The Other Side of the Opioid Crisis: Untreated Acute & Chronic Pain
March 17, 2018 1:42 PM   Subscribe

 
Not that it matters, but the first pic is from the Altoona Center for Clinical Research, whose jingle I can sing for you by way of hearing it on my local radio all the damn time.
posted by which_chick at 1:43 PM on March 17, 2018 [3 favorites]


Wasn't there a study that was published recently that showed that for short term pain opioids are great but for long term maintenance they don't do any better than other drugs? Oh yeah, there was.
posted by hippybear at 1:50 PM on March 17, 2018 [3 favorites]


Oh FFS.

Is JAMA Opioid Study Based on Junk Science?
“Opioids Don’t Treat Chronic Pain Any Better Than Ibuprofen” reads the headline in Newsweek, an article that never mentions the JAMA study was limited to patients with back pain or osteoarthritis.

“Opioids Don’t Beat Other Medications for Chronic Pain” was the headline in NPR.com, while the Chicago Tribune went with “Opioids no better than common painkillers for treating chronic pain.”

Notice the news coverage strongly suggests that opioids are ineffective for all types of chronic pain – not just back pain and osteoarthritis. Patients living with chronic pain from arachnoiditis, trigeminal neuralgia or some other intractable pain condition would probably disagree about that. And they'd find the idea of taking ibuprofen laughable, if not infuriating. But no one asked for their opinion.

Also unmentioned is that opioids are usually not prescribed for osteoarthritis or simple back pain, which are often treated with NSAIDs and over-the-counter pain relievers.

So, what JAMA has published is a government funded study designed to look at a treatment (opioids) that most people with back pain and arthritis never actually get...
What the JAMA Opioid Study Didn’t Find

A Study Found That Opioids Don't Work Best for Some Types of Chronic Pain. Here's What Patients Think.
posted by homunculus at 2:15 PM on March 17, 2018 [59 favorites]


Also unmentioned is that opioids are usually not prescribed for osteoarthritis or simple back pain

I've been to the doctor and have been offered opioids for the most basic pain possible when I was there to see if something was actually broken and not there to have my pain treated.

I know people who have been handed opiod scripts for having a twisted ankle.

This statement is fundamentally wrong, and any good survey of the US populace would prove that.

I believe the JAMA study may be flawed based on your articles, but this one sentence is absolutely incorrect.

Doctors were marketed oxycontin or whatever as being safe and non-addictive by drug company representatives. They were prescribing them freely for decades. I even have on my medical record that I can't take opioids because they make me suicidal and I was given a prescription for tramadol (a name I didn't recognize) and I took one before I realized what it actually was. One of the worst nights of my life.
posted by hippybear at 2:24 PM on March 17, 2018 [5 favorites]


Contrast, hippybear: I have two fractures in my foot from a fall two weeks ago. At least. They only x-rayed the ankle area and it turns out that I think I also messed up a metatarsal bone down by the toe but I'm not paying to have that checked again when I'm stuck in a boot for another 4-6 weeks either way. I went to urgent care for this and even after they had the x-rays back with the fractures confirmed? No pain meds, even after I explained how much pain I was in even though I was still on the post-accident endorphin high. Just crutches and instructions to take Tylenol but no NSAIDS because it would make the bruising worse, and a referral to an orthopedist.

The orthopedist finally gave me tramadol. Even he gave me serious side-eye and said some things that suggested that I wouldn't have needed them if I was thinner. I basically spent several hundred dollars extra to get the pain meds, because nothing else he told me differed from what the urgent care said.

A few doctors are still out there prescribing them at the drop of a hat, and that's clearly a problem. But then there are others who have swung hard in the other direction. I haven't seen one of those easy-prescription doctors in like fifteen years now, but I never expected that I was going to have a hard time even with an injury like this.
posted by Sequence at 2:39 PM on March 17, 2018 [35 favorites]


Mostly what I get from hearing everyone's stories about their pain management (or lack thereof) is that there is apparently no standard of care for treatment of extremely common causes of pain. I've had a bad back for years, caused by an acute injury leading to a herniated disc. I've seen my PCP, a physical therapist and a physicalist over the years. Number of times I was offered any prescription pain killer: zero. But I don't doubt the veracity of the many stories like hippybear's. It's just...so wildly different from my experiences with pain. (I did get my hands on some oxycodone once due to an ER visit for a totally unrelated injury, and I hoarded that one bottle for over a year to take when my back got particularly unbearable. It didn't make my pain go away, but it did help me not care for a few hours, and that was often enough to help me go on and not just collapse in despair that I was going to be in pain literally forever.)
posted by soren_lorensen at 2:44 PM on March 17, 2018 [18 favorites]


I basically spent several hundred dollars extra to get the pain meds

Ypur co-pays are utterly out of control.

I"ve been to doctors about 18 times in the past few months because I have a mystery tremor that is so far a medical mystery and walking into a doctor's office for me is $40.

If you don't have insurance, I'm really sorry about that. We need single payer here, the populace also agrees but it's unlikely for at least a generation.
posted by hippybear at 2:45 PM on March 17, 2018


Interesting post that touches on a number of topics. As far as the problem of drug shortages goes, opioids are only part of the problem, and a small one at that since there are so many alternatives to choose from, at least in terms of the injectable opioids I use to treat acute pain in the OR. This is for a number of reasons from manufacturing issues to hoarding of drugs by large purchasers; this issue is explored in some detail in this paper (from 2011, but most of these problems have only gotten worse). For an idea of the scope of the problem information on current drug shortages can be found here and here. Medicine has made great strides in treating acute pain by other methods but opioids are still part of our armamentarium

Chronic pain is a different issue, and one that I don't deal with directly but do work with people who do. In discussions (including here on MeFi) it is important to keep in mind that there are a huge number of causes for chronic pain and many of them are very poorly understood. During my 3 decades in medicine I have watched the pendulum swing back and forth on opioid use in chronic pain, but there has been a steady progression in non-opioid treatments. There is no one treatment that works for everyone, though, and there probably never will be. The study mentioned by hippybear is worth looking at and suggests directions for further work; you can read the original here. As usual the reporting on it oversimplifies things, so it is worth going straight to the source to see what it says. This part is significant:

Limitations
This study has several limitations. First, the complexity of interventions precluded masking of patients. Because primary outcomes were patient-reported, results are subject to potential reporting bias that would likely favor opioids. Second, there was an imbalance in prerandomization treatment preference. Any effect of this imbalance would likely favor opioids. Third, because this study was conducted in VA clinics, patient characteristics differ from those of the general population, most notably in sex distribution. Fourth, patients with physiological opioid dependence due to ongoing opioid use were excluded, so results do not apply to this population.


(apologies in advance if any links don't work. I am at work where my IP address sometimes gives me access to resources that aren't publicly available. I think everything I linked is OK, though; if not let me know and I will see if there are better sources.)
posted by TedW at 2:49 PM on March 17, 2018 [11 favorites]


I'm not disabling ad-block to read Salon, so this may have already been covered in TFA.

Currently there is a nationwide shortage of IV opioids, specifically morphine, hydromorphone, and fentanyl. The proximal cause is manufacturing delays from Pfizer, which makes about 60% of the injectable opioids used in the US. Pfizer has reported that all production of these drugs has been halted and is not estimated to be restored until 2019.

Unfortunately, other manufacturers can't simply pick up the slack because the DEA establishes production quotas that limit the amount each manufacturer can produce. A few weeks ago, representatives of several medical associations wrote a joint letter (PDF) to the DEA requesting temporary changes to production quotas to help alleviate the shortages.
posted by dephlogisticated at 2:51 PM on March 17, 2018 [4 favorites]


Yeah Ibuprofen works well for some stuff - inflammatory conditions- but it does fuck all for a nerve that's partially severed and entrapped in a hemotoma. Ask me how I know. Or a nervous systemt that is misfiring, like in CRPS. Some people have to live with that kind of pain for extended periods or their whole lives and I think they should get all the help they can. The side effects of opiods are so crappy that no one would stay on them for years voluntarily unless they were an addict which most people are not. Not that you can't accidentally kill yourself with Tylenol and Ibuprofen too but at least you can live a fairly normal life on them.

I've had a lot of injuries and chronic headaches and a few other weird conditions and I can tell you that all pain killers work differently. Pain is not a monolith. Also when they give you your own Toradol and needles to inject yourself at home you have really fucked up this time and should probably take the rest of the week off work.
posted by fshgrl at 2:58 PM on March 17, 2018 [17 favorites]


Super-enjoying watching my BFF who has an ultra-rare form of angina no one knows how to treat go through this. (Sarcasm).

The best protocol they’ve found is giving her morphine. They want to give her some to keep at home but now no one wants to prescribe it and everyone is passing the buck. Meanwhile she’s in appalling pain more often than you can possibly imagine so... thanks, dummies. She has to suffer when there is at least one way to keep her at a manageable, able-to-work pain level. It’s fucking awful. If her pain goes too high she will actually go into cardiac arrest (and has, three times now, at least one of them wired up to every possible machine). It’s monstrous.
posted by bitter-girl.com at 3:04 PM on March 17, 2018 [21 favorites]


#It'sComplicatec

I don't deny that opioids have a place in our medication spectrum.
posted by hippybear at 3:06 PM on March 17, 2018


it is important to keep in mind that there are a huge number of causes for chronic pain and many of them are very poorly understood.

This really is huge. I know a number of people with "chronic pain" who really just had a disease or injury that was missed and were easily cured once they found someone who took the time to investigate. But some of them lost years of their lives and they often received diagnoses that were bizarrely wrong in retrospect.

I had a run in with that myself- it was really eye opening. I was able to be fixed with two surgeries, but if I wasn't so pushy and willing to fire several doctors I'd have been sent to a pain clinic and given god knows what and would never have gotten better.
posted by fshgrl at 3:15 PM on March 17, 2018 [12 favorites]


I’ve heard a big factor in the opioid crisis is also that doctors are more or less forced to shunt patients through the system. Where some treatments like physical therapy may work, patients are instead given painkillers because the medical system incentivizes against that kind of long term treatment.

I’m badly paraphrasing, but is there any truth to that? Like, it speaks to the US healthcare system not only being expensive, but altering the diagnosis and treatment plans as well.
posted by shapes that haunt the dusk at 3:19 PM on March 17, 2018 [6 favorites]


I’m badly paraphrasing, but is there any truth to that? Like, it speaks to the US healthcare system not only being expensive, but altering the diagnosis and treatment plans as well.

Absolutely true; our system is definitely skewed in favor of drugs over other therapies that may be more effective but also more time and personnel consuming.
posted by TedW at 3:25 PM on March 17, 2018 [12 favorites]


(Also, relatively few people have a schedule that is conducive to treatments that take several hours a week versus taking a pill every so often, especially related to work.)
posted by TedW at 3:26 PM on March 17, 2018 [10 favorites]


Absolutely true; our system is definitely skewed in favor of drugs over other therapies that may be more effective but also more time and personnel consuming.

I was thinking about that: the US consumes the majority of the world's opioid supply, and it seems that other countries with better medical systems use fewer. I don't think it's because the American medical system is so awesome at dealing with pain, either. Maybe in countries with universal (or near-universal) health care, pain can be caught before it becomes chronic, and other, effective but time-consuming treatments like physical therapy are more often used.

Opioids have their place, and I don't like seeing addiction as a criminal issue when it's more properly a public health matter. (Though if Purdue and other pharma companies were made to help pay for addiction treatments, that would be great.) If a needed medication has the potential to be addictive, perhaps doctors could work with their patients to monitor them and tell them "hey, this stuff might get you hooked, let's make regular appointments to evaluate you, and if you want to stop using them, we'll work on weaning you off slowly."

Then there's the question of sexism and racism, where people who are perceived to be "good" and upstanding citizens and not whiny malingerers have access to every pill under the sun, but others who are thought to be "less deserving" (female-bodied? POC?) are blown off or regarded with suspicion.

tl;dr: the opioid crisis is part and parcel of the US medical system which is terrible.
posted by Rosie M. Banks at 3:38 PM on March 17, 2018 [14 favorites]


And, p.s.: legal weed is saving lives in Colorado. People with access to marijuana are using that and not opioids, with a consequent decrease in overdoses. Let the Confederate Keebler Elf and his prohibitionists put that in their pipes and smoke it.
posted by Rosie M. Banks at 3:41 PM on March 17, 2018 [10 favorites]


I was thinking about that: the US consumes the majority of the world's opioid supply

That's what I thought, but this piece challenges the numbers: It's a Myth America Consumes 80% of World’s Opioids
posted by homunculus at 3:48 PM on March 17, 2018 [5 favorites]


Maybe I'm missing something, but why on earth would the DEA think that reducing production would help with opioid addiction? It might result in less being diverted to the black market (in terms of raw quantity, not percentage, so you've still reduced the legitimate supply), which raises the price or decreases access, but people aren't going to say "Price went up, guess I better get over my addiction now." They'll either come up with the money somehow (legally or not) or switch to heroin. Granted, that might reduce the number of people abusing prescription painkillers, but moving them to using heroin instead isn't progress.
posted by hoyland at 4:00 PM on March 17, 2018 [4 favorites]


I’ve heard a big factor in the opioid crisis is also that doctors are more or less forced to shunt patients through the system. Where some treatments like physical therapy may work, patients are instead given painkillers because the medical system incentivizes against that kind of long term treatment.

That has not been my experience at all, I've always had doctors be happy to refer me to PT. I do think very few PTs are actually good at their jobs though, which is an issue. When you get a good one it's striking how bad the others were A good PT is the best asset you can have, imho. 90% of the PTs I've seen were not good.

I think the big thing in the US is the prevalence of surgeons and the poor outcomes. My physiatrist, who has seen me though many stupid injuries an is a great diagnostician, told me that only 30% of back surgeries are considered successful and even then follow up is only a couple years in most studies. A full 30% make people worse immediately. Steroid epidural shots are worse: meta analysis shows they do no good and often cause harm, sometimes devastating. They aren't even FDA approved. Things like spinal stimulators or vagus nerve stimulators are often unapproved medical devices and therefore there are no mandatory long term studies and patients who are harmed cannot sue. There is newish evidence of crazy levels of side effects. He's agnostic on things like gabapentin believing they should only be used short term if possible. He reckons we are creating a generation of disabled people via medicine by carrying out experimental, unsupported surgeries and treatments on them and catering to their hope that they "get better" knowing they won't. He also sees women with childbirth epidural injuries regularly and those can apparently be full blown spinal cord injuries, which no one warns them about.

Obviously he's a bit burnt out, but I don't think he's wrong. Being an old who is active with active friends an having lived in several countries people in the US seem to get more aggressive treatment and end up worse off in the long run.

But back to the article- if someone suffers devastating injury during back surgery I think it's morally indefensible to just abandon them and that's what surgeons do. They might need strong painkillers just to be comfortable for months or years or for ever. No one wants to be in that position, no one. We shouldn't villify them.
posted by fshgrl at 4:10 PM on March 17, 2018 [11 favorites]


I’ve heard a big factor in the opioid crisis is also that doctors are more or less forced to shunt patients through the system. Where some treatments like physical therapy may work, patients are instead given painkillers because the medical system incentivizes against that kind of long term treatment.

Yeah, it’s a big mess. Doctors are kind of pushed to spend minimal time with patients, which forces them to make snap diagnoses, which usually results in the easiest, least expensive treatment. Pills.

And, when it comes to alternative treatments, like physical therapy, insurers often limit the number of visits a patient can make.

The system is rigged from start to finish to minimize useage by the patient.
posted by Thorzdad at 4:13 PM on March 17, 2018 [1 favorite]


This is entirely true in my experience. I've had pretty difficult and mysterious medical problems over the last nine months (I don't even know how many of them are related or are totally separate issues, neither do the doctors), and it's only been with this last really frustrating issue that I've had a doctor spend more than 10 minutes with me. My last visit (on Tuesday) was 45 minutes which I thought was amazing.
posted by hippybear at 4:17 PM on March 17, 2018 [2 favorites]


This recent Cracked article gives a perspective from the author who suffers from chronic pain. He is being denied proper pain pills due to fears the doctors have about addiction, and he details how terrible his life can be without proper pain management.
posted by Homo neanderthalensis at 4:37 PM on March 17, 2018 [15 favorites]




It's always fun when you save up to go to a doctor when you're uninsured for pain and they spend 5 minutes ignoring you and then give you a script for ibuprofen. I asked what good a script was for a thing I could buy cheaper otc and basically got the "You're young, stop being a pussy" speech. Who cares that my ankle was the size of an orange and I couldn't stop working because I needed cash to stay afloat. Great use of 150 bucks to see a non-urgent care doctor because they're useless for pain.
posted by Ferreous at 6:02 PM on March 17, 2018 [12 favorites]


Oh, I also got some great printouts on RICE, despite the fact that I told the shitheel doctor that I had been using that regimen to little effect.
posted by Ferreous at 6:04 PM on March 17, 2018


I had two molars extracted and two root canals all at once and I got a prescription for 5 Norco and a snide comment from the dentist.
posted by elsietheeel at 6:54 PM on March 17, 2018 [1 favorite]


Yeah, that Cracked article was great. It really nails the lovely oroborous between physical and mental pain - the pain your body feels matched by your depression, your depression making it difficult to do even the things that you can to mitigate the physical pain.

You know what is also fun is having chronic pain while fat, because clearly if you would just stop being so fat, you wouldn't be in pain anymore. Why don't you exercise? Why don't you have the willpower to just push on through the physical pain and overcome the depression that makes it hard for you to even force yourself to get out of bed? You don't deserve painkillers, you clearly haven't tried hard enough.

I should note, I do not want or need serious opioids. I was fine with panadeine that I used to be able to get over the counter until the TGA got caught up in the anti-opioid trend and now requires you to get a script for even tiny amounts of codeine with your paracetamol. I have enormous sympathy for those in more pain than I am.
posted by Athanassiel at 7:40 PM on March 17, 2018 [11 favorites]


Yeah, I agree on the whole "standard of care" thing. I was in a car accident maybe 12 years ago. Hit a patch of black ice went through the guardrail into the nearly frozen creek, and head-on into the concrete wall under the bridge. I could tell my knee and towns were broken and there is something wrong with my face, so I pulled myself out of the car on my elbows across the hood, drop down into the water and pulled myself through the creek, up the snowy banks through a snowdrifted garden, over another flat Bridge, across the road, and to the nearest house. It happened to be my grandmother's house. She called my mother, who left work and took me to the hospital. (My insurance didn't cover ambulance rides.) List of injuries turned out to be:
Four metacarpals broken on each hand (my hands looked like cartoon cow udders
Broken sternum
Broken but not displaced nosbroken knee and shattered patella
Facial abrasions from air bag
Hypothermia
Pneumonia

After the scans and X-rays, they said I could have some ibuprofen but not on an empty stomach. They left blister packs of ibuprofen to take along with some individually wrapped saltines. I was supposed to open this and maneuver it to my mouth with hands that made Mickey Mouse's look like Albrecht Dürer's. I described the winding hill path and slippery Stone steps to get into my house, and they gave me a pair of crutches. To use with my smashed hands, bruised chest muscles, and broken sternum. A couple of Advil for the pain, and a list of orthopedic surgeons to try to call on Monday morning. And I had damn good insurance, too. They were just so afraid of getting a reputation as a place you go to get pain medication. Next time I'm in any kind of accident, I'm having myself airlifted directly to hippybear's doctor.

My doctor at the pain management center sends my prescription to my pharmacy the same time every month. But they won't keep it in stock, even though they have three regular customers who get it every month. They will only special-needs it in after they've gotten the paperwork from the doctor. Sometimes they get it within the next few days, sometimes there are delays from the manufacturer, sometimes there are delays from the shipping service live gotten the paperwork from the doctor. Sometimes they get it within the next few days, but sometimes there are delays from the manufacturer, sometimes there are delays from the shipping service, sometimes the insurance company decides out of the blue that they need a prior authorization this month because they're bored or something... Getting medication to treat pain is on the short list of Things That Are Not Easy To Do.
posted by The Underpants Monster at 10:30 PM on March 17, 2018 [13 favorites]


Our system only knows how to do all or nothing. Either opium is great and everyone should use it for everything or it’s evil now and no one actually needs pain control. The thing that makes no sense to me is that like doctors really just don’t care about pain control at all anymore and seem to be offended by the very idea. I feel like the entire medical system is deeply traumatized themselves and treating patients like the wife who gets beaten by her husband and takes it out on her kids. We really need to reboot our entire society. It’s broken.
posted by bleep at 11:45 PM on March 17, 2018 [12 favorites]


Isn't the whole "pain epidemic" thing what got us into the opioid epidemic in the first place?
posted by runcibleshaw at 12:04 AM on March 18, 2018


On the opposite side of the spectrum, and I have to caution that this is the one time I've ever been to a VA hospital, so it's anecdata, but man oh man did it fulfill stereotypes: I was the getaway driver for a veteran relative of mine who went in to a (private-practice) oral surgeon, from which we left with a stack of written prescriptions to try to get those already-written prescriptions approved to be filled at the nearest VA hospital. Short story: we eventually got everything, including the opiods, except for the antibiotics (after surgery!) for some reason.

It was utterly Kafkaesque: we must have spent three hours, longer than the actual surgery had taken, getting shuffled from office to office, with my relative's mouth stuffed with gauze and him in pain and barely able to answer the repeated questions he was getting. In the end we only got out so "quickly" because he started to hulk out when the office workers on that floor began holding a party of some sort in front of us and the handful of other patients in the waiting room, and his garbled incoherent rage was evidently enough to twist some arms... but then we got back to the "dispensary" or whatever the equivalent of a pharmacy was, and were told we had another wait ahead of us. (Even though that's where we'd started with prescriptions in hand, but of course they couldn't expedite things by putting the order together while we went on our grand administrative tour of the rest of the hospital.)

He was exhausted at that point, so I took him home and said I'd come back to the hospital to pick up the meds when they were ready. When I got back an hour and a half later, they finally had everything, including the opioid pain meds—except for the antibiotics the surgeon had prescribed. For some unfathomable reason, the on-duty doctor who our paperwork had eventually reached refused to approve that one prescription out of four or five in total, and the people at the dispensary said there was nothing that could be done except to take the prescription to a normal pharmacy and pay cash for the antibiotics. (Fortunately, when I explained the situation at a nearby Rite Aid, the pharmacists were just as flabbergasted but managed to find some combination of discount codes they could use to get the cost down below ten dollars.)

I assume our parallel-story counterparts were somewhere at another VA hospital, being refused the pain medication after a veteran who just had surgery had spent hours in the waiting rooms of bureaucratic hell despite already having the written prescriptions, only to be turned away.
posted by XMLicious at 1:17 AM on March 18, 2018 [6 favorites]


Isn't the whole "pain epidemic" thing what got us into the opioid epidemic in the first place?

More or less. It's a combination of things, all related to the shitty level of healthcare most Americans are subjected to, combined with the shitty attitudes of employers toward sick workers. It all combines to create a society where people are loathe to go to the doctor, for fear of ending up having to stay away from their jobs for any short amount of time (else they be canned.) So, they live with whatever issue they are suffering from, including chronic pain, swallowing bottles of ibuprofen in hopes of dulling the pain.

Then, eventually, it gets bad enough to where they can't even walk, and they finally go to the doctor (having to skip an afternoon of work, of course) and the doc has to resort to serious pain-killers because the issue has gone on so long. Lather, rinse repeat.

I often wonder, as I watch people walking around a big box store or down the street...Do other countries have so damned many people waddling and limping around like the US does, obviously affected by un/poorly-treated pain of some sort or another?
posted by Thorzdad at 6:44 AM on March 18, 2018 [9 favorites]


It is terrifying to read about how pain as a standard of care is just so early 2000's and we need to stop that kind of "customer is always right" thinking in favor of telling patients to listen to some harp music and toughen up. I say this as as a person who once needed Vicodin for a UTI 15 years ago. I can't imagine what it's like to have actual chronic pain.
posted by Ralston McTodd at 7:02 AM on March 18, 2018 [5 favorites]


I can't imagine what it's like to have actual chronic pain.

My wife has a friend who suffers from a raft of physical maladies as well as pain from prior surgeries (she has a stent in her brain, for instance) She is utterly unable to hold-down a job, and is living exclusively thanks to an accumulation of pretty much every form of social service that might be available (medicaid, medicare, hud, etc.) Her pain levels are quite severe. Severe enough for her neurologist to put her on methadone (among other stuff, like high doses of gabapentin.) However, over the past year, everyone, from her neurologist to her pharmacy, have put-up roadblocks to getting her methadone refilled. The pharmacy is especially loathe to re-fill her prescription because they don't believe she needs it...that's she's just a junkie.

This is all, I believe, a direct result of the increased scrutiny the government has put on doctors and the like over opioid prescribing. No one wants to get red-flagged by DEA or whomever as a possible supplier. This is a woman is actual, debilitating, chronic pain, and she's fighting for her life to get the medications she needs, because she's been swept-up in the national hysteria over opioids. She is the baby in the bath water.
posted by Thorzdad at 8:18 AM on March 18, 2018 [18 favorites]


So, it’s opioids or nothing?

Prior to hip replacement surgery I repeatedly, and strongly, told everyone involved in my care that I was unable to tolerate opioids, even in small doses, and that I did not want to be given any. I was terrified of the surgery but was reassured over and over that “my team” would control my pain.

Somehow I was still given a dose of opioid prior to surgery such that I awoke in a state that I can only describe as unbearable. In the hours that followed, during which the spinal block wore off and the horror of the postoperative pain came on, I received a parade of hospital employees who basically stood at the foot of my bed with sad faces, every one shrugging and apologizing for their inability to control my pain.

With sky-high blood pressure and total inability to sleep, I was kept at the hospital for an additional day due to this failure. Again, I received multiple visits from hospital staff, none of whom could do a thing to help me. I became increasingly angry, especially when realizing that having access to legal weed would have at least helped me get through the worst, but it wasn’t available to me as mine was not a “qualifying condition.” (I would have had to be terminal or have cancer, apparently.)

Months later I discussed this situation with my surgeon; he actually suggested that my intolerance to these drugs may make me unable to tolerate surgery AT ALL. This is more terrifying than I can express—what happens if I’m in an accident, or become seriously ill? These doctors are telling me I’ll have to kill myself???? What the serious ever-loving f**k.
posted by kinnakeet at 10:06 AM on March 18, 2018 [5 favorites]


Total knee replacement four weeks ago and doc gives me 30 Tramadol. I literally said ‘you’re fucking kidding me’. This after having a partial ten years ago.
I know pain and I know what works. It’s a disgrace. Lucky for me I have friends with inventory.
posted by repoman at 10:11 AM on March 18, 2018 [3 favorites]


One thing that really gets my goat is having to see elderly relatives with severe chronic pain jump through all sorts of hoops to get appropriate opioid pain relief. It's particularly bad here in my corner of southwest Ohio where, understandably, health systems have clamped down on it. But folks, let's get real - my 85 year old father with osteoporosis and a growing number of fractures in his spine does not require the same kind of long-term medical plan of care as a young worker with a back injury.

And yet the reaction seems to assume anyone needing opioids needs to be weaned off them immediately because the local cultural conversation around opioids is so dominated by the circumstances of people decades younger than the elderly. When I have tried to advocate for my dad's prescription to be refilled at the current dosing, I've been told they would only do this if he had cancer. Nevermind that when you're 85 and in increasingly bad health, living with chronic pain becomes a serious quality of life issue at the same time you start having to confront end of life issues.
posted by mostly vowels at 4:20 PM on March 18, 2018 [3 favorites]


There are not as many people limping around in any other developed country I have ever been to. Or as many on disability. Or as many sick as I've seen here. Russia maybe, although I've not been there much, but no other first world country.

I once had a laproscopy and didn't take any pain killers because I didn't need them. It hurt a bit but no big deal. Then a week or so later I went back and said "this just started to REALLY hurt"- my surgeon wasn't there and all the other doctors and the urgent care and the ER would do was try to give me pain killers "because you just had surgery!". I was like "no guys, that was 10 days ago and I was fine for 9 days. Something is wrong.". After I turned down the pain killers enough times they finally were like oh- maybe something is wrong! And lo, it was. And I had another surgery and I was fine.

It's lazy doctoring really- just pushing pills at people. But I'll tell you, if you consistently refuse pain killers they have to treat you eventually and they won't like it one bit. But if you accept the painkillers you'll be flagged as "drug seeking". It's a lose lose and I will be dammed if I have to beg a company that I paid $50K to to actually do their damn job and treat me.
posted by fshgrl at 8:16 PM on March 18, 2018 [4 favorites]


I just wanted to chime in as a person on the other side of the discussion. I don't think of myself as having chronic pain. It's easier, and I think more accurate to say I have a chronic autoimmune/autoinflammatory disease in which one bothersome aspect is persistent acute pain. The best way to manage things is to keep the underlying condition in check, which doesn't always work. Plus there's permanent physical damage the longer the disease is active.

As noted earlier, Australia has just made all OTC formulations including codeine prescription only. I fear the war on opiates will progressively get worse here as well. FWIW, the changes in the law don't really affect me as my stuff has always been prescription only.

So, I see my GP every four weeks to renew my scripts for Targin and Panadeine Forte, a 500mg paracetamol / 30mg codeine preparation. The Forte is easy. The Targin requires a call to the PBS for authorisation. There's clearly a script and key words my GP goes through. All after a long series of appointments with Pain Management Specialists, trialing the Gaba, Pregaba, the SNRIs and various other options. NSAids are a no go due to gastro issues, Cortico-steroids are a frequent necessity, frequent hospital visits for infusions of Infliximab.

All this is to say, I need the opiates to handle the stuff everything else can't get to. Every time my GP (bulk billed) makes that authorisation call, I stress. I stress that it will get denied, that the laws will change requiring me to make 4-weekly visits to the Pain Specialist (seen privately == expensive including the Medicare rebates, and really inconvenient.)

I'm not ashamed that I need and take opiates, but it feels like pretty much every article and discussion around the topic is trying to make me so. My disease will progress, leading to more damage and acute pain. My quality of life is already low. Right now, I'm fairly certain the War on Opiates will get more restrictive. I just hope like hell I don't end up getting caught in the net as collateral damage.

Oh, and while I might be physiologically dependent, I've never felt a high or the need to take an extra dose outside of my normal schedule.
posted by michswiss at 4:15 AM on March 19, 2018 [9 favorites]


FWIW, I had thoracic back surgery several years ago. Opiods were vital in getting through the pain of recovery. Today, I'm relatively pain-free. But, every so often, I do something very dumb and the resulting day of pain would be pretty intolerable without being able to take a hydrocodone or similar. I've managed to stockpile some, with an eye on possibly not being able to get a script filled anymore because of all this.
posted by Thorzdad at 10:37 AM on March 19, 2018


I often wonder, as I watch people walking around a big box store or down the street...Do other countries have so damned many… people limping around like the US does, obviously affected by un/poorly-treated pain of some sort or another?

A couple of generations ago, Yanks who couldn't get around like the average American (e.g. the chronically ill, mobility-impaired, and elderly) were often considered bedridden or housebound, and many didn't have the same expectation of going to the same places as their able-bodied friends and family as they do now. (Public buildings were less accessible, as was public transportation.) That is, if they were even living freely outside an institution in the first place.*

But when I was in the UK years ago, I noted a number of signs at buildings, park walkways, and historic sites, reading, “No push chairs allowed.” Some similar places in the U.S. would surely be sufficiently historical to get a variance, but I think the Americans with Disabilities Act would probably empower some advocacy groups to sue for more accessibility. So, I guess the closest thing I have to a point might be that you may see fewer wheelchairs on the streets of, say, London or some other large non-U.S. city, but itdoesn't necessarily mean that it's a smaller percent of all Londoners requiring them if they were to go for a long walk.

Medical science has made tremendous improvements over the last century in saving, extending, and improving lives in a number of ways. But the physical quality of those lives, while serviceable enough for most everyday purposes, like a fine china cup whose handle has been glued back into place is likely never going to be quite as strong as the others that were never dropped on the floor in the first place. For instance, there’s a whole generation of adults with cystic fibrosis, who were told they would never even live to be adults. Its awesome that they survived beyond the prediction! But that doesn't mean they're all going to be able to walk ten miles a day carrying a backpack.

💊💊💊
Pardon me while I have a strange interlude. If you’ve read many female-centric novels set in the eighteenth or nineteenth centuries, you've probably run across the "semi-invalid.” This was a person who could get up and get around the house, dress themself, albeit in simple house clothes instead of fashionable daywear like stiff collars or whalebone stays. They lacked stamina, napped, and only left the house when absolutely necessary. If unmarried, they weren't able to be live-in domestic service for relatives; some kind of light work was found for them to keep busy, and/or they made items to sell at church bazaars. Most of the ones I've read about were women, because complications of childbirth had even fewer effective treatments than they do now.
💊💊💊

*I know the subject of 20th-century institutions is complicated. I'm not saying nobody was ever helped by one, and we don't really know how well they would or wouldn't have have served society if they hadn't immediately become a dumping ground for anyone who happened to be inconvenient to their family or community, or for people trying to avoid a prison sentence, thereby becoming too crowded to help much of anyone. I personally know retired NH nurses who really did their best under the circumstances.
posted by The Underpants Monster at 1:23 PM on March 19, 2018 [3 favorites]


(A "push chair" is British English for "stroller".)
posted by elsietheeel at 1:28 PM on March 19, 2018


Thanks, elsietheeel; it's been a dozen years and I couldn't remember the exact wording on the signs. Since there were definitely lots of strollers around but no wheelchairs, I must have gotten the word mixed up.
posted by The Underpants Monster at 1:32 PM on March 19, 2018 [1 favorite]


> Maybe I'm missing something, but why on earth would the DEA think that reducing production would help with opioid addiction? It might result in less being diverted to the black market (in terms of raw quantity, not percentage, so you've still reduced the legitimate supply), which raises the price or decreases access, but people aren't going to say "Price went up, guess I better get over my addiction now." They'll either come up with the money somehow (legally or not) or switch to heroin. Granted, that might reduce the number of people abusing prescription painkillers, but moving them to using heroin instead isn't progress.

It's already happening: Just like they did in the 80s, Americans are increasingly going straight to heroin, skipping prescription opioids. Too bad US policy doesn't reflect that.
posted by homunculus at 10:17 PM on March 19, 2018


I've been on the same dosage of hydrocodone for 10 years and it's gotten incredibly difficult to get recently. My regular GP stopped prescribing it to anyone because of how difficult the rules have become, even though she acknowledges I am not in any danger and am getting benefit from them. So now I have to visit a pain specialist every month to get a small prescription. Which means a half day wasted every month, plus dealing with hostile pharmacy staff, etc.

It absolutely works for my chronic pain, and nothing else that I've tried ( a long long list) has come close.
posted by thefoxgod at 1:13 AM on March 20, 2018 [5 favorites]




This article gives a good view of the problem: The Pain Refugees.
posted by TedW at 11:07 AM on March 21, 2018 [5 favorites]


That was an excellent article, TedW. Thanks. If I'd known about it I'd have used it as the main link and framed the post around it.
posted by homunculus at 1:53 PM on March 22, 2018 [1 favorite]






I missed this last week when my internet connection went out for a few days:

People with Chronic Pain Will Protest the CDC’s Crackdown on Opioids: There are rallies planned in almost every state this weekend.
posted by homunculus at 9:52 AM on April 11, 2018






« Older I'm a Hot Knife   |   Never stop chest compressions to slap or yell... Newer »


This thread has been archived and is closed to new comments