Anthony Boudain actually did an episode of Parts Unknown where he went to MA and looked at heroin use and explicitly mentioned how we looked the other way when it was an inner-city black problem.
The story of the Oxycontin patent is exceptionally shitty. Scammy, skllful privately held company manipulated the clinical trials in order to make a mint from an obviously addictive painkiller.
More people in the US die from overdoses of this compound than from heroin overdoses, that's been true for a decade or two.
At this point it would probably be a net positive to go back to the pre-Purdue-lobbying rules: no prescription of strong opioids except for cancer, trauma, and other severe cases. They work better in the short term (perceptually, since we can't objectively measure pain), but there's a treadmill effect, plus it addicts and debilitates people in general.
I don't know anything about this firsthand, but why not prescribe opiods for chronic pain? Is there anything else that works as well for intense pain?
it addicts and debilitates people in general.
Addicts, yes, but I thought responsible (properly prescribed) opiate use wasn't terribly debilitating; that even heroin didn't do you all that much harm so long as you didn't overdose and maintained self-care.
Even without the addiction, I think there's concern that with the treadmill (or whatever they call it), you need higher doses over time for the same effect.
And can we really push addiction to one side conceptually? Responsible prescribing will help, but even with better practices it could end up being the case that there are enough bad cases inevitably resulting to make more opiate indications a bad proposition for society as a whole.
It's not my field, but I thought it was still an open question as to whether or not long-term opiate use is effective outside of some very narrow circumstances.
I would have been faster, but for all the Percocet.
Right, but so?
My vague impressions on this come partially from a friend with serious chronic pain; I don't know her medical/painkiller situation in any particularly detailed sense, but it's been a decade or so, and from bits of conversation over the years I believe she's on enough opiates that she, e.g., can't take Percocet anymore because at the necessary dosages her liver would explode from the acetaminophen. And she's fine -- successfully employed at a high pressure job, energetically domestic. In the absence of enough morphine to kill a donkey daily, I have the impression she would be significantly less fine.
I'm sure in some physiological sense she's an addict, but she's got pain, the painkillers kill the pain, and so her life works pretty well. Why is that a bad thing?
(Admittedly, that's a single anecdote, and one where I really don't know the details.)
According to a report in "Brain" scientists at St. Louis University have discovered an "off" switch for certain kinds of pain: a particular receptor ("A3"). This is only the rodent stage as yet. (Obligatory wet blanket biologist comment, heard in a previous life: "Sure they cured diabetes in mice. They do that a couple of times a year. Mice aren't people.")
The other thing that gets me about this is that easily-available simple facts
-(prescription opiate deaths in the US > heroin deaths)
-(main seller got caught and fined lying in order to sell poison)
are completely outside the conventional wisdom. This shouldn't be specialist knowledge, there's a clear story to tell.
When I had my nose cauterized in the ER, the attending, who may be the chair of the department, told the resident to give me any analgesic I wanted for the pain. The resident, who was in anesthesiology and only in the ER on a one-month rotation said, "Do you want some Percocet?"! No thanks.
9: There is some debate as to what is the result of just getting a higher tolerance for the opiates (in which case continuation with higher doses may work until your liver explodes) and opioid-induced abnormal pain sensitivity (in which case higher doses will just result in more sensitivity and not pain relief).
continuation with higher doses may work until your liver explodes
Correct me if I'm wrong, but 'liver explodes' isn't actually an opiate problem, AFAIK. It's a Tylenol problem.
Yes. Liver damage is definitely a Tylenol problem. They use it at higher doses in Europe and have more people with fucked-up livers to show for it. I was speaking flippantly assuming that there is an upper limit on dosage on pure opiates but I don't know what organ will go first.
I'm in treatment for chronic back pain and would be very upset to see restrictions on opiates. I'm not currently taking any, but I have periodic flareups that are absolutely crippling, and Oxycodone is the only thing that helps.
opioid-induced abnormal pain sensitivity (in which case higher doses will just result in more sensitivity and not pain relief).
I didn't know about this; there's an effect where opiates stop working as painkillers and leave you only addicted without getting the pain relief?
Dormandy's history of opium is a great read, as i recall if you ramp up slowly and have an unadulterated and reliably dosed supply you can go up to coleridgean doses so long as you can take the constipation. It's the impurities and inconsistent doses that kill.
I've a friend who was severely damaged by back surgery gone wrong and takes I suspect fairly epic amounts of opiates via prescription. If that is what allows him to be functional and have a relationship with his child, why not?
18: It isn't just that the opiates stop working as pain killers, but that they increase your sensitivity to pain by more than they relieve your pain. Or maybe that's a distinction without difference.
Or maybe that's a distinction without difference.
Sounds like it.
he went to MA and looked at heroin use and explicitly mentioned how we looked the other way when it was an inner-city black problem
And now it's an "epidemic" in MA (Patrick says so!) and there's a bunch of money being pumped into it, but in blankets that just infuse cash into programs one time without incorporation into their maintenance budgets. Meanwhile, a lot of these addicts end up in alcohol treatment programs, which are supposed to treat co-addictions but aren't funded to the levels needed for qualified staff to do that.
Meanwhile, a lot of these addicts end up in alcohol treatment programs
A reminder of the good old days when doctors would prescribe morphine as a treatment for alcoholism.
minivet: you could not possibly be more wrong if you tried. there are scores of thousands of people suffering agonizing pain because of misplaced worries about addiction. rising physical tolerance for opioids (needing increasing amounts to get the same effect) is totally distinguishable from addiction. my sister suffers truly awful agony because of her ehlers-danlos syndrome (we can hear her sit bolt upright in bed screaming when she dislocates her shoulder in her fucking sleep). the dea/FDA cracked down on all the doctors in her region so badly that they cut her dose by 60% with no taper, sending her into the misery of physical withdrawal and causing her health to permanently, irreversibly deteriorate as she was rendered incapable of doing any physical therapy, and became bed-bound for six months. and all because the government was worried that somewhere, someone was having fun getting high. this crackdown on "pill mills", aka "motherfucking pain specialists" is constantly threatening to drive her to the streets of baltimore for $10 of the best pain relief in the world, or into the drawer of her nightstand, where there is a loaded .357. NO. THE GOVERNMENT SHOULD ERR ON THE SIDE OF PEOPLE IN PAIN BEING GIVEN SAFE, EFFECTIVE MEDICINE TO TREAT THEIR PAIN. if some addicts get high in the process, so fucking what. people die of cancer suffering the torments of the "crab" that was thought to be mercilessly gnawing at your vitals in the ancient world, even though they could live out the rest of their lives without pain. if you support that, you have fucked-up priorities. and doctors are incredibly sexist. restrictions on pain medication will always be more stringently applied to women, whose pain is never taken as seriously as men's. yours, a person who is prescribed an inadequate dose of pain meds for chronic pain and suffers every day, unable to take part in the life of the people she loves, whom she sees moving beyond the thick, impenetrable glass of misery and exhaustion. and who has been a drug addict. and who knows the difference.
I can see my words shading into moral disapproval of addiction. Yes, sorry, screw that, it's all about harm.
I do wonder if pain specialists on the whole have a decent understanding of what the incessant new federal crackdowns/guidelines actually mean for them. I heard stories from a practice a relative was in, making me think they go into spasms of very nonspecific paranoia whenever something happens, maybe resulting in irrational clampdowns on patients. Of course better federal work (not centered as much on prosecutions) would certainly help.
Thanks, Al, for putting into words what I couldn't. Previously, I had seen my health care providers as my allies in combating my chronic pain issues. But after the latest crackdowns (which resulted in a significant cut in my opioid dosage), I've gone from seeing them as helpful to seeing them as a potential obstacle to my long-term health.
Consequently, I can no longer work pro-actively with my doctors and feel like I can trust them less, which is surely less good for my overall health, but being extra cautious/conservative feels necessary since keeping a low profile seems like the only way to prevent further cuts of my dosage.