Vicodin? I have an opinion.) I understand the temptation of the initial "it just stands to reason" argument, but I don't understand why it keeps popping up over and over again in the face of facts to the contrary. Just as with discussions of weight loss. Hmmmm.....
posted by praemunire at 10:51 AM on May 5, 2016 [12 favorites]


I don't know what species these kids belong to who take Cymbalta and Neurontin and don't get high from it, but more power to them. Every doctor I talked to while I was deciding to get off Cymbalta and made sure to stress not to give it up cold turkey but to taper it off slowly over at least 4 to 6 weeks because the withdrawal was known to be particularly bad. I've never met anyone who took Cymbalta and didn't have either crying jags are laughing fits; I had both and the scary part was I couldn't tell them apart. I have a family member has Driven Crazy by the twitching caused by Neurontin, but she's tried everything else for neuropathy. That's what both of these drugs are: the treatments of absolute last resort. No doctor I've been to likes prescribing them.
posted by The Underpants Monster at 1:27 PM on May 5, 2016 [1 favorite]


Did those people die of the hydrocodone or the acetaminophen in their Vicodin? I have an opinion.

The number of people that die from acetaminophen-induced liver failure is in the neighborhood of 300-500 annually, and most of those are intentional overdoses. The number of people that die from unintentional overdose of prescription opioids is somewhere north of 18,000 annually. Deaths from opioid overdose result from acute respiratory depression (e.g., you pass out and stop breathing), whereas acetaminophen-induced liver failure involves some pretty characteristic symptoms evolving over the course of several days. In other words, the presentation of these two types of overdose are unlikely to be confused. Acetaminophen is basically negligible as a casual factor in opioid-related deaths.

The issue of how/when to use opioids is complicated. Like all types of drug therapy, there are risks and benefits that have to be weighed and these are not necessarily the same for every patient. The data regarding efficacy for chronic pain is not encouraging, but in some cases there may not be better options. I'm not firmly for or against their use; I think they're essential drugs that are entirely appropriate in some cases and less appropriate in others. From a public health standpoint, however, I don't think it's controversial to suggest a relationship between the increased frequency of opioid prescriptions and the increased frequency of opioid-related deaths. Some nonzero percentage of users are going to overdose, either due to intentional abuse or unintentional over-use or drug interaction, and if you increase the number of people using the drug you're going to increase the incidence of that occurring. The only question is whether that risk is significant enough to justify a change in prescribing practices.
posted by dephlogisticated at 2:44 PM on May 5, 2016 [3 favorites]


The number of people that die from acetaminophen-induced liver failure is in the neighborhood of 300-500 annually, and most of those are intentional overdoses.

My point is just that there are some, and could be other, complicating factors, which means that it's not just a matter of saying "hey, scripts have increased, deaths have increased, QED."

From a public health standpoint, however, I don't think it's controversial to suggest a relationship between the increased frequency of opioid prescriptions and the increased frequency of opioid-related deaths.

No doubt there is one. If the drug is not being put in the market somehow, it's not going to be available to kill you. However, considering that diversion at all levels is a well-known phenomenon, it seems to me almost willfully simple-minded to act as though we could be confident that the opioid-related deaths are primarily of people taking the opioids prescribed to them, as they were prescribed to them. If half of the people prescribed Percocet end up addicted, then, wow, there definitely is an overprescription problem; the drug is very risky and we need to weigh those risks much more heavily than we do now in prescribing it. If only a small percentage do, and the addicts were mostly not prescribed the drug but got it illegally, then the problem is not overprescription but insufficient care in dispensing, and we need to think hard about ways to prevent theft, but we don't need to deny a chronic pain sufferer relief in the same way as we would in the first scenario. If most patients don't get addicted, but, say, a significant portion of patients with a prior history of substance abuse do, then we need to take the elevated risk for that group into consideration when prescribing. If deaths are resulting largely from intentional overdose, then we need to alter dosing. If deaths are resulting from unintentional overdose or dangerous combination with something else like alcohol, then we need to figure out how to educate patients more effectively on those dangers. And so on.

Now, I don't know which of the above is true; from my poking around, all I've seen is some limited and inconclusive data. Certainly the data is not being put forward by the current advocates for changing practices. But without that data, we're just doing the very real harm of cutting people in pain off from relief (oh, yes, limited relief is still relief; only someone who hasn't experienced or watched a loved one experience serious chronic pain would act as though it were trivial) without having any idea of whether we will be saving lives as a result.
posted by praemunire at 4:18 PM on May 5, 2016 [3 favorites]


DrRotcod: "We're also having the conversation because people are dying from them, in those aged 35-54 years prescribed opiates kill more people than car crashes or guns."
This can be easily fixed by handing out more guns and reducing auto safety regulations.

Seriously, "more people die from X than Y" is an incredibly stupid metric for deciding where to focus. More and more people are dying from cancer, but that's in large part because we've become better at stopping people from dying of other stuff.
posted by brokkr at 3:21 AM on May 6, 2016 [5 favorites]


But the CDC's data says the opioid overdose deaths involve prescription opioids, there is no distinction between overdosing on your prescribed painkiller or overdosing on someone else's or because of interactions with other drugs.
posted by Smibbo at 3:37 PM on May 6, 2016 [3 favorites]


And for those of us with neurological damage, the word "dependence on opioid painkillers" is like "dependence on a wheelchair"
posted by Smibbo at 3:40 PM on May 6, 2016 [8 favorites]


Well, they mean a direct pharmaceutical physical dependence, but your comparison is still apt. A type-I diabetes patient is physically dependent on insulin. Is that an argument against insulin? Of course it's not. If I get my hips replaced (which I should have done fifteen years ago and I really can't walk much at all now), will I be physically dependent upon those artificial hips? Of course, profoundly and irreversibly. Is that a bad thing?

And obviously there are all sorts of medications which have serious withdrawal symptoms when stopped suddenly. Those are all physical dependencies. That's a concern about managing medication and switching medication and whatnot. But in those other cases, we don't see this dependence used as a synonym for "addiction". As the article discusses, dependence is just a biological fact of one sort or another (and to whatever degree). Addiction is a nebulous cluster of possible predispositions, psychological context, and, most importantly, behaviors. Dependence is neither necessary nor sufficient for addiction, though it correlates to it. Dependency makes addiction much more likely, all else equal. For most people, all else isn't equal.

It's not the case that acetaminophen induced liver failure is a large portion of opioid-related fatalities. It's super obnoxious that it's specifically used for that purpose, as a disincentive to abuse opioids, and that, as a consequence, many people are bearing a much higher load on their livers than they ought to be. But, even so, that's not what's distorting the statistics.

But, as discussed, what is distorting the statistics is the failure to distinguish between use-as prescribed (by an individual doctor), abuse (legal and otherwise), and involvement of other CNS depressants. It would be disingenuous to claim that almost all fatalities involve doctor shopping or diversion, or that almost all fatalities involve other CNS depressants, or any one specific alternative to use-as-prescribed. But, collectively, everything that isn't use-as prescribed almost certainly makes up the larger portion of fatalities. I don't know how much larger, but I suspect that it's much more than slightly. Yet all the discussion is centered around use-as-prescribed.

Yes, it's true that at this point the only way to control much of the abuse is to control use-as-prescribed because most of the abuse originates from what is putatively use-as-prescribed, but is not. An individual doctor who's been doctor-shopped doesn't know about the others. An individual doctor with an addict inventing chronic pain that doesn't exist can be hard-pressed to tell the difference. An individual doctor correctly prescribing to a patient who finds it worth more to them to sell on the black market than to take for their genuine pain has no ability to detect or stop that from happening. So the blunt instrument available at this point is just choking off the supply.

I'm really unhappy about that because I don't think we got to this point merely because doctors were more willing to prescribe opioids. We got here because of some really dumb decisions by regulators and the predictable short-sighted greed of pharmaceutical companies. But now that we're here, I concede that the cycle has to be interrupted and one aspect of that is necessarily more carefully controlling the supply.

But what infuriates me is that the the public rationale for controlling the supply is a mishmash of fear and dishonesty that makes it seem as if everyone who is prescribed opioids for chronic pain will eventually become an addict and/or may die from an overdose. As I wrote earlier, there is a social context for this. Some of what's being done is right, as I just wrote. But to some degree it's being done for the wrong reasons and in a way that will continue to have bad effects even if the epidemic of opioid abuse is stopped in its tracks. Because the public rationale has become that opioids aren't that effective for chronic pain, anyway, they're therefore unnecessary, and they inevitably lead to addiction and death. Long after this opioid abuse epidemic is history, genuine sufferers of serious chronic pain will be paying the price. We're paying the price now. The foundation is being laid such that we'll be paying the price for a generation.
posted by Ivan Fyodorovich at 6:30 PM on May 6, 2016 [8 favorites]


I don't think non-chronic-pain sufferers should be allowed to decide what is and isn't "very effective" against chronic pain. This Calvinist attitude towards pain needs to be addressed in addition to any other plans anyone comes up with.
posted by Smibbo at 2:56 PM on May 7, 2016 [8 favorites]










Prince isn't the best example here. His fame allowed him access to opioids that most people wouldn't have. By all reports, he suffered chronic pain. However, he did not experience the conditions of most people suffering from chronic pain. The over-prescription of the elite does not justify taking away the relief of the masses.
posted by Ruki at 9:50 PM on June 2, 2016 [5 favorites]


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