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Comment by ransom1538 | Hacker News Reader

What bothers me about this epidemic is how easy it could be for authorities to stop. Fentanyl isn't created in the back of a motor home. It is a manufactured and controlled narcotic. How controlled - just see the link below. All that needs to happen is for the DEA (et al) to stop raiding homes and torturing people and to pay a visit to these out of control doctors. Why a "Nurse Practitioner" is allowed to prescribe opioids 21937 times - wtf? Opioid prescribing is totally open and public - they aren't hiding it.

Here I have a list of the highest prescribing opioid doctors (sunday with beer project): https://www.opendoctor.io/opioid/highest

(let me know if you want the sql or whatever).

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I remember that about a decade ago, doctors and others were criticizing the DEA for being draconian in their regulations surrounding opiate prescriptions. They were complaining that doctors often felt that they couldn't prescribe even when there was legitimate need.

I don't know what happened in the interim, whether or how the DEA's policies changed, but if only we had draconian DEA policies aggressively stopping overprescription now.

As someone who used to naively believe in legalizing all drugs for recreational use, this addiction epidemic has opened my eyes to why that's a horrible idea.

> I don't know what happened in the interim

The VA noticed a lot of people had untreated pain. They pushed a campaign to make pain the fifth vital sign. Every time someone went into a hospital they'd be asked about pain. Pain was seen as something that absolutely must be treated.

They also said that opioids are not addictive if prescribed for pain.

It turns out that both of these are mostly wrong. If someone is in pain they'll tell you, you don't need to ask. And if someone has chronic pain they can become addicted to opioids.

The VA withdrew that document. Here's a Google cache: https://webcache.googleusercontent.com/search?q=cache:pUQ-mc...

We knew some time ago that it didn't help. Here's a report from 2006: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/

Actually I agree with asking about pain. If someone's REALLY in pain they'll tell you, but if it's "minor suffering" some are predisposed to tough it out.

I can't remember having ever been in 'real pain', maybe for that the addictive drugs should be considered under a monitored regime.

For lesser pain something lighter should be used.

> but if only we had draconian DEA policies aggressively stopping overprescription now.

Not sure what the policies are now, but around me, I can not go get any prescription for any back pain (have really needed it twice in the past 3 years). "Nope, go see your GP" (vs going to a walk-in clinic). The walk-ins around here all have signs on the front door saying "no prescriptions for oxycontin, etc"

Now... yes, I could try to "see my GP", which generally means waiting a few days. (and, I don't really have a GP anymore, because I can never get in to see him).

What's strange is that about... 6 years ago, going to one of the same clinics, my wife went with an eye problem. Specifically, she'd had a small piece of sand get in her eye, and it was really sort/irritated. Home flushing wasn't working, so we went to the clinic. As she was leaving, they asked if she felt she needed any pain medication. "Well, not really, but it's a bit sore, and I do have a headache". They gave her a script for 14 oxycontin on the spot. Same place last year would not even talk to me about pain medication ("go see your GP").

Those practices (handing out oxy) are a major contributor to the current epidemic, if not the root cause.

I've gotten opiate prescriptions I had no business having without asking. I get that some people need pain medication or will suffer, but there's a whole lot of suffering that opiate addiction causes and that is not really factored into the 'do no harm' calculation doctors are supposed to be doing.

It really is a great thing to see legitimate restrictions on these prescriptions, as that should cut down on new addicts at the very least.

I guess part of this is doctors overprescribing to prevent patient complaints, based on how much patient satisfaction surveys are used to rate their year over year performance.

I don't know if its the AMA to blame for that or not, but everyone in the system seems to think its an upstream problem.

I'm hearing on the one side that these legal prescriptions are causing the problems but on the other had others say that these drugs being illegal is causing the problem and if we made them legal that people will use them in a safe manner. If people get addicted them when prescribed legally then how can making them legal have any hope?

Making them legal at least keeps the problem out in the open, where it can be regulated. Notice that the response to the opioid epidemic, as described in this thread, is that clinics have stopped giving out oxycontin. When we had a crack epidemic in the 80s or a heroin epidemic in the 60s and 70s, the response was to send troops into the regions that produced those drugs. This was both expensive and ineffective, and in many ways just made the problem worse: with the whole distribution chain being completely illegal, street prices went up, more money was made by a few outlaw kingpins, and that gave them more resources to buy arms and escalate violence.

These are highly addictive substances. If doctors can't stop the abuse now on prescribed medicines who in the regulatory agencies can do better?

And so the people that got addicted to those opiates 6 years ago that are now unable to get new ones turn to heroin.

If you go into a walk-in (or even GP office) asking for pain meds, that sets off all kinds of alarms.

If you go in with an obvious injury and they offer the painkillers without you asking, they probably feel a lot more confident that you are not drug-seeking.

> but around me, I can not go get any prescription for any back pain

Can I check: have you sought treatment for back pain, and not got it?

Have they offered physiotherapy or exercise?

(these might be relevant to your type of pain).

clarification - my back pain episodes were 2x in ... about 3 years. in both cases this was a sudden onset - like, standing up from a seated position, some sort of switch was flipped, and I had immediate massive pain.

In both cases, talking to a local "urgent care" clinic, "go to your GP for a referral for physical therapy" was the standard line. "we don't treat back pain".

I get it, in some sense, like... yeah, I may be an addict, etc. But in both cases, I'd been to the clinic multiple times before for other things. I had a history with them. Actually, the last time I'd been there I said I had no primary care physician, and wanted to use them as primary (3 miles from house vs 11 miles to previous dr).

In both cases, the back pain episode lasted more than a week, was debilitating to the point of not being able to walk without massive pain or sleep normally for several days. And then, it wore off, and ... 'back to normal'. Historically, I'm learning, we have some back issues in the family, but I can't get much info from anyone on specifics yet.

> why that's a horrible idea

Making drugs that people want illegal has never worked. Why should it work now?

Besides, the drugs being illegal increases the death rate from them, because users now have little idea of what they are taking, and overdose easily.

Prohibition worked pretty well from a public health perspective. https://en.wikipedia.org/wiki/Prohibition_in_the_United_Stat... It was the organized crime that was the problem.

Organised crime is bad for public health

On balance it's still a win. Alcoholism kills a lot of people.

Depends on what you're measuring. If it's pure death rates sure but throw in quality of life and it's not as clear cut.

I personally wouldn't want to live in a world where I can't enjoy a glass of whiskey.

That's not going to offset fetal alcohol syndrome or people raised by drunk parents or recovered alcoholics living with health issues for the rest of their lives.

You can make the same arguments about salty foods (hypertension), fatty foods (heart disease), sugary foods (diabetes), premarital sex (STDs), and just about anything else that people consume or partake in.

If you believe in personal responsibility then you're okay with taking some bad with the good.

What does personal responsibility have to do with fetal alcohol syndrome or kids raised badly? And how can you believe in personal responsibly when public health can change so drastically in response to policy changes?

> What does personal responsibility have to do with fetal alcohol syndrome or kids raised badly?

Both are the result of negligence of their parents. It may not be pleasant to lump that together under personal responsibility but that's the root of the problem and addressing it is the real solution.

A mother that drinks alcohol while pregnant is at fault for the harm that comes to her child. It's not society's fault, it's hers and indirectly her spouse's fault for allowing that to happen.

> And how can you believe in personal responsibly when public health can change so drastically in response to policy changes?

The fundamental disagreement is that I believe people are capable of good on their own and should not be baby sat by a nanny state. I'm willing to accept some of the adverse consequences of people making their own choices in exchange for the freedom and quality of life it brings.

But what good is responsibility? The point is this shouldn't happen in the first place. There's no way someone can make up for something bad they did in the past. Assigning blame after the fact seems hollow to me.

It's a tradeoff. "If men were angels no government would be necessary." Personal responsibility might be an ideal but it can't be an absolute. Trading lives for a "glass of whiskey" is morally bankrupt.

I'm not dealing in anyones lives but my own as nobody is getting hurt by my personal enjoyment of a glass of whiskey.

It sounds like you think that either you or others are incapable of such self control and thus nobody should be able to enjoy them. I put such lack of faith in humanity as itself being morally bankrupt.

Many died being poisoned by ineptly made bootleg liquor.

Crime is the reaction to prohibition. Its not a separate phenomenon.

Worked fine with Methaqualone.

> As someone who used to naively believe in legalizing all drugs for recreational use, this addiction epidemic has opened my eyes to why that's a horrible idea.

You may be surprised to learn that opium and cocaine used to be sold widely at pharmacies over the counter. Curiously, there was not a widespread "epidemic" of addiction. Why is that?

Alcohol and nicotine are legal and ubiquitous, where are the epidemics of their addiction? Curiously, smoking has been declining despite it being widely available and very addictive.

Blaming the existence of a substance for addiction, and then harassing doctors and patients as a result, is nearing the height of absurdity.

Don't both alcohol and nicotine have far more dependent users than opioids?

What is the comparison meant to illustrate? That easy availability will increase use and that the effects of the drug are the more important matter?

You're right that doctors can prescribe fentanyl, but I'm not so sure about your (implied) claim that prescribed fentanyl is contributing to the opioid epidemic. To my knowledge, fentanyl is safe to take when done in proper doses (as are most painkillers). The problem with fentanyl is that since it is so much more potent than drugs like heroin, when the two are mixed people can overdose much more easily since they won't know that the fentanyl. And the fentanyl being mixed in with heroin isn't coming from Dilaudid prescriptions, it's coming from China: http://securepackages.org/wp-content/uploads/2017/02/USCC-St...

So unless you can figure out a way to stop the drug trafficking industry, fentanyl+heroin aren't going away. Perhaps we will see fentanyl produced less if China cracks down / increases regulations on their pharmaceutical industry.

Unfortunately the opioid epidemic is going to have to be stopped by moving away from the casual prescription of opioids, which is what creates opioid addiction in the first place. I think your open doctor project is really cool and is a good way to start: shame doctors who are essentially operating as pill mills for their "patients." My hope is that people so obviously abusing the system like the doctors at the top of your list end up losing their license to practice medicine, or behind bars.

A lot of fentanyl is coming from Mexico, where they easily synthesize it, and it's introduced into the heroin supply as a cutting agent. Whether or not it's "contributing to the opioid epidemic" depends on how you interpret that phrase. In other words, people are getting HOOKED on opioids because of the 12hr dosing of oxy etc that has been discussed on HN in the past. But people are DYING OF OVERDOSES because they cannot afford/lose access to pills and switch to heroin from the street (adulterated with fentanyl).

The source I linked mentions that the primary route fentanyl takes is from labs in China to Mexico, then to the US.

Yes, we are in agreement then. I just don't think the epidemic (or the deaths) is as easy to stop as ransom1538 thinks, because the fentanyl problem by itself stems from trafficking instead of prescriptions. AndYou can't really stop the drug trafficking part of things very efficiently, see the DEA for proof.

Personally I believe that the deaths are secondary to the addiction anyway. Of course, it's very, very bad that people are dying due to adulterated heroin, but the most effective way to lower deaths is probably to prescribe less of those 12hr oxies.

According to most of what I’ve read and seen, opioid prescriptions are contributing to the problem. It’s true that people aren’t overdosing when following their prescribed dosages, but some people are getting addicted.

A common story for opioid addicts starts with, “I was in a car accident, and they prescribed opioids to deal with the pain. Once the prescription ran out, I was in incredible pain, maybe even worse than before I started taking the pills. I started buying pills illegally. Once the pills got too expensive, I switched to heroin.”

I’ve seen far too many stories that follow that basic path. It’s definitely not the only way people get addicted, but it’s too common.

Have you ever considered that perhaps there are just a lot of people with various levels of chronic pain, and, shockingly, some of them may want to manage their pain and see a doctor and end up with medication?

> "an estimated 25.3 million adults (11.2 percent) experience chronic pain—that is, they had pain every day for the preceding 3 months. Nearly 40 million adults (17.6 percent) experience severe levels of pain."

https://nccih.nih.gov/news/press/08112015

Yes but opoids has many risks and should only be prescribed to a minority. This is not what is happening.

Are you a doctor, anesthesiologist, or other clinical pain management specialist?

Not a doctor but working on a daily basis with them.

Leaving aside the question of competence, what alternatives would you suggest?

> Fentanyl isn't created in the back of a motor home.

But it probably could be, if there's a market for it. There are trained chemists making meth [0]. The sale of the precursors of fentanyl is controlled, but so are the precursors to meth. If fentanyl (or an analog) stays popular we'll have people making their own.

Edit: I'm not saying it would be as obtaining PSE, but if you're a member of a chem lab, the only thing between you and an order to Sigma is ~two signatures? There's too much money involved for it to not happen.

[0] http://news.sky.com/story/inside-the-cartels-cooking-crack-i... (I know, Sky News..)

My brother studies Chemistry. One of the first things they told them was that they could make Meth (I think) with a street value of about 1000 times the cost of the materials, but the police would know where to start looking as soon as they got their hands on some, because it would be too pure, too well made.

Mind you, this was told to incoming (freshmen) students, presumably the professors would be able to make the precursors in such a way that the authorities wouldn't know.

So is the idea that the school tells them they could totally do this, and they'd get caught, so as to preempt students from coming up with the idea on their own?

Eh, it sounds like the teacher is just trying to get their class excited about the chemistry. Come for the very pure drugs, stay for the molecular orbital theory and the love of the lab.

That, and because some of the more enterprising students would come up with the idea on their own, so better to depress any such tendency ahead of time than end up with two or three people a year finding out via prison sentences that they weren't quite as smart as they thought they were.

Yep. In O-chem lab many years ago one of the first things we did was "alkaloid extraction", where we pulled caffeine from tea bags, which was a yellow, clumpy powder, which we then washed out the impurities and it was a clean white crystal. Caffeine is in the same family as meth, and the process is similar.

The teacher joked that she used to teach in San Bernardino and there were a lot of chemicals that the department never had to buy because the police would turn it over after raiding meth labs.

> Caffeine is in the same family as meth

If by family you mean CNS stimulant with an amino group, then yes, I guess? They are very different structurally and pharmacologically.

A synthesis of methamphetamine would not look very much at all like an alkaloid extraction, except, possibly, for the final workup and isolation of the salt.

"Oh, we could totally synthesize meth and make tons of money, but it would be so good we'd get caught immediately." Talk is cheap. POC or GTFO.

Setting up a lab capable of producing fentanyl has significant up-front costs associated with it. Running the lab and keeping it stocked with precursors is an ongoing risk. For better or worse, the golden age of american clandestine laboratories is probably past: it is far easier to import an uncontrolled, custom-synthesized fentanyl analog, although I would not recommend getting into this business.

Fentanyl isn't popular _at all_ among opioid addicts. The duration of effect is short relative to morphine-like molecules and it absolutely wrecks one's opioid tolerance. Fentanyl is popular among unscrupulous heroin dealers that try to pass off a cheap synthetic opioid as $200/gram diacetylmorphine.

A lot of the fentanyl in Canada comes from china and was ordered over the dark web.

Fentanyl and other opioid synthetics were legal to export in China until very recently, so ordering it was as simple as going on Alibaba or other wholesaler chemical sites and just bringing in enough of it that customs would miss a few shipments. Now that there are regulations involved on the Chinese side the price of Fentanyl smuggling has risen and it's no longer an attractive synthetic to maximize profits for dealers so they are importing other synthetics or Fentanyl from countries who still don't have export laws.

Realistically the only way to stop this problem besides legalization is labs for testing pills and powders like they have in Spain and Netherlands, and mobile Suboxone clinics[1] which were proven here (Vancouver, Canada) to be the best solution for addict recovery as they can pick up the phone and have somebody quietly prescribe them Suboxone treatment without having to queue up at the methodone clinics everyday. Suboxone was described to me as satisfying the 'fiend' cravings while not making you high, so you can function sober and no longer need to chase daily money to satisfy a drug addiction and can actually plan things. It also ensures you won't use again since the antagonist ingredients makes it more difficult or impossible to use other opioids at the same time, making relapse less likely.

The safe injection sites here are a double edged sword. On one hand they are helpful for street addicts but on the other hand they are more likely to take risks, knowing there's a nurse there so aren't afraid of mystery powders like they used to be, according to anecdotes of people I've talked to who frequent them. The city handed out overdose kits to street users who demanded a peer to peer type safe injection network but the junkies stole the needles out of the kits to shoot up with basically rendering them useless and wasting the hundreds of thousands it cost to distribute them.

There's some data here about the Netherlands success in drug use reduction, they put a lot of funds into prevention instead of just treatment. http://www.emcdda.europa.eu/publications/country-drug-report...

[1] https://www.theglobeandmail.com/news/british-columbia/a-bc-c...

Fentanyl even killed Prince

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