Opioid Overreaction (1 Viewer)

[rockaction]

I now have another dentist

Two conversations I just had with people involved this and their stupidity about addition. They were within my family. These people also vote. I was dismayed.

On a similar note, I once had a doctor remove a tooth without pain meds. I was almost crying the next day, drove back, and watched his boss tear him a new one in front of me. Ridiculous.

 

[Ilov80s]

Two conversations I just had with people involved this and their stupidity about addition. They were within my family. These people also vote. I was dismayed.

On a similar note, I once had a doctor remove a tooth without pain meds. I was almost crying the next day, drove back, and watched his boss tear him a new one in front of me. Ridiculous.

I would hate to see them try to subtract. 

 

[rockaction]

I would hate to see them try to subtract. 

There was just a dosage disagreement. It was eye-opening. Maybe I'm the one who is wrong, but I don't think so.

 

[Ilov80s]

There was just a dosage disagreement. It was eye-opening. Maybe I'm the one who is wrong, but I don't think so.

I was just being a smart ### with your typo. I have a bit of insomnia tonight. 

 

[rockaction]

I was just being a smart ### with your typo. I have a bit of insomnia tonight. 

No, you're actually reading a non-typo. I meant addition. The mg dosage Orton is talking about, which is that 200 mg plus four equals 800 mg. That's where my family says I'm wrong about ibuprofen. I feel like they shouldn't vote.

 

[rockaction]

Thankfully, it's my vegan SiL that argues the opposite, so it's not blood or genetic.

 

[rockaction]

But good luck with the insomnia.

 

[Ilov80s]

There was just a dosage disagreement. It was eye-opening. Maybe I'm the one who is wrong, but I don't think so.

Wait they just had a problem with addition? I am curious now 

 

[rockaction]

Wait they just had a problem with addition? I am curious now 

They think a pill with 800 mg of straight ibuprofen is different than four 200 mg of straight ibuprofen.

 

[Ilov80s]

They think a pill with 800 mg of straight ibuprofen is different than four 200 mg of straight ibuprofen.

That’s it? I thought that was just a joke people made 

 

[Ilov80s]

Sorry if your family is dumb, I have some real morons in mine as well 

 

[rockaction]

That’s it? I thought that was just a joke people made 

Nope. Two really did. I just shake my head.

 

[rockaction]

Sorry if your family is dumb, I have some real morons in mine as well 

It's trying...it's taken them two weeks to figure out that when a culture eats at eight, eating at six means lesser food and service. Good work, folks.

I sort of realize that sociopolitical stuff can he a zero-sum game.

 

[Ilov80s]

Nope. Two really did. I just shake my head.

My MIL is like that and it’s actually ####ty because she keeps getting worse 

 

[rockaction]

My MIL is like that and it’s actually ####ty because she keeps getting worse 

Yep. And one of that thought this has an advanced degree and is now worse.

Ay de mi.

 

[Ilov80s]

It's trying...it's taken them two weeks to figure out that when a culture eats at eight, eating at six means lesser food and service. Good work, folks.

I sort of realize that sociopolitical stuff can he a zero-sum game.

Haha I get this too much 

 

[Ilov80s]

Yep. And one of that thought this has an advanced degree and is now worse.

Ay de mi.

My MIL didn’t even graduate high school so it’s easier for me to justify her insanity 

 

[Ilov80s]

While we are on family, how good is this song?

Going in Circles

 

[rockaction]

While we are on family, how good is this song?

Going in Circles

Good if it's a sunny, stoney day like it is here.

 

[Ilov80s]

I'm a faceless clock
With timeless hopes that never stop
When I feel that way
You know my soul's at stake

 

[parasaurolophus]

They think a pill with 800 mg of straight ibuprofen is different than four 200 mg of straight ibuprofen.

My mom carries a bottle of "special ibuprofen" around in her purse. Mention you have a headache or your back is sore and she springs to action. Cracks me up every time. 

 

[Tau837]

the data shows no long term benefit from using opioids for non-cancer pain

This is false. First of all, absence of evidence does not equal evidence of absence. It is well known that the number of studies on long term opioid use for chronic non-cancer pain (CNCP) is insufficient to draw substantive conclusions. For example:

From The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop (2015): 

Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function.

It is very challenging to conduct studies on long term opioid use. Most Phase III Randomized Controlled Trials (RCTs) of opioid analgesics for chronic non-cancer pain are 3 months long, (i.e., not long term). Conducting long term (i.e., > 3 months) placebo-controlled, double-blind RCTs presents ethical and operational challenges. This is further complicated because, in general, patients in these trials have discrete pain diagnoses and lack many of the physical and emotional co-morbidities of patients seen in clinical practice.

That said, there is some support for long term benefit to CNCP patients who use opioids long term.

From Opioids in chronic non-cancer pain: systematic review of efficacy and safety (2004):

The mean decrease in pain intensity in most studies was at least 30% with opioids and was comparable in neuropathic and musculoskeletal pain.

From Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain (2009):

Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain.

From The long-term safety and efficacy of opioids: a survey of 84 selected patients with intractable chronic noncancer pain (2010):

RESULTS AND CONCLUSIONS:
Both long- and short-acting opioids were reported to be effective, with few significant long-term adverse effects in many subjects in the present selected cohort. The majority of patients reported at least 50% or greater pain relief and a moderate improvement in disability.

From Long-term opioid management for chronic noncancer pain (2010):

We reviewed 26 studies with 27 treatment groups that enrolled a total of 4893 participants. Twenty five of the studies were case series or uncontrolled long-term trial continuations, the other was an RCT comparing two opioids. Opioids were administered orally (number of study treatments groups [abbreviated as "k"] = 12, n = 3040), transdermally (k = 5, n = 1628), or intrathecally (k = 10, n = 231)... Signs of opioid addiction were reported in 0.27% of participants in the studies that reported that outcome. All three modes of administration were associated with clinically significant reductions in pain, but the amount of pain relief varied among studies.

From Long-term efficacy and safety of opioid therapy for chronic non-cancer pain: evidence from randomized and open-label studies (2013):

We conducted a literature search of open-label studies to evaluate the efficacy and safety of long-term opioid therapy in CNCP patients... There were 2 RCTs and 40 open-label extension studies (17 were ≥6-<12 months long, 23 were ≥12 months long). Both RCTs demonstrated a reduction in pain scores of ≥30%. The majority (>75%) of open-label studies demonstrated a reduction in pain scores - all but one had a ≥25% reduction in pain from baseline to 6 or 12 months and a few studies had a >65% reduction from baseline (baseline of de novo open-label trials or baseline of RCT for open-label extensions).

From Long-Term Opioid Use in Non-Cancer Pain (2014):

Some, but not all, patients treated with opioid analgesics experience long-term relief (for at least 26 weeks) of pain and subjective physical impairment, without any major adverse effects.

From Long-term opioid therapy in chronic noncancer pain. A systematic review and meta-analysis of efficacy, tolerability and safety in open-label extension trialswith study duration of at least 26 weeks (2014):

Only a minority of patients selected for opioid therapy at randomization finished the long-term open-label study. However, sustained effects of pain reduction could be demonstrated in these patients. 

From Effectiveness of long-term opioid therapy among chronic non-cancer pain patients attending multidisciplinary pain treatment clinics: A Quebec Pain Registry study (2017):

Among lasting users, more than 20% of patients experienced a meaningful amelioration in pain intensity and interference as well as mental quality of life (mQOL), whereas only 8% exhibited improved physical QOL (pQOL).

From Efficacy of opioids versus placebo in chronic pain: a systematic review and meta-analysis of enriched enrollment randomized withdrawal trials (2018):

This meta-analysis of FDA-required double-blind, randomized, placebo-controlled clinical trials of opioid analgesics for the treatment of chronic pain has shown that there is an ample evidence base supporting the efficacy of opioid analgesics for at least 3 months’ duration, a standard period for the evaluation of treatments for chronic pain and other chronic disorders. This evidence base is at least as large as that for any other class of analgesics, and analysis of responders demonstrates clinically meaningful improvements.

Furthermore, there is also an absence of evidence showing long term benefits from long term use of any non-opiod treatment(s) for non-cancer pain.

From Durations of Opioid, Nonopioid Drug, and Behavioral Clinical Trials for Chronic Pain: Adequate or Inadequate? (2016):

A recent US federal review and clinical guideline on opioids for chronic pain asserted that the literature contributes no evidence on efficacy because all trials had “inadequate duration.”...

No common nonopioid treatment for chronic pain has been studied in aggregate over longer intervals of active treatment than opioids. To dismiss trials as “inadequate” if their observation period is a year or less is inconsistent with current regulatory standards. The literature on major drug and nondrug treatments for chronic pain reveals similarly shaped distributions across modalities. Considering only duration of active treatment in efficacy or effectiveness trials, published evidence is no stronger for any major drug category or behavioral therapy than for opioids...

In fact, the opening words of the first recommendation of the CDC guideline [5] (“Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain”) and the rationale presented directly below it make no mention of the overwhelmingly strong evidence for significant morbidity and mortality risk from the most likely nonopioid alternatives to opioid therapy for chronic pain: NSAIDs, coxibs, and acetaminophen [71–73]. The morbidity and mortality likely to result from an increased population-wide consumption as a consequence of following this recommendation are difficult to estimate [74] but likely to be of the same magnitude as from opioids. Safety concerns about these nonopioid alternatives are sufficiently compelling as to have prompted the US FDA to issue its latest of many NSAID safety warnings in a 2015 “Drug Safety Communication” [75].

It appears there is actually as much or more evidence of long term opioid efficacy than anything else. You might want to reconsider your statement.

 

[JZilla]

Where are you living gb?

Yo Joe SF city, how you been gb?

 

[AAABatteries]

Sometimes this country is dumb. 

Welcome to America!

 

[Terminalxylem]

This is false. First of all, absence of evidence does not equal evidence of absence. It is well known that the number of studies on long term opioid use for chronic non-cancer pain (CNCP) is insufficient to draw substantive conclusions. For example:

From The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop (2015): 

It is very challenging to conduct studies on long term opioid use. Most Phase III Randomized Controlled Trials (RCTs) of opioid analgesics for chronic non-cancer pain are 3 months long, (i.e., not long term). Conducting long term (i.e., > 3 months) placebo-controlled, double-blind RCTs presents ethical and operational challenges. This is further complicated because, in general, patients in these trials have discrete pain diagnoses and lack many of the physical and emotional co-morbidities of patients seen in clinical practice.

That said, there is some support for long term benefit to CNCP patients who use opioids long term.

From Opioids in chronic non-cancer pain: systematic review of efficacy and safety (2004):

From Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain (2009):

From The long-term safety and efficacy of opioids: a survey of 84 selected patients with intractable chronic noncancer pain (2010):

From Long-term opioid management for chronic noncancer pain (2010):

From Long-term efficacy and safety of opioid therapy for chronic non-cancer pain: evidence from randomized and open-label studies (2013):

From Long-Term Opioid Use in Non-Cancer Pain (2014):

From Long-term opioid therapy in chronic noncancer pain. A systematic review and meta-analysis of efficacy, tolerability and safety in open-label extension trialswith study duration of at least 26 weeks (2014):

From Effectiveness of long-term opioid therapy among chronic non-cancer pain patients attending multidisciplinary pain treatment clinics: A Quebec Pain Registry study (2017):

From Efficacy of opioids versus placebo in chronic pain: a systematic review and meta-analysis of enriched enrollment randomized withdrawal trials (2018):

Furthermore, there is also an absence of evidence showing long term benefits from long term use of any non-opiod treatment(s) for non-cancer pain.

From Durations of Opioid, Nonopioid Drug, and Behavioral Clinical Trials for Chronic Pain: Adequate or Inadequate? (2016):

It appears there is actually as much or more evidence of long term opioid efficacy than anything else.

You might want to reconsider your statement.

That’s a lot of words and articles to review. Unfortunately, none of them refutes my original statement, consistent with the conclusions of every major professional society and regulatory guidelines for the management of chronic non-cancer pain. Rather than me attempting to refute any of them individually, can you provide some insight how all those hurdles were overcome for treating cancer pain, ie., how do you think the distinction between cancer and CNCP was arrived at in the first place?

To be clear, I think opioids can be used in select patients for the treatment of any type of pain. But in general, they have been over prescribed with a paucity of data (at best) to support their use. Until an objective measure of pain is developed, balancing the legitimate use of opioids and their abuse potential is extremely problematic.

 

[Tau837]

none of them refutes my original statement

False. Everything I quoted in my post refutes your original statement. It is like you are willfully ignoring the information that contradicts your perspective.

consistent with the conclusions of every major professional society and regulatory guidelines for the management of chronic non-cancer pain

False. There are many professional medical societies that disagree with your statement, either explicitly or implicitly (e.g., by denouncing use of the 2016 CDC guideline). From Stop persecuting doctors for legitimately prescribing opioids for chronic pain:

The CDC guideline became controversial almost immediately after it was published. Despite major criticism, it was widely interpreted by physicians, hospitals, insurance providers, state legislators, medical boards, and the DEA as a mandate for hard limits on prescribing opioids — even for so-called legacy patients for whom long-term or high-dose opioids had already proven safe and effective.

Since the publication of the guideline, the American Medical Association, the American Association of Family Physicians, and other organizations have repudiated the science, logic, and conclusions of the CDC guideline...

In April 2019, under fire from medical professionals across the country, the CDC advised against “misapplication” of the guideline. Writing in the New England Journal of Medicine, three authors of the guideline said it was never intended to become a mandated standard, even though more than 30 states had incorporated it into legislation in the three years since its publication. At about the same time, the FDA issued a safety warning against rapidly tapering individuals off opioids or suddenly stopping their administration, based on known harms to patients...

Physicians have been stepping up their criticism of the CDC guideline and the DEA’s presence in their medical practices. Last month, the American Academy of Family Physicians and five other professional groups representing 560,000 physicians and students called on politicians to “end political interference in the delivery of evidence based medicine.” 

The HHS released a Pain Management Best Practices Inter-Agency Task Force Report earlier this year emphasizing that the 2016 CDC guideline was misinterpreted and inappropriately applied, resulting in extensive unintended negative consequences for pain patients and pain physicians. The report emphasizes that there is wide variation in patient and disease factors that determine the dose of opioids that is optimal for pain relief, and appropriate duration of therapy is best determined by the treating clinician, not bound in any way by the guideline.

Even in its own published content, the CDC guidelines acknowledge that recommendations are grounded upon very weak medical evidence.

• Conclusions were drawn that were not well-supported by the available medical evidence. 
  
• Conclusions were drawn which contradicted or omitted previous research published in FDA and NIH studies.  Particularly damning are published NIH Panel workshop findings from October 2014 that confirm the existence of a substantial cohort of patients among whom opioid treatment is appropriate, effective, and the only available last resort after the failure of all other therapies.
  
• Extended commentary submitted by the American Academy of Pain Medicine among the 4,000-plus comments received by the CDC on its draft guideline was ignored with neither explanation nor rationale.
  
• Public health statistics were misinterpreted and may have been deliberately distorted to support a largely fictitious "epidemic" of deaths incorrectly attributed to opioids prescribed to chronic pain patients.
  

The CDC Consultants Working Group which wrote the guidelines deliberately biased their consideration of medical research to unfairly disadvantage and discount the effectiveness of opioids in treating chronic pain.  They also substantially inflated the perceived risks of opioid prescription by ignoring multiple confounding factors in the studies used to support their guidelines.

Key figures associated with the CDC attempted to write guidelines which would divert research and treatment funds to professionals in addiction psychiatry, to the disadvantage of professionals in chronic pain.  The guidelines process up to December 2015 was dominated by participants who had vested financial and professional interests in this attempted diversion of resources.  That process was also largely closed to the public until challenged by Congressional watchdogs.

how do you think the distinction between cancer and CNCP was arrived at in the first place?

More than $100B has been invested in cancer research, including pain. Because the scope of those studies is restricted to cancer patients, the outcomes of those studies are generally held to be restricted to cancer pain. It is a foolish distinction. Does anyone really believe that the pain experienced from cancer is by definition worse than any and every other kind of pain? That is absurd.

Until an objective measure of pain is developed, balancing the legitimate use of opioids and their abuse potential is extremely problematic.

There can be no objective measure that works for every individual. Genetic factors create a wide variability in opioid metabolism and drug absorption among the patient population.

I have also posted many links in this thread that show abuse potential is exceedingly low, generally shown to be less than 1% in many recent studies. I even linked to an article published by the Director of the NIH National Institute on Drug Abuse saying that addiction occurs in only a small percentage of patients exposed to opioids.

I'm not sure why you are ignoring the information I am posting, which is all linked to reputable sources.

 

[Joe Summer]

I feel like, if "underprescribing" leads to pain and suffering......and "overprescribing" leads to pain, suffering, and thousands of deaths......then I'm OK with erring on the side of underprescribing.

 

[culdeus]

I need opioids to sift thru these posts.  

 

[Tau837]

I feel like, if "underprescribing" leads to pain and suffering......and "overprescribing" leads to pain, suffering, and thousands of deaths......then I'm OK with erring on the side of underprescribing.

Spoken like someone who does not suffer from chronic pain and has no loved ones who do.

Also spoken like someone who is ignorant to the facts, despite the fact that a ton of facts and links have been posted in this thread.

I have to also ask, are you in favor of restricting tobacco? alcohol? firearms? etc. All of those lead to more annual deaths in the US than prescription opioids do... and prescription opioids actually provide a benefit when used appropriately, which isn't true of tobacco or alcohol and is debatable on firearms.

 

[CGRdrJoe]

Yo Joe SF city, how you been gb?

Hey gb just pm’d you my digits, I just moved back to marin. Let’s do a giants game soon 

 

[culdeus]

Spoken like someone who does not suffer from chronic pain and has no loved ones who do.

Also spoken like someone who is ignorant to the facts, despite the fact that a ton of facts and links have been posted in this thread.

I have to also ask, are you in favor of restricting tobacco? alcohol? firearms? etc. All of those lead to more annual deaths in the US than prescription opioids do... and prescription opioids actually provide a benefit when used appropriately, which isn't true of tobacco or alcohol and is debatable on firearms.

Why not argue on the merits rather than go this route?   

 

[Tau837]

Why not argue on the merits rather than go this route?   

In case you haven't noticed, I have made a lot of posts in this thread and every other thread in this forum about prescription opioids. Those posts are all about the merits. I am interested in engaging on the merits anytime. Having posted all that and seeing a post that ignores it all, I have to assume that the poster isn't interested in arguing on merits. 

As for "go this route", I think there is no question that the poster does not suffer from serious chronic pain, nor has any loved ones who do. So I don't see what is wrong with that statement. Commenting that the poster was apparently ignorant to the facts is just stating what is evident from his post. Asking about tobacco, alcohol, and firearms is a bit of a tangent, but it is typically the case that those who are critical of prescription opioids have no such qualms about stuff they actually care about, which often includes at least one of those... which is hypocritical at best.

 

 

[Chaka]

So we seemed to have transitioned from a society where pain pills were handed out like candy, to one where prescribing pain pills is now so scrutinized that people with real need are left to suffer.

My friend was in a freak accident the other day, got hit by a double truck tire that flew off the truck's axel.  He's lucky to be alive but as you can imagine he's pretty banged up with 15 stitches in his noggin, a concussion, and massive bruising on one side.  Was in the ED all night, given IV pain killers there, but sent home with nothing.  He's the classic case of someone who'll need meds for a couple of days afterwards and if he didn't have any left over from a prior surgery, he'd end up back in the ED if he couldn't get through to his doctor.

Sometimes this country is dumb. 

Has he asked his doctor for an pain med scrip?

I have no problem with the ER not giving him any because he has options.

 

[culdeus]

In case you haven't noticed, I have made a lot of posts in this thread and every other thread in this forum about prescription opioids. Those posts are all about the merits. I am interested in engaging on the merits anytime. Having posted all that and seeing a post that ignores it all, I have to assume that the poster isn't interested in arguing on merits. 

As for "go this route", I think there is no question that the poster does not suffer from serious chronic pain, nor has any loved ones who do. So I don't see what is wrong with that statement. Commenting that the poster was apparently ignorant to the facts is just stating what is evident from his post. Asking about tobacco, alcohol, and firearms is a bit of a tangent, but it is typically the case that those who are critical of prescription opioids have no such qualms about stuff they actually care about, which often includes at least one of those... which is hypocritical at best.

 

It's weak.  

Don't fall into that trap.  It weakens any interest in hearing your point of view. 

 

[The_Man]

Excellent new book in this topic, “In Pain,” out this week from a Johns Hopkins bioethicist who became opioid dependent after a motorcycle crash:

https://www.harpercollins.com/9780062854643/in-pain/

Makes a compelling argument for a new medical speciality that helps people wean themselves off opioids after they’re no longer needed, or to help manage long term use if they’re needed for chronic pain. Basically they’re a medicine like any other, but there’s no one overseeing their use in patients. Surgeon sends you home with 30 after a surgery or whatever, and there’s no one tracking your use or helping make sure you step down in a responsible way that manages pain while avoiding dependence 

 

[Chaka]

No formal protocol restrictions but doctor's are so gun shy about prescribing that they now only give them in extreme cases.  Just hope you don't get a kidney stone or anything similar painful, you'll be told to take extra strength Tylenol. 

I doubt that. The pendulum has merely shifted to requiring the patient to be more proactive about their own health care. Ask your doc for the pain med, if it isn't a recidivist behavior they wont bat an eye to write the scrip.

 

[culdeus]

My point of view is entirely shaded by the fact I was given and then didn't finish some stuff for a knee operation.  Finding this out a fbg at a Cornhole pressured me a bit to sell him the remainder of my bottle.  Talking like 12 percs I think.  Tiny amount. Was one of the more awkward things I've been pushed on and at the time none of this was in the news. 

Guy got hooked ended up in rehab and as far as I know killed himself about a year or two later though not exactly clear when he did it. 

 

[Tau837]

It's weak.  

Don't fall into that trap.  It weakens any interest in hearing your point of view. 

Thanks for your advice.

 

[Tau837]

Basically they’re a medicine like any other, but there’s no one overseeing their use in patients

That may be true after surgery, but don't overgeneralize. There are 10K+ pain phyisicans in the US who have full practices of patients who suffer from chronic pain. Those physicians oversee the use of prescription opioids in their patients.

 

[Tau837]

I doubt that. The pendulum has merely shifted to requiring the patient to be more proactive about their own health care. Ask your doc for the pain med, if it isn't a recidivist behavior they wont bat an eye to write the scrip.

Another ignorant post. I'm sorry to call it that, but I have to call a spade a spade.

You should consider educating yourself before posting stuff like this.

 

[Tau837]

My point of view is entirely shaded by the fact I was given and then didn't finish some stuff for a knee operation.  Finding this out a fbg at a Cornhole pressured me a bit to sell him the remainder of my bottle.  Talking like 12 percs I think.  Tiny amount. Was one of the more awkward things I've been pushed on and at the time none of this was in the news. 

Guy got hooked ended up in rehab and as far as I know killed himself about a year or two later though not exactly clear when he did it. 

That is terrible. It also represents (a) someone who was illegally using drugs and (b) one of a minority segment of the pain patient population, if indeed he ever was prescribed opioid medication himself. While deaths like that are tragic, they do not constitute a basis for Government policy without proper consideration of the millions of pain patients on prescription opioids.

 

[Christo]

Why was he sent home with nothing?  Even in states that have passed regulations regarding opioids, I wouldn’t think there would be any restrictions in prescribing meds for a few days post-discharge. 

They just don't like to do it. I had a second degree burn on my thumb and went to the ER. They gave me one hydrocodone while I was there and told me to take my preferred OTC pain killer if it started to hurt. I asked if they'd give me a few days worth of hydrocodone. They said no. It started to hurt, of course. Nothing helped. Sucked for about a week.

 

[IC FBGCav]

Two conversations I just had with people involved this and their stupidity about addition. They were within my family. These people also vote. I was dismayed.

On a similar note, I once had a doctor remove a tooth without pain meds. I was almost crying the next day, drove back, and watched his boss tear him a new one in front of me. Ridiculous.

I just had on removed and didn't use pain meds.  I don't recall if they offered or not but the next 2 days were rough.

I don't take opiods, codeine has always made me have terrible night terrors and made me feel worse than the pain I was taking it for.

 

[Terminalxylem]

False. Everything I quoted in my post refutes your original statement. It is like you are willfully ignoring the information that contradicts your perspective.

False. There are many professional medical societies that disagree with your statement, either explicitly or implicitly (e.g., by denouncing use of the 2016 CDC guideline). From Stop persecuting doctors for legitimately prescribing opioids for chronic pain:

The HHS released a Pain Management Best Practices Inter-Agency Task Force Report earlier this year emphasizing that the 2016 CDC guideline was misinterpreted and inappropriately applied, resulting in extensive unintended negative consequences for pain patients and pain physicians. The report emphasizes that there is wide variation in patient and disease factors that determine the dose of opioids that is optimal for pain relief, and appropriate duration of therapy is best determined by the treating clinician, not bound in any way by the guideline.

Even in its own published content, the CDC guidelines acknowledge that recommendations are grounded upon very weak medical evidence.

• Conclusions were drawn that were not well-supported by the available medical evidence. 
  
• Conclusions were drawn which contradicted or omitted previous research published in FDA and NIH studies.  Particularly damning are published NIH Panel workshop findings from October 2014 that confirm the existence of a substantial cohort of patients among whom opioid treatment is appropriate, effective, and the only available last resort after the failure of all other therapies.
  
• Extended commentary submitted by the American Academy of Pain Medicine among the 4,000-plus comments received by the CDC on its draft guideline was ignored with neither explanation nor rationale.
  
• Public health statistics were misinterpreted and may have been deliberately distorted to support a largely fictitious "epidemic" of deaths incorrectly attributed to opioids prescribed to chronic pain patients.
  

The CDC Consultants Working Group which wrote the guidelines deliberately biased their consideration of medical research to unfairly disadvantage and discount the effectiveness of opioids in treating chronic pain.  They also substantially inflated the perceived risks of opioid prescription by ignoring multiple confounding factors in the studies used to support their guidelines.

Key figures associated with the CDC attempted to write guidelines which would divert research and treatment funds to professionals in addiction psychiatry, to the disadvantage of professionals in chronic pain.  The guidelines process up to December 2015 was dominated by participants who had vested financial and professional interests in this attempted diversion of resources.  That process was also largely closed to the public until challenged by Congressional watchdogs.

More than $100B has been invested in cancer research, including pain. Because the scope of those studies is restricted to cancer patients, the outcomes of those studies are generally held to be restricted to cancer pain. It is a foolish distinction. Does anyone really believe that the pain experienced from cancer is by definition worse than any and every other kind of pain? That is absurd.

There can be no objective measure that works for every individual. Genetic factors create a wide variability in opioid metabolism and drug absorption among the patient population.

I have also posted many links in this thread that show abuse potential is exceedingly low, generally shown to be less than 1% in many recent studies. I even linked to an article published by the Director of the NIH National Institute on Drug Abuse saying that addiction occurs in only a small percentage of patients exposed to opioids.

I'm not sure why you are ignoring the information I am posting, which is all linked to reputable sources.

I appreciate your passion, but you seem to be the one ignoring information which doesn't affirm your bias, and reading more into my posts than I've actually intended. I only stated the evidence doesn't support opioids for chronic non-cancer pain, in the context of someone suggesting they be used for chronic musculoskeletal pain. I said nothing about the CDC's use of MME in their guidelines, which is the biggest criticism as far as I can tell. And I never said the research is perfect, nor did I say it's impossible opiates may be safe and effective for other types of chronic pain. I recognize the alternatives have their limitations as well, though targeted approaches like nerve blocks and cognitive behavioral therapy are way underutilized IMO. 

Unfortunately, until the data improves or pain can be better quantified (numeric and visual analogue scales are a joke), health providers have to weigh the risks of contributing to opioid abuse and adverse effects versus potential benefit. I know you poo-poo the abuse potential, but I think you are underestimating the role of diversion of prescription meds in facilitating addicts. We need to improve smart pill delivery devices and develop more drugs like buprenorphine, which has lower abuse potential.

As this thread attests, prescription practices vary wildly. For every person complaining their pain has been under treated (the premise of the OP), there are others who've had no trouble accessing pain meds, have leftover pills, etc. As we discussed in the other thread, opioid prescriptions in the US were disproportionately high compared to the rest of the world, arguably too high. The pendulum is definitely swinging, but it remains to be seen what the appropriate balance is in the risk:benefit continuum.

 

[Joe Summer]

Just Win Baby said:

I have to also ask, are you in favor of restricting tobacco? alcohol? firearms? etc. All of those lead to more annual deaths in the US than prescription opioids do... and prescription opioids actually provide a benefit when used appropriately, which isn't true of tobacco or alcohol and is debatable on firearms.

We already restrict access to tobacco, alcohol, and firearms. Those restrictions vary from product to product, based on a wide variety of factors -- including chemical content and addictive properties. There's no good reason to not treat opioids in a similar fashion.

If that makes it more difficult for people in chronic pain to access their medication........well, I'm willing to trade that inconvenience for a few thousand lives.

 

[Tau837]

We already restrict access to tobacco, alcohol, and firearms. Those restrictions vary from product to product, based on a wide variety of factors -- including chemical content and addictive properties. There's no good reason to not treat opioids in a similar fashion.

If that makes it more difficult for people in chronic pain to access their medication........well, I'm willing to trade that inconvenience for a few thousand lives.

Prescription opioids are and always have been much more "restricted" than tobacco, alcohol, or firearms. These restrictions are not comparable in any way, shape, or form - no one needs a doctor's prescription to obtain tobacco, alcohol, or firearms. It has gone far beyond "inconvenience" for pain patients who legitimately need prescription opioids.

And those things lead to many more annual deaths in the US than prescription opioids. It's not close.

 

[Tau837]

I appreciate your passion, but you seem to be the one ignoring information which doesn't affirm your bias

I respectfully disagree. I am posting about facts that are counter to the bias that has been created by the ill-informed politicians and mass media, facts that have not been refuted by you or anyone in this thread.

I know you poo-poo the abuse potential

No, I post facts about it. Facts that are counter to the widely held myths perpetuated by biased parties and ill-informed politicians and mass media.

 

[Chaka]

Another ignorant post. I'm sorry to call it that, but I have to call a spade a spade.

You should consider educating yourself before posting stuff like this.

Much respect to you @Just Win Baby but your response offers nothing of any value. I'm in the health care industry on the insurance work comp side. I have extensive experience (about 15 years and my wife even longer) and regular interactions with primary care physicians in the front lines of devastating injuries. While opioids are tightly regulated (and they technically were during the inception of this "crisis") my experience tells me that what I said is exactly correct. 

Rather than simply calling me ignorant I would sincerely like to hear why you think that is the case 

 

[Tau837]

Much respect to you @Just Win Baby but your response offers nothing of any value. I'm in the health care industry on the insurance work comp side. I have extensive experience (about 15 years and my wife even longer) and regular interactions with primary care physicians in the front lines of devastating injuries. While opioids are tightly regulated (and they technically were during the inception of this "crisis") my experience tells me that what I said is exactly correct. 

Rather than simply calling me ignorant I would sincerely like to hear why you think that is the case 

Because you posted this:

The pendulum has merely shifted to requiring the patient to be more proactive about their own health care. Ask your doc for the pain med, if it isn't a recidivist behavior they wont bat an eye to write the scrip.

Sorry if it hurts to hear it, but that is an ignorant take. Read the articles linked in the thread. Doctors are being persecuted and are reluctant to write prescriptions they would have written a few years ago. Pain patients have been abandoned. Other pain patients have been forcibly tapered. Some of those patients have committed suicide as a result. Others have turned to illegal drugs. These are facts, not opinions. Those things didn't happen simply because the patients weren't "proactive."

ETA: Also much respect to you @Chaka. I appreciate your response. I am not intending this to be combative.

 

[Terminalxylem]

I respectfully disagree. I am posting about facts that are counter to the bias that has been created by the ill-informed politicians and mass media, facts that have not been refuted by you or anyone in this thread.

No, I post facts about it. Facts that are counter to the widely held myths perpetuated by biased parties and ill-informed politicians and mass media.

OK, Why didn't you choose to include the largest meta analysis regarding opioids for CNCP? 

Question  Is the use of opioids to treat chronic noncancer pain associated with greater benefits or harms compared with placebo and alternative analgesics?

Findings  In this meta-analysis that included 96 randomized clinical trials and 26 169 patients with chronic noncancer pain, the use of opioids compared with placebo was associated with significantly less pain (−0.69 cm on a 10-cm scale) and significantly improved physical functioning (2.04 of 100 points), but the magnitude of the association was small. Opioid use was significantly associated with increased risk of vomiting.

Meaning  Opioids may provide benefit for chronic noncancer pain, but the magnitude is likely to be small.

Abstract

Importance  Harms and benefits of opioids for chronic noncancer pain remain unclear.

Objective  To systematically review randomized clinical trials (RCTs) of opioids for chronic noncancer pain.

Data Sources and Study Selection  The databases of CENTRAL, CINAHL, EMBASE, MEDLINE, AMED, and PsycINFO were searched from inception to April 2018 for RCTs of opioids for chronic noncancer pain vs any nonopioid control.

Data Extraction and Synthesis  Paired reviewers independently extracted data. The analyses used random-effects models and the Grading of Recommendations Assessment, Development and Evaluation to rate the quality of the evidence.

Main Outcomes and Measures  The primary outcomes were pain intensity (score range, 0-10 cm on a visual analog scale for pain; lower is better and the minimally important difference [MID] is 1 cm), physical functioning (score range, 0-100 points on the 36-item Short Form physical component score [SF-36 PCS]; higher is better and the MID is 5 points), and incidence of vomiting.

Results  Ninety-six RCTs including 26 169 participants (61% female; median age, 58 years [interquartile range, 51-61 years]) were included. Of the included studies, there were 25 trials of neuropathic pain, 32 trials of nociceptive pain, 33 trials of central sensitization (pain present in the absence of tissue damage), and 6 trials of mixed types of pain. Compared with placebo, opioid use was associated with reduced pain (weighted mean difference [WMD], −0.69 cm [95% CI, −0.82 to −0.56 cm] on a 10-cm visual analog scale for pain; modeled risk difference for achieving the MID, 11.9% [95% CI, 9.7% to 14.1%]), improved physical functioning (WMD, 2.04 points [95% CI, 1.41 to 2.68 points] on the 100-point SF-36 PCS; modeled risk difference for achieving the MID, 8.5% [95% CI, 5.9% to 11.2%]), and increased vomiting (5.9% with opioids vs 2.3% with placebo for trials that excluded patients with adverse events during a run-in period). Low- to moderate-quality evidence suggested similar associations of opioids with improvements in pain and physical functioning compared with nonsteroidal anti-inflammatory drugs (pain: WMD, −0.60 cm [95% CI, −1.54 to 0.34 cm]; physical functioning: WMD, −0.90 points [95% CI, −2.69 to 0.89 points]), tricyclic antidepressants (pain: WMD, −0.13 cm [95% CI, −0.99 to 0.74 cm]; physical functioning: WMD, −5.31 points [95% CI, −13.77 to 3.14 points]), and anticonvulsants (pain: WMD, −0.90 cm [95% CI, −1.65 to −0.14 cm]; physical functioning: WMD, 0.45 points [95% CI, −5.77 to 6.66 points]).

Conclusions and Relevance  In this meta-analysis of RCTs of patients with chronic noncancer pain, evidence from high-quality studies showed that opioid use was associated with statistically significant but small improvements in pain and physical functioning, and increased risk of vomiting compared with placebo. Comparisons of opioids with nonopioid alternatives suggested that the benefit for pain and functioning may be similar, although the evidence was from studies of only low to moderate quality.

So, opioids may help CNCP to a small extent, less than the minimally important difference in pain and functionality scales and comparable to non-opioid modalities. If you read the actual paper, you'll see the median duration of therapy was relatively short (60 days), and most of the studies (79%) received funding from the pharmaceutical industry - a potential red flag for the findings, as underwhelming as they may be. And many excluded patients with mental illness (45%), or history of substance use disorders (72%), so one would expect abuse potential would be less than the general chronic pain population. 

This is the most recent, biggest data set we have, to my knowledge. It ain't very compelling.

I don't know what you do for a living, but you can imagine how a physician might interpret this data: Opioids may make an inconsequential difference in chronic non cancer pain that probably isn't better than alternatives, with less abuse potential and manageable side effect profiles. And that ignores tolerance, which increases opioid requirements over time, along with potential for side effects, addiction and diversion of the extra meds. 

ETA: Here is an older study which looked at risk of OUD and duration of opioid use for non-cancer pain. As one might expect, the likelihood of abuse increases the longer one receives opioids, with a 122x greater risk in those receiving high dose opioids chronically.

Increasing rates of opioid use disorders (abuse and dependence) among patients prescribed opioids are a significant public health concern. We investigated the association between exposure to prescription opioids and incident opioid use disorders (OUDs) among individuals with a new episode of a chronic non-cancer pain (CNCP) condition.

Methods

We utilized claims data from the HealthCore Database for 2000–2005. The dataset included all individuals aged 18 and over with a new CNCP episode (no diagnosis in the prior 6 months), and no opioid use or OUD in the prior 6 months (n=568,640). We constructed a single multinomial variable describing prescription opioid days supply (none, acute, and chronic) and average daily dose (none, low dose, medium dose, and high dose), and examined the association between this variable and an incident OUD diagnosis.

Results

Patients with CNCP prescribed opioids had significantly higher rates of OUDs compared to those not prescribed opioids. Effects varied by average daily dose and days supply: low dose, acute (odds ratio (OR)=3.03, 95% confidence interval (CI)= 2.32, 3.95); low dose, chronic (OR=14.92, 95% CI=10.38, 21.46); medium dose, acute (OR=2.80, 95% CI=2.12, 3.71); medium dose, chronic (OR=28.69, 95% CI=20.02, 41.13); high dose, acute (OR=3.10 95% CI=1.67, 5.77); and high dose, chronic (OR=122.45, 95% CI=72.79, 205.99).

Conclusion

Among individuals with a new CNCP episode, prescription opioid exposure was a strong risk factor for incident OUDs; magnitudes of effects were large. Duration of opioid therapy was more important than daily dose in determining OUD risk.