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Comment by atdrummond | Hacker News Reader

It has become an absolute joke. I have had 6 surgeries for Crohns, a back surgery due to wear and tear from high level athletics, and am a long term sufferer of an aggressive leukaemia. Despite using opioids responsibly for over a decade, I am regarded as nothing more than a drug seeking pest the very few times I have actively sought pain relief during in-patient hospital stays. Prior to being dropped entirely from my Oxycodone IR script (30 10mg pills a month, truly not a large amount) without any warning due to my pain doctor finally simply giving up on the system, I had never asked for an increase in a dose ever - despite still having plenty of untreated pain.

Legitimate chronic pain patients are being abused at this point in order to save face for the broken, rent-seeking pharmaceutical system that enabled the prescription opioid 'crisis' in the first place.

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Yep, absolutely. My doctor of 10+ years recently retired, leaving me in search of a new doc. I've been managing my pain for 15+ years just fine with 10mg Hydrocodone. In 15 years I only once asked to increase the dose, and it was only from two pills per day to three to help me get through the afternoon/evening better. A minuscule dose.

After doing "new patient" appointments (which by the way were like $200 to $300 each) and not having a doc willing to take me on as a patient unless I dropped the opioids, and making several calls (who refused to tell me over the phone whether the doctor was even open to controlled substances without that $300 "new patient" appointment) I gave up. Since coming off the opioids my quality of life has plunged. I struggle with depression and thoughts of suicide now, especially when I'm unable to leave the house or my bed. I went from stable and productive and what doctors used to say is the model patient, to being miserable. Every doc has offered to give me additional antidepressants or crank up the doses of those, but none are willing to treat the pain that is exacerbating it.

I absolutely believe that what the medical establishment is doing to people like us (withholding treatment that we know works) is cruel and borders on torture. It is the epitome of taking macro-level stats and explanations and applying them broadly on the micro-level, regardless of the harm caused.

I believe Hippocrates would be rolling over in his grave to hear that these people took an oath to "do no harm."

For the record. I mostly don't blame the doctors. They are protecting their medical licenses, which the DEA and FDA have proven they are willing to revoke over the slightest anomaly. When the feds started throwing pain specialists in federal prison because some tiny percent of their patients were abusers, it really drove home that individual doctors are not allowed to think anymore. You implement government policy, or you risk financial ruin and even jail time. I don't blame them for being cowards. I probably wouldn't risk imprisonment on a stranger either.

I don't blame the doctors either. My pain doctor was a rural boy from my hometown who made good, graduated from Berkeley and finished medical school and finished desirable postdocs at Harvard. He simply straight up quit pain management as a specialty rather than be forced to provide his patients with what he considered subpar care. The loss of doctors like him hurts particularly badly, as it leaves us with pain specialists who either knowingly ignore the decades of successfully treated patients who used opioids or the remaining (and they do still exist) pill mill operations, who have simply gotten more sophisticated in their execution. Regardless of which doctor archetype chronic pain patients end up with, they're going to suffer.

We also now know that those treatments kill people and users gain dependence and tolerance to opioids. It’s more than just protecting their medical license.

The proportion of patients who become addicted from properly prescribed opioids is extremely small. The majority of addicts created were provided with opioids that were not appropriate for their particular medical situation, in doses that were too high, and on a regimen that exceeded in length what was supported by the medical evidence. The proportion of new cancer patients who go on to receive palliative care that includes opioids who end up becoming addicted has always been, and remains, in the low single digits. For patients with a genuine need and who are properly inducted and maintained on them, opioids are a powerful and useful medical tool.

Further, the bulk of use in illegal opioids stateside, such as fentanyl and its analogues, is not (at least today) driven by the conversion of the legal opioid user to an illegal drug user. Fentanyl is now commonly found in drugs that never previously would have contained an opioid, such as counterfeit benzos and MDMA. Further, the majority of fentanyl users on the street arrive at its use after consuming other illegal/street drugs. For those who started on other opioids, their first opioid will tend to be the illegally diverted pills or liquid cough treatments containing codeine/hydrocodone called "lean". Very few new users of fentanyl and fentanyl analogues come from legal opioid users, mainly because very few new users are now inducted on reckless prescriptions such as an immediate script for 180 Oxycontin and 240 benzodiazepene pills a month. Your narrative is about a decade out of date at this point.

Thomas Kline is a superb resource if you want to take a deeper dive into the actual statistics and how the narrative of a crisis was used to systematically deny law abiding patients the pain treatment they should receive. https://twitter.com/thomasklinemd

A meta study of 38 studies from 7 years ago on patients using opioids for chronic pain found that 21-29% of the patients misuse the drugs and 8-12% of the patients are addicted to them. That doesn't seem "extremely small" like you said, though maybe it's better now. I think there are reasons why opioids are no longer recommended for the treatment of most patients with chronic pain that you aren't fairly acknowledging.

https://journals.lww.com/pain/Abstract/2015/04000/Rates_of_o...

https://www.nejm.org/doi/full/10.1056/NEJMra1507771 Volkow is a mainstream researcher, using data from the peak of the crisis, and cites the rate at just under 8%. It is not at all unreasonable to assume that with proper prescribing (unlike what happened in the 90s and 2000s) that chronic pain patients can have opioid misuse and addiction numbers near or matching that of palliative care patients, where addiction rates are closer to 1% than 10%.

I’ll agree I wouldn’t describe that as extremely small. The misuse stat is pretty bad. The addiction though…essentially for every 10 people who are treated for chronic pain, 1 of them gets addicted? With 9/10 of those people getting to live a more pleasant life…Chronic pain is awful, and the good done by alleviating it might be worth that cost.

And let's not forget the 1/10 very likely would be in extreme pain bordering on torture instead of addiction. It's lose lose for them.

I’m not sure how you figure that this hypothesis is “very likely” true. It’s actually very likely not. The papers don’t mention this at all.

Just to be clear - the cohort in his paper is not all opioid users. It is the subset most likely to become addicts, for the following reasons:

1. The meta-analysis occurred during the period of time that pill mills and other unscrupulous prescribing was rampant. See that there was no note regarding patients' (legal) polydrug use or by morphine equivalent dosing, nor was there any modification to the analysis of the data to see how this period in the legal drug market impacted patient outcomes.

2. This analysis selects for chronic pain patients, which tends to mean the long term users of opioids while excluding the acute patients who, particularly among the in-patient subset, pretty much never become addicts during their course of use - which is what we'd expect if these compounds were as addictive as claimed.

3. These cohort selections often do not include some or all palliative care patients. I won't accuse them of doing this to sensationalize their numbers but it does have a significant impact on results, as again palliative care patients very rarely cease their use and carry forward afterwards an opioid misuse disorder.

4. They do not control for or look at the specific impact of the main problematic legal opioid - Purdue Pharma's original OxyContin formula. Because this drug did not have the pharmacodynamic profile claimed by the firm and represented in the safety studies, it was considerably more likely to cause opioid use disorder, as patients would be much more likely to take extra doses to cover the shortfall in the dosing window. This would lead to patients who otherwise would exist on a steady dose asking for increasing doses - or, worse, turning to the street to acquire diverted doses.

> properly prescribed opioids

They were incentivised to not properly prescribe opioids. Don't be so quick to let the doctors off the hook. They're pleading ignorance isn't going to work. These were highly intelligent people who knew what they were doing and did it anyway in exchange for bribes from "Big Pharma".

Who fucking cares? This wouldn't be nearly as huge of a problem if people with a physical dependency — inclusive of addicts, but by NO MEANS exclusively addicts — could reliably access safe, reliably dosed opioids instead of getting pushed to street drugs.

If these people have access to a doctor/health care then there they definitely have options to treat their addition. Any family physician would be happy to discuss treatment options.

The problem of people without health care is a bigger and separate issue.

Sorry if i sound blatantly stupid with my question, maybe In your case this could not be a sufficient solution for pain but did you ever tried with something like Marijuana and if it's illegal in you state considered migrating where it's legal? Or even considered to relocate to somewhere where you can get access to proper medication ?

Weed is a joke medication for many (most, I'd argue) types of pain. And yes it is condescending to suggest it to a longtime sufferer of chronic pain. It's akin to asking a suicidal person if they've tried exercising.

Anecdotally, with N being roughly 5 people, THC/CBD do nothing for several types of chronic pain, short of getting high enough that you stop caring about the fact that you are in pain.

Worth a shot, but I wouldn't recommend anyone getting their hopes up trying it.

Tiger balm, on the other hand, is nothing short of magic.

You can buy oxy on the street. Super expensive. $1/mg.

And 50/50 odds it's actually an unknown dosage of fentanyl.

If it is a 30mg pill, it is likely a synthetic analog.

the actual probability depends on your location,

but in general:

the kids are FUCKED

Not true! They’re real pills sold by people who have an rx in my case.

Be smart and learn how to identify fakes. I can spot fake m30s by texture.

you can get research chemical opiod derivatives legally OTC such as ODSMT or Kratom however I would be extremely careful regarding addicition potential, not all opiods are created equal, e.g. tianeptine sulfate should never be attempted

Thank you for another reason when people ask why I don't go to doctors.

I’m curious what the situation is outside the US. My personal experience has always been that I’ve been able to access whatever drugs I’ve needed in the UK, but I also am white and don’t look like a “Drug user™”. I’ve never heard the words opioid crisis in a European context (but have of course heard it in a US context).

Sorry to hear you have this problem. Chronic pain understanding and management is medieval, and seemingly getting worse rather than better over time.

I really appreciate your kind thoughts. Thankfully Vipassana meditation has helped keep me sane in spite of the inane restrictions my doctors have been put under and also just so happens to help reduce the pain to a somewhat more manageable level. It's funny that a lot of the patients most aggressively hurt by simplistic one-size-fits-all reforms like the 90 MME cap are the patients most likely to support, and already be utilizing, integrative medicine. Such patients have been dealing with pain for years, decades often - they're not going to turn down any potential solutions that might help. All they ask is for their doctors to be given the autonomy necessary to prescribe legal, needed medications when called for.

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