How much of the opioid epidemic is accidental vs. pleasure-seeking addiction?

Posting in here as I have not seen a factual answer to this and assume some opinion may be involved…

I have heard a lot about the opioid epidemic over the past few years and believe that it is horrendous. One thing that never seems to come up, however, is the origin of the individual cases of addiction. Let’s assume a base case of someone who started his/her addiction with a legitimate prescription (I know the epidemic includes other types of cases, though this seems to be the type that is most talked about). There would seem to be two main possible scenarios:

  1. Someone starts a prescription for pain and gets accidentally addicted to the drug. They never use it for pleasure, escape, etc., and never gets any enjoyment out of it at all, but they nevertheless become addicted.

  2. Someone gets a prescription, tries it, and likes the drug. They keep taking it for fun, escape, etc.

Of course, there needn’t be a black-and-white division between the two scenarios; no doubt, some people fall into both categories at the same time. But I haven’t heard a word about this.

What kinds of facts/opinions can you provide? Thanks!

To a large extent, doctors started following a study that concluded that they weren’t addictive. Manufacturers started pushing prescriptions and also not looking too closely when a bunch if the prescriptions should have looked suspicious.

A huge segment of working class Americans were dealing with chronic pain from backbreaking jobs or injuries or other health issues.

Every societal force—medical, commercial, legal—pushes this on the public. They got hooked.

And when the government started acting yo stop this cycle, people who were already hooked turned to cheap and potent heroin.

This—like a lot of societal problems—is complex and tied to a whole host of economic, commercial, democratic, political, legal, and public health issues. Wanting to chalk it up to “pleasure seeking” is an attitude that has failed to effectively address a lot of things in our society.

The fact that a lot of opioid addiction is in working class people in small towns (much like meth) would suggests that there’s a fair amount of people for whom the two are meshed. Quite a few people might feel down, have unhealthy lifestyles and start getting more pain/injuries as they get older or more out of shape. The opioid takes away physical pain but also dampens psychological suffering. I doubt many people who got addicted through a prescription never used it for pleasure or escape. To an extent, escape is the point of opioids. The problem is practically separating the escape of physical pain from the escape of psychological suffering. If you could do that, addiction would be much lower.

Can someone more knowledgeable say how prevalent obesity, tobacco and alcohol use are among opioid users or addicts?

So, those who tried opioids for kicks deserve whatever they get, so fuck them, right?

Well, that started in a seemingly harmless way and quickly got out of hand.

It would be nice if we could explore the issue a bit before you start hammering on straw men. The moral denigration of people who have tried opioids in pursuit of pleasure is not automatically implicit in the act of noticing that they exist. Helping people who become addicted because of pleasure-seeking/escapist behavior may require a different approach than helping people who become addicted simply because they received a prescription to treat an acute injury - but we can’t figure that out until/unless we first acknowledge that there might be multiple paths to addiction.

AIUI, part of the problem in the early days was that doctors were overprescribing opioids. Not just handing out prescriptions that weren’t strongly indicated, but handing out enormous quantities of pills in a single prescription. Recovering from back surgery? Here’s a prescription for 300 pills, with an option for three more 300-pill refills if you need it. Enterprising individuals who had managed to avoid becoming addicted themselves were selling their unused pills, fostering addiction in others. I get the impression that this kind of abuse is under control now. In fact, possibly overcontrolled: some doctors, fearing attention from the DEA, are now underprescribing opioids, making it difficult for some patients to manage real pain.

There was another issue - which is when these opioids came out, two things happened:

People were told that there was no reason for pain, ever. Which as anyone who has chronic pain knows, is simply not at all true.

Doctors started to be graded on “customer satisfaction” - which is about the stupidest metric that you can use for a doctor - you aren’t going to be satisfied if your doctor tells you - even in the nicest way - that you are obese, that your weight needs to come down because your blood pressure is high and your blood sugar numbers are not looking good…much less if they tell you - nicely - that the best thing for your pain is a few OTC ibuprofen.

In people I personally known more than half started with an Rx from the doctor and continued from there. And the ones I know who went into it from the beginning for fun were mostly back in the 60s and 70s. It seems like its been prescribed so much lately. Now how many of those had a bad back and how many had a “bad back” we could debate but that’s been my experience.

I’ve complained about this before: Dentists and doctors give out opioid’s way too much. Here are examples from me:

  • Hurt my ankle: 20 pills
  • Wisdom teeth pulled: 20 pills
  • Oral skin graft: 20 pills
  • Abdomen surgery: 30 pills

These are all within the last few years. For the first 3 examples, I only needed 1-3 pills each incident. For the last, I needed all 30 and was extremely careful to track and reduce my intake (they were a stronger variety as well). I felt I could’ve become addicted if I wasn’t so paranoid about it. I have about 30 spare pills (I didn’t fill one of the prescriptions because I already had so many). I even asked the dentist if I could get a much smaller prescription and he said no - I think the reason was “we don’t want to have to refill when you run out” or something like that.

Here is a recent, relevant article about young people, opiods, addiction and dentists:

For the case I am most familiar with, it started with a mis-diagnosis.

The patient had non-specific complaints of pain that went for years mis-diagnosed as fibromyalgia, with doctors prescribing different drugs and higher dosages every few months since nothing seemed to manage the pain. This fostered a path that lead to a willingness by the patient to try every and any drug that might work. Addiction ensued.
By the time a real diagnosis of MS was reached, 10 years and a pharmacy of drugs had passed and the underlying medical condition was the least of the problems.

I don’t think we should have a Drug War at all, nor should we take a punitive approach to drug users at all. That said, I am curious about the causes of crisis. Perhaps it is not being talked about precisely because the government and media don’t want to sound judgmental or encourage that stance in others. That’s a good thing but I think we should still be clear about causes.

We had another thread earlier this year that covers a lot of information on this topic.

I found a study that I shared in that article. Here are a few quotes from from it:

On the rate of addiction among long term users for chronic pain management

One number that is frequently mentioned as the addiction rate for opioids is 26%. The article points out that:

The article covers several other interesting areas, such as the fact that many people who become addicted are not users who were prescribed the drugs in the first place. There are other risk factors as well, such as prior addictive behavior. This means that prescription management makes sense. We also see that the pendulum has swung too far, and people in genuine need are feeling the brunt of it. They live with chronic pain, and those who are addicted simply shift to other sources.

I don’t think this category of person gets addicted, (with a small number of exceptions). If it doesn’t give them pleasure, they stop taking it when the pain stops, and they take only the prescribed amount. With this type of person, the side effects often are disturbing enough that they stop taking it as soon as they can.

If the drug is causing euphoria, it’s easy to find justifications to continue taking it, and to take more than indicated, especially because it’s from a doctor, and doesn’t require one to do things which attract negative attention. And as Sunny Daze points out, those that take medication prescribed to someone else are obviously doing so for the high. A lot of kids throughout Southern California who got addicted to opioids started by taking those left-over pills they found in the medicine cabinets of relatives, after they started to become so widely prescribed.

According to a recent article by Marcia Angell (once editor-in chief of the New England Journal of Medicine) in the New York Review of Books, the number of opioid deaths in the US last year was 64,000. Sounds horrible, but she added that the number of deaths due to alcohol was 90,000 (this includes murders and suicide, but is mainly attributed to cirrhosis) and to tobacco is an astounding 480,000. And as she points out, the latter two drugs have no legitimate medical use, while opioids do. She strongly feels the pendulum has swung far to far in the opposite direction. From handing them out life penny candy, doctors are now withholding needed pain-killers because they are afraid of the law.

Drug epidemics usually occur among people who are trying to cope with psychic pain.

The modern opiate epidemic is not the first drug epidemic. It won’t be the last. Meth is/was very big in a lot of places. Crack was big in a lot of places. Benzo abuse is huge in a lot of places. Alcoholism is big all over the place.

It seems to me that the biggest ingredient is just general misery, and drugs allow you to escape that temporarily. Areas with more than the average amount of misery are going to have more than the average amount of drug abuse.

But then again the ‘happy’ places (safe, upper middle class neighborhoods) probably have a lot of behind the scenes alcoholism and pill popping.

I have no scientific answer to the OP. However there were drug epidemics long before opiates became a mainstream drug therapy, and not all drug epidemics are due to opiates. They are also due to stimulants, benzos, alcohol, etc.

If anything, in modern society we should be physically healthier than we’ve ever been.

For one thing, a lot of jobs are less physically demanding than they were 60 years ago. A lot of jobs are office jobs now vs the past when most were actual backbreaking work.

For another, we have a ton of medical interventions for pain that will either eliminate or reduce the source of the pain (joint replacement, surgeries, etc) or alternative ways to control the pain (spinal cord stimulators, epilepsy meds, TENS units, etc).

So I would assume society in 2018 has much less physical pain than a society in 1948. But then again, pain wasn’t treated back then, people just lived with it.

But the point is that, drug epidemics happened in the past when people were, on average, in less physical pain.

Opiate addiction is not a character flaw. It is not a sign of weak will or low morals. Opiate addiction is due to chemical changes in the brain brought on by repeated exposure to opiates. There absolutely are individual differences in predisposition to getting addicted. These individual differences are due to both genetic and environmental factors, and in a large part we don’t know exactly what they are.

The idea that people using opiates for pain won’t get addicted goes back to a 1980 letter to the editor, not even a peer reviewed study. I was taught that in a graduate level pharmacology class in the 90s, but it is wrong. The longer and more opiates somebody uses, the more likely that person is to become addicted. Once addicted, there is an irresistible craving for the drug, which can leads to all sorts of harmful behavior.

As said, there are individual differences, so some people may never get addicted even using opiates long term for chronic pain, while others might get addicted after having their wisdom teeth out. Certainly somebody who finds opiates pleasurable is more likely to use more, and so more likely to become addicted. Just as people who get sick from drinking small amounts, for example due to variation in alcohol dehydrogenase, are less likely to become alcoholics than people who feel great when they drink.

One thing which I found fascinating when studying neuroscience is that there is often* a kind of duality between psychology and neuroscience.

With depression for example, sufferers can describe all the problems in their life and the triggering event that pushed them into full depression.
But you can also just study the chemistry of the brain and tell a different story based on that person’s brain being deficient in a particular neurotransmitter for concrete physical reasons.

I suspect the situation is similar for drug addiction. The effect of the drug, and the effect of a person’s psychology are too enmeshed to separate them out into two kinds of cases.

  • “Isn’t there always necessarily this duality?” – well yes, of course, but I am talking about a more specific phenomenon here. The fact that the mind is the brain does not mean at all times we can easily map things the mind does to the underlying neurology. Just some of the time.

Drug addiction is also due to low quality of life. It is a chicken and the egg issue.

A traumatic, unfulfilling existence with a low quality of life drives people to escape through drugs and alcohol.

I think part of what’s so insidious about the current opioid epidemic is that there is a group of non-stereotypical addicts who became addicted due to what was originally medical uses of the drug.

With addiction in general, the chicken and egg problem can go all the way down. People with addiction problems are more likely to have parents with addiction problems. Parents with addiction problems are more likely to provide poor environments for their children…

A sad case I just ran across today:

Note she was given multiple chances to straighten out her life before this draconian prison sentence.