The Opiate and Heroin Epidemic in America (3 Viewers)

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Post is also tabloid-esque but this is pretty well documented issue...

"Tranq" (Animal Tranquilizer Xylazine-laced Fentanyl) known for causing ****loads of deaths and necrotic/rotting flesh at injections sites... has contaminated the bulk of "heroin" supply in some cities. We need better harm reduction and rehab programs in place.

Flesh-eating drug ‘tranq’ meant for animals now linked to thousands of heroin, fentanyl ODs

The flesh-eating animal tranquilizer xylazine has been linked to thousands of drug overdoses across the country as it inundates heroin and fentanyl supplies in places such as Philadelphia, Delaware…

nypost.com

 

[[icon]]

Shocking no one (or at least not me) the legalization of marijuana has resulted in a surge of addiction and mental illness, particularly among teens.

The whole concept that MJ is harmless is and was bunk.

Your link is to a Daily Mail article, which is a UK tabloid. I'd prefer to look at actual studies that show this "surge of addiction and mental illness". Do you have any peer reviewed studies that show this causal relationship?

I too base my medical opinions on Tabloid articles that don't cite any actual peer reviewed studies.

NIH ok with you guys?

Implications of Marijuana Legalization for Adolescent Substance Use - PMC

Marijuana that is legally available for adults has multiple implications for adolescent substance use. One potential effect that legalization may have is an increase in adolescent use to due increased availability, greater social acceptance, and ...

www.ncbi.nlm.nih.gov

Adolescent marijuana use has been associated with impairment in a number of areas: impaired cognitive functioning,36 increased risk of developing marijuana dependence,37 elevated rates of school dropout,38 an elevated risk of developing psychotic illnesses,39,40 and an increased rate of engaging in risky behaviors.41 Weekly marijuana use under age 18 years has been associated with an eight-point drop in intelligence among those who develop persistent dependence, while those with adult onset of comparable levels of use are less affected; importantly, the loss of cognitive capacity may not recover completely after desisting from marijuana use.42

That is the pertinent part. Mental illness, dependence, school dropout, permanent drop in IQ. Not sure what the outrage is here - I figured these kind of effects were well known and accepted as par for the course. IMO, the onus should be on folks to show this stuff doesn't happen - that it does happen is common sense (and, as can be seen, well documented).

You mean the paper that went on to say this?

However, the authors noted that “although adolescents who use marijuana heavily demonstrate decrements compared to non-using teens, it is still unknown whether marijuana use caused or contributed to these effects.” Similarly, early use has been associated with poor outcomes in a number of other domains, however, these associations do not necessarily signify causality. Instead early use may act as a marker of a more generalized tendency to engage in risky behaviors.

Also, I'm not aware of any legalization efforts that support use under the age of 18... I may be missing something, though.

 

[The Z Machine]

Agreed that we should try and restrict cannabis use by those under 18.

But is there a surge of addiction and mental illness for adults post legalization? I'd like to see that analysis.

 

[Tau837]

Oregon Medical Board Should Resign – Or Be Fired

“I live in the state of Oregon and have been a chronic pain patient for almost 20 years. The Oregon State Medical Board is holding ALL physicians—including pain management specialists -- to the extremely low dose threshold of 90 Morphine Milligram Equivalent (MME) daily dose, based on the outdated 2016 CDC Guidelines.”

“If an Oregon physician crosses over that 90 MME dose threshold, they are issued a ’Complaint & Notice’ by the Oregon Medical Board -- which almost always then turns into a “Stipulated Order” In which the Medical Board directs that all of the physician’s patients must be “tapered to 90 MME or less, or transitioned to Buprenorphine.”

“The physician has absolutely no choice but to comply. If they do not follow the order, then further action will be taken against them, including possible loss of license, fines, etc… The only patients listed by the Oregon Board as exempt from the 90 MME in these ’stipulations’ are end-of-life, active cancer, or hospice patients.”

“The Oregon State Medical Board is causing patients dire harm with these Stipulated Orders, mandating widespread forced tapers that are strongly warned against by multiple Federal agencies. It is the patients that end up paying the price in dire harm, not the physician.”

Wow. I feel for any residents of Oregon who suffer from severe, chronic pain.

 

[Tau837]

U.S. Prescription Opioid Use Fell 7.4% in 2022

The amount of prescription opioids sold in the United States fell another 7.4% last year, according to a new report by the IQVIA Institute, a healthcare data tracking firm.

Since their peak in 2011, per capita use of prescription opioids by Americans has declined 64 percent, falling to levels last seen in the year 2000. Despite that historic decline, fatal overdoses in the U.S. have climbed to record levels, fueled primarily by illicit fentanyl and other street drugs.

“The greatest reductions in prescription opioid volume — measured in morphine milligram equivalents (MME) — have been in higher-risk segments receiving greater than 90 MMEs per day,” the IQVIA report found. “Despite significant progress in reducing opioid prescriptions to combat the opioid overdose epidemic, overdose deaths have been rising, primarily due to illicit synthetic opioids.”

The CDC estimates there were 108,712 overdose deaths in the 12-month period ending in November, 2022. About 72,000 of those deaths involved heroin or synthetic opioids such as fentanyl.

By comparison, drug deaths involving legal prescription opioids have remained relatively flat, averaging about 16,000 a year since 2017. They ticked upwards in 2020 and 2021, but appear have trended downward again in 2022, according to the IQVIA.

More evidence that this Government war on presciption opioids is completely misguided.

From the same article:

It appears likely that prescription opioid use will fall again in 2023, due in part to further cuts in opioid production quotas imposed on drug makers by the Drug Enforcement Administration. The DEA says the opioid supply will still be “sufficient to meet all legitimate needs,” but as PNN has reported, some manufacturers are currently reporting shortages of oxycodone and hydrocodone.

The DEA is actively harming pain patients with this policy approach. My wife has been on a particular medication that is very helpful to her for more than a decade, and starting last month, she is unable to get it due to shortage of supply. This is crushing after getting past all of the hurdles related to insurance and pharmacies, only to find that there is no supply available to fill the prescriptions. There is no true subsitute for this particular medication, so her suffering has increased and her quality of life has declined. Thanks to the DEA.

I can't adequately express how stressful and depressing it is to be a severe chronic pain patient or a caregiver for such a patient in this climate the Government has created. Before all of this started, we already had to deal with her pain and many associated health issues, insurance challenges, pharmacy challenges, and associated financial challenges... but at least she could get her legitimately prescribed medication. Over the years of this opioid hysteria, her health has progressively declined and her pain has progressively increased, while at the same time the challenge of getting legitimate pain medication to help her has become harder and harder.

I hope none of the rest of you here are going through this. If so, you have my empathy.

 

[rockaction]

I hope none of the rest of you here are going through this. If so, you have my empathy.

I've told you before you have my sympathy and continue to do so. I hate seeing you bump this thread in obvious grief over your wife's situation. There is no reason that a patient should not be able to request palliative care for chronic pain. I'm truly sorry.

 

[Tau837]

I hope none of the rest of you here are going through this. If so, you have my empathy.

I've told you before you have my sympathy and continue to do so. I hate seeing you bump this thread in obvious grief over your wife's situation. There is no reason that a patient should not be able to request palliative care for chronic pain. I'm truly sorry.

Thanks, GB. I appreciate it.

 

[Tau837]

Everything the government thinks it knows about the opioid crisis is wrong

 

[Tau837]

Large Study Debunks Myths About Rx Opioid Addiction

In an analysis of nearly 3.5 million Australians who were prescribed opioids for the first time, researchers found that 92% never progressed beyond low opioid use and only 3% became persistent users or needed higher doses. The “sustained use” of opioids occurred mostly in seniors (65 and older) suffering from cancer, depression, anxiety and other chronic health problems...

“Overall, these findings suggest that most people who initiate an opioid prescription are likely to have low, time-limited exposure to opioids with little indication of ongoing use. This possibility is an important consideration for policymakers and stakeholders considering population-level prescribing of high-risk drugs,” researchers reported in JAMA Network Open.

“Opioids are essential drugs for acute and cancer pain, and many people with CNCP (chronic non-cancer pain) benefit from opioids. Continued focus and policy responses based on findings from a small group of people with increased risk of harms run the risk of limiting access to people who safely derive objective benefits from opioids.”

No surprise to anyone who was paying attention all along.

 

[Tau837]

US Opioid Guidelines 2022 -More and Less Than Meets the Eye

ABSTRACT

The United States is currently embroiled in a contentious and multi-dimensional public conversation about addiction-related mortality, chronic pain, and government regulation of clinicians who employ opioid analgesic pain relievers in treating pain. The US Centers for Disease Control and Prevention (CDC) have published and updated guidelines to clinicians concerning appropriate practices for managing severe chronic pain by means of opioid analgesic pain relievers.This Critical Policy Review briefly outlines the history of US public health policy on regulation of prescription opioid pain relievers. The author then compares recommendations and data sources of the updated November 2022 CDC guidelines against findings from a wide range of pertinent clinical literature. He finds that the most recent effort by CDC is fatally flawed by weak evidence and methodologically unsound research, disproportionate emphasis on risk, and failure to address genetically mediated variability in minimum effective opioid dose between individuals. Compounding these difficulties are indications of professional conflicts of interest and persistent anti-opioid bias on the part authors of the most recently released CDC guidelines.

Conclusions

...However, multipleinstances were foundwhere CDC authors appear to have over-generalized or misinterpreted from very weak medical evidence. Despite repeated assertions that patient care must be individualized, a one-size-fits-all framework wasconstructed of proposed restrictions on prescribing, based on Morphine Milligram Equivalent Dose thresholds. There are also indications of preexisting and unacknowledged professional conflict of interest on the part of at least one of the writers.

Overall, the most significant–and methodologically fatal –error of CDC-2022 may beits failure to address genetics of opioid metabolism. Genetic polymorphism in expression of CYP450 liver enzymes introduces a wide range in opioid minimum effective dose and sensitivity toside effects between individuals. None of the outcome’sreviews referenced in CDC-2022 even acknowledgedsuch variations, rendering their findings of very limited value,if notoutright biased. Of secondary import are persistent over-emphasis on “risk” and a naïve over-generalization of the supposed benefits of non-opioid or non-invasive modalities of therapy as substitutions for opioid analgesics.

Taken in combination, these factors may warrant the repudiation of both CDC-2016 and CDC-2022, and withdrawal of CDC from policy making roles in the practice of pain medicine.

 

[Todem]

Watched the Netflix limited series Painkillers.

Man…..

 

[Tau837]

Government Data Refute the Notion That Overprescribing Caused the 'Opioid Crisis'

 

[Kev4029]

Government Data Refute the Notion That Overprescribing Caused the 'Opioid Crisis'

I don't think I read that data the same as you. First, it pulls two charts from an entire article from Science and ignores the rest of that article - maybe most importantly the "Caveats" section of the article. Second, the Science article and the charts don't provide any sort of data that conclude anything regarding what role prescribing opioids had on drug overdoses in the US, nor could there be anything really pulled to support your linked articles conclusions. Third, the one sweeping conclusion of the Science article is that overdose deaths, and specifically with opioids, have increased exponentially between the late 70s and mid 10s. Last, your linked article is building a strawman argument anyway making it sound like 1. the general consensus is that prescription opioids are exclusively the cause of overdoses and that 2. over prescription of opioids was/is the only cause of the opioid epidemic.

 

[Tau837]

I don't think I read that data the same as you. First, it pulls two charts from an entire article from Science and ignores the rest of that article - maybe most importantly the "Caveats" section of the article.
Second, the Science article and the charts don't provide any sort of data that conclude anything regarding what role prescribing opioids had on drug overdoses in the US, nor could there be anything really pulled to support your linked articles conclusions.

I know the author of the Reason article, Red Lawhern. I have previously linked some of his articles in this thread. He doesn't need to refer to the rest of the article to make the points he made with the charts. And he obviously linked the article so readers could easily read it in its entirety, which I did.

From the Science article:

By examining all available data on accidental poisoning deaths back to 1979 and showing that the overall 38-year curve is exponential, we provide evidence that the current wave of opioid overdose deaths (due to prescription opioids, heroin, and fentanyl) may just be the latest manifestation of a more fundamental longer-term process...

The epidemic of drug overdoses in the United States has been inexorably tracking along an exponential growth curve since at least 1979, well before the surge in opioid prescribing in the mid-1990s.

IMO those statements clearly show that prescription opioids didn't cause the problem.

As for the caveats in the Science article, IMO they support Red's primary point. I have posted multiple times about these same caveats in this thread. They are well known to most people who seriously follow this "prescription opioid epidemic" subject.

Last, your linked article is building a strawman argument anyway making it sound like 1. the general consensus is that prescription opioids are exclusively the cause of overdoses and that 2. over prescription of opioids was/is the only cause of the opioid epidemic.

It doesn't really matter if people in the Government (CDC, DEA, etc.) have said that prescription opioids have been the exclusive cause. They have inappropriately cited it as at minimum a primary cause significant enough to justify putting in place regulations and initiatives that have actively harmed chronic pain patients and their physicians and continue to do so. That harm is indisputable. I have probably posted 50+ articles in this thread documenting it.

When is the Government going to stop doing that harm to innocent people who are suffering and those who want to help treat them?

 

[Psychopav]

I don't think I read that data the same as you. First, it pulls two charts from an entire article from Science and ignores the rest of that article - maybe most importantly the "Caveats" section of the article.
Second, the Science article and the charts don't provide any sort of data that conclude anything regarding what role prescribing opioids had on drug overdoses in the US, nor could there be anything really pulled to support your linked articles conclusions.

I know the author of the Reason article, Red Lawhern. I have previously linked some of his articles in this thread. He doesn't need to refer to the rest of the article to make the points he made with the charts. And he obviously linked the article so readers could easily read it in its entirety, which I did.

From the Science article:

By examining all available data on accidental poisoning deaths back to 1979 and showing that the overall 38-year curve is exponential, we provide evidence that the current wave of opioid overdose deaths (due to prescription opioids, heroin, and fentanyl) may just be the latest manifestation of a more fundamental longer-term process...

The epidemic of drug overdoses in the United States has been inexorably tracking along an exponential growth curve since at least 1979, well before the surge in opioid prescribing in the mid-1990s.

IMO those statements clearly show that prescription opioids didn't cause the problem.

As for the caveats in the Science article, IMO they support Red's primary point. I have posted multiple times about these same caveats in this thread. They are well known to most people who seriously follow this "prescription opioid epidemic" subject.

Last, your linked article is building a strawman argument anyway making it sound like 1. the general consensus is that prescription opioids are exclusively the cause of overdoses and that 2. over prescription of opioids was/is the only cause of the opioid epidemic.

It doesn't really matter if people in the Government (CDC, DEA, etc.) have said that prescription opioids have been the exclusive cause. They have inappropriately cited it as at minimum a primary cause significant enough to justify putting in place regulations and initiatives that have actively harmed chronic pain patients and their physicians and continue to do so. That harm is indisputable. I have probably posted 50+ articles in this thread documenting it.

When is the Government going to stop doing that harm to innocent people who are suffering and those who want to help treat them?

Not only chronic pain sufferers either. The regulations have allowed insurance companies to make providers jump through hoops to prescribe opioids. I've had multiple situations where a family member was prescribed an opioid due to a critical pain situation (ER, surgery, etc.) but the prescriptions were denied by the insurance company. So while I could still access the medications, I was forced to pay out of pocket when they would have otherwise been reduced cost or free.

The upshot is that CVS is my pharmacy and Aetna (owned by CVS) is my insurance carrier. This is a class action lawsuit waiting to happen imo, and I'll be happy to join when it does. Ridiculous.

 

[Tau837]

An Indictment ofUS Public Health Policy onPain Management

 

[Tau837]

Where Have All the Pain Doctors Gone?

In recent years, it’s become increasingly difficult for a patient in pain to find a new doctor. Many physicians have stopped treating pain, retired early or switched specialties, rather than run the risk of being investigated or even put in prison for prescribing opioids.

In a recent PNN survey, one in five patients said they couldn’t find a doctor to treat their pain. Others said they were abandoned or discharged by a physician (12%) or had a doctor who retired from clinical practice (14%)...

A new study suggests the problem is only going to get worse, because medical schools are seeing fewer anesthesiology residents applying for fellowships in pain medicine. The number of applications fell 45% from 2019 to 2023.

 

[Tau837]

Opiophobia: Misinformation, Misconceptions, Misrepresentations, Perspectives, and Consequences

Scientific Review Dismantles Myths Behind ‘Opiophobia’ (references link above)

 

[Terminalxylem]

Opiophobia: Misinformation, Misconceptions, Misrepresentations, Perspectives, and Consequences

Scientific Review Dismantles Myths Behind ‘Opiophobia’ (references link above)

The article makes some good points, but this entire section is waaaay overstated:

Published in ACS Pharmacology & Translational Science and authored by John Bumpus, PhD, the paper looks at the irrational fear that prescribing opioids in any capacity is harmful – and how little evidence there is to back up such claims.

Bumpus opens his report by saying that there is a false narrative that “even short-term (seven days or less) use of opioids under medical supervision to treat acute pain will often lead to opioid use disorder (OUD) and/or addiction.”

As a result of that narrative, many healthcare professionals and policy makers believe that the best way to address this problem is to “avoid using opioids altogether or to severely limit the use of prescription opioids, especially after surgery.”

I work/interact with many physicians, all of whom prescribe opioids. AFAIK, none of them are concerned about short-term opioid use for acute pain, including in the post-operative setting.

As a general rule, physicians are far more worried about issues when treating chronic, non-cancer pain. That's not to say opioids have no role in that setting, but the indications and risk:benefit are less clear, which may lead to prescribing hesitancy.

Case in point: I just had hamstring surgery. Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none. How many patients out there are like me, versus those with inadequate pain control using multimodal, opioid-sparing regimens?

ETA I'm hoping this will become less of an issue, as cannabinoids and suzetrigine provide more options in the analgesic armamentarium.

 

[Tau837]

OxyContin Fueled the Opioid Crisis, But Not How You Might Think

 

[Tau837]

Opiophobia: Misinformation, Misconceptions, Misrepresentations, Perspectives, and Consequences

Scientific Review Dismantles Myths Behind ‘Opiophobia’ (references link above)

The article makes some good points, but this entire section is waaaay overstated:

Published in ACS Pharmacology & Translational Science and authored by John Bumpus, PhD, the paper looks at the irrational fear that prescribing opioids in any capacity is harmful – and how little evidence there is to back up such claims.

Bumpus opens his report by saying that there is a false narrative that “even short-term (seven days or less) use of opioids under medical supervision to treat acute pain will often lead to opioid use disorder (OUD) and/or addiction.”

As a result of that narrative, many healthcare professionals and policy makers believe that the best way to address this problem is to “avoid using opioids altogether or to severely limit the use of prescription opioids, especially after surgery.”

I work/interact with many physicians, all of whom prescribe opioids. AFAIK, none of them are concerned about short-term opioid use for acute pain, including in the post-operative setting.

As a general rule, physicians are far more worried about issues when treating chronic, non-cancer pain. That's not to say opioids have no role in that setting, but the indications and risk:benefit are less clear, which may lead to prescribing hesitancy.

Case in point: I just had hamstring surgery. Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none. How many patients out there are like me, versus those with inadequate pain control using multimodal, opioid-sparing regimens?

ETA I'm hoping this will become less of an issue, as cannabinoids and suzetrigine provide more options in the analgesic armamentarium.

That's good to hear about your own experience with providers you know, but I don't think it is disputable that "many healthcare professionals and policy makers" believe in avoiding or limiting the use of prescription opioids after surgery, which is hte last part of the section you quoted. Many obviously doesn't mean all, and note that policy makers are included in the statement, not just doctors.

I agree that treating long term severe chronic pain is the bigger issue.

 

[STEADYMOBBIN 22]

I have a buddy who has a neck injury and is prescribed pain meds. He doesn’t use his meds because he isn’t in pain. Instead, he sells his pain meds to this woman for $700/mo.

He’s being doing this for at least a decade.

 

[Joe Bryant]

I have a buddy who has a neck injury and is prescribed pain meds. He doesn’t use his meds because he isn’t in pain. Instead, he sells his pain meds to this woman for $700/mo.

He’s being doing this for at least a decade.

Yes. My little brother, unfortunately, was a customer for people like that before he died.

 

[Joe Bryant]

Opiophobia: Misinformation, Misconceptions, Misrepresentations, Perspectives, and Consequences

Scientific Review Dismantles Myths Behind ‘Opiophobia’ (references link above)

The article makes some good points, but this entire section is waaaay overstated:

Published in ACS Pharmacology & Translational Science and authored by John Bumpus, PhD, the paper looks at the irrational fear that prescribing opioids in any capacity is harmful – and how little evidence there is to back up such claims.

Bumpus opens his report by saying that there is a false narrative that “even short-term (seven days or less) use of opioids under medical supervision to treat acute pain will often lead to opioid use disorder (OUD) and/or addiction.”

As a result of that narrative, many healthcare professionals and policy makers believe that the best way to address this problem is to “avoid using opioids altogether or to severely limit the use of prescription opioids, especially after surgery.”

I work/interact with many physicians, all of whom prescribe opioids. AFAIK, none of them are concerned about short-term opioid use for acute pain, including in the post-operative setting.

As a general rule, physicians are far more worried about issues when treating chronic, non-cancer pain. That's not to say opioids have no role in that setting, but the indications and risk:benefit are less clear, which may lead to prescribing hesitancy.

Case in point: I just had hamstring surgery. Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none. How many patients out there are like me, versus those with inadequate pain control using multimodal, opioid-sparing regimens?

ETA I'm hoping this will become less of an issue, as cannabinoids and suzetrigine provide more options in the analgesic armamentarium.

I'm sure you interact with more physicians than I do. But that's not been my experience. My experience in talking with my MD friend is that section you mention is not overstated at all. And certainly not waaaay overstated.

He, and other physicians I know are extremely concerned about all opioid use. Including short term opioid use. Even after surgery. They will prescribe but they treat it extremely seriously and watch closely for any warning signs. Which seems proper to me.

 

[STEADYMOBBIN 22]

I have a buddy who has a neck injury and is prescribed pain meds. He doesn’t use his meds because he isn’t in pain. Instead, he sells his pain meds to this woman for $700/mo.

He’s being doing this for at least a decade.

Yes. My little brother, unfortunately, was a customer for people like that before he died.

Lost my little brother for the same exact reasons a few years ago.

 

[Terminalxylem]

Opiophobia: Misinformation, Misconceptions, Misrepresentations, Perspectives, and Consequences

Scientific Review Dismantles Myths Behind ‘Opiophobia’ (references link above)

The article makes some good points, but this entire section is waaaay overstated:

Published in ACS Pharmacology & Translational Science and authored by John Bumpus, PhD, the paper looks at the irrational fear that prescribing opioids in any capacity is harmful – and how little evidence there is to back up such claims.

Bumpus opens his report by saying that there is a false narrative that “even short-term (seven days or less) use of opioids under medical supervision to treat acute pain will often lead to opioid use disorder (OUD) and/or addiction.”

As a result of that narrative, many healthcare professionals and policy makers believe that the best way to address this problem is to “avoid using opioids altogether or to severely limit the use of prescription opioids, especially after surgery.”

I work/interact with many physicians, all of whom prescribe opioids. AFAIK, none of them are concerned about short-term opioid use for acute pain, including in the post-operative setting.

As a general rule, physicians are far more worried about issues when treating chronic, non-cancer pain. That's not to say opioids have no role in that setting, but the indications and risk:benefit are less clear, which may lead to prescribing hesitancy.

Case in point: I just had hamstring surgery. Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none. How many patients out there are like me, versus those with inadequate pain control using multimodal, opioid-sparing regimens?

ETA I'm hoping this will become less of an issue, as cannabinoids and suzetrigine provide more options in the analgesic armamentarium.

That's good to hear about your own experience with providers you know, but I don't think it is disputable that "many healthcare professionals and policy makers" believe in avoiding or limiting the use of prescription opioids after surgery, which is hte last part of the section you quoted. Many obviously doesn't mean all, and note that policy makers are included in the statement, not just doctors.

I agree that treating long term severe chronic pain is the bigger issue.

You’ll get no argument from me in limiting the role policy makers hold in individualized clinical decisions. But still, I’d wager most doctors don’t subscribe to “opiophobia”.

 

[Terminalxylem]

Opiophobia: Misinformation, Misconceptions, Misrepresentations, Perspectives, and Consequences

Scientific Review Dismantles Myths Behind ‘Opiophobia’ (references link above)

The article makes some good points, but this entire section is waaaay overstated:

Published in ACS Pharmacology & Translational Science and authored by John Bumpus, PhD, the paper looks at the irrational fear that prescribing opioids in any capacity is harmful – and how little evidence there is to back up such claims.

Bumpus opens his report by saying that there is a false narrative that “even short-term (seven days or less) use of opioids under medical supervision to treat acute pain will often lead to opioid use disorder (OUD) and/or addiction.”

As a result of that narrative, many healthcare professionals and policy makers believe that the best way to address this problem is to “avoid using opioids altogether or to severely limit the use of prescription opioids, especially after surgery.”

I work/interact with many physicians, all of whom prescribe opioids. AFAIK, none of them are concerned about short-term opioid use for acute pain, including in the post-operative setting.

As a general rule, physicians are far more worried about issues when treating chronic, non-cancer pain. That's not to say opioids have no role in that setting, but the indications and risk:benefit are less clear, which may lead to prescribing hesitancy.

Case in point: I just had hamstring surgery. Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none. How many patients out there are like me, versus those with inadequate pain control using multimodal, opioid-sparing regimens?

ETA I'm hoping this will become less of an issue, as cannabinoids and suzetrigine provide more options in the analgesic armamentarium.

I'm sure you interact with more physicians than I do. But that's not been my experience. My experience in talking with my MD friend is that section you mention is not overstated at all. And certainly not waaaay overstated.

He, and other physicians I know are extremely concerned about all opioid use. Including short term opioid use. Even after surgery. They will prescribe but they treat it extremely seriously and watch closely for any warning signs. Which seems proper to me.

Of course they prescribe opioids judiciously, as they should. But I don’t think the majority shy away from them, when indicated.

The crux of this discussion is: collectively, are we prescribing too few, or too many opioids in this country?

My contention is overprescribing is still more common than under, even though mistakes are made, and some pain is undertreated. It’s a really difficult balance to prescribe just the right amount, as widely applicable, objective measures of pain are lacking.

FWIW, my wife, a physician, when asked the above question, responded overall opioid prescriptions are “just right”.

 

[Tau837]

Opiophobia: Misinformation, Misconceptions, Misrepresentations, Perspectives, and Consequences

Scientific Review Dismantles Myths Behind ‘Opiophobia’ (references link above)

The article makes some good points, but this entire section is waaaay overstated:

Published in ACS Pharmacology & Translational Science and authored by John Bumpus, PhD, the paper looks at the irrational fear that prescribing opioids in any capacity is harmful – and how little evidence there is to back up such claims.

Bumpus opens his report by saying that there is a false narrative that “even short-term (seven days or less) use of opioids under medical supervision to treat acute pain will often lead to opioid use disorder (OUD) and/or addiction.”

As a result of that narrative, many healthcare professionals and policy makers believe that the best way to address this problem is to “avoid using opioids altogether or to severely limit the use of prescription opioids, especially after surgery.”

I work/interact with many physicians, all of whom prescribe opioids. AFAIK, none of them are concerned about short-term opioid use for acute pain, including in the post-operative setting.

As a general rule, physicians are far more worried about issues when treating chronic, non-cancer pain. That's not to say opioids have no role in that setting, but the indications and risk:benefit are less clear, which may lead to prescribing hesitancy.

Case in point: I just had hamstring surgery. Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none. How many patients out there are like me, versus those with inadequate pain control using multimodal, opioid-sparing regimens?

ETA I'm hoping this will become less of an issue, as cannabinoids and suzetrigine provide more options in the analgesic armamentarium.

I'm sure you interact with more physicians than I do. But that's not been my experience. My experience in talking with my MD friend is that section you mention is not overstated at all. And certainly not waaaay overstated.

He, and other physicians I know are extremely concerned about all opioid use. Including short term opioid use. Even after surgery. They will prescribe but they treat it extremely seriously and watch closely for any warning signs. Which seems proper to me.

Of course they prescribe opioids judiciously, as they should. But I don’t think the majority shy away from them, when indicated.

The crux of this discussion is: collectively, are we prescribing too few, or too many opioids in this country?

My contention is overprescribing is still more common than under, even though mistakes are made, and some pain is undertreated. It’s a really difficult balance to prescribe just the right amount, as widely applicable, objective measures of pain are lacking.

FWIW, my wife, a physician, when asked the above question, responded overall opioid prescriptions are “just right”.

And, as we have discussed previously, they are often not "just right" for patients suffering from long term, severe chronic pain. Patients like my wife, who has been directly harmed for years by opioid hysteria.

 

[Terminalxylem]

Opiophobia: Misinformation, Misconceptions, Misrepresentations, Perspectives, and Consequences

Scientific Review Dismantles Myths Behind ‘Opiophobia’ (references link above)

The article makes some good points, but this entire section is waaaay overstated:

Published in ACS Pharmacology & Translational Science and authored by John Bumpus, PhD, the paper looks at the irrational fear that prescribing opioids in any capacity is harmful – and how little evidence there is to back up such claims.

Bumpus opens his report by saying that there is a false narrative that “even short-term (seven days or less) use of opioids under medical supervision to treat acute pain will often lead to opioid use disorder (OUD) and/or addiction.”

As a result of that narrative, many healthcare professionals and policy makers believe that the best way to address this problem is to “avoid using opioids altogether or to severely limit the use of prescription opioids, especially after surgery.”

I work/interact with many physicians, all of whom prescribe opioids. AFAIK, none of them are concerned about short-term opioid use for acute pain, including in the post-operative setting.

As a general rule, physicians are far more worried about issues when treating chronic, non-cancer pain. That's not to say opioids have no role in that setting, but the indications and risk:benefit are less clear, which may lead to prescribing hesitancy.

Case in point: I just had hamstring surgery. Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none. How many patients out there are like me, versus those with inadequate pain control using multimodal, opioid-sparing regimens?

ETA I'm hoping this will become less of an issue, as cannabinoids and suzetrigine provide more options in the analgesic armamentarium.

I'm sure you interact with more physicians than I do. But that's not been my experience. My experience in talking with my MD friend is that section you mention is not overstated at all. And certainly not waaaay overstated.

He, and other physicians I know are extremely concerned about all opioid use. Including short term opioid use. Even after surgery. They will prescribe but they treat it extremely seriously and watch closely for any warning signs. Which seems proper to me.

Of course they prescribe opioids judiciously, as they should. But I don’t think the majority shy away from them, when indicated.

The crux of this discussion is: collectively, are we prescribing too few, or too many opioids in this country?

My contention is overprescribing is still more common than under, even though mistakes are made, and some pain is undertreated. It’s a really difficult balance to prescribe just the right amount, as widely applicable, objective measures of pain are lacking.

FWIW, my wife, a physician, when asked the above question, responded overall opioid prescriptions are “just right”.

And, as we have discussed previously, they are often not "just right" for patients suffering from long term, severe chronic pain. Patients like my wife, who has been directly harmed for years by opioid hysteria.

Yes, I get it, and am sorry your wife, and others have suffered.

I know that’s little consolation for individuals with uncontrolled pain, but doesn’t prove widespread opioid hysteria, either.

 

[Tau837]

Opiophobia: Misinformation, Misconceptions, Misrepresentations, Perspectives, and Consequences

Scientific Review Dismantles Myths Behind ‘Opiophobia’ (references link above)

The article makes some good points, but this entire section is waaaay overstated:

Published in ACS Pharmacology & Translational Science and authored by John Bumpus, PhD, the paper looks at the irrational fear that prescribing opioids in any capacity is harmful – and how little evidence there is to back up such claims.

Bumpus opens his report by saying that there is a false narrative that “even short-term (seven days or less) use of opioids under medical supervision to treat acute pain will often lead to opioid use disorder (OUD) and/or addiction.”

As a result of that narrative, many healthcare professionals and policy makers believe that the best way to address this problem is to “avoid using opioids altogether or to severely limit the use of prescription opioids, especially after surgery.”

I work/interact with many physicians, all of whom prescribe opioids. AFAIK, none of them are concerned about short-term opioid use for acute pain, including in the post-operative setting.

As a general rule, physicians are far more worried about issues when treating chronic, non-cancer pain. That's not to say opioids have no role in that setting, but the indications and risk:benefit are less clear, which may lead to prescribing hesitancy.

Case in point: I just had hamstring surgery. Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none. How many patients out there are like me, versus those with inadequate pain control using multimodal, opioid-sparing regimens?

ETA I'm hoping this will become less of an issue, as cannabinoids and suzetrigine provide more options in the analgesic armamentarium.

I'm sure you interact with more physicians than I do. But that's not been my experience. My experience in talking with my MD friend is that section you mention is not overstated at all. And certainly not waaaay overstated.

He, and other physicians I know are extremely concerned about all opioid use. Including short term opioid use. Even after surgery. They will prescribe but they treat it extremely seriously and watch closely for any warning signs. Which seems proper to me.

Of course they prescribe opioids judiciously, as they should. But I don’t think the majority shy away from them, when indicated.

The crux of this discussion is: collectively, are we prescribing too few, or too many opioids in this country?

My contention is overprescribing is still more common than under, even though mistakes are made, and some pain is undertreated. It’s a really difficult balance to prescribe just the right amount, as widely applicable, objective measures of pain are lacking.

FWIW, my wife, a physician, when asked the above question, responded overall opioid prescriptions are “just right”.

And, as we have discussed previously, they are often not "just right" for patients suffering from long term, severe chronic pain. Patients like my wife, who has been directly harmed for years by opioid hysteria.

Yes, I get it, and am sorry your wife, and others have suffered.

I know that’s little consolation for individuals with uncontrolled pain, but doesn’t prove widespread opioid hysteria, either.

These things prove the widespread opioid hysteria:

• The CDC guidelines that were created without scientific basis and based on invalid data, driven by biased anti-opioid contributors, along with all of the laws and regulations spawned by those guidelines
• The unjust prosecution of pain management doctors who never ran "pill mills"
• Doctors choosing to stop prescribing opioids altogether to escape the risks to their licenses / practices and turning away patients with no identified alternative doctors
• The government mandated opioid quotas that have led to nationwide pain medication shortages multiple times
• The high number of suicides by long term chronic pain patients denied sufficient medication

I'm sure there is much more, that is just off the top of my head. I have linked many articles about most of these things throughout this thread.

 

[Joe Bryant]

FWIW, I asked my MD friend what he thought about the idea of physicians not being concerned about short-term opioid use for acute pain, including in the post-operative settings.

He replied, "Everyone SHOULD be concerned. It's maybe just lacking awareness. There is even a term “opioid naive” - keep patients unexposed "

Chat GPT defined "opioid naive":

"Opioid naive" means someone who has not taken opioids before or has not taken them regularly enough to have developed a tolerance.

In medical settings, this matters a lot. If a person is opioid naive and is given a strong dose, they’re at much higher risk for dangerous side effects, including respiratory depression (slowed or stopped breathing), which can be life-threatening.

Doctors usually adjust opioid dosing carefully based on whether someone is opioid naive or opioid tolerant.

I agree it really comes down to what is the right balance.

 

[Joe Bryant]

I know that’s little consolation for individuals with uncontrolled pain, but doesn’t prove widespread opioid hysteria, either.

Can you elaborate on what you mean by "widespread opioid hysteria"?

 

[Tau837]

I know that’s little consolation for individuals with uncontrolled pain, but doesn’t prove widespread opioid hysteria, either.

Can you elaborate on what you mean by "widespread opioid hysteria"?

I'm not attempting to speak for @Terminalxylem , but I think he was repeating my use of the term in responding to me. In addition to what I posted about it above and throughout this thread, here is the Google AI answer to the question "what is opioid hysteria"?

"Opioid hysteria" refers to the intense public fear, misconceptions, and exaggerated concerns surrounding opioid use, particularly those fueled by media reports and public discourse. While the opioid crisis is a real and significant public health issue, the "hysteria" aspect refers to potentially harmful and misinformed reactions.
Here's a breakdown of what opioid hysteria entails and its consequences:
Misinformation and Fear:

• Exaggerated risks of exposure: There have been reports of public safety officers claiming serious harm from minimal fentanyl exposure, contributing to unnecessary fear and potentially impacting their willingness to provide assistance.
• ** conflation of therapeutic use with addiction:** Opioid hysteria can lead to the misunderstanding that all opioid use, even for legitimate pain management, will lead to addiction, a concept also known as "opiophobia".
• Stigma and blame: Media coverage has been criticized for shifting narratives from focusing on legitimate pain care to framing opioid use as a criminal issue, contributing to the stigmatization and marginalization of individuals struggling with opioid use disorder (OUD).

Negative Consequences:

• Undertreatment of pain: "Opiophobia" can lead to reluctance among patients and even clinicians to utilize opioids for pain management, even when medically necessary, resulting in unnecessary suffering and a worsened quality of life for individuals with chronic pain, such as cancer patients.
• Inappropriate policies and responses: Fear-driven narratives can result in policies focused on punitive measures like criminalization rather than evidence-based solutions like harm reduction and treatment.
• Reduced access to care: Stigma can discourage individuals with OUD from seeking treatment, particularly medication-assisted treatment (MAT) which is considered the gold standard of care.
• Reinforcement of structural stigma: Opioid hysteria can perpetuate negative stereotypes and discrimination against individuals with OUD, hindering their reintegration into society and access to necessary services.

In summary, opioid hysteria refers to the excessive fear and often misinformed perspectives surrounding opioid use, leading to negative consequences for individuals with OUD, patients requiring pain management, and society as a whole. It's crucial to distinguish between addressing the opioid crisis with effective interventions and the harmful impacts of excessive fear and misinformation.

 

[Joe Bryant]

I know that’s little consolation for individuals with uncontrolled pain, but doesn’t prove widespread opioid hysteria, either.

Can you elaborate on what you mean by "widespread opioid hysteria"?

I'm not attempting to speak for @Terminalxylem , but I think he was repeating my use of the term in responding to me. In addition to what I posted about it above and throughout this thread, here is the Google AI answer to the question "what is opioid hysteria"?

"Opioid hysteria" refers to the intense public fear, misconceptions, and exaggerated concerns surrounding opioid use, particularly those fueled by media reports and public discourse. While the opioid crisis is a real and significant public health issue, the "hysteria" aspect refers to potentially harmful and misinformed reactions.
Here's a breakdown of what opioid hysteria entails and its consequences:
Misinformation and Fear:

• Exaggerated risks of exposure: There have been reports of public safety officers claiming serious harm from minimal fentanyl exposure, contributing to unnecessary fear and potentially impacting their willingness to provide assistance.
• ** conflation of therapeutic use with addiction:** Opioid hysteria can lead to the misunderstanding that all opioid use, even for legitimate pain management, will lead to addiction, a concept also known as "opiophobia".
• Stigma and blame: Media coverage has been criticized for shifting narratives from focusing on legitimate pain care to framing opioid use as a criminal issue, contributing to the stigmatization and marginalization of individuals struggling with opioid use disorder (OUD).

Negative Consequences:

• Undertreatment of pain: "Opiophobia" can lead to reluctance among patients and even clinicians to utilize opioids for pain management, even when medically necessary, resulting in unnecessary suffering and a worsened quality of life for individuals with chronic pain, such as cancer patients.
• Inappropriate policies and responses: Fear-driven narratives can result in policies focused on punitive measures like criminalization rather than evidence-based solutions like harm reduction and treatment.
• Reduced access to care: Stigma can discourage individuals with OUD from seeking treatment, particularly medication-assisted treatment (MAT) which is considered the gold standard of care.
• Reinforcement of structural stigma: Opioid hysteria can perpetuate negative stereotypes and discrimination against individuals with OUD, hindering their reintegration into society and access to necessary services.

In summary, opioid hysteria refers to the excessive fear and often misinformed perspectives surrounding opioid use, leading to negative consequences for individuals with OUD, patients requiring pain management, and society as a whole. It's crucial to distinguish between addressing the opioid crisis with effective interventions and the harmful impacts of excessive fear and misinformation.

Thanks. The word "Hysteria" seemed odd.

I see opioids as a highly dangerous but effective tool that can be incredibly useful in proper cases. Obviously, they can have amazing benefits. But obviously, as we've seen, they can have devastating negatives.

So it feels to me like huge amouns of caution and care and concern is warranted. It doesn't seem like something to be associated with "hysteria".

 

[Terminalxylem]

I know that’s little consolation for individuals with uncontrolled pain, but doesn’t prove widespread opioid hysteria, either.

Can you elaborate on what you mean by "widespread opioid hysteria"?

The idea that opioids aren’t being prescribed, particularly in the acute setting, for fear of promoting addiction. While that definitely happens, I don’t think it’s nearly as pervasive as @Tau837 suggests.

There have been multiple studies on the topic of unused post-surgical opioids, for example. Here’s one:

Findings Six eligible studies reported on a total of 810 unique patients (range, 30-250 patients) who underwent 7 different types of surgical procedures. Across the 6 studies, 67% to 92% of patients reported unused opioids. Of all the opioid tablets obtained by surgical patients, 42% to 71% went unused. Most patients stopped or used no opioids owing to adequate pain control, and 16% to 29% of patients reported opioid-induced adverse effects. In 2 studies examining storage safety, 73% to 77% of patients reported that their prescription opioids were not stored in locked containers. All studies reported low rates of anticipated or actual disposal, but no study reported US Food and Drug Administration–recommended disposal methods in more than 9% of patients.

Now, that study is nearly a decade old, and prescribing practices have changed somewhat, but I believe the phenomenon still exists. Why? I see patients with dubious prescriptions, and the doctors who prescribe them. Moreover, my personal experience: every time I’ve had a surgical procedure, I was given excess opioids - not overdosed; just too many pills, which I neither needed, nor used.

I also contend the US’ opioid use is disproportionately high, relative to the rest of the developed world. Tau and I have gone back-and-forth on this topic several times in this thread and others, but suffice it to say, he disagrees.

I’m not necessarily saying these excess prescriptions caused the opioid epidemic, nor are they fueling opioid addiction and deaths. And I agree patients receiving opioids for chronic pain face barriers to relieving their pain, in part due to the assumption of drug-seeking behavior, and addiction concerns.

So my gestalt is, overprescribing still exceeds undertreated pain, and “opioid hysteria” is not widespread. This belief does not preclude agreeing with the Tau that overly restrictive policies have harmed some patients.

 

[Tau837]

I know that’s little consolation for individuals with uncontrolled pain, but doesn’t prove widespread opioid hysteria, either.

Can you elaborate on what you mean by "widespread opioid hysteria"?

I'm not attempting to speak for @Terminalxylem , but I think he was repeating my use of the term in responding to me. In addition to what I posted about it above and throughout this thread, here is the Google AI answer to the question "what is opioid hysteria"?

"Opioid hysteria" refers to the intense public fear, misconceptions, and exaggerated concerns surrounding opioid use, particularly those fueled by media reports and public discourse. While the opioid crisis is a real and significant public health issue, the "hysteria" aspect refers to potentially harmful and misinformed reactions.
Here's a breakdown of what opioid hysteria entails and its consequences:
Misinformation and Fear:

• Exaggerated risks of exposure: There have been reports of public safety officers claiming serious harm from minimal fentanyl exposure, contributing to unnecessary fear and potentially impacting their willingness to provide assistance.
• ** conflation of therapeutic use with addiction:** Opioid hysteria can lead to the misunderstanding that all opioid use, even for legitimate pain management, will lead to addiction, a concept also known as "opiophobia".
• Stigma and blame: Media coverage has been criticized for shifting narratives from focusing on legitimate pain care to framing opioid use as a criminal issue, contributing to the stigmatization and marginalization of individuals struggling with opioid use disorder (OUD).

Negative Consequences:

• Undertreatment of pain: "Opiophobia" can lead to reluctance among patients and even clinicians to utilize opioids for pain management, even when medically necessary, resulting in unnecessary suffering and a worsened quality of life for individuals with chronic pain, such as cancer patients.
• Inappropriate policies and responses: Fear-driven narratives can result in policies focused on punitive measures like criminalization rather than evidence-based solutions like harm reduction and treatment.
• Reduced access to care: Stigma can discourage individuals with OUD from seeking treatment, particularly medication-assisted treatment (MAT) which is considered the gold standard of care.
• Reinforcement of structural stigma: Opioid hysteria can perpetuate negative stereotypes and discrimination against individuals with OUD, hindering their reintegration into society and access to necessary services.

In summary, opioid hysteria refers to the excessive fear and often misinformed perspectives surrounding opioid use, leading to negative consequences for individuals with OUD, patients requiring pain management, and society as a whole. It's crucial to distinguish between addressing the opioid crisis with effective interventions and the harmful impacts of excessive fear and misinformation.

Thanks. The word "Hysteria" seemed odd.

I see opioids as a highly dangerous but effective tool that can be incredibly useful in proper cases. Obviously, they can have amazing benefits. But obviously, as we've seen, they can have devastating negatives.

So it feels to me like huge amouns of caution and care and concern is warranted. Calling that hysteria seems odd to me.

It is proper to call it hysteria when policies are made that negatively affect millions of pain patients based on invalid, unsubstantiated information, driven by biased anti-opioid medical professionals. That is what has happened. If you really want to understand what I mean, there are more than 100 articles linked in this thread that help to explain it.

It is tragic that some people suffer opioid use disorder based solely on opioids legitimately prescribed to them and suffer negative life consequences up to and including death. But the rate of that is relatively low. Just as a simple example, in 2023 (most recent year available), per CDC:

1. There were 105,007 drug overdose deaths.
2. 25,649 of those did not involve any opioid.
3. 79,358 of those drug overdose deaths involved at least one type of opioid.
   1. 72,776 drug overdose deaths were from synthetic (illegal) opioids other than Methadone, primarily Fentanyl.
   2. 5,640 drug overdose deaths were from prescripion opioids without synthetic opioids other than Methadone.
      1. Even here, it is unknown how many of these prescription opioids were diverted, i.e., used illegally by someone other than the patients for whom they were prescribed.
      2. It is unknown how many of these overdose deaths involved additional illegal drugs other than synthetic opioids (e.g., cocaine or heroin) which were contributory to death, since the data is not broken down to that level of detail.
      3. It is unknown how many of these deaths involved alcohol. Alcohol contribution to opioid OD deaths is likely underestimated.
      4. It is unknown how many of these deaths were intentional vs. unintentional. In 2003-2008, GAO found that approximately 20-24% of opioid overdose deaths identified by CDC were intentional suicide, intentional homicide, and deaths for which accidental vs. intentional cause could not be determined.
      5. The data is also likely overstated for reasons mentioned in this article. While the article is from 2016, and thus some of this has hopefully been improved, it seems unlikely that all of the issues have been corrected.

All that said, any number of legitimate prescription overdose deaths is tragic.

But there are 20M+ Americans who suffer from severe chronic pain. Our society has gone too far in making policies and regulations that do harm to those patients in order to try to prevent a relatively low number of deaths annually. It is a worthy objective, but not at the expense of the much larger patient population suffering from severe pain.

Also, to put that number in perspective, different studies have shown a range of 3,200 to 16,500 annual deaths due to nonsteroidal anti-inflammatory drug (NSAID)-related complications. NSAIDs include ibuprofen. Like prescription opioids, there are many possible comorbid factors, so it is very hard to pinpoint an annual number of deaths attributable to NSAIDs. But it seems safe to say it is 3,200+ given that particular study was of 1990s patients. No one is thinking about banning or restricting ibuprofen, nor should they.

 

[BLOCKED_PUNT]

Instead, he sells his pain meds to this woman for $700/mo

Isn't that technically illegal? I think we've all done it or at least I have-shared a pain pill or 2 with my family but I was under the impression that your prescription is for you and ONLY you.

 

[Terminalxylem]

Also, this may be a regional phenomenon in the US.

Look at this map. Why do prescribing practices vary so much from state to state? Do southerners experience more pain than their counterparts in other parts of the country? Are more people suffering in the states with lower opioid use?

How do we determine the optimal balance?

 

[Joe Bryant]

Instead, he sells his pain meds to this woman for $700/mo

Isn't that technically illegal? I think we've all done it or at least I have-shared a pain pill or 2 with my family but I was under the impression that your prescription is for you and ONLY you.

Correct. It's illegal to distribute. And also to possess without a prescription.

But for someone who literally feels like they're dying trying to score their next Oxycontin hit, they don't care. And there are plenty of people who don't mind pocketing an extra $700 a month.

 

[Joe Bryant]

How do we determine the optimal balance?

It's a difficult question.

I think one step would be changing the mindset that you say you see among physicians who are not concerned about short-term opioid use for acute pain, including in the post-operative settings. That feels like a start.

It seems to me another thing we can do is reduce the situations you said you found yourself in with opioids prescribed you didn't ask for and didn't need.

 

[Terminalxylem]

How do we determine the optimal balance?

It's a difficult question.

I think one step would be changing the mindset that you say you see among physicians who are not concerned about short-term opioid use for acute pain, including in the post-operative settings. That feels like a start.

It seems to me another thing we can do is reduce the situations you said you found yourself in with opioids prescribed you didn't ask for and didn't need.

To be clear, I’m certain most physicians think about the consequences of opioid prescriptions, including side effects, and the potential for abuse/addiction.

And I believe the majority aren’t caught up in “opioid hysteria”.

But what is the alternative to preemptively prescribing them in the post-op setting? Wait and see if pain is uncontrolled?

How does that strategy ameliorate Tau’s concerns?

 

[Tau837]

How do we determine the optimal balance?

It's a difficult question.

I think one step would be changing the mindset that you say you see among physicians who are not concerned about short-term opioid use for acute pain, including in the post-operative settings. That feels like a start.

It seems to me another thing we can do is reduce the situations you said you found yourself in with opioids prescribed you didn't ask for and didn't need.

It is a very complex issue. Some steps we should take as a society:

• Don't let organizations like CDC and DEA drive how we set and enforce policy for opioid prescribing. It doesn't fall under either of their charters, but those are the organizations that have driven the misguided and inappropriate policies and actions taken by our government over the past 12+ years.
• Don't let the group of individuals who drive policy include people with obvious conflicts. It's fine to allow some experts who are anti-opioid, but also make sure to include balanced support from relevant medical pain organizations. That hasn't happened to date.
• Properly apply sound process and scientific data to the policy making process. That hasn't happened to date.
• Stop persecuting pain management doctors/practices that are not operating "pill mills."
• Consider whether the amount of pain management education for medical disciplines other than pain management specialists should be increased. If so, increase it.
• Stop enforcing annual drug manufacturing quotas that result in nationwide shortages for needed pain medication.
• Invest more resources in studies related to non-cancer pain. There are plenty of studies for cancer pain already, and it is silly to make a distinction between cancer pain and non-cancer pain, but that is what happens when studies are focused on cancer patients. Note that performing studies on people in pain is difficult... it is hard to account for all possible comorbid factors, and it is also hard to have a cohort in severe pain that is receiving placebos. It's a challenge that needs more devoted resources.
• Require all people who receive opioid prescriptions to keep that medication in a locked location to prevent easy theft. This probably won't be a big needle mover, but it would have a non-zero benefit and is low hanging fruit.
• Prosecute people with serious penalties for diverting their prescription opioids. Maybe this is already in place to a sufficient degree, not sure.

This is all off the top of my head with as much thinking time as it took me to write it out. I'm sure there is more, some easier to implement than others.

 

[Joe Bryant]

But what is the alternative to preemptively prescribing them in the post-op setting? Wait and see if pain is uncontrolled?

How does that strategy ameliorate Tau’s concerns?

I'm just an observer here. But I'd think one key part of the strategy in the case of your surgery would be asking the patient about their pain and trying to determine the right answer for solving the pain problem with as non serious a solution as possible.

Basically, whatever it takes to not have a patient be in the position you were in:

Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none.

 

[Tau837]

How do we determine the optimal balance?

It's a difficult question.

I think one step would be changing the mindset that you say you see among physicians who are not concerned about short-term opioid use for acute pain, including in the post-operative settings. That feels like a start.

It seems to me another thing we can do is reduce the situations you said you found yourself in with opioids prescribed you didn't ask for and didn't need.

To be clear, I’m certain most physicians think about the consequences of opioid prescriptions, including side effects, and the potential for abuse/addiction.

And I believe most physicians aren’t caught up in “opioid hysteria”.

But what is the alternative to preemptively prescribing them in the post-op setting? Wait and see if pain is uncontrolled?

How does that strategy ameliorate Tau’s concerns?

Agree. The problem with "waiting to see" in the case where the patient has uncontrolled pain is that the patient would have to be able to report the pain resulting in a prescription being sent to the pharmacy without requiring another in person vist, or it becomes burdensome for the patient, who is in pain and recovering from surgery in this scenario. Even then, how would the doctor know to prescribe 2 days' worth vs. 7 days' worth to avoid the problem of overprescribing? There is no algorithm for this.

 

[Alex P Keaton]

Also, this may be a regional phenomenon in the US.

Look at this map. Why do prescribing practices vary so much from state to state? Do southerners experience more pain than their counterparts in other parts of the country? Are more people suffering in the states with lower opioid use?

How do we determine the optimal balance?

What’s your hypothesis on why prescribing practices vary so much from state to state?

 

[Terminalxylem]

But what is the alternative to preemptively prescribing them in the post-op setting? Wait and see if pain is uncontrolled?

How does that strategy ameliorate Tau’s concerns?

I'm just an observer here. But I'd think one key part of the strategy in the case of your surgery would be asking the patient about their pain and trying to determine the right answer for solving the pain problem with as non serious a solution as possible.

Basically, whatever it takes to not have a patient be in the position you were in:

Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none.

It’s not so straightforward, because:

1. Not everyone has the same pain threshold, or ideas about what constitutes adequate control
2. Pain can wax and wane
3. For same day surgery, residual anesthesia may dull pain for a while, extending beyond discharge
4. There is no universally accepted, objective measure of pain
5. It can be more difficult to prescribe controlled substances over the phone
6. A surgeon’s busy schedule can preclude prompt response for pain med requests after hospital discharge. Moreover, calls after hours are a red flag for drug-seeking behavior.

Considering all these factors, and the fact most unused opioids aren’t diverted/abused, many (most?) doctors err on the side of providing the medications, when a reasonable expectation of significant post-op pain exists.

ETA Add Tau’s point about post-op patients potentially having limited mobility, or other difficulties retrieving post-discharge meds.

 

[Terminalxylem]

Also, this may be a regional phenomenon in the US.

Look at this map. Why do prescribing practices vary so much from state to state? Do southerners experience more pain than their counterparts in other parts of the country? Are more people suffering in the states with lower opioid use?

How do we determine the optimal balance?

What’s your hypothesis on why prescribing practices vary so much from state to state?

Probably regulatory differences, at least in part, as I doubt the overall experience of pain is different in Tennessee, versus Hawai’i, or Japan, for that matter.

ETA Thinking about it further, there surely are biologic/genetic differences in pain perception, which probably extend across cultures. Yet another challenge in determining the need for analgesia.

 

[Joe Bryant]

But what is the alternative to preemptively prescribing them in the post-op setting? Wait and see if pain is uncontrolled?

How does that strategy ameliorate Tau’s concerns?

I'm just an observer here. But I'd think one key part of the strategy in the case of your surgery would be asking the patient about their pain and trying to determine the right answer for solving the pain problem with as non serious a solution as possible.

Basically, whatever it takes to not have a patient be in the position you were in:

Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none.

It’s not so straightforward, because:

1. Not everyone has the same pain threshold, or ideas about what constitutes adequate control
2. Pain can wax and wane
3. For same day surgery, residual anesthesia may dull pain for a while, extending beyond discharge
4. There is no universally accepted, objective measure of pain
5. It can be more difficult to prescribe controlled substances over the phone
6. A surgeon’s busy schedule can preclude prompt response for pain med requests after hospital discharge. Moreover, calls after hours are a red flag for drug-seeking behavior.

Considering all these factors, and the fact most unused opioids aren’t diverted/abused, many (most?) doctors err on the side of providing the medications, when a reasonable expectation of significant post-op pain exists.

I agree it's not easy or straightforward.

But I still think it's a good place to start with whatever it takes to not have a patient be in the position you were in:

Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none.

And for physicians to be very concerned about short-term opioid use for acute pain.

In my brothers experience, it seemed pretty common for the addiction stories to start with, "I had a surgery..."

 

[Terminalxylem]

But what is the alternative to preemptively prescribing them in the post-op setting? Wait and see if pain is uncontrolled?

How does that strategy ameliorate Tau’s concerns?

I'm just an observer here. But I'd think one key part of the strategy in the case of your surgery would be asking the patient about their pain and trying to determine the right answer for solving the pain problem with as non serious a solution as possible.

Basically, whatever it takes to not have a patient be in the position you were in:

Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none.

It’s not so straightforward, because:

1. Not everyone has the same pain threshold, or ideas about what constitutes adequate control
2. Pain can wax and wane
3. For same day surgery, residual anesthesia may dull pain for a while, extending beyond discharge
4. There is no universally accepted, objective measure of pain
5. It can be more difficult to prescribe controlled substances over the phone
6. A surgeon’s busy schedule can preclude prompt response for pain med requests after hospital discharge. Moreover, calls after hours are a red flag for drug-seeking behavior.

Considering all these factors, and the fact most unused opioids aren’t diverted/abused, many (most?) doctors err on the side of providing the medications, when a reasonable expectation of significant post-op pain exists.

I agree it's not easy or straightforward.

But I still think it's a good place to start with whatever it takes to not have a patient be in the position you were in:

Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none.

And for physicians to be very concerned about short-term opioid use for acute pain.

In my brothers experience, it seemed pretty common for the addiction stories to start with, "I had a surgery..."

It happens, but isn’t common at all. That’s not helpful when your loved ones are adversely impacted, of course.

In contrast, I just ended up with three unused bottles of opioids. If stored and disposed of properly, no harm caused.

 

[Joe Bryant]

But what is the alternative to preemptively prescribing them in the post-op setting? Wait and see if pain is uncontrolled?

How does that strategy ameliorate Tau’s concerns?

I'm just an observer here. But I'd think one key part of the strategy in the case of your surgery would be asking the patient about their pain and trying to determine the right answer for solving the pain problem with as non serious a solution as possible.

Basically, whatever it takes to not have a patient be in the position you were in:

Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none.

It’s not so straightforward, because:

1. Not everyone has the same pain threshold, or ideas about what constitutes adequate control
2. Pain can wax and wane
3. For same day surgery, residual anesthesia may dull pain for a while, extending beyond discharge
4. There is no universally accepted, objective measure of pain
5. It can be more difficult to prescribe controlled substances over the phone
6. A surgeon’s busy schedule can preclude prompt response for pain med requests after hospital discharge. Moreover, calls after hours are a red flag for drug-seeking behavior.

Considering all these factors, and the fact most unused opioids aren’t diverted/abused, many (most?) doctors err on the side of providing the medications, when a reasonable expectation of significant post-op pain exists.

I agree it's not easy or straightforward.

But I still think it's a good place to start with whatever it takes to not have a patient be in the position you were in:

Despite requiring no perioperative pain meds, I was discharged with a week's worth of oxycodone. I didn't ask for them, and took none.

And for physicians to be very concerned about short-term opioid use for acute pain.

In my brothers experience, it seemed pretty common for the addiction stories to start with, "I had a surgery..."

It happens, but isn’t common at all. That’s not helpful when your loved ones are adversely impacted, of course.

I don't know how common overall among all opioid prescriptions, but among the addiction stories, it was common in my experience talking to people with addiction struggles. Granted, that's a small sample. And they also could be lying. But sharing what I'd heard myself.