Fact checking the opioid epidemic

[erwins]

That's still a big increase, even with the population increase. And when the point is that large numbers of people are dying, and we should do something about it, using the rate would miss the point. It's the numbers that matter. And I do agree that they matter, and that we should try to prevent most of those deaths.

But I also think this issue is complicated. Because, for example, during the period before the recent more liberal prescribing trend, even patients with near-term terminal illnesses who were in severe pain had trouble getting sufficient pain medication to manage their pain. They were subject to the same kinds of controls that are meant to prevent addiction from long-term use of Rx opioids, or were kept on lower doses than would control their pain because higher doses might hasten their deaths.

Similarly, there are some kinds of chronic pain where addiction to opioids might be an acceptable risk, or even an acceptable side effect. I spent a weekend with an irritated trigeminal nerve due to a dental abscess. I took the maximum dose of my Rx pain meds on schedule for the entire weekend. (I've never before or since taken the maximum dose, or probably more than 3 doses in a row.)

I was able to cope in part because I knew it was being caused by something that would be treated on Monday. Still, it was an indescribably horrifying weekend. Frequently, for people who have chronic trigeminal neuralgia, the alternative to effective pain management -- if surgery is not successful -- is suicide. It's nicknamed "the suicide disease." And I can understand why. (I did not have suicidal thoughts, but I did have some very disturbing recurrent thoughts of pulling my own tooth.)

Comparing numbers from a more tightly controlled time to a more liberal prescribing period isn't as simple as saying that controlling Rx numbers would prevent x number of opioid-caused deaths. Because it might just mean that some people would die in more pain.

[Ali Infree]

From my perspective the current cycle (and it does seem cyclic to me) began in the late 1990s. A number of these prescription drugs as jimmy101_again notes came to be prescribed for pain. Medical opinion, at that time, was that pain was being under-treated (Hence the 1-10 scale for describing your pain now.) Oxycontin and its relatives were described to doctors as being non-addictive.
First places where the abuse of these drugs became apparent was in more rural areas--southeastern Ohio, West Virginia, Virginia, Kentucky, Maine, and other places where workplace injuries led to prescriptions. Rudy Guiliani's firm represented the Oxycodone companies when it became clear that their product was addictive and main thing preventing them from being abused could be circumvented by grinding the pills and then snorting, ingesting them. Large settlements were made to states that sued.
However, as has already been described, once addicted, many people switched to illegal drugs. Despite the lawsuits, the pills kept coming. In West Virginia according to one reporter, enough to give everyone in the state 433 pills over a six year period. New lawsuits now ensue, and deaths from overdoses continue to rise.
It is going to be a long time before we see a downturn in this issue. Addiction is a terrible disease and while many people recover, the net result before that happens is pain--not just physical pain but also the anguish of family members.
I have taken to using social media to show obituaries where family members admit their loved one died from addiction ( and often tell of the love and interests which made them loved ). Not many of these are published, so the deaths go under the radar, everywhere.

Ali

[Lainie]

The 1-10 scale predates the 1990s, I think.

And I don't think we can rule out the possibility that pain is under-treated, or might be, depending on how we address the opioid problem. That's one of the difficulties: addressing the abuse without unnecessarily condemning some people -- possibly including some who never misused pain meds -- to suffer unnecessarily.

[jimmy101_again]

Originally Posted by Lainie

The 1-10 scale predates the 1990s, I think.

And I don't think we can rule out the possibility that pain is under-treated, or might be, depending on how we address the opioid problem. That's one of the difficulties: addressing the abuse without unnecessarily condemning some people -- possibly including some who never misused pain meds -- to suffer unnecessarily.

You definitely can't rule out the under treatment of pain or the valid use of even highly addictive pain killers when nothing else works.

What can be addressed though are;

1. The prescribing must be medically justified
2. MDs that write thousand of scripts per month are doing something wrong
3. pharmacies selling tens of thousands of pill per month are doing something wrong
4. A couple of pharmaceutical companies misrepresented many of these drugs as "non-addictive", which was incorrect and should be prosecuted

[Plurabelle]

Locally we are dealing with carfentanil, which is an elephant tranquilizer, I believe.

I had a young friend who was trying to get sober for her son (she was 20, her son was 18 mo) and her baby's father gave her a single dose of carfentanil and killed her. He's being prosecuted for murder because he was sober and knew what the drug would do to her.

Carfentanil is causing most of the deaths from opiates around here, but I don't quite understand it on behalf of the dealers - why would you kill your customers?

Our vet has a pretty intense process for picking up painkillers for our 2 cancer stricken dogs - we have to show ID and they make a note of it, and we can only pick up 15 at a time. It's stricter than with humans. I can't imagine it'd be easier with elephants.

I'm in the hospital right now after surgery but they have me on something, and when they let me go home tomorrow any extra pain pills get flushed.

[Little Pink Pill]

Get well soon, Plurabelle!

According to this article, some of the big guns like Fentanyl and Carfentanil are coming in from underground Chinese labs. They aren't from vets being irresponsible with elephant tranquilizers.

http://www.sciencemag.org/news/2017/...es-can-respond

[erwins]

I experienced some of the bad effects of the more restrictive approach. I was unable to get a prescription painkiller when I had a broken wrist, which kept me from being able to sleep well for a while, while I was attending law school. It isn't like I couldn't take the pain, but I definitely lost productivity. I would have had to take off work if I had been working.

I have issues with my teeth, and have sometimes needed Rx painkillers for toothaches. When prescribing is tight, I could not get those meds until something like a root canal. Because I typically only used a few pills, I used to then hang onto the rest in case I could not get any the next time they were needed. It created a sort of hoarding mentality that is a bad thing, because it means people have stores of these meds lying around that they are not using.

I also think that some diversion or misuse occurs because of the lack of access to medical care for many in this country. If a person is unable to see a doctor but is in pain, others may offer them Rx painkillers that had been legally obtained, with the intention of helping the person. But then they are not dealing with the medical problem, and are now taking Rx meds without medical supervision. It's easy to see how that could lead to addiction and other adverse consequences.

[RichardM]

Originally Posted by Plurabelle

I'm in the hospital right now after surgery but they have me on something, and when they let me go home tomorrow any extra pain pills get flushed.

In general, flushing is not recommended for pill disposal. See https://www.fda.gov/drugs/resourcesf.../ucm186187.htm

[Little Pink Pill]

Originally Posted by erwins

I also think that some diversion or misuse occurs because of the lack of access to medical care for many in this country. If a person is unable to see a doctor but is in pain, others may offer them Rx painkillers that had been legally obtained, with the intention of helping the person.

I've had 2 close friends, non addicts, call me and ask me to share my migraine medicine while they waited for doctor's appointments (the wait time in our area has become absurd, sometimes several months at a time unless you want to sit for 6 hours in the ER). I declined, but I could understand why they were asking. They were desperate. One had a migraine herself after being free of them for years, and the other was waiting to see a specialist for a painful condition. Like you, I had been "hoarding" one prescription that I never used, but after that I disposed of it so I couldn't be put in that position again. I felt bad but, no.

[thorny locust]

I've been unable even to get a codeine cough syrup when I had a cough bad enough to prevent me from sleeping. And no, the stuff they gave me instead didn't work; and I've taken codeine before with no problems (and no temptation, on my part, to keep taking it after the need was gone; though I now have a pretty severe temptation to hang on to it if I did legitimately come by some, in case the cough situation comes up again.)

That's pretty minor, compared to people with chronic severe pain. But it seems odd when other people are describing other opoids being handed out like candy.

[jimmy101_again]

Originally Posted by thorny locust

That's pretty minor, compared to people with chronic severe pain. But it seems odd when other people are describing other opoids being handed out like candy.

That is a big part of the challenge. Some MDs are giving them out like candy because they can charge for the prescription. More ethical MDs (i.e., nearly all) get blamed for the entire problem and become leery of prescribing at all. The net result is that people that need them have trouble getting them and people that are abusing them have no problem getting them. The likely outcome of the"opioid epidemic" is that people that medically need the drugs wont be able to get them in a timely fashion.

[Plurabelle]

I am an admitted addict (to alcohol) and have had to re-adjust my entire life as a result - I was doing very well on Ritalin for 7 years and not abusing it at all, but suddenly I was not allowed to take it anymore.

It's incredibly frustrating to explain that just because I abuse one drug doesn't mean I care about abusing a second. I really struggle to manage my ADHD without ritalin these days.

But still doctors will give me painkillers out to wazoo. I just had a hysterectomy and I'm home and they gave me 60 vicodin. RichardM says not to flush them, but I'll dispose of the extra pills properly once my abdomen stops hurting.

[RichardM]

I personally will not take opioids for pain control. This is for 2 reasons, 1: they don't seem to do anything to alleviate the pain; and 2 they cause severe constipation. YMMV

I was able to dispose of those prescribed for my shoulder surgery by taking them to the local police on a '"turn in" day. But I trust the Sachse TX police.

[Lainie]

Some pharmacies will accept drugs for proper disposal.

ETA: Opiate effects do vary widely. I know several people who can't keep them down, and RichardM is far from the first person who says they don't get relief from pain. OTOH, I get pretty good results with them -- maybe not complete elimination of the pain, but significant reduction -- with minimal side effects. The slight "buzz" doesn't bother me (I avoid inappropriate activities, of course), but my mother considered that sensation worse than all but the most severe pain, and even then could barely tolerate it.

[dfresh]

The local police station has a drop box where you can put in unneeded medications or drugs, no questions asked.

[thorny locust]

I never even got a buzz from codeine; just pain relief (menstrual cramps, before iboprofen came on the market) and/or cough relief. And no lethargy, unusual sleepiness, or constipation. I was only taking small doses, however.

My mother used to take low doses codeine for pain (headaches mostly), with no side effects at all so long as the dose was low; she would sometimes do so for weeks, then stop taking it for months or years, then take it again if she had pain. She never had any trouble stopping.

Results however do vary widely. I'm only giving those as examples of the other end of the spectrum; not meaning to contradict that some people do have significant trouble with the stuff. And I had a friend in high school, back when the cough syrup was OTC unrestricted, who used to drink it for the fun of it, and got yanked out of school for a while by her family in order, I think, to dry her out (my knowledge of just what was going on was blurry; I'm pretty sure they shifted her to a different school, not took her out of school entirely except maybe briefly.)

It is not however my general impression that more people got into trouble with opiates when you could buy codeine cough syrup OTC than they do now. I'm pretty sure people even get into trouble with the cough syrup that you can buy now -- the difference seems to be primarily that the codeine version actually stopped the cough, which the newer cough syrup substitutes don't.

[erwins]

This article has an interesting analysis and data.

https://blogs.scientificamerican.com...not-the-cause/

But the simple reality is this: According to the large, annually repeated and representative National Survey on Drug Use and Health, 75 percent of all opioid misuse starts with people using medication that wasn’t prescribed for them—obtained from a friend, family member or dealer.

And 90 percent of all addictions—no matter what the drug—start in the adolescent and young adult years. Typically, young people who misuse prescription opioids are heavy users of alcohol and other drugs. This type of drug use, not medical treatment with opioids, is by far the greatest risk factor for opioid addiction, according to a study by Richard Miech of the University of Michigan and his colleagues. For this research, the authors analyzed data from the nationally representative Monitoring the Future survey, which includes thousands of students.

[kitap]

Originally Posted by jimmy101_again

This is what I meant earlier by "ingrained". Many health practitioners prescribe opioids more readily than they prescribe acetaminophen, ibuprofen, or even aspirin. Like Musicgeek, I have three or four old bottles of Oxycontin at home from wisdom tooth extractions and other dental procedures for my family. I suspect that a total of 3 pills were actually used out of more than a dozen in the prescriptions.

Back in 2006 I had a peritonsillar abscess. I told them honestly my pain was a 2, if that. They still gave me prescription for some heavy-duty painkiller. I did not realize this as my stepmother (a physician) had taken charge of the prescriptions and then filled them while my dad and sister got me out of the ER and back home. My stepmother didn't realise I'd described my pain as a two or she never would have bothered filling it, especially knowing my reluctance to take painkillers as they don't really work well on me.

I never touched them and disposed of them a few months later when I remembered I had them.

And I still wonder: why bother prescribing them to someone who outright admits to not being in pain?

[Sue]

The son of a friend of mine got addicted to fentanyl. It took him from a bright university student with a promising future to a sad mess back living with his parents who will be lucky to hold down a job stocking shelves at the local supermarket, and that's assuming that this time the therapy has worked and he's finally kicked his habit .

[Lainie]

Originally Posted by kitap

And I still wonder: why bother prescribing them to someone who outright admits to not being in pain?

In case the pain gets worse after they leave the medical facility, maybe.