The Opiate and Heroin Epidemic in America (2 Viewers)

[Tau837]

Have Opioid Restrictions Made Things Better Or Worse?

By any measure, it is now more difficult for patients with legitimate needs to obtain the powerful opioid pain-killers that they need just to function. Much of the blame for this changing paradigm has been placed at the feet of the CDC. You don't need to look very hard to find stories of both individuals and organizations who have expressed dismay at the agency's recent "voluntary guidelines" to physicians regarding opioid prescribing practice. David Hendry, writing for the Pain News Network called the CDC's advice to doctors as "the phrasing and logic of an extortionist."

There is no question that many people have been impacted by their inability to get the drugs that they had used responsibly for years. Both individuals and  organizations have called the new rules Draconian.

But, has there been any benefit of these new guidelines to society as a whole? Or is this just another knee-jerk government reaction that will make the solution worse than the problem. It is too soon to have hard data on the impact of stringent opioid restrictions, but given historical precedent as well as fragments of emerging information, it is all but certain the effect of limiting opioids have had a downside. Perhaps even more than an upside...

Although not definitive, these graphs when taken together suggest that not only did the crackdown on opioid prescriptions failed to stop overdose deaths during that time, but may have even increased them. Furthermore, these data do not reflect what has happened since 2015, when the CDC's "voluntary" guidelines were implemented, so this effect will most likely be magnified...

Did we make things better or worse? Are we prepared as a society to accept guaranteed suffering for some to protect others from addiction?

Tough question, but David Hendry has his own thoughts, and they are not optimistic: "The callous decision-makers exemplify the words of Francois de La Rochefoucauld: 'We all have enough strength to endure the misfortunes of others."'

As usual, simple answers to complex problems rarely work, something many of us will eventually find out the hard way. The painful way.

 

[Tau837]

Fed Assault on Pain Patients Continues

I wanted to know how the CDC's distinguishes between a prescription opioid death and those caused by  incorrect coroner determinations, polypharmacy, counterfeit drugs, history of drug abuse, and even deaths from severe pain.

So I wrote to Deborah Dowell, MD, co-author of the CDC guideline and lead author of a recent article published in JAMA, which analyzed underlying factors in drug overdose deaths...

After clearing my questions with CDC’s legal team, Dowell replied a week later.  Her response should send a shiver down the spine of any pain patient who has been denied opioids, titrated down, or dismissed by his or her physician: 

“The reality is that many of the answers to these highly specific and technical questions cannot be answered in a definitive manner based on available data.” 

The bottom line is CDC does not have a grip on what’s really happening. CDC is targeting pain patients who are increasingly tortured by a medical profession scared silly by investigations and law enforcement. Yet they press on, with very little effect, continuing to blame prescription opioids and pain patients as the root cause of the opioid “epidemic” they aren’t responsible for.

 

[wikkidpissah]

Today, i am thankful for you figtin' the fight, JWB. Keep on keepin us in the loop - pain treatment resonates with my personal history and is an issue that crosses all the aspects of a society whose care for itself is slipping. welldone -

 

[boots11234]

Are some people more susceptible to becoming addicted? I was prescribed Oxy and thought it sucked.  I didn’t feel ‘high’ at all. Now Demerol, that stuff knocked my socks off!

 

[Tau837]

Are some people more susceptible to becoming addicted? I was prescribed Oxy and thought it sucked.  I didn’t feel ‘high’ at all. Now Demerol, that stuff knocked my socks off!

Yes. Posted previously in this thread: Per NIH: "An addiction disorder occurs in about 5 percent of people who take these pain relievers as directed."

(Note that addiction and dependency are not the same thing.)

 

[parasaurolophus]

Article from the BBC

Why are opioids such an American problem

A funny anecdote from the article

Doesn't shock me at all. Look at what is happening with workers comp. Go to the doctor and you are guaranteed to get a diagnosis of some sort.

Are american doctors just that afraid of getting sued?

 

[msommer]

Doesn't shock me at all. Look at what is happening with workers comp. Go to the doctor and you are guaranteed to get a diagnosis of some sort.

Are american doctors just that afraid of getting sued?

I think there are a lot of reasons, really. Not least that if you are off sick (because you overdid it during the marathon or whatever) you might get fired.

Not that you will but anecdotally I've seen that fear in many Americans, which to some extent is linked to the common occurrence of not taking your vacation days because (you have to show your boss) you are really busy etc.

 

[parasaurolophus]

I think there are a lot of reasons, really. Not least that if you are off sick (because you overdid it during the marathon or whatever) you might get fired.

Not that you will but anecdotally I've seen that fear in many Americans, which to some extent is linked to the common occurrence of not taking your vacation days because (you have to show your boss) you are really busy etc.

Sure i can see that from the employee side, but why does the doctor just roll with it? 

 

[msommer]

Sure i can see that from the employee side, but why does the doctor just roll with it? 

Because he makes money by people coming to his office to renew their prescription?

 

[PIK95]

It's like if you were a drug kingpin operating out of some backwater town and you offered all the sherriff's deputies big bucks to work as your personal security, and they were able to write laws legalizing heroin and meth, and the mayor rubber stamped it. 

If it seemed weird that these pills are so widely available, now we know. Fairly stunning, if not necessarily surprising once taken into context of how DC operates. 

Lots of folks in business suits need to be in prison.

Hampsterdam?

 

[Tau837]

Great article: Opioid Commission Mistakenly Blames Pain Treatment for Drug Deaths

In the report it published yesterday, the President's Commission on Combating Drug Addiction and the Opioid Crisis, chaired by New Jersey Gov. Chris Christie, endorses what has become the standard explanation for the rise in opioid-related deaths during the last decade and a half. "A widely held and supportable view is that the modern opioid crisis originated within the healthcare system," the report says. The problem began, it explains, with "a growing compulsion to detect and treat pain."

According to this narrative, doctors in the late 1990s began to underestimate the risk of addiction and overdose among patients prescribed narcotics for pain. Responding to ill-informed advocacy on behalf of pain patients and deceptive marketing by drug companies, they lost their entirely appropriate fear of opioids and began prescribing them left and right. The surge in prescriptions led to a surge in "iatrogenic addiction" (i.e., addiction caused by treatment) and overdose deaths. To correct that disastrous mistake, the Christie commission says, doctors need to worry less about the suffering caused by untreated pain and more about the dangers posed by painkillers.

That response is fundamentally misguided because the narrative endorsed by the commission is wrong in several crucial ways. Doctors did not mistakenly believe that the dangers posed by opioids had been greatly exaggerated. They correctly believed that the dangers posed by opioids had been greatly exaggerated, and they were right to think that excessive fear of opioids had led to inadequate pain treatment. Contrary to the impression left by a lot of the press coverage, opioid addiction and opioid-related deaths rarely involve drug-naive patients who accidentally get hooked while being treated for pain. They typically involve polydrug users with histories of substance abuse and psychological problems. Attempts to prevent overdoses by closing off access to legally produced narcotics make matters worse for both groups, depriving pain patients of the analgesics they need to make their lives livable while driving nonmedical users into a black market where the drugs are more variable and therefore more dangerous.

"The catalyst of the opioid crisis was a denial of [these drugs'] addictive potential," the Christie commission says. The report does not try to quantify that potential, but survey data and studies of patients help to put it into perspective.

According to the National Survey on Drug Use and Health (NSDUH), 98 million Americans used prescription analgesics in 2015, including both legal and illegal use. About 2 million of them qualified for a diagnosis of "substance use disorder" (SUD) at some point during the previous year. SUD is a catchall category that subsumes what used to be known as "substance abuse" and the more severe "substance dependence." The Substance Abuse and Mental Health Services Administration, which oversees the survey, does not report the breakdown between mild, moderate, and severe SUD. But based on this survey, it looks like somewhere between 1 and 2 percent of prescription opioid users experience addiction in a given year. By comparison, NSDUH data indicate that about 5 percent of past-year drinkers had an alcohol use disorder in 2015. That group was about evenly divided between "abuse" and "dependence."

The NSDUH numbers provide a one-year snapshot. Some studies of patients who take opioids for extended periods of time find higher addiction rates, but they are still generally modest. A 2010 review found that less than 1 percent of patients taking opioids for chronic pain experienced addiction. A 2012 review likewise concluded that "opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence." A 2015 review noted addiction rates in various studies ranging from 3 percent to 26 percent in primary care settings and from 2 percent to 14 percent in pain clinic settings.

The risk of fatal overdose among patients is very low. The CDC cites "a recent study of patients aged 15–64 years receiving opioids for chronic noncancer pain" who were followed for up to 13 years. The researchers found that "one in 550 patients died from opioid-related overdose," which is a risk of less than 0.2 percent. A 2015 study of opioid-related deaths in North Carolina found 478 fatalities among 2.2 million residents who were prescribed opioids in 2010. That's an annual rate of 0.022 percent.

The risk of addiction and overdose is not random. A 2012 study of opioid-related fatalities in Utah found that 87 percent of the decedents had received prescriptions for analgesics in the previous year and 89 percent were reported to have suffered from pain. Those results may seem consistent with the story the Christie commission is telling about pain treatment leading to iatrogenic addiction and death. But when you look at the characteristics of the people whose deaths were attributed to prescription opioids, you see that 61 percent had used illegal drugs, 80 percent had been hospitalized for substance abuse (including abuse of alcohol and illegal drugs as well as prescription medications), 56 percent had a history of mental illness, and 45 percent had been hospitalized for psychiatric reasons other than substance abuse. Troubled people who find emotional relief in various drugs, including prescription opioids, are far more common than accidental addicts like the law school classmate frequently cited by Chris Christie, who died after washing down Percocet pills with a bottle of vodka.

So-called overdose deaths typically involve combinations of drugs. In the North Carolina study, for example, benzodiazepines were detected in 61 percent of the deaths attributed to prescription opioids. The numbers in New York City are similar, and that's just for one class of depressants. Over all, more than 90 percent of opioid-related deaths in New York involve drug mixtures. For the most part, people are not dying simply by taking too many pain pills. Even Christie's friend, whom he describes as getting hooked on oxycodone prescribed for back pain, mixed the pills with alcohol.

What's true of prescription opioids is also true of heroin: Most "overdoses" involve combinations. The danger is magnified by the unpredictable potency of black-market heroin, which in turn has been magnified by the recent proliferation of fentanyl as a heroin adulterant and substitute. The dramatic increase in heroin-related deaths since 2010 seems to be driven largely by the crackdown on prescription opioids (including the 2010 reformulation of OxyContin), which has pushed nonmedical users toward more hazardous substances.

The crackdown also has affected patients, leaving many without the medication they need to keep agony at bay and driving some to suicide. The prescription guidelines that the CDC issued last year, which encourage physicians to be stingy with opioids, already have had a noticeable impact on patients' ability to get adequate treatment for their pain. "There are many pain clinics flooded with patients who have been treated previously by their primary care physician," says Jianguo Cheng, president-elect of the American Academy of Pain Medicine. "They have a lot of patients trying to find a physician, and it has been a problem for many, many pain specialists." He says these refugees include patients who have responded well to opioids for years.

The Christie commission thinks there is nothing wrong with the CDC guidelines. In fact, the report recommends updating and extending them to pain specialists. It calls for "a national curriculum and standard of care for opioid prescribers," presumably aimed at reinstilling the good, old-fashioned fear that the commission credits with preventing abuse. The commission thinks patients should no longer be asked about the adequacy of pain treatment in surveys mandated by the Centers for Medicare & Medicaid Services, lest providers "use opioids inappropriately to raise their survey scores." The commission criticizes the campaign to treat pain as "the fifth vital sign," which it blames for encouraging excessive opioid use. It recommends closer and more comprehensive scrutiny of prescription practices.

If the aim is reducing deaths from drug poisoning, there is not much logic to making prescription analgesics even harder to obtain. According to a 2016 analysis of opioid-related deaths in Massachusetts, just 8 percent of the decedents "had an opioid prescription in the same months as their deaths." Prescription opioids were the deadliest drug in just 5 percent of the cases, while 85 percent involved heroin and/or fentanyl.

Today I heard from one of the pain patients I interviewed for an upcoming Reason feature story about recent trends in opioid use. He fits Cheng's description of patients who have functioned well on opioids for years but were arbitrarily cut off by providers in response to the CDC guidelines. This patient thinks the Christie commission is pushing the government further in the wrong direction. "If they go through with those recommendations," he wrote to me on Twitter, "I may as well drive my car off a cliff. This is horrible news. The CDC will threaten MDs, the DEA will step up their intimidation practices, and the few pain MDs that are left will fold. This is barbaric."

There are links in the article to substantiate the facts referenced.

 

[msommer]

Opioid crisis linked to two-year drop in US life expectancy

US life expectancy fell last year for a second year running for the first time in more than half a century, reportedly driven by the worsening opioid crisis.

Life expectancy in 2016 fell 0.1 years to 78.6, according to the National Center for Health Statistics.

It was the first consecutive drop since 1962-63. The last two-year decline before that was in the 1920s.

"The key factor in all this is the increase in drug overdose deaths," said Robert Anderson, the chief of mortality statistics at the National Center for Health Statistics (NCHS), calling the two-year drop "shocking".

 

[siffoin]

My Mom is a 77 year old conservative Republican evangelical church lady who has been daily dependent on prescription narcotics for about 10 years.  Her current daily dose is 50mg Methadone + 100mg Fentanyl patch.  On a "bad day" she of course supplements from her vast store of Ultram, Vicodin, or Oxy.   She makes Keith Richards look like a light weight.  She looks terrible, often slurs her words, spends most of her days in her room.  I fear greatly for her health, well-being, and safety.  Because of her conservative belief system, and the fact that these are prescribed from a doctor she doesn't believe there is any problem with her continued use.  Discussions of "treatment" are met with the same anger as would be asking her to convert to Islam.  Like I said, I fear greatly for her well-being, and pretty helpless overall.  

 

[wikkidpissah]

My Mom is a 77 year old conservative Republican evangelical church lady who has been daily dependent on prescription narcotics for about 10 years.  Her current daily dose is 50mg Methadone + 100mg Fentanyl patch.  On a "bad day" she of course supplements from her vast store of Ultram, Vicodin, or Oxy.   She makes Keith Richards look like a light weight.  She looks terrible, often slurs her words, spends most of her days in her room.  I fear greatly for her health, well-being, and safety.  Because of her conservative belief system, and the fact that these are prescribed from a doctor she doesn't believe there is any problem with her continued use.  Discussions of "treatment" are met with the same anger as would be asking her to convert to Islam.  Like I said, I fear greatly for her well-being, and pretty helpless overall.  

wOw

 

[Tau837]

From Addiction, Hotline Bling and the Opioid Thing:

It is safe to say that we have a cellphone “epidemic”...

...here are some of the individual and societal harms from excessive cellphone use:

1. Motor vehicle accidents: Cellphone use while driving leads to 1.6 million crashes every year leading to 330,000 injuries and over 3000 deaths. Texting while driving is 6x more likely to result in an accident than driving drunk. Texting while driving has reached an epidemic. A 2010 study found that nearly half US adults admit reading or sending a text message while driving and nearly one in three 16- or 17- year olds admitted texting while driving.

2. Pedestrian injuries: A study of pedestrians in midtown Manhattan found that 42% of drivers that enter traffic during a “Don’t Walk” signal were using their cellphone. No surprise, a 2013 study found 10-fold increase in injuries related to pedestrians using cell phones from 2005 to 2010.

3. Loss of work productivity: the average worker spends 5 hours on their cell-phone for non-work related activities...

Is the answer to the opioid epidemic is continued efforts to limit prescribing? Then for the cell-phone epidemic, do you think cellphone carriers should have a maximum daily tweet dose? Should local agencies enforce a Snap Chat equivalent daily dose? Should the CDC place restrictions on Instagram posts? Should cell phones be Schedule II Narcotics because of a high abuse potential? Should Apple and other Cell Phone manufacturers be sued for the “cell-phone epidemic” by various state agencies? ...

No matter how you slice it, cell phones may prove to be similarly addicting compared to opioids.  We wonder what would happen if regulatory agencies abruptly cut-off cell phone use, reduced the maximum allowable daily cell phone dose, or set up a cell phone state monitoring program. Would there be a black market for cell phones? Would people kill for cell phones? Would the cost of prescription cell phones increase as the street value decreased?  Would phone manufacturers be encouraged to develop abuse deterrent cell phones, the dose of which needs to be used gently over 8-12 hours instead of immediate release bursts?

This whole line of thinking for cell phones seems ridiculous, which is exactly the point, to highlight the absurdity of the Government's actions against opioid prescribing.

 

[PlayaHata]

My daughter had her tonsils taken out over Christmas break and was prescribed Oxy to manage pain during recovery.  I was scared/paranoid practically the entire time about the possibility (however slim) of addition.  Same thing after my wife had surgery early last year.  Both times I wanted them off the medication and taking regular Tylenol/Advil ASAP.  I know pain pills are a necessity sometimes, and I'm thankful my family had access to them during recovery, but am fearful of potential consequences at the same time.  It's tough to know what to do in situations like that.  I'll admit I am not an expert on prescription opiates.  Are there other alternatives to manage pain, especially after surgery?

 

[Tau837]

The other side of the opioid epidemic — we're people in severe pain

The prescribing of opioids has dropped every year since 2012 and is at 10 year low — and yet drug overdose deaths have skyrocketed. Meanwhile, our public policy looks backward in time, intruding on the doctor patient relationship and burdening patient care.

The Attorney General recently responded to the concerns of pain patients by telling them to “take a few Bufferin or something and go to bed.”  

His comment shows an astonishing misunderstanding of a condition whose quality of life index (QLI) is akin to that of late-stage cancer. Fifty million Americans suffer from severe or persistent pain, which is twenty-five times more than those who misuse opioids.

Chronic pain is also the primary cause of disability in the US, and it costs the economy half a trillion dollars every year.

 

[PIK95]

The other side of the opioid epidemic — we're people in severe pain

I was in too much pain to go to work today fwiw.

 

[Tau837]

This study was published in January: Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study

• Objective: To quantify the effects of varying opioid prescribing patterns after surgery on dependence, overdose, or abuse in an opioid naive population.
  
• Participants: 1,015,116 opioid naive patients undergoing surgery.
  
• Results: 568,612 (56.0%) of patients received postoperative opioids, and a code for abuse was identified for 5,906 patients (0.6%, 183 per 100 000 person years).
  

ZERO POINT SIX PERCENT

Yep, that seems to indicate an opioid crisis.   

 

[Tau837]

And now it comes out that the Government has been misleading the public about the extent of the opioid 'crisis'. From CDC Admits Rx Opioid Deaths ‘Significantly Inflated’:

Researchers with the Centers for Disease Control and Prevention have acknowledged that the agency’s methods for tracking overdose deaths are inaccurate and have significantly overestimated the number of Americans that have died due to prescription opioids.

...

How inflated were the overdose numbers?  Using the agency’s “traditional definition” for prescription opioids, the CDC estimated that 32,445 Americans died from overdoses of pain medication in 2016.

Under a new “conservative definition” – one that excludes the “high proportion of deaths” involving synthetic opioids like fentanyl – the death toll from prescription opioids is cut nearly in half to 17,087 overdoses.

...

We’ve written before about how confusing, flimsy and exaggerated the numbers can be for overdoses (see “Lies, Damned Lies, and Overdose Statistics”). Last October, PNN reported that the Drug Enforcement Administration changed its definition of prescription drug deaths for three consecutive years in an annual report, apparently in an effort to inflate the number of Americans dying of overdoses.

In 2016, we reported that within one week the CDC and the White House Office of National Drug Control Policy released three different estimates of the number of Americans that died from prescription opioids the year before. The numbers were wildly different, ranging from a low of 12,700 to a high of 17,536 deaths.

To be clear, one overdose is too many. But if we are ever going to find real solutions to the overdose crisis, we need to find accurate numbers to reflect what is causing so many drug deaths. Pinning the blame on prescription opioids, pain patients and prescribers has only led to a growing catastrophe in pain care –  where doctors are too fearful to prescribe opioids and patients can’t get treatment. 

As the CDC researchers say in their editorial, "inaccurate conclusions” not only mask what’s driving the overdose crisis -- they mask the solutions too.

 

[Tau837]

From TRUMP’S FALSE WAR ON OPIOIDS WILL ONLY PUNISH PATIENTS IN PAIN:

...Our government is now, in effect, dictating what constitutes acceptable prescribing of controlled substances, mostly opioid painkillers. That is both unprecedented and disturbing, and patients who need potent pain medications are suffering.

...Thus, it can reasonably be assumed that the number of deaths from opioid pills alone is probably about 5,000, roughly as many people who die each year from bicycle and bicycle-related accidents. Yet, we don’t hear scaremongering alerts about a bicycle accident epidemic.

...Once the false narrative is peeled away, the policy flaws and the suffering they cause become evident. Deaths from appropriate and responsible use of opioid pain medications are, in fact, relatively uncommon, but the politicians and bureaucrats soldier on. Their one-size-fits-all legislative and regulatory remedies are doomed to fail and can inflict tremendous inconvenience and pain on patients along the way.

 

[Sand]

From TRUMP’S FALSE WAR ON OPIOIDS WILL ONLY PUNISH PATIENTS IN PAIN:

This author willfully ignores the connection between opiod users and abusers.  Completely misleading article.

 

[Tau837]

This author willfully ignores the connection between opiod users and abusers.  Completely misleading article.

What is that connection, as you see it?

 

[Sand]

What is that connection, as you see it?

Users become abusers (a percentage).  Some of those will turn to heroin/fentanyl.

There was a study linked a bit up in this thread about opioid use have much better outcomes with close monitoring.  The corrollary would be that a low restriction environment leads to more addicts.

 

[Tau837]

Users become abusers (a percentage).  Some of those will turn to heroin/fentanyl.

There was a study linked a bit up in this thread about opioid use have much better outcomes with close monitoring.  The corrollary would be that a low restriction environment leads to more addicts.

You know that percentage is exceedingly low, right?

Surely you do not agree with the Government's approach on opioid prescribing due to the low percentage of those who are prescribed opioids who end up abusing them. Right?

 

[eoMMan]

I got some hydrocodone prescribed to me today after getting a wisdom tooth extracted. 

To be honest, I'd be fine with some extra strength Tylenol. The hydrocodone is overkill and shouldn't be given out so quickly, imo.

 

[Galileo]

I got some hydrocodone prescribed to me today after getting a wisdom tooth extracted. 

To be honest, I'd be fine with some extra strength Tylenol. The hydrocodone is overkill and shouldn't be given out so quickly, imo.

Are you worried you will become addicted if you use the hydrocodone?

 

[eoMMan]

Are you worried you will become addicted if you use the hydrocodone?

No.

 

[Sand]

You know that percentage is exceedingly low, right?

Surely you do not agree with the Government's approach on opioid prescribing due to the low percentage of those who are prescribed opioids who end up abusing them. Right?

The generally accepted number is about 5 percent.   You may or may not agree that's a small number.   I consider it significant. 

That number is about the same as the number of folks who try gambling and get addicted (we have strong laws to regulate that), etc. 

 

[Tau837]

The generally accepted number is about 5 percent.   You may or may not agree that's a small number.   I consider it significant.

Generally accepted by whom? I do not agree that there is a generally accepted number. Reported numbers vary widely due to variations between study parameters and the broad spectrum of pain conditions and patients. There is also a problem with inconsistent terminology and definitions. For example, some studies do not distinguish between misuse, abuse, and addiction; some do.

Here is one example from Prescription Opioids and Chronic Pain, a recent white paper by the Alliance for the Treatment of Intractable Pain:

A 2018 study investigated more than 586,000 patients prescribed opioids for the first time after surgery. Less than 1% continued renewing their prescriptions longer than 13 weeks. 0.6% were later diagnosed with Opioid Abuse Disorder during follow-up periods averaging 2.6 years between 2008 and 2016... It is quite possible -- even likely -- that the diagnosis of Opioid Abuse Disorder in many of these patients was incorrect...

That study examined patients prescribed opioids for the first time after surgery, and the rate who became opioid abusers was less than 1%.

From Opioid Addiction Is a Huge Problem, but Pain Prescriptions Are Not the Cause:

In general, new addictions are uncommon among people who take opioids for pain in general. A Cochrane review of opioid prescribing for chronic pain found that less than one percent of those who were well-screened for drug problems developed new addictions during pain care; a less rigorous, but more recent review put the rate of addiction among people taking opioids for chronic pain at 8-12 percent.

...The vast majority of people who are prescribed opioids use them responsibly—recent research on roughly one million insurance claims for opioid prescriptions showed that just less than five percent of patients misused the drugs by getting prescriptions for them from multiple doctors.

Those studies are linked in the post.

I don't think that last study is valid on its face, since it operates on an assumption that getting opioids from multiple doctors inherently equates to misuse. My wife is a chronic pain patient who gets prescriptions for opioids from multiple doctors. There are good reasons for it, and each doctor knows what is prescribed by the other and approves the arrangement. This is just one small example that illustrates the complexity of properly quantifying this issue.

Anyway, these studies are just a few examples, and there are many others. I do not believe there is a generally accepted rate of opioid users abusing their medication. My belief is that it is well below 5% for patients who are properly screened and monitored.

That number is about the same as the number of folks who try gambling and get addicted (we have strong laws to regulate that), etc. 

1. We have strong laws/regulations/policies to regulate opioid prescribing as well. I assume you are aware of that. Are you suggesting that we need more/stronger laws/regulations/policies to address opioids?

I can tell you this. What has been done so far has not had the desired effect on reducing opioid deaths - opioid prescribing is at a 10 year low, yet opioid deaths are at a 10 year (all time?) high. See Figure 1 in the white paper I linked above. Meanwhile, what has been done is harming millions of pain patients.  

2. Also, your gambling example is a terrible analogy. Opioids have legitimate medical use for millions of people suffering from acute and/or chronic pain. There is no such benefit for gambling. Apples and oranges.

 

[eoMMan]

1. We have strong laws/regulations/policies to regulate opioid prescribing as well. I assume you are aware of that. Are you suggesting that we need more/stronger laws/regulations/policies to address opioids?

We do?

 

[Slider]

I was in a bad wreck in 2012. I'm in pretty good shape and wasn't feeling all that bad. They prescribed me Vicodin, Delaudid, Xanax and Ambien the first night. I took none of it. Had labrum/cuff surgery and months of rehab. Was given 63 bottles of pills in total. Took one. Absolutely ridiculous what they give out.

 

[stbugs]

I was in a bad wreck in 2012. I'm in pretty good shape and wasn't feeling all that bad. They prescribed me Vicodin, Delaudid, Xanax and Ambien the first night. I took none of it. Had labrum/cuff surgery and months of rehab. Was given 63 bottles of pills in total. Took one. Absolutely ridiculous what they give out.

I agree. It’s not surprising to see how easy it is for those pills to be abused. You could have made quite a bit of money selling the other 62. Why were they even giving you more? I’m assuming you didn’t ask since you weren’t using them. 

 

[Slider]

I agree. It’s not surprising to see how easy it is for those pills to be abused. You could have made quite a bit of money selling the other 62. Why were they even giving you more? I’m assuming you didn’t ask since you weren’t using them. 

Lawyer said take what they give you and turn down nothing. It was corrupt trash all the way around. 

 

[wikkidpissah]

Corruption all around. Just Win Baby fights the good fight because, just as our system of jurisprudence is built on "let no innocent be convicted", pain treatment need be based upon "let no one suffer needlessly". But our ever-devolving level of citizenship allowss level upon level of corruption - govt letting pharma market, resulting in heightened addiction (at its beginning, a corruption, not a disease), pharma moving from marketing to enabling, addicts moving up the ladder of toxicity, justice & treatment failing to both hold people responsible and reduce recidivism - to prevail. Insane - every bit of this process is a moral failure on all fronts, and good people suffer as a result.

 

[Tau837]

We do?

Yes.

Doctors who inappropriately prescribe are subject to malpractice and/or prosecution. Scrutiny of opioid prescribing has increased to the point that many doctors and practices have stopped prescribing, even for patients with legitimate need.

States have created many laws relating to opioid prescribing.

CDC has released misguided guidelines that have been over-applied, serving as a basis for organizations like the VA and Medicare to apply inappropriate restrictions on opioid patients.

Seriously, the implication of the post I responded to was that we should make more laws on this. To do what, exactly? Opioid prescribing is already over-regulated, leading to harm to millions of pain patients.

 

[eoMMan]

Yes.

Doctors who inappropriately prescribe are subject to malpractice and/or prosecution. Scrutiny of opioid prescribing has increased to the point that many doctors and practices have stopped prescribing, even for patients with legitimate need.

States have created many laws relating to opioid prescribing.

CDC has released misguided guidelines that have been over-applied, serving as a basis for organizations like the VA and Medicare to apply inappropriate restrictions on opioid patients.

Seriously, the implication of the post I responded to was that we should make more laws on this. To do what, exactly? Opioid prescribing is already over-regulated, leading to harm to millions of pain patients.

Do you think we have any sort of opioid problem in the USA today?

If yes, how do you think we should go about fixing it?

 

[Tau837]

Do you think we have any sort of opioid problem in the USA today?

If yes, how do you think we should go about fixing it?

Yes. I think there are two problems:

1. Growing use of illicit opioids, like illegal Fentanyl and Heroin
   
2. Diversion of prescription opioids to those who misuse/abuse them
   

IMO problem #1 is 1-2 orders of magnitude greater than problem #2. Trying to combat problem #1 falls into the classic "war on (illegal) drugs." I don't think long running efforts to fight the "war on (illegal) drugs" have been very successful, and better methods are needed to yield a higher success rate in that effort.

IMO the solution for problem #2 is for opioid prescribing to be carefully monitored and screened to ensure prescribing is appropriate. In my experience (with my wife, a chronic pain patient), this has largely been achieved over the past several years due to the Government's "war" on our opioid "epidemic." Scrutiny on opioid prescriptions, prescribers, and patients as well as pharmacies filling the prescriptions has drastically increased, and overall opioid prescribing is at a 10 year low. Unfortunately, opioid deaths are at a 10 year high, which underlines the point that problem #2 is not really the main problem.

Unfortunately, our Government is trying to address opioid deaths by attacking problem #2, even though the vast majority of those deaths come from problem #1. The fact that the two problems are mostly unrelated explains why the Government's efforts are not having a positive effect on opioid deaths. Yet their efforts are harming millions of pain patients. It is obvious that this is the wrong approach. Well, obvious to anyone with a clue about the situation, which, unfortunately, does not describe our politicians.

I think additional positive steps could be taken. For example, pass a law that makes patients subject to prosecution if their medications are found to be in possession of others who are not caregivers of the patient. Make a law that opioid medications are required to be locked up in the patient's home, which would prevent family or friends from diverting them. These laws would be difficult to monitor/enforce, but they would likely represent incremental gains without doing harm to pain patients with legitimate need. And that - incremental gains without doing harm to pain patients with legitimate need - should be the focus of the Government's effort to solve problem #2.

I'm sure there are other positive steps that can be taken. Those are just a couple of ideas.

I also think it is very hypocritical of our Government to attack opioid prescribing in the manner it has. Consider that approximately 9 times as many people have already died in 2018 from alcohol than from prescription drugs, including more than 2 times as many people from drunk driving, implying many of those deaths were innocent victims. Drinking alcohol has no benefit equivalent to the benefit of opioids for pain patients. Why are we as a society so de-sensitized to alcohol deaths while being so hyper-sensitive to a relatively small number of prescription drug overdose deaths?

 

[Mystery Achiever]

Opioid prescriptions decline 12% between 2016 and 2017. It's a start.
http://www.businessinsider.com/opioid-prescriptions-decrease-iqvia-data-2018-4

Also, Take Back Day is April 28.

https://takebackday.dea.gov/

 

[Tau837]

The generally accepted number is about 5 percent.   You may or may not agree that's a small number.   I consider it significant.

Generally accepted by whom?

Revisiting this because I ran across this article today: New York Times Succumbs to The False Narrative Driving Opioid Policy-and Deaths

In fact, numerous studies before and after that now “infamous” letter continue to demonstrate the low addictive potential of medically prescribed opioids. For example, 2010 and 2012 Cochrane systematic analyses show chronic non-cancer pain patients on opioids have a roughly 1 percent addiction rate, and a January 2018 study by researchers at Harvard and Johns Hopkins of more than 568,000 “opioid naïve” patients over 8 years who were given opioids for acute postoperative pain showed a total “misuse” rate of 0.6 percent. In a 2016 New England Journal of Medicine article, Dr. Nora Volkow, the Director of the National Institute on Drug Abuse, stated, “Addiction occurs in only a small percentage of patients exposed to opioids—even those with preexisting vulnerabilities.” Furthermore, researchers at the University of North Carolina followed 2.2 million North Carolina residents prescribed opioids in 2015 and found an overdose rate of just 0.022 percent—and 61 percent of those overdoses involved multiple other drugs.

@Sand: Do you still think there is a generally accepted number of "about 5 percent" of "users who become abusers?"

 

[JaxBill]

Incredible thread here 

Highlights ( there are about 10 segments)- 

@brianmcnulty11: I'm 39 years old and have overdosed three times. I am obviously still alive. I am also from swPA and love hip-hop. I have thoughts/feels about @MacMiller and addiction in general. Thread/

@brianmcnulty11: People don't normally *want* to overdose. You just reach a point after a while when the amount of (whatever drug) doesn't quiet your thoughts anymore and so you up the dosage. Thing is: your body can only take so much.

@brianmcnulty11: It starts with the casual use of whatever to feel up or down. "Just a little helper" you tell yourself. And then before you can even realize what is happening, the fun of feeling a little better becomes the absolute need to put it into your system for a million reasons.

@brianmcnulty11: At the worst part of my heroin addiction, I was injecting around 500 milligrams of oxycontin per day. I wasn't getting high, just trying to not get sick. 500 milligrams of oxycontin can knock over a large animal. You know this, but it's your life now.

@brianmcnulty11: So you chase something that never comes and eventually, one of two things happens. You either run out of money (and ways to steal money while all your hookups dry out) and get clean (however), or you die. There is no third option.

@brianmcnulty11: Someone will use drugs for the first time today and not think twice about it. That's the inevitability that needs to change. I think sharing your experiences on certain stuff can help someone maybe. I have a decade clean now, and if I can do it..anyone can. Honestly.

 

[Mystery Achiever]

Tomorrow is DEA's annual Takeback Day. Scroll down to search for local collection sites.
https://takebackday.dea.gov/

 

[culdeus]

@brianmcnulty11: Someone will use drugs for the first time today and not think twice about it. That's the inevitability that needs to change. I think sharing your experiences on certain stuff can help someone maybe. I have a decade clean now, and if I can do it..anyone can. Honestly.

I'm not sure this is super helpful.  

 

[AAABatteries]

John Oliver’s update on Opiods

https://youtu.be/-qCKR6wy94U

 

[Mister CIA]

John Oliver’s update on Opiods

https://youtu.be/-qCKR6wy94U

So good.

 

[Terminalxylem]

Revisiting this because I ran across this article today: New York Times Succumbs to The False Narrative Driving Opioid Policy-and Deaths

@Sand: Do you still think there is a generally accepted number of "about 5 percent" of "users who become abusers?"

Regardless of the exact % of users who eventually abuse, do you think prescribing practices in the US have contributed to the opioid epidemic? Why do Americans require so many more prescriptions than the rest of the world? Are we more susceptible to pain?

I agree that diversion is a big problem, one that is hard to curtail by summarily dismissing those with legitimate pain. But we also need to question how opioids became so accessible in the first place. Even though heroin and fentanyl are the big killers, it's not uncommon for addicts to start their self destruction with prescribed medications.

 

[Tau837]

Regardless of the exact % of users who eventually abuse, do you think prescribing practices in the US have contributed to the opioid epidemic?

Yes, I think prescribing practices contributed. However, I think those practices that contributed have now been curbed through increased regulation and scrutiny. I think that is an obvious conclusion from the facts that opioid prescribing is now at a 10 year low while opioid deaths are at a 10 year high.

Why do Americans require so many more prescriptions than the rest of the world?

There are multiple reasons, including culture and lack of access and availability throughout the world. That last link summarizes a 2012 survey of countries that make up 87% of the world population. From that summary:

The World Health Organization (WHO) estimates there are 5 billion people living in countries with little or no access to pain medicines, including 5.5 million terminal cancer patients and millions of others suffering from acute illness and end-of-life suffering.

You see, context is important.

I agree that diversion is a big problem, one that is hard to curtail by summarily dismissing those with legitimate pain. But we also need to question how opioids became so accessible in the first place.

Actually, we don't need to question it. It is well understood, and it has been posted about extensively in this thread. Assuming you are talking about prescription opioids, prescribing increased beginning in the late 1990s when pain was established as the fifth vital sign. Some level of overprescribing accompanied that increase, some unintentional (e.g., by lack of education/understanding combined with desire to help patients) and some intentional (e.g., pill mills created for financial gain). Some of that was fueled by aggressive marketing campaigns by pharma companies. Over the past 10 years, the overprescribing has been eliminated to the maximum extent that can be expected; it can never be fully eliminated, just as we can never fully eliminate other types of healthcare fraud.

Even though heroin and fentanyl are the big killers, it's not uncommon for addicts to start their self destruction with prescribed medications.

The post you responded to contained a quote I posted about 3 separate studies that all showed addiction/misuse/overdose rates at 1% or lower. It will never be possible to bring addiction rates to zero. Low addiction/misuse rates such as those shown by these studies are an acceptable tradeoff for the medical benefit opioids provide to millions of Americans.

 

[Terminalxylem]

Yes, I think prescribing practices contributed. However, I think those practices that contributed have now been curbed through increased regulation and scrutiny. I think that is an obvious conclusion from the facts that opioid prescribing is now at a 10 year low while opioid deaths are at a 10 year high.

Prescribing practices have changed, but who’s to say the current level is low enough? As opioid addiction and death do not occur instantaneously, one would expect a lag between changes in prescribing and those stats.

There are multiple reasons, including culture and lack of access and availability throughout the world. That last link summarizes a 2012 survey of countries that make up 87% of the world population. From that summary:

You see, context is important.

What about Europe and the developed world, who are far better comparators for our analgesia needs?

ETA I see your first link addresses “culture” as it relates to pain. I’ll contend ours is too willing to turn to pills to solve our problems, including pain.

Actually, we don't need to question it. It is well understood, and it has been posted about extensively in this thread. Assuming you are talking about prescription opioids, prescribing increased beginning in the late 1990s when pain was established as the fifth vital sign. Some level of overprescribing accompanied that increase, some unintentional (e.g., by lack of education/understanding combined with desire to help patients) and some intentional (e.g., pill mills created for financial gain). Some of that was fueled by aggressive marketing campaigns by pharma companies. Over the past 10 years, the overprescribing has been eliminated to the maximum extent that can be expected; it can never be fully eliminated, just as we can never fully eliminate other types of healthcare fraud.

I never stated that overprescribing can be eliminated, but is foolish to dismiss it as minimized. The need for any opioid in managing chronic musculoskeletal pain should be questioned, for example, as no good data supports their long term efficacy for this purpose. Yet low back pain and arthritis top the list for opioid prescription, why? Prescribers are pressured to write for them and reluctant to have the tough discussions needed to wean them from chronic users.

The post you responded to contained a quote I posted about 3 separate studies that all showed addiction/misuse/overdose rates at 1% or lower. It will never be possible to bring addiction rates to zero. Low addiction/misuse rates such as those shown by these studies are an acceptable tradeoff for the medical benefit opioids provide to millions of Americans.

My point was the real killers, heroin and fentanyl derivatives, aren’t usually the first drug an addict tries.

 

[TripItUp]

Does opioid addiction impact the lower class/less educated at a higher rate?

I have a pretty broad network and Dont know a single person struggling with opioid issues. 

 

[Binky The Doormat]

I have a cousin in the Louisville, KY area that continues to have opioid issues.  About 5'9", weighs around 85 lbs.  He's been bad messed up since the late 70s, was kicked out of the army for selling drugs and did some time in the brink before getting out.  Love him, but he's a mess.  Haven't talked to him in several years.