Can somebody give some context on the root cause of the problem - the chronic pain epidemic in US. What caused it, why it is more than in other parts of the world and why so many painkillers?
Is it cultural?
Is it cultural?
>Is it cultural?
That's actually a really common misconception on HN. The United States ranks 27th among countries which abuse opiates, [1] behind many first-world countries like the UK, Italy, Spain, Switzerland, Ireland, and Russia, to name a few.
What's the cause? A lot of HNers like to pin it on unemployment and low-wage, low-skill jobs. I think that's narrowing the field in the right direction, but it isn't quite right; I know many very happy people who just make ends meet. There's something more that no one has been able to pinpoint quite yet.
1. https://en.wikipedia.org/wiki/List_of_countries_by_prevalenc...
I further suspect that the availability of opiate-containing drugs over the counter in some countries accounts for some of the differences in those statistics (e.g. cocodamol in the UK).
Since this discussion is about synthetic opioids it's not a useful source.
Have a look here. The US has considerably higher use than each of the countries you list when we talk about prescription meds.
http://www.unodc.org/documents/data-and-analysis/WDR2011/Sta...
Say you have a messed up disk in your spine. Surgery is tens of thousands of dollars. Getting a prescription for opioids from a primary care physician is a bit cheaper.
You don't see doctors in europe routinely prescribing hard pain killers because they try to fix the problem instead.
Healthcare in america is set up in such a way that hospitals just bill whatever and then have the lawyers argue over whats reasonable. That kinda works when youre part of the medicare system and their lawyers represent your side, but when youre on your own, you're suddenly in hospital recovering from major surgery, facing bankruptcy and have to hire a lawyer to tell the hospital to suck it.
So you just take the painkillers and hope for the best.
There are situations where risks from surgery are potentially worse than the (yes, possibly misinformed) side effects of painkillers.
Is there any data on this? Anecdotally, I know a few people who are either living with pain or taking medication because surgery is too risky.
Its just that there are people who "should" have surgery who "can't" have it because money.
Another issue is that just because a doctor advises you to take opioids doesn't mean that you're not abusing them. Doctors tell you to do all kinds of things that are bad for you because they are the lesser evil. The prime example being chemotherapy.
The primary use-case of morphine-like substances is to treat acute pain. Taking any kind of opioid for prolonged periods of time leads to systemic adaptation and you end up an "addict".
Is there data on this? Probably. Depends on what you want data for. The fact that america is under-insured when it comes to healthcare is well-established fact.
I don't buy "people take opioids because their lives are lame" - because its bullshit. There are drugs that are way easier to acquire that provide a lot more "fun". You don't start on heroin and then switch to vicodin, either. A heroin addiction is treated with methadone.
If you want a really clean "feel awesome" high, you want a benzodiazepine like Lorazepam. I had a prescription for that once. Popping one of those pills, you smile from ear to ear within seconds and experience pure bliss. If you intentionally try to have negative thoughts, you just laugh harder because it feels so ridiculous. If you wanted to "trick" a doctor into prescribing those, faking the necessary symptoms is really simple.
The drug industry has a pretty good grasp on how to engineer drugs to do one specific thing really well without causing a bunch of secondary effects. Modern painkillers are good at dealing with pain, without turning people into loonies. But opioids are opioids and if you take them indefinitely, you mess with brain chemistry.
Who are THEN told that they just can't get drugs anymore because now they're just filthy addicts. That's actually impressive. For a glorious nation like the united states of america. Borderline malice.
Obviously, ceteris paribus, less pain is much better than more pain, and there will probably always be acute and chronic pain for therapeutic innovation to tackle. There's no virtue in the experience of chronic pain. But the evidence strongly suggests that patients are worse off with casual access to powerful opiates, and that these products are packaged and sold irresponsibly.
No legitimate underlying medical phenomenon spurred the uptake in opiates.
50% of American adults suffer from chronic pain. If those levels don't qualify as an epidemic, what levels would?
I tried to avoid this pointless debate with a second paragraph to immunize my argument from the trope that arguments against opiates are arguments in favor of pain.
My point --- I think obviously --- is that no underlying medical pathology occurred to spur the uptake in consumer opiate products.
The uptake of opiates wasn't driven by any change in pathology, but it was partially driven by a change in how we think about pathology. The IOM report I linked to helped to popularize the idea of treating pain itself as a disease that should be treated, rather than as a symptom which shouldn't be treated until the underlying cause is known:
"Because pain often produces psychological and cognitive effects—anxiety, depression, and anger among them—interdisciplinary, biopsychosocial approaches are the most promising for treating patients with persistent pain. But for most patients (and clinicians), such care is a difficult-to-attain ideal, impeded by numerous structural barriers—institutional, educational, organizational, and reimbursement-related. [...] In addition, adequate pain treatment and follow-up may be thwarted by a mix of uncertain diagnosis and societal stigma consciously or unconsciously applied to people reporting pain, particularly when they do not respond readily to treatment. [...] Understanding chronic pain as a disease means that it requires direct treatment, rather than being sidelined while clinicians attempt to identify some underlying condition that may have caused it."
I'm definitely not arguing that opioids should be first line treatments for chronic pain, but I also agree with the IOM that they should be more accessible when needed.
https://www.washingtonpost.com/news/to-your-health/wp/2015/0...
C.f. the IOM report on pain in America: https://www.nap.edu/catalog/13172/relieving-pain-in-america-...
Anecdotal evidence over six decades of life on Planet Earth suggests otherwise.
Perhaps knowing that doctors would be vigilant against prescribing drugs with the potential for abuse, Purdue set out to distinguish OxyContin from rivals as soon as it dropped. The cornerstone of its marketing campaign was the drug's incredibly low risk of addiction, an enviable characteristic made possible by its patented time-release formula. Through an array of promotional materials, including literature, brochures, videotapes, and Web content, Purdue proudly asserted that the potential for addiction was very small, at one point stating it to be "less than 1 percent." (http://theweek.com/articles/541564/how-american-opiate-epide...)
Conversely, the country I live has a benzo problem. Hell, go into any doctor complaining you haven't been sleeping properly and he'll happily prescribe you clonazepam to help you with that. You have just been prescribed an addictive and strong psychoactive drug, just like that. He won't care if you have been working too much, or not eating or sleeping well, he will not care at all about possible factors that may be causing your current insomnia.
"take this and come back to reassess in 2 months", the doctor will say, and ofc, in 2 months you will come back saying this helped immensely, and from that there's a whole slew of problems that everyone knows: try to wane off it, insomnia comes back, sometimes worse. or maybe some new anxiety gets thrown in....
They want money, because if they wanted you to get well they you'd be treating the cause of your symptoms and not your symptoms :D
That's the whole point - doctors have more work, so they can ask for more money and pharmaceutical companies make a killing. Doctors are not interested in curing their patients nowadays, they are interested in making money for pharma.
I know a handful of doctors as well as pain patients, but I'm curious to get more context outside of the small bubble I know.
Seems to me it comes down to competence and ethics of individual doctors, as well as to preferences and susceptability of individual patients, of course.
We are not experiencing quite the epidemic proportions of the US, presumably owing to a different structure of health services, and probably a higher general level of scepticism towards medical authority, but the mechanisms and the potential are clearly in place.
https://www.medpagetoday.com/publichealthpolicy/publichealth...
And, it's culturally acceptable to be on medication so people take it for basically any inconvenience.
Sweating a little? Crank the AC. Small headache? take a pill. Bad day? Have a drink. Workout left muscles sore? Another pill. Sprained ankle? Obviously you need pain medication!
It's easy to see how there is a low threshold to abusing pain medication.
For people who've used opioid medication in the past year most of the developed world has a figure of around 1% or 2%. The US has over 5%.
What we don't have is the drug culture, people look for alternative ways to mitigate the pain.
A quick googling gave me this WHO paper:
https://www.hrw.org/sites/default/files/reports/hhr0511W.pdf
We found enormous unmet need for pain treatment. Fourteen countries reported no consumption of opioid pain medicines between 2006 and 2008, meaning that there are no medicines to treat moderate to severe pain available through legitimate medical channels in those countries.
These countries are concentrated in Sub-Saharan Africa, but are also found in Asia, the Middle East and North Africa, and Central America
https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidem...
My takeaway was that opiates were incorrectly classified as a non-addictive way to treat pain, so doctors started dolling them out far too liberally. Hospitals also started employing pain specialists who's sole job was to treat pain in patients. It's pretty easy to find people in any sort of "pain" if that's all you're looking for.
There have been a few prosecutions of individual sales/marketing people for knowingly supplying pill mills, but it's just a cost of business expense for large pharma companies.
What the farma company did was exploit already existing predisposition of people to take painkillers. They were working on fertile ground.
I don't know - having large population of people that need constant painkillers in their day to day life is just strange. Abusing the people is despicable. But why did this population existed in the first place?
The patent for OxyContin was predicated on the claim that each dose lasted longer than older poducts. When that didn't work they raised the dose instead of shortening dosing intervals, which caused a reward/withdrawal cycle in patients.
You have nothing to back that up. In fact, all the evidence I've seen points towards the opposite: the places with the least opiate abuse are (1) not happy countries (2) with very strict laws. See Qatar, Saudi Arabia, Singapore, etc.
If money and greed on the supply side, and lack of happiness on the demand side is the true cause of this, surely those countries would be ravaged with an opiate epidemic. But they are not. The problem is much more nuanced than you make it out to be.