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> Pseudoaddiction exists. But actual addiction also exists, and it's more dangerous and more likely to happen.

Many people kill themselves over chronic untreated or undertreated pain. I've seen studies showing that people with chronic pain kill themselves at twice the rate of those without chronic pain (even that seems low to me) [0] and various other similar studies. Assuming this is true, and that the two are causally related, then opiate deaths and suicide deaths due to chronic pain are in the same order of magnitude.

If you any of you are unfortunate to end up with a condition that causes significant chronic nerve pain, you'll quickly understand how this can be.

0. https://annals.org/aim/fullarticle/2702061/chronic-pain-amon...

As someone married to someone with chronic pain... Opioid pain killers tend to be ineffective anyways - they will provide a window of pain killing that is longer than other substances (when taken within safe limits) on the order of months but their efficacy is not unlimited and even being willing to heavily addict yourself to Oxy is likely going to cease helping your pain after half a year. This is part of the cause of this epidemic, people were _entirely falsely_ prescribed an ineffective medication that has heavy side effects.

My spouse managed to get a medical supply of mj and that has helped her get back into life, given her pain source is from arthritis and a few other issues it'll probably never be a thing she'll be without but the few studies out there on mj have a positive view of long term pain treatment on it.

Chronic pain is a very serious condition that can ruin lives, it is extremely disgusting to see what has happened with Oxy and heavier penalties are needed.

> This is part of the cause of this epidemic, people were _entirely falsely_ prescribed an ineffective medication that has heavy side effects.

It really depends. Opiates work for some people, with some conditions. People should have the choice, just like with MJ. For me, one opiate worked, and another didn't (and made things worse. it was Oxycontin, incidentally, haven't taken it in many years).

Also, people with chronic pain take opiate breaks for the reasons of tolerance you describe.

And yes, I've heard MJ works for many people (I've never tried it for my conditions, since it's still not legal where I live. Also, I tried it a couple of times in college and hated how it made me feel, no way I could work on MJ). But I'm very happy it works for your spouse and that she's able to obtain it. Chronic pain is brutal. If MJ is ever legalized where I live I might try it just to see if it works.

> It really depends.

In the past, throwing opioids at chronic pain patients and calling it a day was par for the course.

Now, there's a level of awareness that not only are opioids not very good for managing chronic pain all of the time, they can even make pain sensitivity worse in the long-run.

Criminalizing pain patients is disgusting, but I'm hoping we can reach an equilibrium where those who have chronic pain are able to seek adequate treatment and opioids aren't the first line of treatment or overprescribed.

As someone with family members suffering from chronic pain, I know several people who have switched to MMJ or CBD supplements with great success. One of them took pain killers for decades and hasn't needed them in years because of CBD.

CBD won't affect you cognitively, if you have the time, money and your doctor thinks it's a good idea, it wouldn't hurt to give it a go.

There are many varieties of cannabis. Having a bad experience with one is not a reason to eschew in favor of opiates. you didn't eschew opiates because you had one bad variety.

If mj is legalized I'd suggest you give it another go, the strains you'd smoke to get high cause my wife's pain to heighten while as more cbd heavy strains help reduce it from her life - it's not critical to avoid thc entirely (and it may help the cbd act - research isn't in here but pure cbd oil products are less effective than a mix for a lot of people).

And yea, Canada is nice like that.

No way I could work without.

To add to your argument, “addiction” is not a cause of death, it is a risk factor for various unnatural causes such as suicide and overdose. The same could be said for chronic pain, but it is pretty easy to understand why chronic, untreated pain would lead to suicide. The connection between addiction and suicide is much more complex, and may have more to do with the reality of being an addict in modern society than the medical consequences of the addiction itself.

I don't want to detract from your point about sympathy for chronic pain. But you can't mainline oxycodone into everyone who claims to have chronic pain, because that system is easily abused, as we've seen. A more nuanced approach is needed. We need a balance, and IMO we need to improve our ability to objectively measure pain instead of relying on a 1-10 scale.

I am curious about your conclusion that "opiate deaths and suicide deaths due to chronic pain are in the same order of magnitude", though. According to my simple Googling, opioids are the cause of death for 21.7 per 100,000 people in the US, while suicide is only 14 per 100,000. So per your link, chronic pain suicide is about 10% of that, or 1.4 per 100,000. That means opioid deaths are about 10-15x more common, or am I missing something?

edit: I'm realizing my understanding of this debate is significantly out-of-date. So I apologize if anything I've written seems tone-deaf, that wasn't my intention.

But you can't mainline oxycodone into everyone who claims to have chronic pain

You say this like it should be taken for granted, but honestly, with the amount of deaths we have from people overdosing on illegal fentanyl, it might be better at this point if we simply gave less-overdose-prone opioids to anyone who was addicted!

> Many people kill themselves over chronic untreated or undertreated pain.

The answer is to give people access to better treatment for pain.

That isn't giving them opioids.

They end up addicted to opioids, with a bunch of side-effects caused by opioids, and they're still in pain. Their functioning is decreased.

https://www.england.nhs.uk/south/2019/06/25/seans-story/

https://www.bbc.co.uk/programmes/b04wv052

> "Pseudoaddiction" is deliberately defined such that it's indistinguishable from actual addiction.

The point of the article is that it's the other way around -- addiction is defined in a way that includes plenty of non-addicts. It's like the old D.A.R.E. pamphlets that tell you to watch out for teens who are sullen, sleep late, distrust authority, etc.

Yeah, I think the article presents a good point, logically speaking. But I think it's brash to ignore the history of the "pseudoaddiction" term, which is a tool of FUD.

Of course it exists and makes sense, this was marketed to doctors. They're not dumb. Pseudoaddiction is real and important, which is why it's such a good marketing tool.

It's a really tough problem. That's why I think considering both sides is incredibly important. I'm not trying to bash the article, just provide a different perspective on why pseudoaddiction might have been bashed in the press.

edit: Apparently reading a book doesn't make me an expert! I'm realizing that it's actually pseudoaddiction that's getting bashed right now. Which makes sense, given the context of the article. I was still thinking about it from the lens of opioids being over-prescribed but it seems the pendulum has swung in the other direction. Sorry for muddying the discussion.

> But actual addiction also exists, and it's more dangerous and more likely to happen.

Not sure that's obvious, or true. The article itself recounts two situations where the patients denied meds they needed became suicidal, and a third where if the patient hadn't pushed the issue to get his meds (insulin), he would have died.

Yeah, I was wondering who would call me out on that! I'm not aware of any good studies that compare addiction vs. pseudo-addiction.

It's definitely not obvious, because a lot of doctors were convinced to the contrary.

By the way -- I'm not saying those individuals in the article aren't important, but whitewashed "case studies" that are full of snark and biased language and have no sources or timeframes, are not the best sources of evidence. In particular, the "pain management" space is rapidly evolving in the US and without timeframes, many of those anecdotes have negative utility.

I'm not saying "pseudoaddiction" doesn't exist, obviously, but we need statistical arguments that are more nuanced than "does it exist or not."

edit: I'm realizing that my understanding of this debate is out of date. So I'd like to apologize if my stance seems insensitive to what's going on right now w.r.t. opioid prescriptions. My gut feeling is that addiction is a bigger problem, but that varies depending on how freely opioids are prescribed. If opioids are under-prescribed then pseudoaddiction becomes a larger problem, for sure. Being dumb, I just assumed they were still being over-prescribed...

The article suggests that there isn't an easy way of distinguishing pseudoaddiction and actual addiction, no matter how the definition is clarified. It depends on how much pain the patient is experiencing, which is only truly knowable by the patient.

I think ultimately it (obviously) should be the doctor's call. But we've swung to such an extreme now that most people with severe chronic pain are undertreated or (more likely) untreated. I'm convinced that we're 5 years away from yet another backlash when we realize how many people with truly shitty, excruciating conditions are being forced to live in medieval medical conditions due to the current opiate hysteria.

Once again, the number of deaths from prescription opiates is dwarfed by the number of opiate deaths from illegal opiates. There's not even a comparison. And the vast majority of the opiate deaths from illegal substances are from fentanyl and related substances, which are notoriously hard to dose and/or frequently spiked and/or passed off as drugs of lesser potency. Imagine the deaths we could prevent if we (as in Europe) allowed addicts to dose themselves with supervised, clean, hygienic, pharmaceutical-grade heroin while offering them treatment to get off of them if they so desired.

Edit: I looked up current data and it looks like prescription opiates like oxycontin account for about 1/3 of opiates deaths. Maybe not quite "dwarfed" like I claimed above, but a definite minority of opiate deaths are caused by prescription narcotics. And given the current growth rate of deaths from illegal opiates, it could easily be only 10% in the next 1-2 years: https://www.cdc.gov/drugoverdose/epidemic/index.html

You need to look further than just the cause of death, prescription opioids have been the gateway to heroin for many people...

Yeah when they get cut off generally. So maybe cutting them off is putting them in a more dangerous situation then letting them have safer prescription versions.

Exactly, which is why it's such a valuable concept for opioid marketing. The line between addiction and pseudoaddiction is vague. Doctors can't judge it; nobody can judge it. Only the patient -- and the patient wants the drugs in this scenario.

When you give something a name, somehow it becomes more real in people's mind. You can also then build a whole superstructure of advocacy and theory on top of that false concept which a large amount of paid advocates and academics become invested in.

A lot of modern economics that justifies endless financial engineering follows this model.

And I guess that there are also a lot of cases that the right dose, that the patient really needs for his excruciating pain, will lead to addiction as an unwanted side effect. After long enough, it's going to be both.

> Many doctors were convinced.

Fuck those doctors. They should have their medical license revoked for being fucking stupid and gullible.

Your tone is a bit inflammatory, but I can't help but agree a bit. If someone who is selling you something is doing so by trying to convince you of a medical phenomenon that you (as a doctor) aren't familiar with, it's the height of irresponsibility to just accept that at face value. It shouldn't be a secret in the medical community that big pharma sales can be... unsavory.

As someone who has worked in the pharma industry, most doctors are very skeptical of anything a drug rep says, not in the sense that they're lying, but more that they're trying their best to make their products look good.

One shouldn't underestimate other factors in opioid prescribing: 1) the idea that pain is the "fifth sign" and should be aggressively treated and 2) that good pain control leads to positive customer experience.

It's not as simple to say "jesus those docs are stupid to believe Purdue". Some maybe are, but most probably never even saw their rep.

I talked to a retired Doctor about this the other day and he dismissed out of hand the narrative that doctors were fooled by pharma reps.

His read on this was: doctors by and large knew exactly what they were doing.

Perhaps they were irresponsible. Perhaps they just didn’t want to let people be in pain.

But his take was that laying this on the pharma reps is a silly idea.

He would say that. Nobody likes to feel like a dupe, and there’s safety in numbers. I doubt he had a Purdue rep in his office change his mind about prescribing habits.

Still, you go to conferences and there are often a few Gladwell-caliber speakers at the big ones who get your head bobbing up and down for an hour. It’s very much in the drug companies’ interest to convince those speakers. Then the whole thing feels very organic, everyone’s new opinion feels like a reasoned medical choice.

It's also distressing that through undergrad, medschool, residency they never learned that opioids are fucking addicting as fuck and how to think for themselves.

I mean, this opioid crisis didn't just begin this year, or last, but it's been decades in the making. So imo doctors happen to be just as part of the problem as big pharma.

Give me a break.

Also, and more importantly, fuck those drug reps - and if they were ignorant then fuck our society that has come to accept CYOAism so widely. It is your job as an employee to be aware of the effects your labour is having on others - if you're working in a paper mill that is dumping chemicals into a river it's not enough to hope folks downstream don't get sick.

Beyond the devil's advocacy, my personal opinion is that the industry is currently swung too-heavily towards prescribing opioids. We need to swing back the other way. The trick will be not swinging too far, which is I think the brunt of this article's intent.

> currently swung too-heavily towards prescribing opioids

Ah, you would have been right about 10-15 years ago. Things have dramatically changed since then. I'm assuming you've not had any contact with the medical system requiring opiates for you or your relatives in recent years. Now, we've swung far, far too far to the other extreme, to the point that my WWII vet, community leader, church deacon grandfather was brutally undertreated for pain while he was dying of cancer. This is very typical now.

Either that, or the medical system is very different in Silicon Valley or wherever you live.

I think you're right. You're not the only person in the thread with this feedback. I read this book and thought I could contribute, but I haven't read anything with more recent context. (Haven't even finished the book yet, still working on it.) So yeah, I appreciate this callout, I apologize, and I'll try to do better next time.

Something to keep in mind: very few people will write a book about how things are basically okay but could use some small tweaks.

Opioids aren't a great painkiller anyways - they're just a painkiller that can be patented.