The Opioid Crisis

[JoeMorgue]

I guess it being put back on the front page of the news is a good enough reason to start a general discussion thread about it.

For context right now America is a pretty big upward trend of deaths due to overdose deaths from opioids, usually legally (if arguably overly) prescribed for treatment of chronic pain conditions. A lot of chronic pain sufferers claim that only opioids are effective at treating their conditions, while studies seem to refute this.

Some info:

- As of this writing over 42,000 people have died from opioid overdoses.

- ~115 people a day die from intentional or unintentional opioid misuse.

- Roughly a quarter of patients that are prescribed opioides misuse them

So I am interested in hearing whatever thinks of this and what should be done.


_________________________________
CNN Opioid Crisis Fast Facts:
https://www.cnn.com/2017/09/18/health/opioid-crisis-fast-facts/index.html

Department of Health and Human Services Page on the Opioid Crisis: https://www.hhs.gov/opioids/about-the-epidemic/

NBC News: Jury's in, opioids are not more effective: https://www.nbcnews.com/health/heal...t-better-other-medicines-chronic-pain-n854436

National Institute on Drug Abuse: Opioid Overdose Crisis: https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis

 

[Skeptical Greg]

Definitely killing more young people than guns are..

Where's the outrage? The marches? The walkouts?

However, I don't see any reason to spend more tax money on what is essentially
just one of the battlefronts in the ' War on Drugs '..

Reallocation of available resources might be in order..

 

[luchog]

So I am interested in hearing whatever thinks of this and what should be done.

What needs to be done is what just about every reputable medical and social scientist has been saying should be done for decades: stop treating addiction as a moral failing to be punished by the criminal justice system; and start treating it as a medical problem to be addressed by actual credentialed medical professionals.

Unfortunately, politicians rarely get elected by addressing complex issues in a rational and thoughtful manner; so it's highly unlikely this will happen anytime soon. For example, right now in my state, a large number of cities and counties are pushing legislation to prohibit safe-injection sites, despite the proven track record of reducing overdose deaths and engaging addicts with addiction counseling; citing addiction rates and overdose deaths as the reason for the prohibition (they assert that safe-injection sites "encourage addiction", despite the overwhelming evidence to the contrary).

 

[Seismosaurus]

Definitely killing more young people than guns are..

Where's the outrage? The marches? The walkouts?

Long ago I worked in the UK health and safety executive. My boss explained to me that the guiding principle of all health and safety activity was that "It's acceptable to kill 100,000 people so long as you do it one at a time. But you mustn't kill 10 or 100 people all at once."

 

[ahhell]

So, based on half assed paying attention to science based reporting on the issue over the last few years.

It seems as though their are two primary causes:
The AMA added pain the their list of vital signs, so doctor's started treating it like they would high blood pressure.
Drug maker marketed oxycodone and the like as a drugs that couldn't be abused because they were time released. This was BS at the time and they were living up to their stereotype.

I believe the AMA has removed pain from their list of vital signs and we've now caught on to how bad these drugs are. That and they aren't that effective at pain management. Side note, Dr Drew of love line fame has being saying for years if not decades that opoids are useful for pain management.

 

[JoeMorgue]

I believe the AMA has removed pain from their list of vital signs and we've now caught on to how bad these drugs are. That and they aren't that effective at pain management. Side note, Dr Drew of love line fame has being saying for years if not decades that opoids are useful for pain management.

The problem (and yes I get that this is a little anecdotal and I'm gonna go see if I can track down something more concrete) is that a lot of chronic pain sufferers are convinced (either by their doctors, themselves, or both) that opioids are the only thing that helps their condition.

There's plenty of people out there that are already extremely upset at the restrictions we have on opioids now.

 

[Fudbucker]

We've always had junk and other addictive stuff. This crisis is happening because this society is falling apart.

 

[crescent]

My impression is that opiods ARE useful for pain management - for some of the people, some of the time, for a while. For some, it helps forever. It depends on the person and on the sort of pain or the cause of the pain. Definitely over-prescribed which is what led to the current level of crisis. Opium drugs have been around forever, but things are particularly bad right now, due to over-prescription.

I would go with what Luchog posted, but to add to that better non-opiod pain management processes than are currently practiced.

Did you know that acetaminophen/paracetomol/Tylenol and ibuprofen/Advil/Motrin are different enough to allow full doses of both to be taken at the same time? They can be more effective in combination than alone?

When I served in the Peace Corps, the PC medical support staff would not issue us any prescription strength pain medication. They issued us great medical kits with a variety of antibiotics, anti-parasitics, and other stuff usually only available by prescription - but no codeine or anything else opioid based. They told us that if we had severe pain that didn't respond well enough to acetaminophen or ibuprofen alone, we could take two acetaminophen and up to four ibuprofen to kill the pain, but that was only to make us functional enough to get back to the PC/Embassy medical clinic in the capital (which could take days), or to last until they could send someone to us (which could also take days).

And it worked.

I have never heard that from any Dr. here in the states. I looked it up online and it seems the PC Dr.s were right, it is safe and very effective, even for chronic pain (but with less ibuprofen than my old PC medical support recommended, that was just for emergency). But I've never heard of it being suggested by any Doctor for anyone I've ever known. We have a lot of pain management options that just don't seem to be on the radar.


ETA: With of course disclaimer that I am not a medical professional, you should check with your own medical professionals and do your own homework. Don't just jump out and take medications because a pair of glowing eyes on an internet forum said it was okay.

 

[Ranb]

....Drug maker marketed oxycodone and the like as a drugs that couldn't be abused because they were time released. This was BS at the time and they were living up to their stereotype.

I was warned not to crush or take broken tablets. The staff was also careful to make me wait until the next scheduled time for another dose if I didn't request a pill every four hours. It occurred to me at the time that warning some people not to crush them was actually an invitation to try them crushed.

I believe the AMA has removed pain from their list of vital signs and we've now caught on to how bad these drugs are. That and they aren't that effective at pain management. Side note, Dr Drew of love line fame has being saying for years if not decades that opoids are useful for pain management.

When I was prescribed opiates for pain management for my open fracture, I felt that they were more effective than anything else other than morphine. I found that they had undesirable side effects like sleep deprivation. I rarely felt euphoric when taking it. I obeyed the doctor's orders when it came to not driving or certain other activities while taking them. This meant I stopped taking them as soon as the pain was manageable with over the counter meds.

 

[Hlafordlaes]

The problem (and yes I get that this is a little anecdotal and I'm gonna go see if I can track down something more concrete) is that a lot of chronic pain sufferers are convinced (either by their doctors, themselves, or both) that opioids are the only thing that helps their condition.

There's plenty of people out there that are already extremely upset at the restrictions we have on opioids now.

Since I have a non-remissive form of an often quite painful condition, with getting out of bed in the morning similar to emerging from a daily train wreck, I know pain. Since it's incurable, it's a lifetime proposition. However, in my case, opioids are not at all indicated and never prescribed, so I've never faced the issue of addiction. In the case of others with lifelong pain for which opioids work well, barring side effects or complications, I don't see why not.

What opioids should not be is a lightly prescribed medication for passing conditions, with rare exceptions determined by medical professionals. The only measure I'd recommend here, a whopper, is to cease altogether the practice of marketing pharma to doctors directly. It should be done to a panel of professionals who make recommendations to member physicians; i.e., peer reviewed, and properly absent under/over the desk "incentives."

As for chronic pain, cannabinoids are great. Sudden trips or events that leave one without medication have zero impact, other than, of course, the lack of a preferred weapon in the anti-pain arsenal. Wonderful for keeping up an appetite when other daily pain-killers (NSAIDs) do all they can to slowly ruin your digestive system. So, two things: legalize marijuana at the federal level as a medicine, and kick Big Pharma the heck out of doctor's offices. This ain't the 19th century, when keeping up with the times might have been difficult for physicians.

 

[luchog]

I would go with what Luchog posted, but to add to that better non-opiod pain management processes than are currently practiced.

As for chronic pain, cannabinoids are great.

I used to take Codeine for migraines. That has gotten more difficult, and wasn't particularly pleasant when I did take it due to the side effects. I react rather strongly to opiates. When I had to have a wisdom tooth chiseled out it was growing in the wrong direction), the doc put me on oxycodone. I had to go back and request a less potent painkiller, as I wasn't able to handle the nausea it induced, and the pain was nowhere near bad enough to justify that strong an opiate (that was back when over-prescription was just starting to become a problem). And even with milder opiates and smaller doses, I always feel "hung over" when they wear off.

For managing my cyclic migraines, I now use combination of high-CBD cannabis if they are bad enough to need medication. It doesn't stop them, but it does mitigate them sufficiently to let me function close to normally, and sleep through them easily (they never last more than a day). Not just the pain, but it helps with the nausea and other symptoms as well.

For more severe migraines, a combination of drugs helps a great deal. As the majority of my worst migraines, the kind that can keep me bed-ridden for days, are triggered by allergies (particularly seasonal hay fever and mould allergies), hydroxizine works very well as a preventative measure. Since starting it, I've gone years without a severe migraine. The few times I do get really bad ones, a combination of cannabis and a prescription NSAID (in my case, indomethacin) is very effective at mitigating symptoms, although they both make me rather sleepy.

I find that regimen much more effective and useful than opiates ever were.

 

[BobTheCoward]

Solution: remove all government regulation on opiods and opiod treatment.

 

[Loss Leader]

Solution: remove all government regulation on opiods and opiod treatment.

I guess if everybody's dead, nobody can be addicted to opiods.

 

[Tsukasa Buddha]

Counterpoint on blaming prescribed drugs:

Is the opioid crisis the same as the overdose crisis? No. One has to do with addiction rates, the other with death rates. And addiction rates aren’t rising much, if at all, except perhaps among middle-class whites.

The overdose crisis is unmistakable. I reported on some of the statistics and causes in the Guardian last July. I think the most striking fact is that drug overdose is the leading cause of death for Americans under 50. Some people swallow, or (more often) inject, more opioids than their body can handle, which causes the breathing reflex to shut down. But drug overdoses that include opioids (about 63%) are most often caused by a combination of drugs (or drugs and alcohol) and most often include illegal drugs (eg heroin). When prescription drugs are involved, methadone and oxycontin are at the top of the list, and these drugs are notoriously acquired and used illicitly.

Yet the most bellicose response to the overdose crisis is that we must stop doctors from prescribing opioids. Hmmm.

Yes, there has been an upsurge in the prescription of opioids in the US over the past 20 to 30 years (though prescription rates are currently decreasing). This was a response to an underprescription crisis. Severe and chronic pain were grossly undertreated for most of the 20th century. Even patients dying of cancer were left to writhe in pain until prescription policies began to ease in the 70s and 80s. The cause? An opioid scare campaign not much different from what’s happening today. (See Dreamland by Sam Quinones for details.)

...

But the news media rarely bother to distinguish between the legitimate prescription of opioids for pain and the diverting (or stealing) of pain pills for illicit use. The statistics most often reported are a hodge-podge. Take the first sentence of an article on the CNN site posted on 29 October: “Experts say the United States is in the throes of an opioid epidemic, as more than two million of Americans have become dependent on or abused prescription pain pills and street drugs.”

First, why not clarify that most of the abuse of prescription pain pills is not by those for whom they’re prescribed? Among those for whom they are prescribed, the onset of addiction (which is usually temporary) is about 10% for those with a previous drug-use history, and less than 1% for those with no such history. Note also the oft-repeated maxim that most heroin users start off on prescription opioids. Most divers start off as swimmers, but most swimmers don’t become divers.

Second, wouldn’t it be sensible for the media to distinguish street drugs such as heroin from pain pills? We’re talking about radically different groups of users.

Third, virtually all experts agree that fentanyl and related drugs are driving the overdose epidemic. These are many times stronger than heroin and far cheaper, so drug dealers often use them to lace or replace heroin. Yet, because fentanyl is a manufactured pharmaceutical prescribed for severe pain, the media often describe it as a prescription painkiller – however it reaches its users.

Linky.

I have also watched a false narrative about this crisis blossom into conventional wisdom: The myth that the epidemic is driven by patients becoming addicted to doctor-prescribed opioids, or painkillers like hydrocodone (e.g., Vicodin) and oxycodone (e.g., Percocet). One oft-quoted physician refers to opioid medication as “heroin pills.” This myth is now a media staple and a plank in nationwide litigation against drugmakers. It has also prompted legislation, introduced last spring by Senators John McCain and Kirsten Gillibrand—the Opioid Addiction Prevention Act, which would impose prescriber limits because, as a news release stated, “Opioid addiction and abuse is commonly happening to those being treated for acute pain, such as a broken bone or wisdom tooth extraction.”

But this narrative misconstrues the facts. The number of prescription opioids in circulation in the United States did increase markedly from the mid-1990s to 2011, and some people became addicted through those prescriptions. But I have studied multiple surveys and reviews of the data, which show that only a minority of people who are prescribed opioids for pain become addicted to them, and those who do become addicted and who die from painkiller overdoses tend to obtain these medications from sources other than their own physicians. Within the past several years, overdose deaths are overwhelmingly attributable not to prescription opioids but to illicit fentanyl and heroin. These “street opioids” have become the engine of the opioid crisis in its current, most lethal form.

If we are to devise sound solutions to this overdose epidemic, we must understand and acknowledge this truth about its nature.

...

Knowing all this, what should we do about the opioid crisis? First, we must be realistic about who is getting in trouble with opioid pain medications. Contrary to popular belief, it is rarely the people for whom they are prescribed. Most lives do not come undone, let alone end in overdose, after analgesia for a broken leg or a trip to the dentist. There is a subset of patients who are vulnerable to abusing their medication—those with substance use histories or with mental health problems. Ideally, they should inform physicians of their history, and, in turn, their doctors should elicit such information from them.

Still, given that diverted pills, not prescribed medication taken by patients for pain, are the greater culprit, we cannot rely on doctors or pill control policies alone to be able to fix the opioid crisis. What we need is a demand-side policy. Interventions that seek to reduce the desire to use drugs, be they painkillers or illicit opioids, deserve vastly more political will and federal funding than they have received. Two of the most necessary steps, in my view, are making better use of anti-addiction medications and building a better addiction treatment infrastructure.

Linky.

 

[crescent]

Counterpoint on blaming prescribed drugs:



Linky.



Linky.

The second link seems to be pushing a bit of a false dichotomy.

those who do become addicted and who die from painkiller overdoses tend to obtain these medications from sources other than their own physicians

This seems to be ignoring the idea that, although these people are obtaining drugs from other than their regular doctors, the addiction itself started with prescribed medication.

The prescription gets people addicted. Then once they can't get the prescription filled, they get the drugs elsewhere.

Within the past several years, overdose deaths are overwhelmingly attributable not to prescription opioids but to illicit fentanyl and heroin. These “street opioids” have become the engine of the opioid crisis in its current, most lethal form.

And again, this ignores the initial formation of the addiction.

 

[sadhatter]

We've always had junk and other addictive stuff. This crisis is happening because this society is falling apart.

Ever work in pharmacy?

Yes I'm asking that rhetorically, as its super clear you havnt.

 

[sadhatter]

Solution: remove all government regulation on opiods and opiod treatment.

Man, I've seen someone make 5 separate trips for Tylenol 1 in one day.

Your idea would have idiots dropping like flies.

 

[Fudbucker]

Ever work in pharmacy?

Yes I'm asking that rhetorically, as its super clear you havnt.

The availability of highly addictive substances certainly isn't helping things, but a worst-ever drug epidemic doesn't happen in a vacuum. Look at who we elected as President. That doesn't happen in a well-functioning society.

 

[Skeptical Greg]

Man, I've seen someone make 5 separate trips for Tylenol 1 in one day.

Your idea would have idiots dropping like flies.

Why is that not a solution?

 

[wasapi]

Opioids have been a daily part of my life for several years. Because of a degenerative spinal condition, I have had 4 spine surgeries and the last one contributed to permanent damage, resulting in CRPS.

Never, in the 20 years or so that they have been prescribed to me, did any doctor tell me it was the only thing that would work. Many other options were tried. Physical Therapy, other medicine, yes, even woo-ing off on my own with acupuncture. Bad, bad idea.

It is becoming much more difficult for people like me, who have no red flags in 20 years, to obtain them. In a way I have been lucky, in that my spinal issues are so easily identifiable on film, scans, reports. Yet now, there are new hoops to jump through.

To receive a prescription, I must sign a contract. They may urine test me at any time when I'm there. I will never take another - (sorry, the class that valium and zanax are in) - so I went cold-turkey, and I will bring my bottles of medicine to show the doctor how many are left.

That's fine. I receive no euphoria or shift of mood or sleep. It is simply a question of how well I need to function. My history shows that a one-month supply lasts me an average of 7 weeks. Yet, the manner of the doctors, in my experience, is insulting. It feels as if I am being reminded every few weeks that I am a potential criminal. A statistic.

It would be interesting to hear the experiences of others, because I only know the California experience.