The Perfect Recipe for Addiction
May 5, 2016 6:41 AM   Subscribe

The drugmaker Purdue Pharma launched OxyContin two decades ago with a bold marketing claim: One dose relieves pain for 12 hours, more than twice as long as generic medications. OxyContin’s stunning success masked a fundamental problem: The drug wears off hours early in many people, a Los Angeles Times investigation found. OxyContin is a chemical cousin of heroin, and when it doesn’t last, patients can experience excruciating symptoms of withdrawal, including an intense craving for the drug. The problem offers new insight into why so many people have become addicted to OxyContin, one of the most abused pharmaceuticals in U.S. history.
posted by Horace Rumpole (58 comments total) 20 users marked this as a favorite
 
Aw geez. So it's like perfectly designed to create addiction? Awesome.
posted by leotrotsky at 6:48 AM on May 5, 2016 [2 favorites]


Heroin was marketed as non-addictive too.
posted by Faint of Butt at 6:56 AM on May 5, 2016 [1 favorite]


3. Profit!
posted by Kirth Gerson at 6:56 AM on May 5, 2016 [5 favorites]


why so many people have become addicted to OxyContin

Isn't also one of the reasons of the skyrocketing use of heroin in the US in the past few years? People who are treated with OxyContin since their mid-teens (although apparently, it can be given to kids in the early teens now) suddenly lose legal access to the drug and end up going for H because it's cheaper on the street?

The only difference between a lot of pharma and the drug cartels is at the eyes of the law. Both are happy to leave a trail of corpses on their path to money and power.
posted by lmfsilva at 7:02 AM on May 5, 2016 [3 favorites]


If you watch The Nick, you get the impression that the whole world was slinging around Opium, Cocaine, and Heroin for awhile before everyone caught on that this might be the cause of some pretty horrible social consequences. There's one scene in which they treat the main character going through Cocaine withdrawal with Heroin, the implication being that it was a pretty revolutionary approach to addiction.
posted by SpacemanStix at 7:03 AM on May 5, 2016 [2 favorites]


You mean The Knick, SpacemanStix. (And yeah, back then they kinda did.)
posted by Catblack at 7:06 AM on May 5, 2016 [2 favorites]


The only difference between a lot of pharma and the drug cartels is at the eyes of the law. Both are happy to leave a trail of corpses on their path to money and power.

Oh come on. Any ridiculous criminalization of something that should be a public health problem is going to see fuckups like this. Imagine what would happen if OxyContin addicts could get access to detox physicians, methadone and support without shame or stigma.
posted by Talez at 7:09 AM on May 5, 2016 [25 favorites]


Isn't also one of the reasons of the skyrocketing use of heroin in the US in the past few years? People who are treated with OxyContin since their mid-teens (although apparently, it can be given to kids in the early teens now) suddenly lose legal access to the drug and end up going for H because it's cheaper on the street?

This was a story I heard a lot back when I was a public defender, from clients as young as 19, so yeah.
posted by Bulgaroktonos at 7:13 AM on May 5, 2016 [4 favorites]


There's nothing specific about OxyContin, either the formulation or the oxycodone. Now, the more commonly abused medication is Opana, a time release oxymorphone product (see Austin, Indiana).

The problem is the widespread availability of the drug, largely and initially from doctors. Many addicts start out with a prescription and much of the street supply is diverted pharmaceuticals. Some of this is a case of unintended consequences, some is driven, unsurprisingly, by profit. Many states have restricted in various ways the prescribing of narcotics by physicians. At the same time, doctors are told, appropriately, that we should treat pain (which was often minimized, discounted, and undertreated in the past) and alleviate suffering. So, many practicing doctors refer patients to practices specializing in pain management who will deal with the bureaucratic aspects.

Some are professional; others are little more than pill mills. All are very profitable. Of course pharma plays a role with marketing and overproduction. Pharmacies also are part of the chain, dispensing meds in large quantities when it should be apparent that a given community really shouldn't need so many Opana pills. And, there is also abuse on the part of patients. Some have real pain but others, out of work, perhaps with a real illness or disability, obtain meds and sell them to help make ends meet. There's plenty of blame to go around, if you want to start assigning it.

Never underestimate the potent addictive nature of these, drugs, whatever the form.
posted by sudogeek at 7:32 AM on May 5, 2016 [3 favorites]


I have been involved with a substance abuse clinic's intensive outpatient program in the last little while.

The number of adolescents - and up through their 20's - being treated for oxy addiction is pretty horrifying, especially when you consider that most of them are snorting it, which makes it quicker and gives you a more intense high. And this of course leads to more overdoses as it wears off quicker too.

In the past, these IOP programs were full of mostly alcohol addicts. These days, it's 75% prescription pill addicts (no matter how they ingest them) and about 25% alcohol addiction.

I don't know what the long term solution is other than education and peer pressure tactics to make it "uncool" or something.
posted by disclaimer at 7:33 AM on May 5, 2016 [3 favorites]


Speaking as someone in recovery from addiction: one of the things that scares me quite a bit (if I let my mind linger on all the what-ifs) is the prospect of dealing with chronic physical pain. I've been profoundly lucky up to this point, having never suffered any severe, long-lasting pain. I was so nervous about getting hooked on that stuff that I recovered from my wisdom teeth removal with ibuprofen horse pills and ice packs -- I never opened the bottle of Oxycontin that the oral surgeon sent home with me.
posted by Vic Morrow's Personal Vietnam at 7:34 AM on May 5, 2016 [7 favorites]


The only difference between a lot of pharma and the drug cartels is at the eyes of the law.

Not a small difference. Yes, there is slippage to the street, but the drug cartels have zero medical oversight. There's a reason your doctor has eight years of medical school and the guy on the corner does not.
posted by IndigoJones at 7:35 AM on May 5, 2016 [2 favorites]


If I'm reading this right, they basically ensured that a high percentage of Oxy users- legit, q12h prescribed users- would suffer withdrawal on a regular basis. That's just evil.
posted by Pope Guilty at 7:37 AM on May 5, 2016 [8 favorites]


OxyContin is a chemical cousin of heroin, and when it doesn’t last, patients can experience excruciating symptoms of withdrawal, including an intense craving for the drug.

This is a weird sentence. It doesn't surprise me at all to learn that the manufacturers exaggerated the duration of the pain relief provided by the drug; shame on them. But by far the more common scenario caused by the drug wearing off early would be...the patient experiencing the excruciating pain for which the drug was prescribed. You only get to withdrawal if you're already dependent (and rather heavily so, to be going through "excruciating" withdrawal in a couple of hours).
posted by praemunire at 7:39 AM on May 5, 2016 [4 favorites]


(From personal experience, I know that your painkillers wearing off early is a grim experience, so I should make it clear that I don't think that that occurrence is trivial or not to be worried about.)
posted by praemunire at 7:43 AM on May 5, 2016 [2 favorites]


No matter how heavily addicted you are, you aren't going to get excruciating withdrawal symptoms inside of 12 hours. Cravings after a few hours if you've been taking doses more often than prescribed, sure. Maybe a bit of discomfort in the form of feeling too hot or cold after 6-8 hours, but it takes a good 24 hours or so to start getting the shits and all the other fun stuff.

It takes even longer if you use actual Oxycontin, which is a time-release formula, rather than the "instant" generics.

We do have an opiate problem in this country now, but this kind of alarmist crap annoys the piss out of me. Sadly, the crackdowns are just making it worse by forcing people onto street drugs. And, of course, both manufacturers and pharmacies are happily increasing prices as a response. They're up to $1000+ to fill a 90ct 30mg generic oxycodone prescription now. It's to the point where the price of the drug very nearly forces even people with a legitimate need to divert part of their supply just to help cover the cost.

I don't know if they are doing it because they can or if the increased scrutiny has led to increased expenses, but regardless of the reason, it sure isn't helping anybody but heroin dealers. I would be unsurprised to learn that the intelligence agencies are once again selling heroin to supplement their legit appropriations. It would definitely explain the government's unnecessary intrusion into the doctor-patient relationship.
posted by wierdo at 8:10 AM on May 5, 2016 [6 favorites]


Not a small difference. Yes, there is slippage to the street, but the drug cartels have zero medical oversight. There's a reason your doctor has eight years of medical school and the guy on the corner does not.

Yes, it's a gross exaggeration, but reading this article, it paints a picture where legality and quality control are the only things between both, and keeping their customers alive enough for the next fix is the only thing that matters. To maximize profits, The guy in the corner might be cutting his stuff with adulterants that may cause death. The guys with lab coats ignore the addiction potential and exaggerate claims in chase of profit that lead to overdosing. Both are morally reprehensible.
posted by lmfsilva at 8:11 AM on May 5, 2016


The ability to prescribe marijuana instead of opiates sure would be a helpful option for doctors to have.
posted by Mick at 8:15 AM on May 5, 2016 [12 favorites]


Yeah the repeated interchanging of meaning of withdrawal is curious. It seems reasonable - if still a potential pitfall - to not differentiate between physical and mental withdrawal. But to describe the simple wearing-off of a painkiller as withdrawal... I have never seen that done anywhere else. I know at least one physician is following this thread (though this might be a better question for a researcher or librarian) - is this a thing anyone in the medical community says? In all my years on the periphery I have never heard it.

There's a reason your doctor has eight years of medical school and the guy on the corner does not.

At least the guy on the corner needs to pay some attention to how the customer will pay for things, and will tailor the offering to match. This story is about 75% driven by the fact that the cost of this medication is borne by insurance companies and largely hidden from the doctor and patient.
San Francisco public health clinics stopped dispensing the painkiller in 2005, based in part on feedback from patients who said it wore off after eight hours. The clinics switched to generic morphine, which has a similar duration and costs a lot less.
Saw what you will about street dealers, but at least they practice evidence-based methods. They're not accepting golf trips to motivate them to push some specific chemical.
posted by phearlez at 8:24 AM on May 5, 2016 [6 favorites]


Vic Morrow: pain is pain and needs to be managed. Addictive drugs are often given to recovering people undergoing surgeries without cause for concern, because it's done in a managed way. Remember that an addict wants to get high, that's the reason they're addicts, after all ;). When a patient is in severe pain, oxy and other narcotics don't get you high, they just go right to the pain centers of the brain and many times patients don't even get a buzz, just relief.

When a non-addicted person is discharged after surgery, they're often given a scrip for a pain med, and lots of times these are overkill, like prescribing a 90 day supply of OxyContin because it's covered by insurance (and why the hell not?).
Usually, though, only 5 or 10 pills are all that are needed, following on with ibuprofen or another, milder medication.

The bigger threat to your recovery here is not involving a professional in pain management, because that can lead to addicts attempting to self-medicate.

So, if you suffer from chronic pain or are going to be undergoing a surgical procedure and are in recovery for addiction, involve a doctor that specializes in addiction and that can coordinate with your surgeon or PCP to ensure you receive the minimum needed amounts of these kinds of drugs, and you'll be fine.

If chronic pain is going to be present long-term, pain meds CAN (and should!) be part of a recovery program. Typically, recovery involves total abstention from mind-altering substances, right? Consider food addiction, where "the drug" is food or generated by food. But people can't abstain from eating. So, they develop strict management protocols around their eating, sometimes for life, to control their addictive behaviors that involve food. The same approach can be used with chronic pain: careful, managed or supervised access to the pain medication so that it's used appropriately can be part of a successful recovery from addiction.

Just as a minor data point, I know a woman that underwent knee surgery while in a rehab setting. She had about 6 hydrocodone to get her through post-surgery and the next few days at home, but went on Advil when she got home instead. She ended up flushing three of the oxys and is now pain free without affecting her recovery at all. And she had been suffering from chronic knee pain for years: it's what got her addicted to pain pills in the first place. So it can and is done all the time - don't let fear of addiction or relapse get in the way of eliminating or reducing pain.

Tldr: discuss pain management strategy and addiction issues with your doctor or find one that's familiar with the issues around it. There are ways to manage pain without affecting your recovery.
posted by disclaimer at 8:30 AM on May 5, 2016 [10 favorites]


I was prescribed Oxycontin for a sprained ankle (!) back about a decade and a half ago. My doctor told me it was like Vicodin but I wouldn't have to re-dose every four hours. He gave me about two weeks worth.

Partly because of brain-fog and lack of motivation because I wasn't in pain, I didn't do my prescribed exercises at anything close to the recommended schedule. At the end of my two weeks, much of which was spent in a complete fucking stupor, my ankle still hurt like crazy so I called my doctor and they wrote me another two week prescription and told me to do the excercises.

So, with great difficulty, I forced myself to do the exercises on-schedule. But, after close to a month of used-as-directed medication, my ankle hurt like crazy when I ran out. Also my head. And I was depressed. And nauseous. I thought I had the worst flu ever. So I called my doctor. They said to come in.

I went in and explained my situation. My doctor told me I had become addicted to the painkillers and was going through withdrawl. He wouldn't give me any more painkillers because he didn't want to exacerbate my addiction. He seemed disgusted with me. I was disgusted with myself. He let me know that addicts remain addicts for life, and recommended a Christian drug-treatment program.

I told him I was not a Christian. He seemed even more disgusted with me. He told me these programs were very effective anyway, and it was probably the only way to save me from being a lifelong drug addict.

Very next day I went to a meeting. Nice people, but it was way more evangelical than the doctor had let on. They did an "altar call" demanding that the, um, unsaved (That's Me!) bring Christ into their hearts or the program would not work.

I left, in tears, still suffering withdrawl, and went home to not sleep for another two days. Then I started to feel a little better. My head was clearer, my pain was receding. and I got back to normal.

I've used opioids a couple of times since, as-prescribed (by different doctors. Never went back to that guy. Ugh.) with zero problems. I never got two-weeks worth for anything as minor as a sprained ankle again. My subsequent doctors were amazed that I was given Oxycontin for a sprained ankle.

Getting hooked on prescription meds is incredibly common, and incredibly easy. Strong opioids can reduce judgement so you don't even realize what's going on or that there's a problem. And some doctors just fucking suck.

I think the worst part of it for me was related to the stigma of addiction. In my doctor's eyes, I had Failed God. I was ashamed of my (relatively short-term and lightweight) addiction because it was a Moral Failing. Many, many people who end up with addiction problems from prescribed meds get it way, way worse than I did. Sometimes I wonder what would have happened if that doctor had gone ahead and given me another 2-week script.
posted by Cookiebastard at 8:39 AM on May 5, 2016 [52 favorites]


> to describe the simple wearing-off of a painkiller as withdrawal... I have never seen that done anywhere else

Cicero says 'Patients in whom the drug doesn’t last 12 hours can suffer both a return of their underlying pain and “the beginning stages of acute withdrawal,”' [emphasis added] and two other doctors do mention withdrawal, but the patient reports make me think it's a triple whammy for chronic pain sufferers: return of pain, some withdrawal symptoms and the anxiety and fear that the pain is never going to stop.

The relief that a strong dose of an opioid brings is so wonderful. Life without pain? Could it actually be possible? Feeling that slip away is gutting.
posted by morganw at 8:42 AM on May 5, 2016 [4 favorites]


You mean The Knick, SpacemanStix.

Hopefully, otherwise I completely missed the subtext in Doug.
posted by hwyengr at 8:47 AM on May 5, 2016


I just had surgery a few weeks ago. They sent me home with enough Dilaudid to stun a horse. Which was fine while the pain was acute. The pain got to manageable levels so I stopped taking it. Then I had a bad-ish day (really it wasn't that bad, but in comparison to the much lower pain it seemed bad) so I decided to take one. And I sank into a warm bed of mashed potatoes. And, worse, I kept forgetting if I'd taken the next one on time so.. I ended up taking a day's worth in about five hours. I'm really really really really really glad they were the last few pills in the bottle.
posted by feckless fecal fear mongering at 8:50 AM on May 5, 2016 [8 favorites]


Dr. Cicero on the supposed crush-proof new oxy “Some people found ways to get around the abuse-deterrent formulation so that they could snort or inject it, and others simply swallowed the pills, but many people switched to heroin, "

The crush-proof version means even more money for Purdue because the FDA has blocked regular generic oxy. Too bad the DOJ couldn't use anti-trust to force Grunenthal to license the tamper-resistance to someone else, nay, everyone else but Purdue.

Don't know if it's actually common practice, but in the 4th season premiere of Maron, an alternate-reality "what if I slipped" Marc is chewing oxy. Not as steep a high as crushing & snorting, but you can do it while wandering L.A.
posted by morganw at 8:52 AM on May 5, 2016


In my doctor's eyes, I had Failed God.

Or maybe that was his way of dealing with his cognitive dissonance of being an upstanding Christian and prescribing massive doses of opioids for sprained ankle to get that trip to Hawaii conference invitation.
posted by hat_eater at 8:58 AM on May 5, 2016 [13 favorites]


My first and only experience with prescription narcotics was a few months ago following knee surgery. I hate to complain that my doctor gave me too many painkillers because they would have been great if I needed them or could tolerate the side effects. But as it was I stopped taking them after about three days. After the first day it didn't seem like they helped the pain, and the side effects were no fun. I would get nausea as the dose wore off (Was that withdrawal? Unlikely at my low doses but it still suuuucked to wake up at 3 am feeling like you wanted to puke.) And, well, let's just say I like being able to poop.

So I stopped taking them pretty quickly. I tried again two weeks later when I experienced really awful bone pain, but it didn't even help the pain; possibly because I was too scared to take doses high enough to be effective. So I gutted through that excruciating pain for a couple days and now months later I'm just destroying my stomach lining with double doses of Alleve (per my doctor recommendation) as needed.

I still think about those pills sitting in my bathroom cabinet now and then. What if I just took one of those instead of OTC meds when I have cramps, or my knee is sore from PT, or I get that headache just won't go away? I have to admit it's mostly the side effects stopping me from doing so.
posted by misskaz at 9:03 AM on May 5, 2016


Some people (like my wife) experience nausea even taking one Vicodin. I wish I were so lucky. As it was, Oxycontin made me joyous, extroverted, and energized. I never increased my dosage to experience nodding-level opiate bliss, and never made the step to heroin, even though it was (is) easy enough to get on the Dark Web. The addiction was as much psychological as physical, so it took a lot of willpower to stop mailing money to my Mexican connection. (Yeah, the cartels--I'm assuming--smuggle it over the border and mail it to people like me from Southern California.)
posted by kozad at 9:20 AM on May 5, 2016


Oxycontin is far from new and the article, which could basically have come out in 2000, didn't really offer anything new or insightful. It is very direct in closing that 12 hours is very important for Perdue, but doesn't dig as deeply as I would have liked as to why an 8 hours regimen would have destroyed the company and their product.

In 2013, in an effort to curb abuse, the FDA banned generic Oxycontin. Perdue had reformulated it to be more abuse resistant by having it turn into a sludge instead of snortable powder when crushed, which also had the side effect of renewing Perdue's government granted monopoly on manufacturing for a little while longer. I haven't been following closely as to why, but there are now generic versions of oxycodone hydrochloride available, so maybe there will be more to this particular story soon.

Now that generic Oxycotin is available, it is not as popular for doctors to prescribe as it once was, for whatever reason. The article also fails to mention fentanyl as the latest pain reliever on the market that was originally marketed as, you guessed it, less addictive and less abuseable, and yup, you guessed it, turns out to be highly addictive and abuseable.

Still, the psychology of addiction is slowly coming around so it's not pictured a moral failing from God. Even heroin, the boogyman of drugs, many people can take a few times without getting hooked.

Additionally, while marijuana is too broad a category to do any serious scientific study of pain relief, specific cannabinoids from specific strains have been proven to provide non-opiate pain relief.
posted by fragmede at 9:22 AM on May 5, 2016


I don't know if they are tightening up here in LA, but while I was in the hospital for a surgery last August, they were really cautious, bordering on stingy, with the pain meds. Every individualized dose was regulated in the room via a locked machine that even the nurses had to jump through hoops to attain. Everything they did and I took was carefully recorded, and I had the impression that they were often worried about getting into trouble by overdosing. If I asked for a strong med at any point, it felt like the request was received with excessive caution with an eye towards leaving me at as low a dose as possible. There was a lot of lip service about my comfort going in to the hospital (there was even a stated philosophy on pain management), but my lived experience was them trying to keep my pain at "just at the edge of manageable." I was told at one point that they only give pain meds if you register about a 6-7 on the pain scale (sorry, I'm looking for no pain here, if possible). My surgeon, on the other hand, had no qualms about giving me a refill after the surgery. He was a good man. I needed the refill, and it felt like the first time I was treated like a grown up in my request.
posted by SpacemanStix at 9:23 AM on May 5, 2016 [7 favorites]


My doctor told me I had become addicted to the painkillers and was going through withdrawl.

Just FYI, your doctor was completely wrong. You were going through withdrawal because you had become dependent on the medication. You weren't addicted. Nothing in your comment indicates the impact on life that defines addiction.
posted by OmieWise at 9:28 AM on May 5, 2016 [18 favorites]


So we tightly regulate how many methadone patients each doctor can have, but these doctors discussed in a related series linked in the article are prescribing a disproportionate number of fatalities and nothing can be done?

This country is sick.
posted by chainsofreedom at 9:47 AM on May 5, 2016 [1 favorite]


Vic Morrow's Personal Vietnam: "Speaking as someone in recovery from addiction: one of the things that scares me quite a bit (if I let my mind linger on all the what-ifs) is the prospect of dealing with chronic physical pain. I've been profoundly lucky up to this point, having never suffered any severe, long-lasting pain. I was so nervous about getting hooked on that stuff that I recovered from my wisdom teeth removal with ibuprofen horse pills and ice packs -- I never opened the bottle of Oxycontin that the oral surgeon sent home with me."

I have a roommate with chronic pain. She is very good with her opiate regime. Always sticks to her schedule. Never runs out early due to over use. She is fortunate to have a doctor who trusts her. She's also fortunate to not have the addiction. It works for her the best it can. It's not perfect, but it's all she's got at this point in pain management.

My sister had chronic pain, but also emotional pain, and that led to a severe addictive personality. And it meant that she had a hard time getting medication to treat her very real pain. Once labeled a seeker... You know the drill.

After struggling for 7 years to get on disability and wearing down my parent's meager savings (no blame on her, but 100% on the government for making the most disabled person I have ever known to fight so hard to get on disability), she ultimately ended her life in 2013.

Two patients with chronic pain, two very different outcomes. Because one had an addictive personality and the other didn't. How utterly sad.
posted by symbioid at 10:03 AM on May 5, 2016 [14 favorites]


So we tightly regulate how many methadone patients each doctor can have

Methadone is tightly regulated, but not really in this way. Buprenorphine, which is less tightly regulated, is regulated in this way (i.e., in the number of patients a doctor can have).
posted by OmieWise at 10:04 AM on May 5, 2016 [1 favorite]


Dr. Curtis Wright, who led the agency’s medical review of the drug, declined to comment for this article. Shortly after OxyContin’s approval, he left the FDA and, within two years, was working for Purdue in new product development, according to his sworn testimony in a lawsuit a decade ago.
posted by RobotVoodooPower at 10:05 AM on May 5, 2016 [7 favorites]


Discussions about this topic are difficult because most of the terms bandied about are nebulous and poorly defined. What's the difference between addiction and dependence? Is the former a subset of the latter or a matter of degree? What about mental versus physical addiction or withdrawal? Isn't the brain physical? There are opioid receptors in the brain, gut, and elsewhere. Aren't the underlying mechanisms the same even if the manifestations are different? Then there are the conceptual problems (overly rigid insistence on mind-body distinctions, views of emotions, like anxiety and fear, as being psychiatric and not neurochemical), cultural issues (addiction as a failure of will, as evil, etc.), and legal and medical jargon.

@OmieWise above implies that dependence is distinguished from addiction by the social impacts. This could be true for some, but many addicts continue to perform socially, maintain jobs, etc. Most physicians would define addiction by whether the patient suffers a clinically overt withdrawal or abstinence syndrome. Both views have some merit and are not mutually exclusive.
posted by sudogeek at 10:12 AM on May 5, 2016


It is very direct in closing that 12 hours is very important for Perdue, but doesn't dig as deeply as I would have liked as to why an 8 hours regimen would have destroyed the company and their product.

I'm guessing because it would have shed light on the fact that the FDA can approve a drug based on a single positive study on ninety women undergoing similar procedures in a single hospital in Puerto Rico, even if a third of the patients did not get the advertised period of relief. Which is why Purdue is still to this day denying that there's a problem. Because we must not question.
posted by RobotVoodooPower at 10:13 AM on May 5, 2016 [6 favorites]


What's the difference between addiction and dependence?

I've been told by many mental health professionals, that addiction is the disease-model around the behavior, and dependence is a chemical dependence that affects the body.

Example; I have a chemical dependence on coffee, but I am not an addict, as I don't have any of the disease markers for addiction Namely, the seek for caffeine does not alter my life in any way shape or form. If I miss a cup, and experience withdrawal symptoms (and when I skip a day, hooo boy do I), I'm still fully capable of not drinking coffee, even if I have plentiful access. An addict is not necessarily able to override their chemical dependence with willpower, as their bodies and brains are wired differently in the presence of that same chemical dependence.

Basically, the behavior around chemical dependence and addiction are separate, but closely intertwined. You can be an addict but not chemically dependent on anything, and you can also be chemically dependent, but not addicted to anything.
posted by furnace.heart at 10:22 AM on May 5, 2016 [8 favorites]



@OmieWise above implies that dependence is distinguished from addiction by the social impacts. This could be true for some, but many addicts continue to perform socially, maintain jobs, etc. Most physicians would define addiction by whether the patient suffers a clinically overt withdrawal or abstinence syndrome. Both views have some merit and are not mutually exclusive.


Well, most physicians would be wrong, but then, so am I. I'm used to the old DSM-IV, and haven't really adjusted to the ICD-10. In the old nomenclature, dependence was about physical dependence (your withdrawal syndrome) while addiction was about the harmful effects (often subtle, but present) of the ongoing use. The ICD-10 has replaced that with just a blanket term of "Dependence," but even there, you can see that more is required than simply withdrawal. I highlighted what the poster was actually experiencing, which, again, was not addiction.

More generally, I tend to disagree that there is a more general confusion of terms. There are well-defined, even over-defined, terms that often get used incorrectly. There are all kinds of reasons for that incorrect use, but I don't think it's the fault of the terms, and I don't think it can be corrected by more precise definitions. It absolutely is a challenge that the wrong uses are the loudest, but I believe this is a social issue. In this particular case, you had a doctor who had a moral response to "addiction" that lead to them misdiagnosing something that should have been quite clearly diagnosed as something else.
In unqualified form, dependence refers to both physical and psychological elements. Psychological or psychic dependence refers to the experience of impaired control over drinking or drug use while physiological or physical dependence refers to tolerance and withdrawal symptoms. In biologically-oriented discussion, dependence is often used to refer only to physical dependence.

Dependence or physical dependence is also used in the psychopharmacological context in a still narrower sense, referring solely to the development of withdrawal symptoms on cessation of drug use. In this restricted sense, cross-dependence is seen as complementary to cross-tolerance, with both referring only to physical symptomatology (neuroadaptation).

ICD-10 Clinical description

A cluster of physiological, behavioural, and cognitive phenomena in which the use of a substance or a class of substances takes on a much higher priority for a given individual than other behaviours that once had greater value. A central descriptive characteristic of the dependence syndrome is the desire (often strong, sometimes overpowering) to take psychoactive drugs (which may or may not have been medically prescribed), alcohol, or tobacco. There may be evidence that return to substance use after a period of abstinence leads to a more rapid reappearance of other features of the syndrome than occurs with nondependent individuals
ICD-10 Diagnostic guidelines

A definite diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year:

A strong desire or sense of compulsion to take the substance;

Difficulties in controlling substance-taking behaviour in terms of its onset, termination, or levels of use;

A physiological withdrawal state when substance use has ceased or have been reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or closely related) substance with the intention of relieving or avoiding withdrawal symptoms;

Evidence of tolerance, such that increased doses of the psychoactive substance are required in order to achieve effects originally produced by lower doses (clear examples of this are found in alcohol- and opiate-dependent individuals who may take daily doses sufficient to incapacitate or kill nontolerant users);

Progressive neglect of alternative pleasures or interests because of psychoactive substance use, increased amount of time necessary to obtain or take the substance or to recover from its effects;

Persisting with substance use despite clear evidence of overtly harmful consequences, such as harm to the liver through excessive drinking, depressive mood states consequent to periods of heavy substance use, or drug-related impairment of cognitive functioning; efforts should be made to determine that the user was actually, or could be expected to be, aware of the nature and extent of the harm.
posted by OmieWise at 10:34 AM on May 5, 2016 [3 favorites]




I don't know if they are tightening up here in LA, but while I was in the hospital for a surgery last August, they were really cautious, bordering on stingy, with the pain meds.

In-hospital dispensing has some additional concerns they're addressing, like medical professionals shoving them in their own faces.
posted by phearlez at 11:40 AM on May 5, 2016 [1 favorite]


This article seems to hang almost completely on the assumption that waiting to dose until the last dose is no longer effective (withdrawal is the term used but seems a bit over-killish) is more likely to lead to addiction than maintaining an therapeutic dosage. Is that correct? I didn't see anything that supported that conclusion other than off the cuff comments from two people, though admittedly neuroscientists. It seems like that is the kind of conclusion that would be (a) important in the addiction community and (b) well documented.
posted by rtimmel at 1:22 PM on May 5, 2016


Some people (like my wife) experience nausea even taking one Vicodin.

I discovered a few years back, after an unfortunate dental accident, that opioid pain medication does utterly nothing to me. No pain relief, no high, no nausea. Couldn't tell the difference, even after a couple of "well, here's a stronger prescription" conversations with the doctor. Every single time I complained it was either "well here's more of the thing that doesn't help you" or "okay, well, here's hydrocodone with a different NSAID mixed in". Utterly infuriating, and agonizing. But I guess it's better than many alternatives.
posted by Pope Guilty at 1:41 PM on May 5, 2016 [2 favorites]


There's definitely a general medical problem with not "staying ahead of the pain," as they told my wife when she was hospitalized with what turned out to be "motrin meningitis." That was more about comfort in those conversations but the message they were sending her was not to wait till you feel it because then it's harder to tamp it back down again.

I imagine that the concern about it from an addition standpoint is the conditioning, so you're talking about a mental dependence not physical addiction. But perhaps there's also a neurological aspect similar to the issue with using steroids for long periods of time and your body alters its own baseline neurochemical production. In which case you could have physical issues, not just conditioning.
posted by phearlez at 1:44 PM on May 5, 2016


My Oxycontin never lasted as long as I hoped it would, funny. Definitely spot on.

In all seriousness though, there has never been a greater contributing factor to heroin use than Oxycontin and the end of its crushable format.
posted by GreyboxHero at 2:52 PM on May 5, 2016


I have had a hydrocodone prescription for almost 16 years. My doctor, who has been my doctor for the whole time, realises that I'm not addicted to them, and he trusts me enough to write 90 pill scripts, which if taken as directed, would last a month, but usually last a whole quarter or more the way I take them, which is one at night if I know the pain is too bad to sleep, or periodically as a prophylactic if I know I'm going to have a physically challenging day. Oxy has totally interfered with my reality not because I take it, I don't, but because they're treating things like vicoden the same way...doctors and pharmacist have both questioned why I have the scrip, and I have to say either, well you could read my chart, or if feeling fractious, I start listing what is wrong until their eyes glaze and they leave me alone.

That said, they just recently started treating my lupus with plaquinil, and it's been so amazing to wake up and get out of bed without wanting to cry. Even though our house was mostly destroyed a few weeks ago, and I'm running teams of contractors, and on my feet for 10-12 hours a day, today was the first time in a week or so where I know I should have taken a painkiller hours ago, and I thank gods I have one I can take once I get everyone fed.
posted by SecretAgentSockpuppet at 3:52 PM on May 5, 2016 [5 favorites]


Imagine what would happen if OxyContin addicts could get access to detox physicians, methadone and support without shame or stigma.

One can dream but the stigma around dependence/addiction for any drug, prescription or otherwise, seems to be still be incredibly strong. I've spent years attempting to help someone (no this is not a "for a friend" thing) get the meds they need to to attempt a slow, controlled withdrawal plan from benzos (which were prescribed to the person when they were 16, years ago, en masse as it were) and every single doctor treats the person like they must be scum of the Earth. I've begged them to read articles about how people have become dependent on them when they were regularly prescribed before it was supposedly general knowledge that they shouldn't be, how a cold turkey plan is very dangerous, and how a plan of slow controlled withdrawal is the favoured method and they refused to even consider reading them (oh those articles are from England, they can't apply here which I realize in regulatory sense might be true).

Instead they prescribe one pill a day to prevent seizures. Making the person come in every day, get urine tests, and pay outrageous amounts of money for the pill itself and the dispensing fee. It makes for a difficult way to live your life.

We've turned to the street from time to time but that is another horror story.

Telling the truth to the medical community in Toronto has only got this person condemned. It really pisses me off and for the person suffering in this situation, I can't imagine how horrilbly small they've been made to feel.

Going for help just gets you the finger. It's beyond infuriating.
posted by juiceCake at 4:00 PM on May 5, 2016 [5 favorites]


My doctor, who has been my doctor for the whole time, realises that I'm not addicted to them, and he trusts me enough to write 90 pill scripts, which if taken as directed, would last a month, but usually last a whole quarter or more the way I take them

Oh, man. I had a doctor like that in TX. It was great. Now in CA it's mandatory visits once a quarter.
posted by lysdexic at 4:28 PM on May 5, 2016 [1 favorite]


Oh, it's the federal law now that you have to go get a written prescription, and hand carry it to the pharmacy, so now I have to see my doctor every quarter or so too, instead of him being able to write refills. It's a stupid waste of medical dollars and time, but the Puritans are still in control of drug policy in this country.
posted by SecretAgentSockpuppet at 4:48 PM on May 5, 2016 [2 favorites]


The culture is indeed punitive and hateful concerning addiction, in many places. I was concerned that I'd have problems with getting pain meds prescribed after oral surgery, because I had disclosed that I am in alcohol recovery. I did not have any problems however. I certainly do not want to take any prescriptions with an abuse potential lightly, but there are limits to how much pain I would be prepared to suffer.
posted by thelonius at 7:05 PM on May 5, 2016 [1 favorite]


I take Oxy contin, a 40 mg. pill most mornings. Quite strong, but only does a small portion of the pain relief my doctor and I wish it would. It is difficult to get. The prescription my doctor gives is designed to last 30 days. I usually make it last about 80. I am very careful because I fear addiction and I try to be responsible, but I eat a lot of Ibuprofin to try to manage the pain, and I'm not really convinced it's all that much better for me.
posted by scottymac at 1:21 AM on May 6, 2016 [1 favorite]


This is pretty interesting — I'm someone for whom opioids are less effective in general. Really, painkillers across the board. Maybe because I'm a bigger guy than most doctors (or dentists) think, but I'm always at the upper bounds and they always wear off faster than they say.

When I was laid up with a broken arm and leg, I was on Percocet, and definitely had the ups and downs problem — luckily, one of my wife's friends was an RN, and the first thing she said was "Half the dose, twice as often." Going from 10mg every six hours to 5mg every three hours, with the whole 10mg before I went to sleep, was the only way I could do my rehab at all.

I had to do that for about three months, and by the end, I was pretty miserable — I had the terrible constipation, junkie sweats and itchy skin. I joke that the three months ruined any recreational opioid use for me.

But if my doctor had responded by prescribing twice the dose, I can't even imagine how much more miserable the experience would have been — screaming bone-deep pain when they wore off, vaguely sea-sick haze while on 'em, ugh. They already had to adjust my dosage up since my body seems to really rapidly acclimate to most drugs — outside of that longterm stint on Percocet, which had been the only thing that worked consistently with a previous tonsillectomy, I always have to do the ibuprofen/acetaminophen cycle, which I have to imagine is no good for my liver or stomach. As it was, near the end of the prescription, I was alternating with huge doses of ibuprofen, which the doc OKed even though it wasn't as effective for the pain overall, just because if I didn't do that, the Percocet was less and less effective.

I do hate how the general problems of prohibition and addiction make it really hard to be candid with doctors or dentists about stuff like this, and that even when I am, they generally don't believe me at first and I have to go through another round of "No, really, I'm going to need more novocaine than that, and it's going to wear off much quicker than you think. No, the 200mg prescription of ibuprofen is not going to be enough, and I'll have to rotate it with something else."
posted by klangklangston at 11:13 AM on May 6, 2016 [2 favorites]


"Utterly infuriating, and agonizing"

Ironically, for pain, agonists are what you want.
posted by klangklangston at 11:16 AM on May 6, 2016


> Some people (like my wife) experience nausea even taking one Vicodin. I wish I were so lucky.

Mercifully, this describes me. At 18 years old I got home from my wisdom teeth extraction, took a Percocet as instructed, and then spent the next eight hours lying on the couch trying very hard not to move, because moving was what made the queasiness worse. On day two I skipped the Percocet and was fine.

Vicodin also gives me nausea, but a much milder form. It's ideal, really: enough nausea to make recreational usage no fun at all, but not so much to prevent me from taking it if I really need it. I've only ever been prescribed small amounts for dental work, and I'd like to think that I'd be able to stay off the slippery slope toward dependence, but I'm glad I don't have to find out.
posted by savetheclocktower at 1:08 PM on May 6, 2016


juiceCake, if you're reading this, a friend of mine did a controlled benzo withdrawal as an inpatient at CAMH. I have no idea who to contact there and he's intermittent about returning emails but I can try. Switchboard may be able to help.
posted by feckless fecal fear mongering at 4:33 PM on May 6, 2016


(similar situation, prescribed, developed dependency)
posted by feckless fecal fear mongering at 4:34 PM on May 6, 2016


They're up to $1000+ to fill a 90ct 30mg generic oxycodone prescription now. - weirdo

Just looked up the local price for these drugs as this sounded insane:
https://www.chemistwarehouse.com.au/Buy/64236/Oxycontin-80mg-Tablets-28

For the non-Aussies, I think the private price listed there, and the generic price at the bottom are unsubsidised in any way (the PBS and concession pricing has some of the bill picked up by the government). My understanding is the government negotiates pricing for their subsidised doses every few years, keeping the prices down across the board. In the US I think the government is legally prevented from doing that sort of negotiation?
We have issues with opiates here, but I don't think at the rates in the US.
posted by bystander at 2:59 AM on May 9, 2016


If you've got insurance, you don't pay anything near that price, even if they aren't picking up any part of the tab. Their negotiated rate is closer to $200-$300. Same goes if you can use GoodRX or a similar program with negotiated rates, but many states have outlawed the use of such things with controlled substances. Makes no sense to me, since it's OK for an actual insurance plan to have discounted rates on controlled substances. (My SO's generic Ativan is less than $3, but the retail rate is closer to $50)
posted by wierdo at 5:26 PM on May 9, 2016


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