Are we losing our minds regarding opioids?

[Travis]

Yes, the opioid crisis is bad. I've lost family members to overdoses. That said I think we are now terribly overreacting. Twice in the last few months I've had family members get surgery, back and heart, and get sent home with nothing but Tylenol. The hospital has a new policy to not allow any of its doctors with privileges to write any narcotic pain medication prescriptions. The only pain opioid pain meds one can get is by IV when you are actually in the hospital but since insurance companies are always pushing for people to be kicked out of the hospital as soon as possible it leaves us in this strange new place where people are being treated in ways unthinkable long before Oxycontin was even a thing.


Which is really what bothers me. We aren't just rolling back the really problematic meds we are rolling back everything even the ones that were used largely without incident for decades before Purdue sent out armies of leggy drug reps in short skirts to push Oxy on everyone.


There must be better ways to attack this problem. I already know of at least one person who is avoiding getting surgery for an ongoing problem precisely because they are terrified of being booted out of the hospital in unbearable pain with no way to treat it.


What in the hell are we doing?

 

[JoeMorgue]

Again I will ask the question I asked in the previous thread.

Where all these people who's pain can only be controlled via opioids in other countries?

People in the United States a prescribed opioids at, bare minimum, twice the rate of any other country (and those number starts dropping real fast even after that.)

Unless someone can show evidence of some epidemic of people in excruciating pain in the countries that prescribe opioids are far, far lesser numbers... what are we arguing?

There's this mythology in America; created mostly by drug companies (America is only one of two, the other being New Zealand, first world country that allows direct advertising of prescription drugs through ads and are basically allowed to bribe doctors openly to prescribe medication), that there are a lot of people out there in "special pain" that "normal painkillers" just don't work on.

So we can't have the opioid discussion without the "Well whatabout people who need them?" question. Well literally every other first world country has solved this problem so I'm going to assume it's fixable.

 

[cullennz]

I blame Gregory House

 

[Skeptic Ginger]

Travis is right. The medical community is ridiculously over-reacting to make up for their apathy in past years.

 

[Butter!]

Again I will ask the question I asked in the previous thread.

Where all these people who's pain can only be controlled via opioids in other countries?

People in the United States a prescribed opioids at, bare minimum, twice the rate of any other country (and those number starts dropping real fast even after that.)

Unless someone can show evidence of some epidemic of people in excruciating pain in the countries that prescribe opioids are far, far lesser numbers... what are we arguing?

There's this mythology in America; created mostly by drug companies (America is only one of two, the other being New Zealand, first world country that allows direct advertising of prescription drugs through ads and are basically allowed to bribe doctors openly to prescribe medication), that there are a lot of people out there in "special pain" that "normal painkillers" just don't work on.

So we can't have the opioid discussion without the "Well whatabout people who need them?" question. Well literally every other first world country has solved this problem so I'm going to assume it's fixable.

Do other countries really not prescribe opioids for right after surgeries? That is kind of crazy. Maybe I just have a really low pain tolerance, but it seems crazy to me!

 

[JoeMorgue]

Do other countries really not prescribe opioids for right after surgeries? That is kind of crazy. Maybe I just have a really low pain tolerance, but it seems crazy to me!

There's a town in West Virginia. Called Kermit. Sleepy little burg, basically just a few miles along Interstate 52. Got a Methodist Church, a BB&T bank, a couple of corner stores. Population of 400 people.

9 million opioid pills were prescribed in Kermit, West Virginia in a two year period.

That's 22,500 per person. That's averages out to 30 pills a day, per person.

They weren't having that many surgeries.

There's more opioid prescriptions in the state of Alabama then there are people in the state of Alabama.

https://www.bcbs.com/news/press-rel...ama-ranks-first-nationally-having-more-opioid
https://www.wvpublic.org/post/opioid-epidemic-kermit-wva#stream/0

 

[varwoche]

Yes, the opioid crisis is bad. I've lost family members to overdoses. That said I think we are now terribly overreacting. Twice in the last few months I've had family members get surgery, back and heart, and get sent home with nothing but Tylenol. The hospital has a new policy to not allow any of its doctors with privileges to write any narcotic pain medication prescriptions. The only pain opioid pain meds one can get is by IV when you are actually in the hospital but since insurance companies are always pushing for people to be kicked out of the hospital as soon as possible it leaves us in this strange new place where people are being treated in ways unthinkable long before Oxycontin was even a thing.


Which is really what bothers me. We aren't just rolling back the really problematic meds we are rolling back everything even the ones that were used largely without incident for decades before Purdue sent out armies of leggy drug reps in short skirts to push Oxy on everyone.


There must be better ways to attack this problem. I already know of at least one person who is avoiding getting surgery for an ongoing problem precisely because they are terrified of being booted out of the hospital in unbearable pain with no way to treat it.


What in the hell are we doing?

I'm dubious. That's not how things work in my experience, even now. What hospital?

 

[Puppycow]

Do other countries really not prescribe opioids for right after surgeries? That is kind of crazy. Maybe I just have a really low pain tolerance, but it seems crazy to me!

They probably do.

I was trying to find the statistics that JoeMorgue was talking about.

I found this. Don't know how reliable it is, and unfortunately it doesn't give comparable numbers for other countries:

7 Staggering Statistics About America's Opioid Epidemic

1. In 2017, health care providers across the US wrote more than 191 million prescriptions for opioid pain medication—a rate of 58.7 prescriptions per 100 people.
. . .
7. The CDC estimates the total economic burden of prescription opioid misuse in the US is $78.5 billion a year, including the costs of health care, lost productivity, addiction treatment, and criminal justice involvement.

So, 58.7 prescriptions per 100 people. I doubt more than half the people get surgeries in a given year, so they must be prescribing it for things other than surgery.

 

[JoeMorgue]

The pattern of opioids use varies widely around the world. In the United States, one daily dose of opioids was prescribed for every 20 people from 2013-15. In similarly wealthy Japan, one daily dose was prescribed for every 800 people over the same period.

https://qz.com/1198965/the-surprising-geography-of-opioid-use-around-the-world/

_____________________

Dr. Van Zundert: In the last 20 or 30 years in Europe there has been an increase in the treatment of pain just as in the U.S. But opioid treatment is rather limited. We’ve known since the last decade that opioids don’t have the desired effect, and most people stopped using them due to side effects or non-effectiveness. That seems to be a bit different than in the United States where opioid usage was increasing. If the opioids didn’t work, the dosage was increased.

https://consultqd.clevelandclinic.org/the-opioid-epidemic-what-can-we-learn-from-europe/

__________________________________________

For every one million Americans, almost 50,000 doses of opioids are taken every day. That's four times the rate in the UK.

https://www.bbc.com/news/world-us-canada-41701718
___________________________________________

Before 1995, opioids were originally reserved to treat severe, cancer-related and post-surgical pain. In the late 1990s, pharmaceutical companies started increasing the supply of prescription opioids, which they falsely claimed could alleviate chronic pain without becoming addictive.

https://www.therecoveryvillage.com/opiate-addiction/related-topics/americas-opioid-crisis/#gref

______________________________________________

Onishi got her medical training in Japan and spent about a year there practicing medicine before coming to the United States. She was used to that country’s strict attitudes around opioid painkillers like Vicodin or Oxycontin, which are generally only prescribed in cases where a patient is in severe pain, as with cancer. In Japan, opioids for acute pain aren’t typically covered by insurance.

When Onishi started practicing family medicine in Oregon, she was shocked to see patients getting opioids for injuries as minor as toothaches and sprained ankles. And she started seeing a disturbing trend among her own patients: people constantly requesting opioids for pain.

“It’s the patient begging you to ‘give me the opioid,’” Onishi said.

https://www.vox.com/policy-and-politics/2017/8/8/16049952/opioid-prescription-us-europe-japan

 

[Butter!]

I agree, they're really overprescribed in general. I was just remarking on surgeries because that's what the OP mentioned. I was stunned that people are getting serious surgeries without them.

 

[angrysoba]

There's a town in West Virginia. Called Kermit. Sleepy little burg, basically just a few miles along Interstate 52. Got a Methodist Church, a BB&T bank, a couple of corner stores. Population of 400 people.

9 million opioid pills were prescribed in Kermit, West Virginia in a two year period.

That's 22,500 per person. That's averages out to 30 pills a day, per person.

They weren't having that many surgeries.

There's more opioid prescriptions in the state of Alabama then there are people in the state of Alabama.

https://www.bcbs.com/news/press-rel...ama-ranks-first-nationally-having-more-opioid
https://www.wvpublic.org/post/opioid-epidemic-kermit-wva#stream/0

No wonder it’s a sleepy little burg.

 

[Skeptic Ginger]

I agree, they're really overprescribed in general. I was just remarking on surgeries because that's what the OP mentioned. I was stunned that people are getting serious surgeries without them.

I believe that's been challenged though I know from experience providers are being pressured not to prescribe much.

 

[angrysoba]

Do other countries really not prescribe opioids for right after surgeries? That is kind of crazy. Maybe I just have a really low pain tolerance, but it seems crazy to me!

According to this source from the NHS, opiates are used such as morphine, diamorphine, tramadol, etc...

https://www.pat.nhs.uk/downloads/pa...naesthetics/226 Pain relief after surgery.pdf

I expect that people spend longer in the UK in hospital after surgery than they do in the US, and don’t worry, in the UK you don’t have to worry about the bill - because Britain uses unthinkable communist medicine.

Apparently this pain relief treatment is administered under the watch of nurses as well, so there’s a lower risk of abuse in hospital.

I have not experienced this myself so maybe someone who has can chime in here.

 

[a_unique_person]

Now the opioid manufacturers have been successfully sued, maybe medical legal departments are making sure they are legally not touchable.

 

[Loss Leader]

New York has the entire system computerized. They can tell exactly which doctors are prescribing however many pain meds. So, an oncologist may have high numbers, but a gp with the same numbers is going to get investigated.

It seems like a good system.

 

[Fast Eddie B]

My personal experience is that they’re over-prescribed.

A year ago May I had carpal/cubital tunnel release surgery. Last Friday I had a kidney stone blasting. In the first case, they insisted I take a hydrocodone as soon as I got home, whether I thought I needed it or not, and I did. I think I took one the next day, then just ibuprofen. This time I haven’t needed anything for the kidney stones, thought that may change at any time.

But I was given a prescription this time for 20 doses. I think for the hand/elbow surgery at least that many. I don’t mind having them around for emergencies, but I think a more cautious approach would be to prescribe a much smaller amount - maybe 6 or 8 - and then refill only as needed. Of course, for those with chronic pain it’s not that simple.

 

[Puppycow]

My personal experience is that they’re over-prescribed.

A year ago May I had carpal/cubital tunnel release surgery. Last Friday I had a kidney stone blasting. In the first case, they insisted I take a hydrocodone as soon as I got home, whether I thought I needed it or not, and I did. I think I took one the next day, then just ibuprofen. This time I haven’t needed anything for the kidney stones, thought that may change at any time.

But I was given a prescription this time for 20 doses. I think for the hand/elbow surgery at least that many. I don’t mind having them around for emergencies, but I think a more cautious approach would be to prescribe a much smaller amount - maybe 6 or 8 - and then refill only as needed. Of course, for those with chronic pain it’s not that simple.

Insisting that you take hydrocodone whether you think you need to or not sounds like a red flag to me.

 

[Reactor drone]

They're not being generally prescribed because studies found that they were no more effective than combined ibuprofen/paracetamol in most cases.

 

[Darat]

Quite a few things added up to the perfect storm effect in the USA, including

You had the old puritan approach to pain embedded in the culture
Expensive healthcare system
The direct marketing by sales reps. to prescribers
Direct marketing to consumers of prescription only drugs
Use of very weak science to make marketing claims

It's the final one above that the marketing departments of the pharmaceutical industry used to terrible effect, they literally lied about the addictiveness of the "new formulations".

You are a GP, for years you've been cautious about opiod prescriptions because you know they can be addictive and not very effective for some chronic pain treatment. And you are now being told about the new wonder drugs, even more effective at reducing and controlling pain even for chronic pain than the old opiates AND this is the real kicker, not prone to the same level of addictiveness. Why wouldn't you start using them. Indeed you'd be doing your patients a disservice by not using them, why would any caring GP not use them?

Not saying prescribers should be let off the hook for their responsibilities but I can see how the pharmaceutical companies were responsible for opening the gates to all the abuse that followed.

 

[Hevneren]

Quite a few things added up to the perfect storm effect in the USA, including

You had the old puritan approach to pain embedded in the culture
Expensive healthcare system
The direct marketing by sales reps. to prescribers
Direct marketing to consumers of prescription only drugs
Use of very weak science to make marketing claims

It's the final one above that the marketing departments of the pharmaceutical industry used to terrible effect, they literally lied about the addictiveness of the "new formulations".

You are a GP, for years you've been cautious about opiod prescriptions because you know they can be addictive and not very effective for some chronic pain treatment. And you are now being told about the new wonder drugs, even more effective at reducing and controlling pain even for chronic pain than the old opiates AND this is the real kicker, not prone to the same level of addictiveness. Why wouldn't you start using them. Indeed you'd be doing your patients a disservice by not using them, why would any caring GP not use them?

Not saying prescribers should be let off the hook for their responsibilities but I can see how the pharmaceutical companies were responsible for opening the gates to all the abuse that followed.

This sounds strangely familiar. Heroin was originally marketed as a non-addictive morphine substitute. That went well.