Is the War On Addiction Becoming a War On Pain?

Great Debates
1

I’ll provide cites, if requested. But bear with me, much of my data comes from TV reports and my own personal experiences (I have never taken an illegal drug).

I think most people would agree Opioid addiction is a major health problem in the United States. And some people blame the supposed ease with which some doctors prescribe them. But I think that is just an oversimplification of the matter. Some people may blame me for oversimplifying the problem. But isn’t that what they are doing?

In 1999, when my father broke his leg, they gave him a hefty dose of Morphine in the emergency room to set his leg. There is no way he could’ve endured the pain without it. I know that I read in the Merck Manual that when someone ingests lye, Opioids are still the standby treatment, because they are in so much pain.

I have a silent gallstone, that I could pass at anytime, the doctor tells me. It forever hangs over me like the mythic Sword of Damocles. If I did pass it, I’d want a massive dose of Morphine and as soon as possible.

Plus I read somewhere (I forget exactly where :slight_smile: ) that when you’re in horrible pain, and the doctor gives you a measly dose of Morphine, it doesn’t help. It makes it worse! Who wants that?

I know I took a psychology class in community college about 25 years ago. And they said, when you’re in horrible pain, most of the pain killer you take just blocks the pain. Addiction comes as a secondary effect, when you take it longer than you need to. Not because you are morally weak. It is a very complicated matter (as I’ve already said).

Plus as far as addiction goes, if people really want Opioids, they can easily get it illegally anyways. They really shouldn’t. But they still often do.

So is the war on opioid addiction becoming a war on pain :slight_smile: ?

2

Hi Jim.

There are two different aspects of this “war”, which I’ll break down for you. This may get tedious, so I hope you’re sitting down as you read this.

I am a normally healthy (and by the standards of this board, extremely young) male. Once I had a kidney stone, and as I expect you can imagine, it was quite painful. I was in a perpetual sweat, I vomitted up anything I tried to take in, and I was generally not in my right mind.

The doctor at the ER prescribed oxycontin, which was (in my opinion) the correct response. However, I was prescribed 30 days worth. I only needed (and used) two.

Likewise, a friend of mine needed a few days worth to get through the recovery phase of an operation, and was given quite a lot more than needed. He needed five days, he got a full month’s worth.

Taking one or two doses of these things is generally fine. Taking them when you don’t need to is another matter, and that’s where the addiction kicks in.

The specific opioids being “warred” against are the relevatively recent variants: oxycontin, percocet, etc. Most of these were presented as non-addictive, when the reality of it was they were quite the opposite.

So ultimately, this isn’t a war on pain. This is a war on over-prescribing drugs known to be highly addictive, and fighting corporate disinformation that the drugs were, themselves, not addictive.

I can assure you, even though I have never had a lick of medical training, that doctors are not interested in their patients suffering. Really, quite the opposite. There is no “war on pain”, other than (I imagine) there being a keen medical interest in an effective painkiller that also isn’t addictive.

3

It confused me at first, but I think you meaning more like a “War on alleviating pain” or some such?

I agree. The do-gooders won’t mention it, but the pressure on doctors around ten to fifteen years ago to stop the long term opioid prescriptions, caused many people to buy them on the street. And when they realized that heroin was cheaper than pills, they switched to that. Now many communities and lives are destroyed.

I don’t disagree that doctors are to blame for keeping patients on opiods longer than necessary, but if a patient claims to be in pain, a doctor is in a tough place. IMHO, this neo-prohibitionist attitude has fueled a terrible problem. Just like with alcohol, people who want opioids will find them, and better to do it in a clinically safe method than paying for a dangerous substitute in a flop house while carrying a pistol stuffed in your pants just in case.

4

I also missed this part, and it’s something I want to address. This happens a LOT. It’s the reason we’re keen on quelling the use of opioids as pain relief. They work extremely well! There’s just that horrible addiction business that inspires people to do things they’ll regret.

And part of that regret is buying street drugs laced with an unknown amount of fentanyl. Fentanyl is a fantastically-effective drug at blocking pain. It’s also extremely dangerous, and very easy to overdose on.

The current knock-on effect of people being addicted to opioids is the fact that they’re dying because they’re using drugs of unknown purity.

Some people are going to abuse drugs recreationally. But if we have the means to curtail that amount of addiction, morally, as a society, we should. And there’s your “war”.

5

Yes, but, didn’t everyone know that they were addictive? Wasn’t this like “fighting” the tobacco companies when they used to claim that cigarettes were completely harmless?

6

Initially, no, “everyone” did not know that. We, collectively, came to know that. Whether the corporations (owned by Sackler et al.) knew this initially is beyond my current knowledge. But it was certainly, initially, presented as non-addictive and there exists a sort of… let’s call it “medical inertia” where procedures are drawn up and stuck to until disproved later.

There’s a strong comparison to the campaign waged by the tobacco companies, certainly. If you want to use the term “corporate malfeasance” you’ll not find me arguing.

7

Hard to generalize. I’m a former heroin user, and I missed the oxy crisis (thank god), but I’ve kept in touch with people from back then.

The first takeaway from those discussions is that it was (and really still is) so easy to legally get whatever you wanted as long as it was in pill form.

The second takeaway is also anecdotal, but the crackdown is causing some individuals to suffer. My girlfriend recently found out that she needed surgery, but she had been complaining to the doctor for eight or nine months. Take some Advil is all they’d tell her, and never mind that she’d been eating Advil like candy to no avail. Finally, they let her have some hydrocodone and a few oxycontin, and that really helped. (She came through the surgery much improved and is almost pain-free now.)

So is the crackdown good for the population? Certainly. Is it good for individuals? Not always.

8

And then there are people like me who went in to have my guts rearranged permanently [my stoma is nicknamed P’tit Joey, after a French performer Le Petomane ] and they unilaterally decided to put me on some newfangled pain control where they give you 300 mg gabapentin and a couple of tylenol. My normal dose of gabapentin is actually 400 mg and it is paired up with tramadol … that did not fly well at all. Other people on the r/ostomy bunch got morphine pumps … I got cold turkeyed [until I protested mightily]

I am that person who when the docs at various times have seen imaging [xray, MRI, PET] basically are all "damn, girl … " at various things wrong with me. I basically need a whole body replacement =) And I also have rarely bumped my level of dose, only upping it twice in almost 15 years.

9

Not only did Perdue claim that oxycontin was safe, they rewarded doctors who prescribed loads of it with lucrative speaking contracts to audiences of under the fingers of one hand.
When I had a swollen disk my doctor prescribed maybe three days of pills, and told me that they monitored prescriptions very closely. That’s backlash from people prescribing a month’s worth when it was not needed, and it’s really the fault of companies making money by abusing the system.

10

This article talking about the $26 billion settlement is in the same category as Perdue claiming oxy was safe.

“The four companies — which also include Cardinal Health, AmerisourceBergen and McKesson — were accused by states, cities and counties of playing a significant role in funneling a flood of opioid painkillers to communities across the U.S.”

11

Way back c. 1980, IIRC there was a similar (but moving in the opposite direction) situation.

The issue at the time was a preexisting hesitancy to administer the older opiates like Demerol beyond the tightly managed world of the inpatient IV, out of the fear of their addictiveness. This at the time resulted in suboptimal pain management for people beyond the inpatient bed.

Studies came up, however, to the effect that the vast majority of patients using opiates for pain under proper control did not end up in addiction. And a move began towards focusing more on effective pain management. Things like letting people on pumps control the pump, like believing the patient when she’s telling you just how much pain she’s in, etc.

To this, contributed the arrival of a series of “new” opiate preparations that ostensibly could be much more safely managed as an outpatient prescription, allowing people to take the pain management “into their own hands”.

However… ISTM all that was based on the premise that even the post-procedure, at-home pain management would be… well, managed. That all prescribers would prescribe what was needed for what the problem was, no more, no less, and keep up with the case and make timely adjustments. Meanwhile, that patients would be compliant to the letter of the instructions.

That’s a couple of really tall assumptions, and not safe ones to make.

That got tied in with pharmacorps overselling the blessings and minimizing the risks of the then-newer generation opiates, as mentioned in the thread already (*). And a sales/dispensing/insurance coverage model in which many outpatient prescriptions, not just scheduleds, default to being dispensed in batches of a 30 day supply unless it’s stuff that has a specific fixed-duration regimen.

(*Reminding of how Bayer introduced Heroin as a product safer and easier to manage and prevent bad outcomes than morphine, and put it in children’s cough syrup in the 1890s. But that was before there was an FDA or a Controlled Substances Act!)

Anyway, give that 20-30 years and get into the 2000s and the pendulum swings back and once again it was, OMG we’re getting a generation hooked… and people started getting discontinued. Maybe also insurers decided to do what insurers do and stopped paying for more. Maybe profits flattened out and began dropping so the sales pitches slowed down. A whole combination of factors. But in the end what’s up is there was already a “customer base” created… and the street was there to take care of them.

I remember that in dental surgeries of the 80s and 90s I was sent home with Percocets. But by the late 2000s, just Rx-strength Motrin. And for a kidney stone episode in the 20teens, I was given a strong but NON-narcotic IV NSAID and that worked fine.

As to the sales pitch on it being not-as-addictive vs. “should have known better” … Oxycodone itself apparently had been on FDA Schedule II since the 1970s – together with things like straight Morphine, Demerol, Methadone, Cocaine, Fentanyl, Pentobarbital, Seconal, Dexedrine, Methamphetamine… But the lay public would not know that, would they?

12

It has been for quite some time, I know several pain patients who were doing well on opiates, then their doctors quickly cut them down to nothing. The doctors tried to pretend it was for the patients safety, but it was really to lower their malpractice premiums and get off the DEAs radar.

I’ve heard stories of burn victims being given ibuprofen now. Ideally chronic pain should be dealt with in a safer fashion than lifelong opiates, but sadly not everything else always works. Surgery, nerve blocks, physical therapy, topical creams, epilepsy meds, anti-depressants, electric stimulation, etc work but not for everyone.

13

Question for anyone who might know. I hear a very common story from my clients. It goes as follows:

They were in a serious car accident 30, 20, 10 years ago and have a chronic injury that simply must be managed with opiods. At some point several years ago the doctor cut them off and they bought pills on the street and then heroin when they couldn’t afford the pills.

My question: Are there people after a car accident or other such thing that actually need opioids to manage pain? Is this common or rare? Are they truly in pain without these medicines or are they just physically addicted to them?

Just as an anecdote, in 1977 my great grandfather died after a long battle with cancer(this part of the story is second hand). The doctors would only give him X amount of morphine because anymore was considered too addictive. The person who told me the story thought that to be outrageous because he was terminal anyways; so what if he became addicted to morphine.

Fast forward to 1993 when my grandfather suffered from terminal cancer. Man, they loaded that man up whenever he asked. He was goofy and loopy in his last week, but feeling no pain.

Fast forward to 2021. My mother in law suffered from terminal cancer. It was sort of the midway point between the previous two stories. If she was in pain, they would up the dosage a tiny bit at a time after several doctors would sign off on it. They never let her be in too much pain for too long, but I kept asking to bring on the good stuff and quit being so stingy with it. Sorry, procedure.

If I have terminal cancer, I want the 1993 protocol. I understand that they cannot intentionally give you a lethal dose, but if they give you a dose that ends up killing you (and I mean that, no funny business) then that’s fine with me. I don’t think people should suffer needlessly.

14

I think the pendulum has sung to a ridiculous extent. For decades they were handing out potentially addictive pain meds like M&M’s on Halloween. and now they’re so afraid to that people in horrendous pain remain that way.

Earlier this year my Sister-in-Law had a tumor the size of a small football removed from her abdomen and a full hysterectomy. . She was in excruciating agony. They wouldn’t even give her anything in the hospital stronger than Tylenol. And no prescriptions to take home afterwards. Nothing! She was in pain for weeks after the surgery. She ended up going down to the flatlands and getting some gummies which are illegal here. But it was the only way she could deal with the pain during recovery.
Giving her a 30 day prescription for pain meds would not have hurt her or made her an addict. She was recovering from major surgery.

15

I think the problem is discerning between people in legitimate chronic pain and those looking to work the system to get pain meds either for their addiction or to sell to other addicts.

Certainly the person with chronic pain needs those meds. I have a member of my family who has severe chronic back pain. That person was borderline suicidal over it. That person works diligently with doctors to find a solution (from surgery to devices to losing weight to psychological options) but the ONLY thing that reliably works are pain meds.

If the doctors stopped subscribing those I am positive the person would have committed suicide by now.

But how does the doctor distinguish between someone like that and an addict?

Is there a reliable way a doctor can tell the difference?

16

There is apparently little evidence that opioids work for chronic pain:

Opioids do not seem to expedite return to work in injured workers or improve functional outcomes of acute back pain in primary care. For chronic back pain, systematic reviews find scant evidence of efficacy.

Opioids seem to have short term analgesic efficacy for chronic back pain, but benefits for function are less clear.

Loss of long term efficacy could result from drug tolerance and emergence of hyperalgesia.

For my own anecdote, back in 2016, I badly broke my ankle. The ER doctor gave me a scrip for opioids, even though I told him I wasn’t in much pain. I never filled the script. A few days later, I saw the same doctor for the regular visit, and he gave me another script, which I didn’t fill. He recommended surgery, so I got a second opinion. The second doctor also recommended surgery, so I went with her and got surgery done. After the surgery, they said it would be very painful and gave me another script for opioids, so I filled that one. After the nerve blockers wore off, I took one, had weird dreams, and didn’t take any more. They each gave me a script for about 50 pills.

When my daughter had her wisdom teeth out, they gave her a script for about 50 pills. She took one and didn’t like the effects, so didn’t take any more. That was a couple of years ago. Hopefully, they’ve slowed down the scripts since then.

17

Anecdote but my BiL can’t seem to live without them.

Even with them he is in constant pain but he can manage. Without them the pain is unbearable.

FWIW he has had multiple back surgeries and tried all sorts of other pain mitigation things (latest is an electric shock thing surgically implanted).

So, he is not trying to rely on meds only.

He remains in constant pain.

18

Wow. When I had a wisdom tooth out, I was prescribed ibuprofen.

19

There is some puratinism mixed in with the anti-drug business. But the pendulum does swing. 15 years ago I broke an ankle, was operated on with a metal plate and then sent home with 50 dilaudid even though I was not in pain. I still have 50 dilaudid somewhere in my medicine cabinet.

20

One pro of over-prescribing is that medication donation services are doing pretty well. Back in my day, I’d have thought People just give them their drugs? Man, how do I get into that racket? But donated meds can really help people who can’t otherwise get them, though that applies more to heart medication and the like than to opiods.