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The Opiate and Heroin Epidemic in America (1 Viewer)

The search function on this site is awful. Searching for 'opioid' provided no results. Had to resort to Google.

Anyway, more evidence that this "opioid epidemic" is not driven by prescription opioids, from Prescription Opioid Use at 20-Year Lows:

Prescription opioid use in the United States is expected to decline for the ninth consecutive year in 2020, with per capita consumption of opioid medication falling to its lowest level in two decades, according to a new report by the IQVIA Institute, a data analytics firm. 

...

Despite the historic decline in prescription opioid use, U.S. overdose deaths hit a record high last spring, according to a new report from the CDC.  For the 12 months ending in May 2020, over 81,000 people died of a drug overdose.

"This represents a worsening of the drug overdose epidemic in the United States and is the largest number of drug overdoses for a 12-month period ever recorded," the CDC said in a health advisory, adding that the deaths were largely driven by illicit fentanyl, heroin, cocaine and psychostimulants such as methamphetamine. Opioid pain medication is not even mentioned in the CDC report.
Despite this data, the Government continues to press its opioid hysteria agenda against opioid manufacturers and doctors who prescribe pain medication, despite the fact that this does significant harm to chronic pain patients. It has been absurd all along, but grows even moreso as time passes, and we see that the misguided Government crusade is having zero positive effect.

 
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CDC Focused on Rx Opioids While Fentanyl Deaths Soared 1,040%

The study looked at fatal overdoses from 2013 to 2019, a period when U.S. drug deaths rose by over 56 percent, culminating with 70,630 Americans dying from overdoses in 2019.  

Deaths involving prescription opioids remained relatively flat during that period, while overdoses involving other substances rose, led by an astounding 1,040% increase in deaths linked to illicit fentanyl and other synthetic, mostly black market opioids. Overdoses involving heroin, cocaine and stimulants such as methamphetamine also rose...

The new CDC study adds to a growing body of evidence suggesting that the agency’s controversial opioid guideline has been ineffective and misdirected. While the guideline helped reduce the already shrinking supply of opioid medication – prescription opioid use is now at 20-year lows – drug deaths linked to illicit fentanyl and other substances kept rising. Overdoses hit a record high last spring.

"This represents a worsening of the drug overdose epidemic in the United States and is the largest number of drug overdoses for a 12-month period ever recorded," the CDC said in a recent health advisory.
More evidence the Government opioid hysteria is misguided and harmful. At this point, I have to view it as knowing and willful, though I don't understand the motivation. The evidence is there for anyone to understand if they care to and devote even 15 minutes to it.

 
Opioids and Injury Deaths: A population-based analysis of the United States from 2006 to 2017

Conclusion: In every state examined, there was no consistent relationship between the amount of prescription opioids delivered and total injury-related mortality or any subgroups, suggesting that there is not a direct association between prescription opioids and injury-related mortality. This is the first study to combine national mortality and opioid data to investigate the relationship between legally obtained opioids and injury-related mortality.
If anyone is surprised by this, you haven't been paying attention. That includes our politicians. :thumbdown:  

 
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Aren't people who become addicted to prescription opioids many times more likely to turn to heroin and fentanyl?
Yep.

While there certainly are people with legitimate acute and chronic pain who’ve unfairly been denied opioids, it’s hard to say we’ve gone too far in limiting prescriptions. Even after pretty profound reductions in the amount prescribed, we still lead the rest of the world by quite a bit WHO report And there are states/counties with markedly disparate prescribing practices as well. 

Does anyone have a good explanation why Americans require so much more analgesia than their international peers? Do we experience that much more pain?

 
Does anyone have a good explanation why Americans require so much more analgesia than their international peers? Do we experience that much more pain?
Recoil. Yanks project so much more of themselves onto others and upon what they do, If one invests a greater level of identity into endeavor, one will find themselves judged more frequently and harshly. This incites a cycle of defense mechanisms which bounces sound & fury throughout the psyche until noise drowns out any real chance at the introspection by which to resolve reaction and devise response, until yadayadayada, more'n'more'n'more............til the host seeks naught but quiet. I need a drink...

 
Recoil. Yanks project so much more of themselves onto others and upon what they do, If one invests a greater level of identity into endeavor, one will find themselves judged more frequently and harshly. This incites a cycle of defense mechanisms which bounces sound & fury throughout the psyche until noise drowns out any real chance at the introspection by which to resolve reaction and devise response, until yadayadayada, more'n'more'n'more............til the host seeks naught but quiet. I need a drink...
I like the way you put words together, but I’ll be damned if I can extract any meaning from your posts. 

But it appears you’re invoking a psychosomatic component to our collective pain, and by extension, opioid use. If so, I agree, but the solution to that problem ain’t more OxyContin.

 
Yep.

While there certainly are people with legitimate acute and chronic pain who’ve unfairly been denied opioids, it’s hard to say we’ve gone too far in limiting prescriptions. Even after pretty profound reductions in the amount prescribed, we still lead the rest of the world by quite a bit WHO report And there are states/counties with markedly disparate prescribing practices as well. 

Does anyone have a good explanation why Americans require so much more analgesia than their international peers? Do we experience that much more pain?
Curiously, my dentist would not prescribe me pain meds for an infection. The oral surgeon who removed the tooth a few days later (which generally leaves no pain when the local wears off) practically encouraged me to get the vicodin that was coming to me. Had no pain whatsoever.

 
Aren't people who become addicted to prescription opioids many times more likely to turn to heroin and fentanyl?
First off, there is a difference between dependency and addiction, as discussed in this article: Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies. From the article, which was co-authored by Dr. Nora Volkow, the Director of the National Institute on Drug Abuse:

There is lingering misunderstanding among some physicians about the important differences between physical dependence and addiction. The repeated administration of any opioid almost inevitably results in the development of tolerance and physical dependence... In contrast, addiction will occur in only a small percentage of patients exposed to opioids.
Addiction rates for those who take opioids long term are generally low -- different studies and sources linked in this thread report an addiction/opioid use disorder rate between less than 1% and 8-12%. I suspect the truth lies in the middle, but IMO it is on the lower end -- less than 5%.

The National Institute for Drug Abuse says:

  • Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them
  • Between 8 and 12 percent of people using an opioid for chronic pain develop an opioid use disorder
  • An estimated 4-6 percent who misuse prescription opioids transition to heroin
It isn't clear to me if that last item correlates to the first or second item. But, even assuming the larger number in the first item, doing the math suggests that up to 6% of the 29% of patients who misuse their prescription opioids transition to heroin shows that up to 1.7% of patients prescribed opioids may transition to heroin. But that is the worst case based on these numbers; I suspect the real percentage is lower.

I also think there are significant contributing factors outside of just one's susceptibility to addiction to prescription opioids, as described in this study: Socioeconomic marginalization and opioid-related overdose: A systematic review.

A total of 37 studies met inclusion criteria and were included in the review, with 34 of 37 finding a significant association between at least one socioeconomic factor and overdose. The included studies contained variables related to eight socioeconomic factors: criminal justice system involvement, income, employment, social support, health insurance, housing/homelessness, education, and composite measures of socio-economic status. Most studies found associations in the hypothesized direction, whereby increased SEM was associated with a higher rate or increased likelihood of the overdose outcome measured.
This implies that those who are not subject to negative socioeconomic factors such as those identified here are less likely to become addicted to prescription opioids and ultimately transition to other illegal drugs.

 
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I have totally agreed with you since this started. Just so happens that someone I once knew and was in close contact with, a former lecturer at Yale Medical School, wrote an article about how misguided the war on opioids has been. It's in the magazine National Affairs. I'll try and hook up a link. I think you should be able to read the article.

https://www.nationalaffairs.com/publications/detail/the-truth-about-painkillers

@Just Win Baby
Excellent article. Thanks for posting. :thumbup:  

 
Does anyone have a good explanation why Americans require so much more analgesia than their international peers? Do we experience that much more pain?
We already discussed this earlier in the thread. As mentioned there, part of the answer is inadequate access to most of the world's population.

From A First Comparison Between the Consumption of and the Need for Opioid Analgesics at Country, Regional, and Global Levels (2011):

Good access to pain management is rather the exception than the rule: 5.5 billion people (83% of the world's population) live in countries with low to nonexistent access, 250 million (4%) have moderate access, and only 460 million people (7%) have adequate access. Insufficient data are available for 430 million (7%). The consumption of opioid analgesics is inadequate to provide sufficient pain relief around the world. Only the populations of some industrialized countries have good access.
From Quantifying the Adequacy of Opioid Analgesic Consumption Globally: An Updated Method and Early Findings (2019):

With our study, we have shown that the adequacy of opioid analgesic consumption continues to be problematic around the world. Also in 2015, the large majority of people (almost 6 billion) live in countries where access is inadequate, meaning that they will not have their pain managed when falling ill. This number increased over the years, despite an increase in the number having moderate or adequate access. It shows that improvement of adequacy is limited to a number of countries and that policy efforts do not manage to keep pace with the increasing world population.

 
Just Win Baby said:
I know we discussed it, but your answer doesn’t apply for most of the developed world. I’m talking about OECD countries, not Sub-Saharan Africa. Look at countries whose health care/resources are comparable.

Better yet, look at the estimated MME per capita needed for each country in your paper. For most developed countries, it’s 10 or less. The US uses 350, down from a peak of 782. Granted, the distribution is not uniform, but proving underprescribing is a major problem is a tough sell.

I realize it’s possible both under- and overprescribing occur, but I believe the latter remains the bigger issue.

 
Isn't one of the issues with a proliferation of prescription opioids not that the original patient becomes an addict, but rather others around that patient stealing and abusing those drugs?

Maybe that's an urban myth about kids stealing pain pills from granny and crushing and snorting them. That leads them to illegal opiods and overdose. 

 
Other possible reasons US prescribing is higher than other countries:

  • Culture:

    Pain perception and the attitudes of healthcare providers towards pain varies widely between cultures.
  • Americans are more likely than their European or Asian counterparts to view pain as a malady rather than a natural consequence of aging or injury.

[*]Differences in regulatory controls and healthcare provider oversight:

  • In the U.S. much of the regulation and oversight is performed at the state rather than the Federal level, which may afford more variation and less tight control.

[*]Differences in how healthcare is delivered and reimbursed:

  • This can lead to differences in how patients are treated when they present with pain, a multifactorial symptom which can relieve many underlying ailments.

[*]Large older population:

  • While the US is 36th in percentage of population age 65+, they have 53M citizens in that age group. Japan is second, with 36M, and the Russian Federation is third, with 21M. Everything isn't uniform as populations scale, and the US has 150% the number of citizens in this age group as the third highest country.

[*]Surgeries:

Opioid prescribing in the US has been drastically reduced: Prescription Opioid Use at 20-Year Lows. Yet US opioid overdose deaths hit a record high for the 12 months ending in May 2020, as noted in the article.

That's because opioid overdose deaths are not correlated to opioid prescribing. See The Opioid Crisis in Three Charts.

Meanwhile, that reduction in opioid prescribing and associated, misguided opioid hysteria has absolutely done harm to chronic pain patients. That really isn't disputable.

 
Article published last week: Few Patients on Long-Term Opioids Engage in Risky Behavior

Only a small percentage of pain patients on long-term opioid therapy ask for higher doses, renew their prescriptions early or divert their medication to another person, according to a new study that challenges many common assumptions about prescription opioids.

For five years, Australian researchers followed over 1,500 patients taking opioid pain medication, with annual interviews asking them about their opioid use and behavior. The study is believed to be the first of its kind to follow patients on opioid therapy for such a long period... 

Researchers found that “problematic opioid use” was infrequent and steadily declined over time, with less than 10% of patients asking for higher doses or for a prescription to be renewed early. Less than 5% of patients tampered with their medications or diverted them to another person...

By the end of the study, patients were more likely to have stopped taking opioids (20%) than they were to be diagnosed with opioid dependence (8%), suggesting that long-term opioid use does not always lead to dependence or addiction. Even when they were diagnosed as opioid dependent, most patients did not meet the criteria for dependence the following year, suggesting the original diagnosis was faulty...

Webster noted that most people in the study were stable and few demonstrated any abuse or harm from opioids, including those on high doses who were less likely to ask for more medication.

“I think the overriding message of this study is that the one-size-fits all approach to using opioids for CNCP is flawed. The idea that everyone should be at a low level doesn't address individual needs,” Webster said.

 
Isn't one of the issues with a proliferation of prescription opioids not that the original patient becomes an addict, but rather others around that patient stealing and abusing those drugs?

Maybe that's an urban myth about kids stealing pain pills from granny and crushing and snorting them. That leads them to illegal opiods and overdose. 
Yes, diversion is a huge problem. And more liberal prescribing practices certainly won’t help that either.

 
Yes, diversion is a huge problem. And more liberal prescribing practices certainly won’t help that either.
Well, I haven't seen any data showing that it is a 'huge' problem today. I just posted an article about a long term study in which less than 5% of patients tampered with their medications or diverted them. Any diversion is a problem, but I believe the 'huge' problem has been largely mitigated over the past several years of constrained prescribing.

Also, other steps could be taken aside from simply limiting prescribing. For example:

  • Pass a law that those who receive opioid prescriptions are required to keep them locked away, like gun owners for handguns.
  • Pass a law that a person faces potentially serious penalties if their prescribed opioids are found in the possession of someone else.
These things wouldn't completely solve the problems, but could only help. And there might be other improvements.

 
Haven't had time to post regularly in this thread, but there is a lot of compelling new material since the last posts several months ago:

CDC’s Efforts to Quantify Prescription Opioid Overdose Deaths Fall Short (Pain and Therapy, March 2021) [bold/underline emphasis mine]

Key Summary Points

  • The Centers for Disease Control and Prevention (CDC) erroneously reported prescription opioid overdose deaths in 2016 and for more than a decade before.
  • The error was traced to miscoding of illicitly manufactured fentanyl as prescribed fentanyl, using defined T-codes of the International Classification of Diseases.
  • Systemic errors begin with error-prone death certificate information provided to the CDC by state registrars of vital statistics.
  • Besides the fentanyl error, similar limitations were noted for other controlled substances, notably benzodiazepines, cocaine, and methadone.
  • Most methadone today is used for treating opioid use disorder for which it must be administered or dispensed but not prescribed, according to federal law.
  • Yet, the CDC characterizes all methadone-related overdose deaths as involving the prescribed version used to treat pain; thus the integrity of the CDC’s prescription drug mortality data remains in question.
  • The CDC was aware of the error involving fentanyl coding as early as 2005–2007 when illicitly manufactured fentanyl was noted by the CDC in more than a thousand overdose deaths in the U.S.
  • Yet, the CDC ignored the problem until 2016 data showed serious inconsistencies with other, more reputable, data for prescribing volumes of opioids.
  • In 2018, the U.S. Congress mandated the CDC to “modernize” its system for reporting drug overdose deaths but this has not yet occurred.
Conclusions

Why the CDC ignored signals for years that its methodology for calculating prescription opioid overdose deaths was flawed is unknown. What is clear from the authors’ inquiry is that, even today, the CDC has no way of determining the actual number of prescription opioid overdose deaths each year. For more than a decade, the CDC’s erroneous reports went unchallenged while being used by Congress and the Executive Branch as the basis for public policy.
PROP’s Disproportionate Influence on U.S. Opioid Policy: The Harms of Intended Consequences (Pallimed, May 2021)

Conclusion

Despite being turned back from an effort to bluntly reduce opioid prescribing by the FDA in 2013 based on a lack of scientific evidence for its position (17,18), PROP has had a disproportionate effect on opioid policy in the United States for almost a decade. PROP found a willing federal regulatory partner in the CDC, and while PROP may not have “secretly written” the 2016 CDC Pain Guidelines (75), they certainly enjoyed disproportionate representation on CDC’s review panels and Core Expert Group (23-25) in a process that lacked transparency (22, 23, 26, 27). When the CDC admitted that its Pain Guideline had been widely misapplied (40) and joined the FDA in a call against forced opioid tapers (42, 43, 45), PROP doubled down on its rhetoric (46), dismissing legitimate concerns about potential harms in a performative manner (75) that encouraged their ongoing misapplication, while assailing PROP’s critics (76, 77). All of this has occurred as PROP members have repeatedly concealed relevant conflicts of interest, including key conflicts that should have been disclosed during the process of drafting the CDC Pain Guidelines (48-54).

Given this, at a minimum, PROP should no longer enjoy a prominent role in guiding future opioid policy in the United States. This is a particularly urgent concern, as Roger Chou has been linked to authorship of CDC’s New Pain Guidelines, which have not yet been released to the public (78). Chou’s involvement in yet another set of Guidelines and CDC’s recurrent lack of transparency (79) in identifying the new Guidelines’ authors should alarm all advocates who support access to pain medications for all patients with a medically legitimate indication for opioid therapy.
Opioids and Chronic Pain: An Analytic Review of the Clinical Evidence (Frontiers in Pain Research, August 2021)

Conclusions

This analysis of the clinical scientific literature on opioids suggests that many of the conventional assumptions about opioids, including safe opioid dosage, opioid efficacy, the factors that lead to opioid use and abuse, and the risks associated with opioid use, are not supported and in many cases, are refuted by existing scientific data...
Misuse of Rx Opioids Continues to Decline (Pain News Network, 10/26/2021)

For the fifth consecutive year, misuse of opioid medication fell in 2020, according to a new national survey that further documents the declining role of prescription pain relievers in the U.S. drug abuse crisis.

The annual report by the Substance Abuse and Mental Health Services Administration (SAMHSA) estimated that 59.3 million people used an illicit drug last year – about one in every five Americans aged 12 or older... Prescription pain relievers were misused by 9.3 million people, most of them taking a medication that was not their own.

The National Survey on Drug Use and Health classifies “misuse” in broad terms. It means using a prescription drug in any way not directed by a doctor, including using someone else’s prescription or using a drug in greater amounts, more often, or longer than directed by a doctor. That would include someone taking an additional pill during a pain flare.

Nearly two-thirds (64.6%) of respondents who admitted misusing a pain reliever said they did it to relieve physical pain. Only 11.3% said they misused a pain medication to feel good or to get high.  

Although the rate of illicit drug use has been steadily rising in the United States for many years, the misuse of prescription pain relievers has fallen by nearly 30% since 2015, most likely a reflection of fewer prescriptions, decreased supply, and the availability of other illicit drugs. An estimated 3.3% of Americans misused a pain medication in 2020.
A Scathing Rejection of the Case Against Four Drug Companies Highlights Misconceptions About the 'Opioid Crisis' (reason.com, 11/2/2021)

Since 2014, thousands of state and local governments have sued pharmaceutical companies they blamed for causing the "opioid crisis" by exaggerating the benefits and minimizing the risks of prescription pain medication. Given the enormous volume of lawsuits and a pending $26 billion multi-jurisdictional settlement involving four of those companies, you might surmise that there must be something to this accusation. If so, you should read the 42-page ruling that a California judge issued yesterday in response to the lawsuit that started this flood of litigation.

The details are indeed damning, but not in the way you might expect. Orange County Superior Court Judge Peter J. Wilson's scathing rejection of the case against four drug manufacturers highlights some of the misconceptions underlying the false narrative that blames pain treatment for a surge in opioid-related deaths that is better understood as a predictable result of the war on drugs.
Despite all of this strong evidence against the Government-driven prescription opioid hysteria, the harmful 2016 CDC guidelines remain in place, the DEA continues to pursue its 'war' on prescription opioids while non-prescription opioids continue to drive up annual opioid overdose deaths, and legitimate pain patients continue to suffer.  :(   :thumbdown:

 
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Why CDC Dropped One-Size-Fits-All Approach to Pain Care

“It was exciting to open up the draft and see a significant pivot,” said David Dickerson, MD, who chairs the American Society of Anesthesiologists’ Committee on Pain Medicine. “I think the CDC authors have acknowledged that they wanted to do it different this time.”
Finally, some common sense (and science! imagine that) is applied, even if several years late. Better late than never.

The draft removes the Morphine Milligram Equivalent (MME) threshold, which is critically important. It also makes it clear that it should be used to dictate how pain should be treated.

I hope this is the point where the tide turns for chronic pain patients.

 
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Few Fatal Overdoses Found in Rx Opioid Study

Researchers analyzed health claims for nearly 237,000 opioid “naïve” patients in Oregon from 2013 to 2018, and found that about 3 in 1,000 (0.3%) experienced an overdose within three years of their first prescription. The vast majority of the 667 reported overdoses were non-fatal, and researchers could not determine if they involved illicit opioids or the opioids that patients were prescribed.  

“There were relative few fatal overdoses - I believe it was less than 100. So we didn't look further than that because there wasn't statistical power,” said lead author Scott Weiner, MD, an emergency physician at Brigham and Women’s Hospital in Boston. “Unfortunately, it is not possible to ascertain if the overdose was from illicit or prescribed opioids from the data.”  

One of the more surprising aspects of the study is that there was little association found between overdoses and high dose prescriptions. The CDC says opioids prescribed at daily doses that exceed 90 MME (morphine milligram equivalent) raise the risk of overdose, but Weiner and his colleagues found little evidence to support that.  

“Incidence of overdose was not associated with varying levels of MME that were received in the first 6 months, which may indicate that patient factors may be more important than the strength of the opioids prescribed. These are both novel findings,” researchers reported in in JAMA Network Open.
Again, finally. This is not surprising in the least.

 
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The biggest culprit of opioid deaths these days seems to be street  fentanyl.  Not sure how to get rid of that scourge, but it sounds horrible.  Worse than the meth epidemic that happened 10 years ago. 

 
Does anyone have a good explanation why Americans require so much more analgesia than their international peers? Do we experience that much more pain?


I know we discussed it, but your answer doesn’t apply for most of the developed world. I’m talking about OECD countries, not Sub-Saharan Africa. Look at countries whose health care/resources are comparable.
@Terminalxylem

From U.S. Falls to 8th Globally in Per Capita Opioid Sales:

Concerns about opioid addiction and overdoses have caused opioid sales to plummet in the United States in recent years. Opioid consumption has fallen so sharply that Canada, Australia and several European countries have overtaken the U.S. and become the highest consumers of opioid analgesics, according to a new study...

Lau and her colleagues analyzed global pharmaceutical sales in 66 countries from 2015 to 2019...

The highest opioid rate was found in Canada, estimated at 988 milligram morphine equivalents (MME) per day for every 1,000 people...

By comparison, the U.S. rate was 738 MME per 1,000/day, a 45% decline since 2015. Long touted as having the highest per capita opioid consumption in the world, the U.S. now ranks 8th globally in opioid sales...

The Lancet commission said there were several barriers that stood in the way of effectively treating pain, including “opiophobia” – prejudice and misinformation about the medical value of opioids.

“Unbalanced laws and excessive regulation perpetuate a negative feedback loop of poor access that mainly affects poor people,” the commission said...
The article shows that these 7 countries have now surpassed the US: Canada, Switzerland, Germany, Spain, Denmark, Australia, Austria. And just behind the US is Norway, Netherlands, and Belgium. All OECD countries whose health care/resources are comparable.

Also, note this study was for 2015-2019. I expect the US has slipped further down the list over the past 3 years due to the ongoing opioid hysteria in the US.

 
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Just Win Baby said:
@Terminalxylem

From U.S. Falls to 8th Globally in Per Capita Opioid Sales:

The article shows that these 7 countries have now surpassed the US: Canada, Switzerland, Germany, Spain, Denmark, Australia, Austria. And just behind the US is Norway, Netherlands, and Belgium. All OECD countries whose health care/resources are comparable.
Thanks, that’s great news. It’s too bad we can’t have an overall score to serve as proxy for our collective need for opioids, incorporating age, procedures and painful comorbidies, to get a real apples-to-apples comparison between countries. But it’s encouraging that we’re starting to fall in line with some OECD countries.

While I have no doubt developing countries are under treating pain, what differentiates us from New Zealand, South Korea, France, Japan and Italy? What is ideal per capita daily MME consumption?

To be clear, I think opioids are simultaneously over- and under-prescribed in the US. I see both inadequately treated pain and unnecessary chronic opioid use frequently, as well as substance abuse, though it’s less clear which side of the equation predominates. We definitely need more research and resources funneled into pain management and addiction.

 
Thanks, that’s great news. It’s too bad we can’t have an overall score to serve as proxy for our collective need for opioids, incorporating age, procedures and painful comorbidies, to get a real apples-to-apples comparison between countries. But it’s encouraging that we’re starting to fall in line with some OECD countries.
I wouldn't call it great news. It is likely that a lot of pain continues to be undertreated or untreated in the US due to the ongoing opioid hysteria in the US. IMO the pendulum has swung much too far in the wrong direction on this subject, and thousands of good people are suffering.

Meanwhile, we continue to set all-time highs in opioid overdoses every year, because the opioid overdose problem was never strongly correlated to opioid prescribing in the first place. I have probably posted at least 30 articles in this thread that make that clear. The facts are indisputable on this at this point.

While I have no doubt developing countries are under treating pain, what differentiates us from New Zealand, South Korea, France, Japan and Italy? What is ideal per capita daily MME consumption?
A lot of the factors I posted about previously come into play here, e.g., culture, relative ages of the populations, their approach to medical and dental treatments/surgeries, etc.

Also, note the study I posted about was for 2015-2019. I expect the US has slipped further down the list over the past 3 years due to the ongoing opioid hysteria in the US.

What is ideal per capita daily MME consumption?
This illustrates a misconception. There is no ideal. Why? Because every human is different, including:

  • Differing physical and mental conditions
  • Differing pain and diseases
  • Differing abilities to metabolize opioids
  • Differing life situations, which may help to offset or exacerbate the above
The idea of an "ideal per capita daily MME consumption" has no scientific basis. This is one of the biggest problems with the CDC guidelines.

 
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I wouldn't call it great news. It is likely that a lot of pain continues to be undertreated or untreated in the US due to the ongoing opioid hysteria in the US. IMO the pendulum has swung much too far in the wrong direction on this subject, and thousands of good people are suffering.

Meanwhile, we continue to set all-time highs in opioid overdoses every year, because the opioid overdose problem was never strongly correlated to opioid prescribing in the first place. I have probably posted at least 30 articles in this thread that make that clear. The facts are indisputable on this at this point.

A lot of the factors I posted about previously come into play here, e.g., culture, relative ages of the populations, their approach to medical and dental treatments/surgeries, etc.

Also, note the study I posted about was for 2015-2019. I expect the US has slipped further down the list over the past 3 years due to the ongoing opioid hysteria in the US.

This illustrates a misconception. There is no ideal. Why? Because every human is different, including:

  • Differing physical and mental conditions
  • Differing pain and diseases
  • Differing abilities to metabolize opioids
  • Differing life situations, which may help to offset or exacerbate the above
The idea of an "ideal per capita daily MME consumption" has no scientific basis. This is one of the biggest problems with the CDC guidelines.
Ok, we just disagree where we fall in the spectrum of harm:benefit for opioids vs. other options for pain management. We were an international outlier in our prescription practices previously; now we’re more in line with the rest of the developed world. That’s an improvement imo. 

I’m not advocating a one size fits all approach to analgesia, nor do I think there is a good answer to my hypothetical “ideal”  per capital MME. But until we have objective measures of pain severity and analgesic efficacy, we’re taking an educated guess regarding the sweet spot for opioids, at best.

 
Ok, we just disagree where we fall in the spectrum of harm:benefit for opioids vs. other options for pain management. We were an international outlier in our prescription practices previously; now we’re more in line with the rest of the developed world. That’s an improvement imo
Sure, we can agree to disagree on it, as we have pretty much done throughout our exchanges on this subject in this and other threads over the past several years.

I must take issue with your final statment, however (bolding is mine). For anyone like yourself who feels it is an improvement, I must assume you do not yourself suffer nor have any loved ones who are suffering because of the drastic reductions in opioid prescribing that have occurred over the past several years.

My wife falls into that category, so I am obviously biased. But my point is, most people who suffer from chronic pain and/or have loved ones who do would almost certainly disagree that the net effect of the past several years of opioid prescribing crackdowns has been an improvement.

For many, it seems to be the kind of thing that must be personally experienced to get beyond the theoretical.

 
Sure, we can agree to disagree on it, as we have pretty much done throughout our exchanges on this subject in this and other threads over the past several years.

I must take issue with your final statment, however (bolding is mine). For anyone like yourself who feels it is an improvement, I must assume you do not yourself suffer nor have any loved ones who are suffering because of the drastic reductions in opioid prescribing that have occurred over the past several years.

My wife falls into that category, so I am obviously biased. But my point is, most people who suffer from chronic pain and/or have loved ones who do would almost certainly disagree that the net effect of the past several years of opioid prescribing crackdowns has been an improvement.

For many, it seems to be the kind of thing that must be personally experienced to get beyond the theoretical.
I’m a middle aged human, and I work in healthcare. Believe me, I’m quite familiar with suffering. Fortunately, I don’t live with chronic severe pain, but I’ve loved ones who do/did, and interact with people taking opioids all the time. I’ve seen them work wonders for pain, but also their side effects, abuse and addiction. So please don’t dismiss my perspective, implying I’m callous or ignorant.

Perhaps you should consider the possibility your view is a bit extreme, in large part due to your wife’s experience? While I wouldn’t wish chronic pain on her or anyone, it’s really tough to justify our opioid use beginning in the late 90s until the peak of the opioid crisis in 2011 - prescription volume more than quintupled during that period, and the US consumed 80%+ of the world’s opioids. Even with our recent downtrend, we’re still ~60% of peak usage, far above most of the developed world and our historic baseline, before pain became the “fifth vital sign”. 

So yes, my gestalt is the reduction in opioid prescription is a step in the right direction. But as I’ve said repeatedly, that doesn’t preclude the possibility some pain is undertreated. The challenge is identifying who benefits the most from chronic opioids, and how to mitigate the harm caused by their use.

 
I’m a middle aged human, and I work in healthcare. Believe me, I’m quite familiar with suffering. Fortunately, I don’t live with chronic severe pain, but I’ve loved ones who do/did, and interact with people taking opioids all the time. I’ve seen them work wonders for pain, but also their side effects, abuse and addiction. So please don’t dismiss my perspective, implying I’m callous or ignorant.
My statement was "I must assume you do not yourself suffer nor have any loved ones who are suffering because of the drastic reductions in opioid prescribing that have occurred over the past several years."

My point is that people with severe chronic pain are suffering significantly specifically due to the opioid hysteria that has led to reduced/restricted prescribing. Your answer doesn't indicate that you have experience with loved ones in that situation, i.e., who are suffering due to the hysteria. Your answer doesn't indicate that you have a healthcare role where you are dealing with that specific suffering.

BTW, I'm using "opioid hysteria" as a term that covers all of the issues: the CDC guideline, reduced opioid prescribing, forced tapering of chronic pain patients, persecution of pain practitioners and pharmacies, etc.

I'm not assuming you are callous or ignorant. But I do not believe anyone could live the life of a CPP, a caregiver for a CPP, or a pain practitioner and believe that what has transpired with opioid hysteria over the past several years is an improvement.

Perhaps you should consider the possibility your view is a bit extreme, in large part due to your wife’s experience? While I wouldn’t wish chronic pain on her or anyone, it’s really tough to justify our opioid use beginning in the late 90s until the peak of the opioid crisis in 2011
I clearly stated: "My wife falls into that category, so I am obviously biased." If today's perspective on opioids was in place 20 years ago, my wife likely would not be alive today.

That doesn't make my view extreme, it makes it informed.

 
My statement was "I must assume you do not yourself suffer nor have any loved ones who are suffering because of the drastic reductions in opioid prescribing that have occurred over the past several years."

My point is that people with severe chronic pain are suffering significantly specifically due to the opioid hysteria that has led to reduced/restricted prescribing. Your answer doesn't indicate that you have experience with loved ones in that situation, i.e., who are suffering due to the hysteria. Your answer doesn't indicate that you have a healthcare role where you are dealing with that specific suffering.

BTW, I'm using "opioid hysteria" as a term that covers all of the issues: the CDC guideline, reduced opioid prescribing, forced tapering of chronic pain patients, persecution of pain practitioners and pharmacies, etc.

I'm not assuming you are callous or ignorant. But I do not believe anyone could live the life of a CPP, a caregiver for a CPP, or a pain practitioner and believe that what has transpired with opioid hysteria over the past several years is an improvement.

I clearly stated: "My wife falls into that category, so I am obviously biased." If today's perspective on opioids was in place 20 years ago, my wife likely would not be alive today.

That doesn't make my view extreme, it makes it informed.
You’re off-base in multiple ways.

Most importantly, I’ve not experienced “opioid hysteria” because it simply isn’t as ubiquitous a problem as you assume. One doesn’t need to be a chronic pain patient or specialist to know this. You’re free to disagree, claim special expertise, and attempt to prove otherwise, but that doesn’t invalidate my opinion.

I’ve never denied some pain is being undertreated. And I don’t think our current policies are perfect. But I maintain the alternative from the early 2000/10s was worse for society, collectively. So we’re moving in the right direction. If you want to argue about a shorter timeframe, that’s fine, though it’s not the most relevant comparison IMO.

But rather than prolonging this senseless argument, I’ll leave it at agreeing to disagree.

 
Might there be a substitute for opioids on the horizon? 

Biotech Vertex Pharmaceuticals VRTX is getting closer on an approval for its pain pill that could serve as a replacement for opioids since trials showed greater improvements in pain relief.

The company said on March 31 that it received positive results from two Phase 2 proof-of-concept studies that investigated treating patients with acute pain following abdominoplasty surgery or bunionectomy surgery with their drug known as VX-548.

The pain pill, VX-548, was generally "well tolerated in both studies," the company said in a statement.

"Most adverse events (AEs) were mild to moderate and there were no serious adverse events (SAEs) related to VX-548," Vertex said. "Fewer patients discontinued treatment in the mid- and high-dose VX-548 arms than in the placebo group or HB/APAP reference arm."

The next step is for Vertex to advance the pain pill "into pivotal development in the second half of 2022, following discussions with regulators" and enter into Phase 3 of trials, the company said.

“The remarkable consistency in the safety, tolerability and efficacy results in these two studies demonstrate the potential of VX-548 to be a first-in-class non-opioid treatment for acute pain," said Carmen Bozic, Vertex's chief medical officer, in a statement.

"We are working with urgency to advance the program into Phase 3 with the goal of bringing forward the first novel pain treatment in decades to address the unmet needs of patients suffering from acute pain.”

 
But I maintain the alternative from the early 2000/10s was worse for society, collectively.
I'd be interested to know the reasons you believe it was worse.

The entire movement to reduce and restrict opioid prescribing was based on the false premise that doing so would stem the ever increasing number of opioid overdose deaths. That hasn't happened, as we continue to set all-time highs for opioid overdoses every year, despite significant reductions in opioid prescribing (at a 20 year low through 2020, as linked earlier in the thread). Fewer opioid overdose deaths was better, not worse.

It is reasonable to think that less restricted opioid prescribing meant that fewer US chronic pain patients were undertreated or untreated for their pain. That was better, not worse.

So what exactly was worse for society?

 
I have very little knowledge about this topic and find it interesting.

I recently had a root canal and my dentist wrote me prescription for Vicodin. I've had several extractions over the years and she normally just gets me antibiotics and extra strength ibuprofen. This time - Vicodin, despite me having higher pain tolerance these days.

I just took the antibiotics for a few days and shook it off. Seems dangerous to recommend Vicodin considering the state of affairs.

 
I'd be interested to know the reasons you believe it was worse.

The entire movement to reduce and restrict opioid prescribing was based on the false premise that doing so would stem the ever increasing number of opioid overdose deaths. That hasn't happened, as we continue to set all-time highs for opioid overdoses every year, despite significant reductions in opioid prescribing (at a 20 year low through 2020, as linked earlier in the thread). Fewer opioid overdose deaths was better, not worse.

It is reasonable to think that less restricted opioid prescribing meant that fewer US chronic pain patients were undertreated or untreated for their pain. That was better, not worse.

So what exactly was worse for society?
You oversimplify the impact of prescription opioids. It doesn't just boil down to overdose deaths vs. untreated pain.

Beginning in the late 90's, opioid prescriptions dramatically increased, with a commensurate increase in opioid consumption, and presumably diversion. In turn, there was an uptick in recreational abuse of both prescription and nonprescription opioids, creating a new market promoting newer and stronger drugs, culminating with fentanyl derivatives. Addiction and overdose deaths soon followed, and these problems continue despite changes in prescribing practices. The toothpaste is out of the tube, so to speak, because drug dealers no longer need a pipeline of prescription drugs, as they've learned to synthesize the stuff that kills people. But that doesn't absolve unnecessary prescriptions from starting the gears in motion.

And there is a lot of collateral damage. Crime begins with the initial diversion, and may escalate to continue the habit. This includes both petty theft and drug-associated violence, as well as transactional sex work, with associated risk of sexually transmitted infections. More crime eventually taxes law enforcement resources and the criminal justice system, with disproportionate impact on poorer communities, many of which happen to be areas where per capita prescriptions were highest.

But it isn't just criminals taking opioids. There's a lot of lost productivity related to sedation from meds, as well as healthcare utilization from overuse leading to confusion, respiratory suppression and falls, particularly among the elderly. People even get hospitalized for opioid-induced constipation. Plus there are overburdened mental health services needed to manage addiction and psychiatric comorbidities (a critical component in some chronic pain), and social services for consequences of addiction, like unemployment and homelessness.   

And it starts early, as a culture of pill popping has permeated our schools. Readily available meds don't help. 

I'm all for strategies which minimize the harms of addiction, limit diversion and allow pain sufferers access to needed analgesia. Unfortunately, it's really hard to thread the needle between those competing goals, but less restrictive prescription policies aren't the answer IMO. The 20-year low you reference is still well above our baseline from the 90s, and though we've become more in-line with some OECD countries, there's no good way to know if we've reached the right balance.  For starters, we can't even objectively measure pain.

AFAIK, there hasn't been a spike in hospitalizations for intractable pain or withdrawal. Yet I continue to see sequelae of abuse and addiction, as well as opioid users casually complaining of 10 out of 10 pain. The level of suffering, as best I can tell, hasn't changed much despite the decrease in prescriptions. Then again, it's difficult to make any meaningful generalizations the last couple years, due to the pandemic. 

 
Beginning in the late 90's, opioid prescriptions dramatically increased, with a commensurate increase in opioid consumption, and presumably diversion. In turn, there was an uptick in recreational abuse of both prescription and nonprescription opioids, creating a new market promoting newer and stronger drugs, culminating with fentanyl derivatives. Addiction and overdose deaths soon followed, and these problems continue despite changes in prescribing practices.
Data shows that drug abuse and overdose deaths have occurred at a steady increasing rate for decades, starting long before the 1990s. The drugs of choice for abusers and overdosers have varied, but the trend has been consistent.

Beginning in the late 90's, opioid prescriptions dramatically increased, with a commensurate increase in opioid consumption, and presumably diversion. In turn, there was an uptick in recreational abuse of both prescription and nonprescription opioids, creating a new market promoting newer and stronger drugs, culminating with fentanyl derivatives. Addiction and overdose deaths soon followed, and these problems continue despite changes in prescribing practices. The toothpaste is out of the tube, so to speak, because drug dealers no longer need a pipeline of prescription drugs, as they've learned to synthesize the stuff that kills people. But that doesn't absolve unnecessary prescriptions from starting the gears in motion.

And there is a lot of collateral damage. Crime begins with the initial diversion, and may escalate to continue the habit. This includes both petty theft and drug-associated violence, as well as transactional sex work, with associated risk of sexually transmitted infections. More crime eventually taxes law enforcement resources and the criminal justice system, with disproportionate impact on poorer communities, many of which happen to be areas where per capita prescriptions were highest.

But it isn't just criminals taking opioids. There's a lot of lost productivity related to sedation from meds, as well as healthcare utilization from overuse leading to confusion, respiratory suppression and falls, particularly among the elderly. People even get hospitalized for opioid-induced constipation. Plus there are overburdened mental health services needed to manage addiction and psychiatric comorbidities (a critical component in some chronic pain), and social services for consequences of addiction, like unemployment and homelessness.   
This is all unsubstantiated. Do you have data that supports this viewpoint? Data that correlates to opioid prescribing? I am skeptical.

The 20-year low you reference is still well above our baseline from the 90s, and though we've become more in-line with some OECD countries, there's no good way to know if we've reached the right balance.  For starters, we can't even objectively measure pain.
Sure, but there is no reason to believe that we haven't, either. Absence of evidence one way or the other cuts both ways.

AFAIK, there hasn't been a spike in hospitalizations for intractable pain or withdrawal. Yet I continue to see sequelae of abuse and addiction, as well as opioid users casually complaining of 10 out of 10 pain. The level of suffering, as best I can tell, hasn't changed much despite the decrease in prescriptions. Then again, it's difficult to make any meaningful generalizations the last couple years, due to the pandemic. 
There has been a spike in suicides due to forced tapering. That is not disputable.

As for "10 out of 10" pain, it is obviously subjective and biased from any given patient. I don't put a lot of stock into those ratings. What really matters is relativity, i.e., for a given patient, how do their ratings and behavior and presentation compare visit over visit over many visits? If pain practitioners are doing things right (i.e., not acting as pill mills), they know about their patients and can react accordingly.

Agree the pandemic has made it more challenging to assess over the past couple years.

 
Data shows that drug abuse and overdose deaths have occurred at a steady increasing rate for decades, starting long before the 1990s. The drugs of choice for abusers and overdosers have varied, but the trend has been consistent.

This is all unsubstantiated. Do you have data that supports this viewpoint? Data that correlates to opioid prescribing? I am skeptical.

Sure, but there is no reason to believe that we haven't, either. Absence of evidence one way or the other cuts both ways.

There has been a spike in suicides due to forced tapering. That is not disputable.

As for "10 out of 10" pain, it is obviously subjective and biased from any given patient. I don't put a lot of stock into those ratings. What really matters is relativity, i.e., for a given patient, how do their ratings and behavior and presentation compare visit over visit over many visits? If pain practitioners are doing things right (i.e., not acting as pill mills), they know about their patients and can react accordingly.

Agree the pandemic has made it more challenging to assess over the past couple years.
Opioid abuse and overdose deaths were fairly flat through the 70s and 80s, before consistent increases paralleling opioid production began in the late 90s.  

Graph of opioid numbers 1999-2010

Wiki summary of all drug overdose deaths, as it’s tricky to find graphs of data before 1999 (refers to CDC database)

And I don’t know how many suicides resulted directly from opioid tapering, nor how to compare that number to lives lost related to opioid abuse and addiction, plus all the other collateral damage I mentioned.

As I said, I don’t claim to know the optimal amount of opioids to balance the risk vs. benefit. But I think it’s pretty clear the early 2000s missed the mark.

 
I wonder how many of these opioid deaths are due to cocaine laced with fentanyl?  I heard of a local guy who OD'd because of this, and they think this is what happened to the West Point guys in Miami.  

 

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