The Opioid Crisis

[Wolrab]

As a nurse I have been instructed that a patient's pain is what they say it is. Countless times I have had patients ring their call bell and ask for pain meds, usually IV dilaudid, morphine, or fentanyl. When I walk into the room, the patient would be laughing and joking on the phone or with visitors in absolutely no visible signs of pain- no moaning, cringing, guarding of the pain site. When I ask their pain level- zero being no pain and ten being the worst pain ever, they dismissively look at me and state 20/10, then go back to whatever they were doing.

I would administer the drug as ordered and watch as their eyes would roll back in their sockets and dopey smile spread across their face. They knew exactly when the next dose was due and get angry if I couldn't get there within seconds. Those patients were frequent flyers to the hospital.

The doctors are too afraid to not give them pain medication and the patients are savvy enough to play it up when the MD is around.

My favorite is that these drug savvy patients play coy when you ask what their med is and usually say something like, "Last time the only thing that worked was...dilala." Always the same pronunciation from different patients.

 

[Tsukasa Buddha]

Drug Manufacturers: Hey Docs it would be awesome if you would really prescribe a lot of these drugs, hint hint.
Doctors: I think Opioids will alleviate your pain.
Chronic Pain Sufferers: Opioids are the only drugs
Science: There is very little empirical evidence that Opioids are any better at controlling chronic pain than traditional pain killers.
Society: We're overprescribing Opioids!
Government: We need to restrict Opioids!
Chronic Pain Sufferers: But I need them!
Drug Manufacturers: But they need them!

I sort of see a feedback loop where one specific voice is getting ignored here.

You seem to be focusing on a certain finding for a certain group of patients as "science says" and haven't shown that it actually is being ignored or actually caused the crisis or would prevent the crisis.

 

[The Greater Fool]

The good news, TGF:
http://tucson.com/news/local/arizon...cle_8c5fb239-64f9-59b8-b209-fd8adceb5db3.html

Not such good news.

My spouse sees a board certified Pain Management specialist. I have also talked to my certified Pain Management specialist. Neither are inclined to go over the limit and have the State and DEA digging into their affairs. So, while there may seem to be a path, Doctors feel it is too dangerous for them to tread.

Now, I expect there are a few Doctors that aren't concerned with the State and DEA getting intimately familiar with their lives. Unfortunately, these docs don't advertise, so finding them is a problem.

My spouse has been with her current Doc for the 4 years we have been back in AZ. Even before this law, changing Docs is not something that chronic pain patients are inclined to do. Changing Docs can look like "drug seeking behavior," of addicts which is a huge red flag. You see, that's what addicts do.

This is what happens when honest Chronic Pain patients are lumped in with addicts in discussion. It's also self fulfilling, because when your Doc acknowledges you need the meds but won't give them to you, you have to go the illegal path, or die (as many have suggested).

 

[Tsukasa Buddha]

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

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.



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

That was actually addressed in the links, but if you don't like them here are more:

Here’s the first story. It has been endorsed by some excellent journalists and broadcasters, from Sam Quinones to HBO’s John Oliver. It goes, in crude summary, like this: Starting in the late 1990s, a handful of pharmaceutical corporations promoted prescription opiates as the solution to America’s physical pain. Large numbers of people then started to take these drugs — and because Oxycontin and Percocet and the rest have such powerful chemical hooks, many found themselves addicted. Big Pharma is like the drug-pusher in a Reagan-era public service announcement, waiting at America’s metaphorical playground gate with a drug you can’t resist.

This narrative leads to a clear solution: Restrict prescription opiates and prevent addicts from taking them. Since the drug caused the problem, ending access to the drug humanely will end the problem.

Although this is a coherent story, put forward by serious and thoughtful people, there are some key facts that don't fit. Here's one: Doctors in many parts of the world — including Canada and some European countries — prescribe more powerful opiates than their peers in the United States. In England, if, say, you get hit by a car, you may be given diamorphine (the medical name for heroin) to manage your pain. Some people take it for long periods. If what we've been told is right, they should become addicted in huge numbers.

But this doesn't occur. The Canadian physician Gabor Maté argues in his book "In the Realm of Hungry Ghosts" that studies examining the medicinal use of narcotics for pain relief find no significant risk of addiction. I've talked with doctors in Canada and Europe about this very issue. They say it's vanishingly rare for a patient given diamorphine or a comparably strong painkiller in a hospital setting to develop an addiction.

Given that really powerful opiates do not appear to systematically cause addiction when administered by doctors, we should doubt that milder ones do. In fact only 1 in 130 prescriptions for an opiate such as Oxycontin or Percocet in the United States results in addiction, according to the National Survey on Drug Use and Heath.

So what's really happening? The second, clashing story goes, again, crudely, like this: Opiate use is climbing because people feel more distressed and disconnected, and are turning to anesthetics to cope with their psychological pain.

Addiction rates are not spread evenly across the United States, as you would expect if chemical hooks were the primary cause. On the contrary, addiction is soaring in areas such as the Rust Belt, the South Bronx and the forgotten towns of New England, where people there say they are lonelier and more insecure than they have been in living memory.

Linky.

The idea is that the overdose epidemic was caused by evil drug companies pushing greedy doctors to prescribe unnecessary drugs, which turned innocent pain patients into people with heroin addiction, who are now overdosing on street fentanyl.

That, however, is not exactly what happened. Yes, the drug companies irresponsibly and reprehensibly misused the legitimate concern that pain was being undertreated to sell massive amounts of product. Yes, Purdue Pharma inaccurately claimed that Oxycontin was a less addictive opioid—and that its effects lasted longer than they really did. Yes, salespeople pressured many doctors into prescribing far more than made sense.

"The simple story is that addiction happens all the time when people get opioids for pain and that simple story is clearly wrong," says Stefan Kertesz, associate professor of preventive medicine at the University of Alabama.

The research actually shows that people who developed new addictions in recent years were overwhelmingly not pain patients. Instead, they were mainly friends, relatives, and others to whom those pills were diverted—typically young people. Among the older patients, many who appeared to be newly addicted had actually relapsed or never recovered from prior addictions: some faked pain to get pills from well-meaning doctors; others got them from pill mills where shady physicians wrote prescriptions for cash.

The simple story that addiction happens all the time when people get opioids for pain is clearly wrong.

How do we know this—and why is this story so different from the one we hear in the media? For one, the National Household Survey on Drugs has asked about the sources of misused opioids in recent years: this representative survey of tens of thousands of Americans shows that less than a quarter of people who start misusing these drugs obtained them directly from one or multiple doctors. Half of new users, in fact, say they got them from a friend or relative for free.

Secondly, an early study of people being treated for Oxycontin addiction found that 77 percent of them had also taken cocaine—and it's hard to imagine that this was supplied medically or that these pain patients went out in search of a cocaine dealer once they found out how nice opioids are. In addition, only 3.6 percent of people who misuse prescription opioids ever even try heroin. Although 75 percent of heroin users start with prescription opioids these days, very few prescription opioid users actually go on to heroin addiction.

...

Nonetheless, the idea that patients who take medications as prescribed are the cause of this problem is inaccurate. While the media loves to highlight "innocent victims" who became addicted through medicine, the fact is that this group is a minority. Medical use surely increased access to the drugs—but the people who got hooked tended to do so while using medication that was either prescribed for someone else or otherwise distributed illegally.

Linky.

 

[kellyb]

Not such good news.

My spouse sees a board certified Pain Management specialist. I have also talked to my certified Pain Management specialist. Neither are inclined to go over the limit and have the State and DEA digging into their affairs. So, while there may seem to be a path, Doctors feel it is too dangerous for them to tread.

Now, I expect there are a few Doctors that aren't concerned with the State and DEA getting intimately familiar with their lives. Unfortunately, these docs don't advertise, so finding them is a problem.

My spouse has been with her current Doc for the 4 years we have been back in AZ. Even before this law, changing Docs is not something that chronic pain patients are inclined to do. Changing Docs can look like "drug seeking behavior," of addicts which is a huge red flag. You see, that's what addicts do.

This is what happens when honest Chronic Pain patients are lumped in with addicts in discussion. It's also self fulfilling, because when your Doc acknowledges you need the meds but won't give them to you, you have to go the illegal path, or die (as many have suggested).

I am so sorry. That is awful.

ETA - "treatment seeking behavior" needs to be a popular phrase.

 

[catsmate]

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

However we live in the Real World, not libertarian fantasy land.

 

[3point14]

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.

We already know that, didn't we?


During my youth in the 80s, I was exposed, almost daily, to a whole raft of adverts like this:

https://www.youtube.com/watch?v=Zd2lqoB6c1Q

I assume there was similar stuff in the US?

 

[3point14]

The abuse of prescription drugs is notorious...partiuclary in Hollywood, where it is pretty well known there are doctors,who, if you pay them enough,will pretty much prescribe whatever you want. That is how Michael Jackson got the drugs that killed him.

Why are these doctors never investigated and struck off? Why is the practice tacitly accepted when it is flagrant breach of the rules of medicine (as I understand them)

 

[Belz...]

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.

This.

 

[Giordano]

Why are these doctors never investigated and struck off? Why is the practice tacitly accepted when it is flagrant breach of the rules of medicine (as I understand them)

Frankly I do not know. But if forced to guess, I would hazard that they are very wealthy, have rich and powerful friends and clients, have access to very good attorneys, and have set up their practices in clever ways such that it would be very difficult to prove that they committed any illegal actions.

Just a guess.

 

[Belz...]

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?

Yes. When I have particularily annoying headaches or similar pains I take both, though I haven't really looked at how effective it actually is for me.

 

[3point14]

Frankly I do not know. But if forced to guess, I would hazard that they are very wealthy, have rich and powerful friends and clients, have access to very good attorneys, and have set up their practices in clever ways such that it would be very difficult to prove that they committed any illegal actions.

Just a guess.

Oh, one of those where laws are optional if one is rich. There seem to be more and more of those. For the record, if these things are happening - and it seems that the general consensus is that they are - then those doing it need to be prosecuted to the full extent of the law and struck off. If the law does not allow for that, then it needs revising.

 

[Giordano]

Whatever happens, it will happen in a way to preserve (or increase) the profits of large pharmaceutical corporations. The puritanical element will act as if they'd preferred millions to suffer horribly rather than risk a single person having illicit pleasure, and perhaps they even believe that, but ultimately it's all down to money.

Someone I know maintains that the rich will always be powerful and will ultimately always get their way. So it has been throughout history and so it is now. Given that, the best strategy for others is to achieve a moral or political goal is to find some way to link that goal to the greed of a wealthy person or corporation. Probably a useful strategy to remember for virtually all aspects of life.

If our goal is to ensure the proper availability of opioids to those suffering in otherwise intractable pain, the desire of certain pharmaceutical companies to sell as much opioids as possible may be a good thing. The problem, of course, is to achieve this without the opioids being prescribed to large numbers of other people who do not need them, or massively diverted into illegal markets. Unfortunately my experience in life is that the legislators and opioid manufacturers will work out a means by which the companies continue to profit, the politicians pat themselves on the back, the wrong uses are maintained, and the people who legitimately desperately need the drugs will be left without.

 

[Belz...]

It's the exact same concept as gun-control: too often the focus is in the wrong place. Here, the focus is on coming down on doctors and dealers rather than trying to fix the society that makes it so people are so desperate to escape their lives to do whatever they can to get the drugs they know will solve their problems (at least for a few minutes/hours).

Yeah, because the society that pushes politicians to do stuff would rather blame doctors and dealers than themselves.

 

[Belz...]

Yes I'm "insinuating" that if the science says that these particular class of drugs are not really any effective at treating chronic pain conditions than other classes of drugs which don't carry the same risks that's a pretty big factor in all this.

Not exactly sure why that's some crazy position I'm getting so much vitriol over.

Will it help if I send you a hug?

 

[3point14]

Someone I know maintains that the rich will always be powerful and will ultimately always get their way.

Well, not always.

 

[Giordano]

I see us poised on the brink of a possible societal disaster. There is so much ignorance, emotion, scapegoating, political gamesmanship, and religious fervor coming together in response to the "opioid epidemic" that I simply despair of a solution that does not make everything worse. I feel like shouting at everyone involved:

"Hey guys, you know, this is like really, really important! What we do next may leave large numbers of people suffering tortuous unending pain, or conversely may result in yet more people becoming addicts. What we do next may help the people who are addicted, or it may result in their further spiraling into degradation and death. Guys (and gals) this is one of those situations where wrong decisions based on stereotypes or incomplete understandings will have awful repercussions. Make sure you know the facts before you do anything. And act with compassion and not just for political expediency or for campaign money. Perhaps just this once we can do it right! Okay?"

 

[Giordano]

Well, not always.

Oh, she just never had a good head for finances.

 

[Belz...]

Then be astonished.

Here, in AZ and in most states, you can only get a 1 month supply of narcotics. That has not changed. What has changed that in my spouse's case, the new Law allows her only half of what she's had for 20 years. That's 50%. That's how I define 1/2.

I think the question is in what way does this affect dosage? If it doesn't, then Sadhatter is asking what the problem is. I think you're talking past one another.

 

[TomB]

As a nurse I have been instructed that a patient's pain is what they say it is. Countless times I have had patients ring their call bell and ask for pain meds, usually IV dilaudid, morphine, or fentanyl. When I walk into the room, the patient would be laughing and joking on the phone or with visitors in absolutely no visible signs of pain- no moaning, cringing, guarding of the pain site. When I ask their pain level- zero being no pain and ten being the worst pain ever, they dismissively look at me and state 20/10, then go back to whatever they were doing.

I would administer the drug as ordered and watch as their eyes would roll back in their sockets and dopey smile spread across their face. They knew exactly when the next dose was due and get angry if I couldn't get there within seconds. Those patients were frequent flyers to the hospital.

The doctors are too afraid to not give them pain medication and the patients are savvy enough to play it up when the MD is around.

My favorite is that these drug savvy patients play coy when you ask what their med is and usually say something like, "Last time the only thing that worked was...dilala." Always the same pronunciation from different patients.

Interesting. I've seen just the opposite.

Prior to the morphine, my wife was on Fentanyl patches. (Again, she experienced no high or anything. I think I read that legitimate chronic pain patients typically do not get the high. Not sure of the mechanism, though.)

The doctor who prescribed the patches moved to another area, so she had to switch doctors. (As the greater fool pointed out, you don't switch doctors lightly or you'll be seen as doctor shopping. Anyone else with a health condition is encouraged to search for the right doctor to treat them, but if your condition involves chronic pain, then you must be a drug-seeking junkie.) Her new doctor didn't like the patches. While they were effective, they had some drawbacks. They don't deliver the medicine at a steady rate for the entire usage span. The dosage ramps up on day one and down on day three. (Her instructions were to overlap the patches to even this out.) If you forget which day you are on and put the next patch on late, it takes a while for the new patch to be effective. Her new doctor felt that oral morphine gave greater control of the dosage.

Now, the refill routine for the morphine took some getting used to. The doctor can't call the prescription in to the pharmacy, it has to be hand carried. Each month is a new paper script: no refills. You can't get a partial fill and get the rest later. The quantity is more than any pharmacy in town routinely carries on hand. A pain contract limits you to using only one pharmacy. You can't get it filled early...has to be within a couple of days of when you should run out. If your doctor is on vacation, you HOPE his nurse will convince his backup to write the prescription.

We had a few times when the refill didn't happen on time, or we had to explain that the pharmacy couldn't fully fill the prescription. (We had a nurse who would not believe that even when the pharmacist called and confirmed that that was the case.) Any irregularity...preparing for vacation/work trip...and you are treated like a drug seeker.

Forget about going to the ER. We did that one time on the advice of the patient advisory nurse for the hospital. Out of medication (at the normal time) but nurse didn't get the doctor to sign the prescription before he left for the weekend and refused to try to get in touch with him or another doctor. ("I'm supposed to have been off fifteen minutes ago. This is cutting into my weekend.") In ER told the story to the ER doctor (who has full access to her history file) and he literally said: "Not going to happen. Eventually, we did convince him to call her doctor (who was the director of residents at the hospital) and he wrote an Rx for enough to get through the weekend. Grudgingly. He made it very clear that he thought she was a junkie. His (stated) preference was for her to go home, and come back if the withdrawal symptoms got too bad.

So afraid to not give medication? Please.