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Comment by DanBC | Hacker News Reader

> With proper availability, opiates are very well tolerated.

This just is not true. With proper availability people develop tolerance, and require higher doses. That does becomes high enough to become dangerous, and so they need to change to a different, stronger opiate. They develop a tolerance to that too.

Eventually they're cycling through 2 or three different opiates (sometimes at the same time) at very high dose. And their pain is not being managed.

> addicted to antipsychotics or insulin or antidepressants

No tolerance, no seeking, no preoccupation, no continuing to take them when you know they're doing you harm -- those things are not addictive.

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What you keep saying in these threads is that opiates aren't effective. Why then do people continue to use them? Certainly if you're in pain, you're not taking a gram of morphine-equivalent per day just because. If there are effective alternatives, why are they not used? Then with pain under control, you can slowly (over a year, say) taper down.

I'm not saying it. National organisations are saying it - Public Health England (part of government); the Faculty of Pain Medicine (part of the Royal College of Anaesthetists); NICE (The National Institute for Health and Care Excellence, a non-departmental public body) all say it. So, unusually, do the CDC: http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html

If they were effective and if addiction could be safely managed you wouldn't see increasing rates of people addicted, taking dangerous amounts, and dying of overdose. http://www.theguardian.com/us-news/2016/mar/17/cdc-guideline...

People take opiates because doctors inappropriately prescribe them (in some countries); because the word "opiate" is well known; because people reject other treatments; and because people stick to the med they know. That's why co-proxamol (and very dangerous, ineffective medication, is still being prescribed today even though there are many other better meds).

They continue taking them, at massive doses, because they're addicted. And that's the problem - if they were addicted but getting pain relief we could understand the continued use of opioids as first line treatment, but most people don't get good pain control with opiates for long term pain. They end up having to mix different meds, these combinations are often dangerous. https://www.theguardian.com/science/2014/dec/09/us-patients-...

This would be basically why after breaking my hip and having it reassembled around a Dynamic Hip Screw, every week I dropped my dose of codeine so that the pain was back to being as bad as I'd been dealing with a week ago. I do wish people being prescribed opiates for situations where that's possible (i.e. the pain will lessen over time anyway) basically got a guide on doing that, not everybody's an ornery bastard like I am.

The only time opiates for control of pain that wasn't going to lessen over time seems like a good idea is in the case of palliative care for the dying; my father got several months of mostly-pain-free end of life out of it, and whether it was increased pain from the cancer or decreased effectiveness due to addiction that eventually meant the maximum dose allowable didn't help, he was dead within a week after that so even given all the obvious caveats I think he picked the right set of trade-offs.

This is what I've seen firsthand from the treatment facility I've volunteered at. Long term use becomes a problem for many patients and eventually they have pain even with dangerously high doses of opiodes.

There are multiple, large studies of rest home patients on opoids.

The conclusion, patients did not build up a tolerance.

(I know Dr. Dean Edell cited these studies many times, when he was on the air. He wasen't the typical media Doctor.)

You're talking about acute, short term, pain. I have repeatedly said that I am not talking about short term pain. I am talking about chronic, long term, pain.

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