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Comment by Afton | Hacker News Reader

Thank you for sharing this.

Someone I love has chronic pain managed with (legally prescribed) opioids, and they have constant low-level anxiety that a bureaucratic mixup will result in their medication being denied (or heaven forbid they lose a prescription, or that they'll need a refill when their doctor is on vacation and the locum will be 'suspicious of drug seeking behavior'.

They had to sign a document that if they lost a prescription, they understood that they would be denied a refill, even though (a) there isn't actually any reason to physically hand them the piece of paper, it could all be done between the doctor and pharmacy, and (b) people with chronic pain typically also exhibit various degrees of 'being distracted' due to that same pain.

I could go on, and TBH, my friend hasn't had any gaps in getting their medication, but the current wave of anti-opioid hysteria is concerning.

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"current wave of anti-opioid hysteria is concerning"

This is not the media's fault, nor is this is not chronic pain patients' faults. This is the result of criminal corruption and abuse in the pharmaceutical industry and distribution system. There is a real and enormous problem https://www.drugabuse.gov/related-topics/trends-statistics/o... (opioid overdose death rates have more than quadrupled in 20 years, are at a high level already versus other causes of death at 50k annually, and are accelerating). Opioids are some of the most dangerously addictive medicines that exist, and habituation and pill selling is a huge problem that is also ruining and ultimately costing lives.

The death rate from prescription opiates has not budged since 2006[1]. The vast majority of opiate overdoses in America are not prescription opiates, but illicit fentanyl, and to a lesser extent heroin and methadone. Nor do chronic pain patients face any major risk of overdose. The fatal overdose mortality rate for long-term opiate-prescribed patients is 17 per 100,000[2]. And that number doesn't exclude the subset of the population engaged in abusive behavior like mixing with alcohol, snorting pills, or hoarding medication.

Finally the sizable majority of prescription drug abusers in this country do not source from a doctor or the healthcare system at all. The vast majority get their drugs either from the black market or a friend or relative. On the National Drug Use Survey only 18% of prescription drug abusers report doctors as their primary source. And among street prostitutes (a high at-risk group) only 5%[3].

All of this goes to show that there is very little evidence of any sort of over-prescription of opiates in America. To begin with the vast majority of the opiate crisis has to do with fentanyl, not prescription drugs. But even when it comes to prescription drug abuse, the intersection with medical users is vanishingly small.

[1] https://www.ncbi.nlm.nih.gov/pubmed/18489635 [2] http://www.ncsl.org/portals/1/documents/health/APeeples0118_... [3] http://sci-hub.tw/https://www.tandfonline.com/doi/abs/10.108...

You seem to have somewhat missed the point.

You are correct that chronic pain patients are not a high overdose risk and that there is little to no benefit to treating their prescriptions with suspicion. (People who don't have to operate in a black market are MUCH safer.)

Here is here you go wrong:

> All of this goes to show that there is very little evidence of any sort of over-prescription of opiates in America.

There is very clear evidence for over-prescription of opioids. There is very clear evidence that the risks of addiction were deliberately minimized by drug companies and doctors were incentivized to over-prescribe for as many off-label uses as possible.

The issue is: Anyone who does develop a problematic addiction to pill they are prescribed tends to have their access cut off and are thus forced into the black market where their chances of overdose increase dramatically.

Thus while users with drug prescriptions may not be overdosing at high rates, that does NOT mean that the black market overdoses are not directly causally related to the over-prescription of opioids.

> Finally the sizable majority of prescription drug abusers in this country do not source from a doctor or the healthcare system at all. The vast majority get their drugs either from the black market or a friend or relative.

They may not source directly from the healthcare system, but prescription diversion and fraud do indirectly source a lot of product from the the healthcare system. I suspect that crackdowns on this diversion helped spike the blackmarket opiod overdoses as it decreased the quality of the blackmarket supply (and thus increased the prevalence of Fentanyl.)

>All of this goes to show that there is very little evidence of any sort of over-prescription of opiates in America.

Ridiculous. It certainly does not, in any way, shape or form. Your "analysis" also excludes the very clear evidence that people get hooked on opioids from prescription pills and transition to black market products like fentanyl.

"The volumes of the pills handled by the companies climbed as the epidemic surged, increasing 51 percent from 8.4 billion in 2006 to 12.6 billion in 2012. By contrast, doses of morphine, a well-known treatment for severe pain, averaged slightly more than 500 million a year during the same period." https://www.washingtonpost.com/investigations/six-takeaways-...

Only 0.19% of opiate-treated chronic pain patients without a prior history develop any form of abuse or addiction[1]. And remember these are chronic-pain patients who take tolerance-escalating doses over years or even decades. Virtually no one develops an opiate addiction from following their medically prescribed treatment regiment.

[1] https://www.ncbi.nlm.nih.gov/pubmed/18489635

>Virtually no one develops an opiate addiction from following their medically prescribed treatment regiment.

Completely false. You refer to data about a subsection of opioid prescriptions (chronic pain patients), and asserting broad claims that are not accurate.

"In just 10 months, the sixth-largest company in America shipped more than 3 million prescription opioids — nearly 10,000 pills a day on average — to a single pharmacy in a Southern West Virginia town with only 400 residents, according to a congressional report released Wednesday."

https://www.wvgazettemail.com/news/health/drug-firm-poured-m...

Illegal diversion in the supply chain does not tell us anything about whether the healthcare system is over-prescribing pain medication.

Let's just take your example. What do you believe is more plausible? That a town of 400 people are collectively prescribed 10,000 pills a day by well-meaning doctors? Or that the pharmacy from your example is a front for organized crime to funnel prescription opiates into the black market?

There are no statistics that show properly prescribed and taken opioids have anything to do with the crisis. The crisis comes from illegal usage and tainted substances. Sadly this is not clear from the statistics without digging into them, and few do.

That prescription opioids are significantly reduced, yet the death rate continues to climb indicates the focus on the current solution is in the wrong place.

No one, including me, denies "pill selling" is a problem. However that has zero to do with the people with Chronic Pain that are doing everything within the law.

There are bad doctors, and other bad actors, they need dealt with of course. Not at the expense that need such medication.

>That prescription opioids are significantly reduced, yet the death rate continues to climb indicates the focus on the current solution is in the wrong place.

False. There has only been a minor reduction in sales. https://www.fda.gov/media/111695/download

Also, it just means those easy pain pill scripts are drying up, and people are turning to black market alternatives. It's cheaper and easier to import fentanyl from PRC and press it. Also leads to dosing errors (overwhelming cause of deaths).

> The crisis comes from illegal usage and tainted substances. Sadly this is not clear from the statistics without digging into them, and few do.

The crisis was directly contributed by over-prescription ande the deliberate minimization of addiction risks. The crisis was exacerbated by then pushing these people off their legal prescription once they become addicted, forcing them into the black market.

> That prescription opioids are significantly reduced, yet the death rate continues to climb indicates the focus on the current solution is in the wrong place.

When you push more people into the black market, it is reasonable to expect that over-doses will rise.

> There are bad doctors, and other bad actors, they need dealt with of course. Not at the expense that need such medication

Yes, I agree. We are much better served by educating about and being aware of addiction risks than we are by limiting access to prescription medication because we are concerned a person is already addicted.

'hysteria' is the key word here. A blanket ban on more than 7 days of opioid medication is a hysterical reaction to the current problem. Sure, root out the corruption. Blame people and companies and even put people in jail if you think it will help. But in the meantime, it saves lives.

Also, as long as we're here, the reason pill-selling and whatnot exists is because of the war on drugs. But that's a larger discussion than what I/we can do here.

The fault belongs to the enforcement and the enforcement alone. No matter how extreme the criminals they still control their own actions. They cannot be allowed to pass the buck of their collateral damage for that lets them ignore their contribution entirely.

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