Coroner letters changed habits of doctors whose patients died of overdoses
latimes.com
latimes.com
https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm
> Patients are seeing their medication reduced without tapering, they are given no other option than to "suck it up,"
These are both bad, but these are both symptoms of the sometimes terrible healthcare in the US. People should have access to pain management clinics.
That's not how opioid tolerance works. As dose needed to achieve desired effect (analgesia) increases, so does does needed to cause respiratory depression. It's not like there's a single fixed lethal dose and the hapless addict is drawn into it closer and closer.
Anyway the overwhelming majority of opioid-related deaths, at least in US, occur with concomitant use of benzodiazepines or EtOH (which is something inherently dangerous) and that is, if anything, an argument against prohibition, since people potentiating their opioids with EtOH or benzos is pretty flagrantly downstream of scarcity of opioids.
Long-term use of pharmaceutical-grade opioids (in precisely measured doses, and without the scarcity that drives people to compound with alcohol or benzos) is far safer than you imply it is. It's prohibition that's made opioid use perilous, not the actual pharmacological qualities of the drugs (which have been used by humanity for millennia by now).
> People should have access to pain management clinics.
...pain management clinics that do what, besides prescribe opioids? Fix the actual root cause? Do surgery?
I don't think it's helpful to make a blanket statement like that. There is no one size fits all where pain and analgesics are concerned, and genetics play a large role in what works and what you can even tolerate due to side effects. Opioids of course should not be the first choice, but they should be an option.
I've been living with chronic pain for years now, and have been maintaining the same opioid dose - they bring their own issues, but they make a huge difference to my quality of life. Anecdotally, through support groups, I know several others in the same situation.
There is something of mini war on opioids going on here in the UK, spurred by what's happening in the US and stoked by hate rags like the Daily Mail. People who successfully manage long-term pain using opioids should not be shamed and treated like drug addicts.
The blanket comment of "most people are harmed by long term opioid use, and don't get much benefit" is true though.
Your experiences support the point I'm making though: if it's working, and if the dose is maintained at a low level, opioids are better than nothing.
But that involves people agreeing a plan before hand, and continuing checks. (See the links I've already posted elsewhere in this thread).
Luckily the Daily Mail have no influence on healthcare. Your use of opioids is supported by RCA, and NICE.
AFAIK, The only 'checks' in place for me is that I can't request repeat prescriptions more often than my subscription, just the same as for any other medication.
> Luckily the Daily Mail have no influence on healthcare. Your use of opioids is supported by RCA, and NICE.
I wish it were so. The RCA and NICE are in turn supported by the government, and unfortunately many politicians pander to the ignorant outcries of Daily Mail influenced voters.
As you've already asserted in your other comments here and I've asked elsewhere, could you expand on this assertion?
> 1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain.
> 2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation)
> 3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit.
> 4. If a patient is using opioids but is still in pain, the opioids are not effective and should be discontinued, even if no other treatment is available.
> 5. Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detail assessment of the many emotional influences on their pain is essential.
https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar...
> The experience of pain is complex and influenced by the degree of tissue injury, current mood, previous experience of pain and understanding of the cause and significance of pain. Previous unpleasant thoughts, emotions and experiences can also contribute to the current perception of pain and, if unresolved, can act as a barrier to treatment. The assessment of chronic pain needs to be wide-ranging and comprehensive. The persistence of symptoms is particularly relevant in relation to prescribing where patients may be exposed to cumulative harms of drugs over prolonged periods. If a patient continues to have pain despite taking a number of medications, drugs should be sequentially tapered or stopped to establish continued utility. Similarly, if a patient reports reasonable pain relief from a medication regimen in the longer term, it is also necessary to taper medications intermittently to assess whether the symptoms have resolved spontaneously or whether the patient is relatively pain free because of continued efficacy of medication.
https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar...
> Medicines are generally less effective for persistent pain than for other types of pain. When medicines are prescribed they should be used in combination with other treatment approaches to support improved physical, psychological and social functioning.
Opioid sales quadrupled in the US between 1999 and 2014, and a lot of those were family doctors.
This statement is potentially misleading, since it leaves out the "per year" part. To compare it to the number of chronic pain sufferers, as you've done, you'd need to add up all the deaths of people who would otherwise still be alive.
Even just using the wild approximation of adding up the deaths in Table 27 of what you've linked (interpolating the missing 8 years with the lowest number), brings the percentage above 0.17% or almost 1 in 500.
One of the reasons for alarm is that the fatality rate has been increasing (and may even be accelerating), having more than tripled since 1999. Compare that to vehicle deaths, which have been on a downard trend, even per population.
Now this article is about something different - teaching doctors the warning signs of when already addicted patients are drug seeking, so they can avoid prescribing then. The key fact here is that almost all of the deceased had gotten prescriptions from multiple doctors.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4032801/
Here's the raw data on prescriptions and outcomes summarized in that paper, built from claims data for 2000–2005:
Opioid Dose and Days Supply
total addiction
No opioid use 371,371 150 (0.04%)
Low dose, acute 90,415 111 (0.12%)
Low dose, chronic 6,902 50 (0.72%)
Medium dose, acute 83,542 101 (0.12%)
Medium dose, chronic 3,654 47 (1.3%)
High dose, acute 12,378 15 (0.12%)
High dose, chronic 378 23 (6%)
I'm not the right person to do this analysis properly, but I'd hardly call this "thoroughly debunked"
Regardless of whether or not this accounts for the majority of addictions, it is sufficient to say that opioids are far more dangerous for patients than many doctors believe. Addressing prescribing habits is a necessary part of a multi-pronged solution to opioid addiction.
Often what happens is that the 25% that got hooked from being prescribed start buying additional pills. Eventually they can't afford that and they switch to cheaper heroin, often funded by selling their prescription pills.
Also, is “throughly” debunked really the case? That makes it sound like there can be no link at all, but higher levels of these in society legally could lead to an increase in abuse. On complex topics like this it is rarely possible to talk in absolutes.
There is definitely a big complex drug ecosystem otherwise, though.
I am dubious and concerned this doesn't appear to have been addressed in their studies.
So, your doctor takes you through trying some other drugs, again, just as they had before they prescribed you opioids - as is current best practice. Of course, now, for your doctor that option of opioid use is no longer available, even though it is still there - out of reach. How would that feel? Living without pain management because your doctor fears losing their licence or a letter from the coroner more than helping you manage your pain.
These studies need to ensure doctors are reserving opioids for worst case management, but still prescribing them when nothing less works.
These studies need to be longitudinal. Do patients maintain their quality of life? Are doctors trying less addictive/abusable drugs first?
Focusing on reduced opioid prescription is like focusing on reducing antibiotic use. You have to track infection rates to gauge if the ineffective usage has gone down while maintaining outcomes.
You can't just track usage to gauge the effectiveness of a program. It's a vanity statistic unless you measure outcomes. Outcomes are the whole point.
This is a false narrative that needs to go away.
That's only true (if it is true) if they're used short term. People in this thread aren't talking about acute pain, they're talking about chronic (long term) pain.
It's likely that opioids are addictive if used long term to treat long term pain.
Here's what actual doctors say: https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar...
EDIT: FFS, your own link says this:
> “Physiological dependence is the normal response to regular dosages of many medications, whether opioids or others. It also happens with beta blockers for high blood pressure,” said Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse.
Your link says that opioids create physical addiction. The physical addiction to opioids causes all the factors of the newer definition of adddictive: tolerance, drug seeking, preoccupation, and continuing to take it even though you know it's harmful.
What's important is the psychological addiction. You can taper off of a medication on which you are physiologically dependent. However, if it makes you psychologically dependent, you can never forget the high.
Turns out not having pain because a medication helps and you experience it when you stop makes people want to keep taking it. Who knew?
It's when people take more than they need to to address their physical pain, that they experience psychological addiction, that they chase the high, that a problem develops.
Turns out not having pain because a medication helps and you experience it when you stop makes people want to keep taking it. Who knew?
That is not what's happening. People take the medication to treat the pain. Their pain still exists. They develop a tolerance to opioids (one of the mechanisms of addiction) and need to increase the dose. Now they're taking very large -dangerously large- doses of opioids but are still in pain.
This behaviour is long established and well known.
Opioids do not cause drug seeking behaviour in all people.
Opioids are the only thing that has helped with the pain at all - to flip your comment around, not taking opioids could have led to my death.
I only ever take my prescribed dose, and I've been doing this for years. They still have the same efficacy. They don't make me feel good, they constipate me and make me a bit sleepy - I don't know how anyone becomes addicted to them, but amongst many others I guess there are genetic factors at play.
In the US, when I'd get an electronic prescription, I'd have to specify which branch of which pharmacy I was picking it up on. They don't allow electronic prescriptions for opiods, however. (I worked at a pharmacy). Other pharmacies, even in the same chain, could not see my prescriptions without the pharmacy transferring it over to the other physical location. If the pharmacist or doctor suspects something, they basically have to keep the patient waiting to investigate - and if they deny, hope they are getting something wrong instead of someone just getting bad luck.
I now live in Norway. The doctor just does the electronic prescription. I can go to any pharmacy in any location to pick it up. Including the things that aren't allowed to be electronic in the US. This makes such things much easier to be noticed - doctors and pharmacists can get access to this information when filling a prescription.
Opioids are not effective at treating long term pain, so these doctors were probably maintaining the same pain management outcomes for most patients and avoiding addiction on top.
OK, so, please expand on this asssertion. Also, what does then?
My primary concern is maintaining or improving quality of life without impacting the length too negatively. It's difficult to justify saying "sorry, that thing you were taking to make your life bearable makes my colleagues think I'm no better than drug dealer so, uh, you can't have it any more, here's a pamphlet on mindfulness" - if anything it should be buying time for us to find real solutions instead of symptomatic treatment.
And that's all opioids really do for those that take it - buy time. If we're going to reduce opioid use we need to treat it as we're treating antibiotics and make sure we're carefully watching outcomes to make sure we're not dropping opioids but raising suicide rates.
We owe it to patients to solve their problems and not just treat their symptoms when it's clear they won't heal on their own.
Not a GP either.
Source: Many doctors in my family who talk about their experiences.
As the article shows, at worst they get bamboozled by addicts sometimes, who go to multiple doctors and lie.
There was a very strong campaign to re-educate physicians to not consider pain as only a symptom. It was suggested that there was liability in not treating pain for the sake of getting rid of pain alone, but mostly it didn’t just change prescribing practices out of fear of liability, the focus of attention on pain changed prescribing habits.
In practice, someone who hardly has enough time for the patients they see, may subconsciously think that in spite of the prevalence of national opioid deaths, no one they treat has died or destroyed their lives through addiction, simply because those who do also stop booking appointments.
These letters sound like a great idea.
My father had 2 bad operations last year. He suffered a lot of pain afterwards, but he refrained from taking strong drugs. I’m not sure if he did the right thing and if I’d do the same. But there’s is definitely middle ground between killing every pain and enduring all of it.
I found this article interesting: https://www.nytimes.com/2018/01/27/opinion/sunday/surgery-ge...
I was given 36x325Mg Hydrocodone (not a typo) and 14x600 Mg Ibuprofen. Which is pretty absurd.
I only used 6 of the Ibuprofen. I'm not sure why I wasn't just given a two day supply of Hydrocodone and if more was needed I could have just called it in asking for a more if the pain was bad.
It was such a over-prescription I hope it was just sloppy handwriting.
I was told to take the ibuprofen for swelling and the hydrocodone for pain.
But there is a line break. after "5-" so since I am not a doctor I think my interpretation is a reasonable one.
You knew exactly what I meant, so cool.
Presumably people felt the same levels of pain in the past as they do now, given the same maladies. Is the situation:
A) More surgeries with extremely painful and long recovery periods are happening, where these meds are truly necessary
B) Doctors are prescribing opiods more freely for lower levels of pain than in the past
C) People are faking pain more often
D) People who really do need pain meds are staying on them longer than they should
B) seems to be the accusation that I usually see, but have doctors really gotten worse and less careful over time? To an extent that explains the whole crisis?
My guess is that D) is the real cause, for may different reasons.
> but what is different now that makes so many more people get hooked on them?
The US VA noticed that pain was not being adequately treated. They created a campaign to make every HCP ask patients about pain. They looked at the science of the time which seemed to be saying that opioids were not addictive if you use them to treat pain. (they're less addictive if used short term for short term pain (post surgery, for example) but more addictive if used long term.) Drug companies put out new formulations that they claimed were less addictive - turns out they were more addictive. US doctors prescribe huge amounts of opioids.
The tragedy is that pain is still left untreated. The VA campaign meant people got opioids (cheap, but not particularly effective for long term pain) but didn't get access to pain management clinics.
https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital...
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/
> Routinely measuring pain by the 5th vital sign did not increase the quality of pain management. Patients with substantial pain documented by the 5th vital sign often had inadequate pain management.
https://www.cdc.gov/drugoverdose/data/prescribing.html
> Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014,1 but there has not been an overall change in the amount of pain Americans report.2,3 During this time period, prescription opioid overdose deaths increased similarly.
That, there, is the "money" quote. You've been criticized elsewhere in the thread for the assertion that opiates "don't work" for long-term pain, but that strikes me as a very reasonable summary in the face of this kind of evidence.
Sure, there may be exceptions, but they must be quite rare for the above to remain true. (Some of them may not even be true exceptions, if "intermittent" use for long-term pain actually looks the same as repeated use for short-term pain).
And when I say marketing here think ads on the tv, heavy lobbying with politicians, inviting doctors to exclusive events and pampering them, sponsoring studies on chronic pain, etc.
If you check the maps here:
https://ppsg.medicine.wisc.edu/
the phenomenon seems mostly regional (the colour scale on the map makes very little sense, you need to check the single amounts as everywhere (both North America and EU zone is blue but with very different values ) example 2015, "ME minus Methadone":
Canada 661 mg/capita
US 484
Germany 517
UK 156
France 151
Spain 233
Italy 131
"Unfortunately, our website is currently unavailable in most European countries."
In common: we can't be bothered respecting your privacy.
OK then.
And the site does indeed load JS from a horrendous number of domains.