Comment by DanBC | Hacker News Reader

Comment by DanBC | Hacker News Reader

This article misses several points.

When we ask people with a substance misuse disorder who use opioids what they started on we find, very often, that they started on meds prescribed by a doctor. Those meds may not have been prescribed to them - they may have been prescribed to a neighbour or family member - but they were prescribed.

This is why the massive over-prescription of opioids is a problem. It floods American homes with opioids that people keep "just in case" and that are experimented with by family members or handed out to neighbours to help out.

Opioids may be a good choice for some people with long term pain (I personaly don't think they are), but that would be in a carefully controled setting being closely monitored by a doctor. It's definitely not using opioids that your neighbour has given you for your dodgy back.

The article makes an incoherent point about what is classed as a CPD. Benzos are dangerous (especially in combination with other meds or alcohol) but far fewer people are dying from benzos than from opioids.

> Opioids may be a good choice for some people with long term pain (I personaly don't think they are)

They definately are for some people, because I'm one of them. I've tried everything else, and nothing even touches the pain.

I've tried numerous anticonvulsants (carbamazepine, lamotrigine, topiramate, levetiracetam, gabapentin, pregbalin...), tricyclics (amitriptyline, nortriptyline, dosulepin...), muscle-relaxants (tizanidine, diazepam...), anti-depressants (venlafaxine, reboxetine, duloxetine...), as well as NSAIDs like diclofenac, and assorted things like topical capsaicin and topical gabapentin. A lot of these made me dizzy and uncoordinated, where I couldn't function normally, and some made me extremely nauseous - while not touching the pain. The rest did nothing.

I realise I'm probably a statistical outlier, but I resent the idea that I should be left to suffer because my body and genetics don't conform to some p value from a meta-analysis.

Opioids should of course not be the first choice for chronic or neuropathic pain, because statistically other things are more effective and safer (e.g. pregbalin) - but doctors should not be prohibited from prescribing opioids when pain cannot be adequately controlled by other means.

If I had to deal with my chronic pain 24/7 without any pain relief... well, opioids have likely saved my life. I've been taking them for years now, and while I will obviously be physically dependant on them now (that's just how receptors work), I feel absolutely no psychological addiction to them whatsoever.

> > > Opioids may be a good choice for some people

> I realise I'm probably a statistical outlier,

Do you think you might be who I'm referring to to here?

The US massively over-prescribes opioids. They could probably reduce prescribing by 75% and it wouldn't affect people like you, other than having to go to a specialist pain clinic. Since you have specialist pain you deserve best quality treatment from specialist.

> Opioids should of course not be the first choice for chronic or neuropathic pain, because statistically other things are more effective and safer

Isn't this just agreeing with what I said?

> Do you think you might be who I'm referring to to here?

That sentence continued with "(I personaly don't think they are)".

> Isn't this just agreeing with what I said?

Well, no, because you explicitly stated that you personally didn't agree.

I realise that the US has a huge problem with over-prescribing opioids. I think that great care needs to be taken in how that is reduced - there are many instances of a heavy-handed approach being used, and those that have a genuine need have their pain relief removed. The consequences of this can be disastrous.

Do you need to keep increasing the dosage? Or have you found a long-term dosage that despite tolerance, it still maintains a reasonable degree of efficacy?

No, I've been on the same dosage for years.

I mentioned in another comment that I take magnesium, which is an NMDA antagonist, and there is a lot of evidence that these prevent the buildup of tolerance. I don't know if that's why I can remain on the same doseage, or if it's simply that I always stick to the prescribed dose.

magnesium sulfate? citrate? dose?

I take citrate, which I initially chose for it's laxative effects. Not sure if it's the most effective for reducing tolerance.

Agmatine is a more potent NMDA antagonist, but is unfortunately no longer available in the EU, due to the fairly 2017 Novel Food Regulation[1]

  [1] https://ec.europa.eu/food/sites/food/files/oc_oof_analysis_main_outcome_en.pdf

> Opioids may be a good choice for some people with long term pain (I personaly don't think they are)

What do you suggest be given to people with chronic pain which can't be managed with lower powered pain killers, say people with cancer induced pain?

Can I check how you're using "chronic"?

You added "which can't be managed with lower powered pain killers" -- that step often isn't tried in the US. Doctors and patients are leaping direct to large quantities of opioids.

I'd prefer it if doctors followed the RCoA guidance: https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar...

"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)."

I am from India. I have two close family members who are fighting metastatic cancer.

Their pain is not manageable with lower pain killers. I am thankful we have opoids to prescribe, which is making significant improvement to their quality of life.

Chronic is a jargon word. It means "long term pain".

Cancer pain is not long term pain, cancer pain is short term pain (or acute pain). I've never argued against using opioids for cancer patients or for end of life treatment.

Cancer pain can involve both acute and chronic pain - death is not always swift.

That kind of pain management is more technically referred to as "palliative care", which often involves both acute and chronic pain. I don't think anyone here would argue that palliative care is a bad use of opioids.

Don't you think there's a danger that because of the opioid epidemic, doctors might hesitate to prescribe the drugs to people that actually need them?

Yes, I do, and I mention this in another comment here.

If you take a look at /r/ChronicPain/, you'll find lots of people who have been unfairly affected in exactly this way, some even becoming suicidal because of it.

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