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Comment by stef25 | Hacker News Reader

It's a really complicated problem but one thing that just stands out to me is the role the doctors play: It's not normal to send people home with these massive prescriptions for opiates.

Here in Europe doctors are very, very conservative with that stuff (and meds in general) while it seems to me that in the US if your "medical experience" even entails the slightest bit of discomfort people get all up in arms over it. Doctors are highly educated people who can no longer play the "I didn't know it was addictive" card.

I have a friend in the US who told me they have an app on their phone where they can just tap a button and the next day they can refill their benzo prescription, and it's been like that for years without having seen a doctor again. That's just criminal behavior from the part of the medical establishment.

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My recent experience in the U.S. has been that, at least at major hospitals, it's flipped to the opposite extreme, and doctors are so worried about the backlash, that they will leave patients in pain and fail to prescribe analgesics sufficient for post-surgical pain control, if they don't have non-opioid options.

My partner had a post-cancer DIEP flap reconstruction last month at a top cancer center in NYC, and due to the nature of the surgery, couldn't take NSAIDs, which are typically most effective for her (they have blood thinning side effects and were banned for 2 weeks post-surgery to avoid risk of hematomas). So she was left with taking over the counter Tylenol plus prescription opioids. They prescribed opioids 2 days of pills at a time, which required me to constantly drive to pick up new prescriptions (since obviously she couldn't drive), and it felt like some kind of interrogation each time she'd call up and report her current pain levels. As if they assumed by default she was lying or was a drug addict or something, versus someone recovering from major surgery that doesn't heal in 2 days, and furthermore is not allowed to take anything else that's effective (NSAIDs). Hours spent writhing in pain trying to get some pills prescribed and picked up. It only got resolved once the two-week NSAID ban was up. Then she stopped calling about the opioid-based analgesic and just started taking large ibuprofen doses instead. Problem solved, since you can buy as much ibuprofen as you want. But a pretty shit two weeks up until that point.

As a result, I strongly dislike a number of aspects of the anti-opioid backlash. It made our lives worse and caused us more suffering.

I had open heart surgery in the US and the doctors refused to give me opiates to take home in the few days after. They gave me opiates while I was in the hospital, quite generously, which was for four or five days, but they would not let me take any home. I even asked for just five pills in case the pain was unbearable (they literally had just broke my ribs and sternum and sawed my chest open).

I don’t respond much to opiates anyways, but I still find it completely ridiculous.

What you experienced is obviously the pendulum swinging too far (in the right direction). Then again, it should just be accepted that major surgery will always involve some discomfort.

There's a big distance between "5 days worth of low dose Tramadol" (+ max dose of Paracetamol) and "2 months worth of Oxycodone". It's really not a hard problem to solve for the medical establishment.

Yup, there are a lot of people with chronic pain, and the only things that reliably treat pain without being really bad for your system are opiates and weed. Paracetemol (and to a lesser degree ibuprofen) are so bad for you they mix it into opiates so that if you take enough to get high the paracetemol sends you to hospital, and weed is stigmatised at best, and still illegal in most of the world. Ketamine in useful doses has too strong side effects, cocaine-derivatives are only really good locally, and also not great for your system. And that's about all we've got.

As a kid I had migraines, and quickly developed an immunity to the pain-relieving aspect of paracetemol, they were basically candy by the time I was a teenager. Luckily they disappeared in my late teens, but now I'm in my 40s and I get weird pains they call "cluster headaches" in my face. I did some tests, got an MRI, and they didn't turn up anything, which is pretty much the end of medicine, pain management is all there is for me. In Australia we need a prescription for any opiates, so I have to be treated like a drug addict to get painkillers the rest of the world can buy over the counter, it's a disgrace.

> I get weird pains they call "cluster headaches" in my face

if you have not already done this, you could consult an "migraine center". There is no cure but there are some effective (for some people at least) options for treating cluster headaches, like triptans and lifestyle changes (regularity in sleep patterns, etc.)

They're very different from migraines (which I had as a kid), in that there's no visual effects or nausea, and seem to be more localised and less "systemic". I'm always trying to work on my sleep, with very little success overall. I've never tried any of the serious sleeping pills, they seem too risky; but a combination of restavit (an antihystamine) and melatonin can get me to sleep pretty reliably, the problem becomes that it sometimes leaves me a bit too slow and stupid in the mornings.

That is very different to when I was at BIDMC for my plastic surgery rotation as a medical student - I was shocked at the quantity of opiates people were going home with for simple things, let along DIEPs. I gave a talk to my team when I left on differences and focused on opiate prescribing (this was in 2013)

Are the only options doctors can prescribe NSAIDs vs opioids? There is nothing else in between?

As far as I know, there surprisingly aren't other options. I also assumed they would have something else up their sleeve that was stronger than OTC ibuprofen but weaker than a morphine analogue. But, the three classes of analgesics really seem to be Tylenol, NSAIDs, and opioids. A few other things are usable for anesthesia but not something you can prescribe as a pill for at-home pain control. There is also some evidence for cannabinoids, but they're stuck in legal limbo. The other thing that comes to mind is that benzodiazepines can also help in some patients. They don't have a direct analgesic effect, but can help people relax or sleep so as to ignore pain (they can also be habit-forming, but probably not to the same extent as opioids).

There are other painkillers coming and going. In my country, the middle ground was, for years, metamizole. This drug is currently baned in some countries (e.g. USA) for its side effects, while is sold nearly OTC in others (e.g. Mexico). Other drugs like flupirtine or nefopam are about the same: middle ground painkillers, but too bad side effects.

The good thing about opioids is that you can dosage them precisely, and that you have plenty of opiates in a ladder of potency. Tramadol (sold as Ultram in the US) is a middle-ground painkiller despite being an opiate. Same as codeine. Slightly above is tapentadol. Curious thing is despite tapentadol has not been found addictive (at least as addictive as other opiates), it's still an opiate, and so the FDA put it in the same bucket as fentanyl and morphine.

Another analgesic is cannabis. Sadly, it has the same problem as opiates: it was deemed too fun or too good, it seems we must endure pain to make the regulators happy. It turns out people hate pain, so they end up taking fentanyl and heroing under a bridge.

The sad thing about all this is that the regulators decided pain is not a bad thing, so you must endure it. But they decided anxiety is a terrible thing, so you can get as much bromazepam as you need. Even when bromazepan and other benzodiazepines create dependence and tolerance (and the withdrawal is terrible), I'm sure you now at least a dozen people taking it cronically (I do). They are as hooked to that thing as it was heroin but, hey, it's legally prescribed, so no problem here: one pill for breakfast, one before bed, and they are 24/7 high while nobody bats an eye.

You can give Codeine or Tramadol, which are opiates that produce no "high" when taken in standard therapeutic doses. People do abuse them by taking a whole box at once, but you won't end up in a scenario like in OP's story where someone discovers it "solves all their problems" after receiving them for moderate pain from a routine medical procedure, and has them shooting heroin 6 months later.

Pregabalin/Lyrica, I think. It's a seizure medication but as it was explained to me it increases the amount of signal your nerves can take, or it slows the signal, and that reduces pain. It helped me in the past but it makes you tired.

What's so fascinating to me, is that the current opiate epidemic is largely centered in the US, as we bear the majority of the deaths. That attitude of Drs. over-prescribing, it definitely happened in the US, to various degrees in different places, and not that long ago.

Docs in the US tend to think they are above being marketed to, but Purdue Pharma knew better, and they paid their drugs reps a ton to go out to "everytown US" and convince doctors that they had made a non-addicting opiate. Enough docs bought it, and here we are.

How did they do? Well, 20 years ago drug reps used to be able to take doctors on trips: to sports games, to see the dog races, to museum trips, the price of a day trip with you and one or two loved ones was to sit through an hour (or two) lecture by a rep that convinced you to to prescribe a drug. Not a bad deal!

There were complex reasons why the opiate crisis started, but the environment was ripe for an upstart company like Purdue to come in, reformulate an old opiate, pretend the addiction problem isn't there, then sell a miracle drug because opiates are extremely effective short term analgesics. Long term, we're still paying for it!

I've looked a lot into the opiate crisis, and it's a pretty bad stain on the US medical institution, particularly our medical science. We fucked up.

(To start: Just to clarify there's a significant difference between benzodiazepines and opiates.)

> I have a friend in the US who told me they have an app on their phone where they can just tap a button and the next day they can refill their benzo prescription, and it's been like that for years without having seen a doctor again.

Is this the "request a refill" feature that every US pharmacy offers? Granted, benzodiazepines are less restricted than stimulant drugs¹, but a doctor in the US need to at least review a prescription twice a year.

Chronic (daily) of benzodiazepines is bad, and doctors will not² start new patients on this.

There's still a lot of legacy patients who are on chronic benzodiazepine treatments -- doctors should work with them to wean them off, but it's very challenging and disruptive.

Requiring a patient receiving a benzodiazepine at a non-daily level (e.g. for seizures, anxiety, occasional insomnia) to go back to see their doctor when nothing's changed several times a year is just pushing medical costs (money/time) on the disabled.

¹: e.g. Adderall, which can't be refilled

²: Providers are trained not to these days, at least

Once, about 10 years ago, I had some mild pain in my shoulder after skiing. It was hardly debilitating, just annoying. I went to the doctor, and within about 15 minutes I walked out with a prescription for 60 Vicodin. I don’t know if things have changed in the states much in that time, as I haven’t had a need to find out. But it still strikes me as odd that they would give me that kind of a pain killer so easily.

I don't think it's a really complicated problem, other countries have tried different things that have worked.

It's complicated for some people to admit the 'war on drugs' has failed maybe, but that's a different issues all together.

What's complicated is that it's not really the drugs, it's the fact that people experience their lives in such a miserable way that oblivion through opiates is a better option.

IMHO this is because of alienation, a loss of community, strong personal bonds, lack of goals.

There's a famous experiment that sums it all up perfectly - the one where animals were given an unlimited supply of cocaine and they took it until they basically starved themselves to death. But when they put the animals in a nice stimulating environment with toys and friends to play with they basically ignored the drug supply.

So yes, providing govt run shooting galleries will stop people from dying and you'll make them slightly less miserable but those people will still live lives that you wouldn't want for your children. They have an illness that needs to be cured.

There's a famous experiment that sums it all up perfectly

I think you're referring to the Rat Park experiment (https://en.wikipedia.org/wiki/Rat_Park), and (as always) its conclusions are not as solid as the myth implies. That's not to say its results have been disproven, but they haven't been confirmed with other studies either.

Still relevant though because if you have a medical problem (addiction) and rather than be provided with care you’re treated like a criminal, you’d feel even more isolated and less part of something good.

I can tell from experience that having to go to doctor, then wait there then having to go to pharmacy then wait there, all in pain massively massively sux.

Having to do it on the regular would be just cruel.

The amount of pain meds my wife came home with after her c-section was like 100x what she ever used. I’m sure there are some folks who need that much but I doubt it’s the median.

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