Was I on another planet while the opiates explosion occurred?

The narrative seems to be that over the course of a couple decades we let pharmaceutical companies promote the heck out of their pain pills and encouraged the doctors to hand out narcotic pain-relievers like harmless candy and thus our society irresponsibly got zillions of people hooked on opiates and now they’re shooting heroin.

That sure doesn’t mesh with my recollection of the 1990s and 2000s. WTF?

I trained as an LPN in the early 1980s, when the attitude had shifted away somewhat from “pain is often just in people’s head, don’t prescribe narcotics unless they really need it” and was now “pain is always real, there’s no such thing as imaginary pain; when your patient is in pain they deserve relief from it”. But by the beginning of the 1990s I was hearing from people from a wide and varied segment of society (including my own parents) that there was a crackdown going on, that doctors were now afraid to prescribe narcotic pain medication lest they be accused of supporting addicts’ habits. People told me they had gone in for operations and been sent home without a prescription for anything stronger than Motrin unless they requested it. When you did get a prescription it was for a more limited supply and no refills, and you’d have to come in in person if you needed more.

Situations in which, in the late 1970s and early 1980s, would have resulted in a prescription for codeine were now being addressed with Tylenol 3. Go in with a painful sore throat and instead of an automatic turpin hydrate with codeine prescription in the big brown bottle, you’d get a recommendation to try chloraseptic or cepacol, and only if that didn’t do the trick would you get a grudging scrip for hycodin in a much smaller bottle (and, again, no refills).

Glossy magazine ads and commercials on television touted the wonders of prescription medications for high blood pressure, high cholesterol, erectile dysfunction, depression, memory deficits, hyperactive bladder, etc, with the “ask your doctor” tagline, but I don’t recall one single ad for hydrocodone or oxycodone or fentanyl or dilaudid.

Was I unduly influenced by my nursing instructors so that I saw puritanical disapproval of pain relief when actually prescription pain meds were being dispensed willy-nilly left and right? How did I manage to formulate an impression that seems diametrically opposite to what we’re now being told was the trend over the last 20 years?

Doctors were assured that all of these new opioid drugs were ‘non-addictive’ by the pharmaceutical companies, which led them to believe that there was no actual danger in handing them out like candy.

  1. I don’t know if there are rules against advertising opiate/opioid-based medications;

  2. the real explosion came after Purdue Pharma came up with extended release OxyContin and promoted it heavily to doctors as having a low risk of addiction (which was an absolute lie)

  3. Doctors took them at their word and prescribed them even for long-term pain management, which combined with 2) set a lot of people on the road to addiction.

  4. no longer able to get prescriptions, people unable to break their addiction bought shit off the street.

It was in the mid 1990s that Purdue started to market Oxycontin, specifically in response to the “crackdown” you mention, as “safe” from addiction. So doctors started to prescribe it over more expensive types of treatment for pain, I think. It didn’t need a lot of advertising to the public, so long as doctors were starting to prescribe it.

Addiction usually develops slowly, so it wasn’t until the early 2000s that the increase in overdoses started to really get noticed. Also, I think the problem has been more “hidden” in that many were not addicts getting caught in public for boosting merchandise or ODing in gas station bathrooms–at least not at first.

So maybe it wasn’t really an “explosion,” so much as a creeping epidemic.

ETA: And what jz78817 and Chimera said right before.

It is a shit situation. Either prescribe opiates and get addicts or under-prescribe them and get a bunch of undertreated patients in chronic pain.

A big part of the opiate explosion is cheap chinese fentanyl. Doctors have nothing to do with that.

well, that’s a big part in the increase of overdoses, IIRC fentanyl’s therapeutic dose is somewhere in the micrograms. if you’re unaware that it’s in whatever you just bought off the street, it’s probably going to kill you.

This has been my experience. Hurt your ankle? Here are 30 hydrocodone. Have your wisdom teeth pulled? Here are 30 hydrocodone. Have a minor surgery? Here are 30 hydrocodone. Have a minor gum graft? Here are 30 hydrocodone.

Those aren’t hypothetical questions either. I didn’t fill my last hydrocodone prescription because I have so many of them already. If you ask if they can just prescribe a couple, they won’t.

That was my experience, too.

Doctor: “Here’s an Oxy prescription for your broken ankle.”
Me: “No thanks, I’m not really in any pain”
D: Take it just in case.
Next week, for follow-up:
D: You’ll need surgery. Here’s an Oxy prescription in the meantime.
M: I never even filled the last one, no thanks.
D: Take the script just in case.
New doctor, the actual surgeon:
D: Here’s an Oxy script for the pain after surgery.
Nurse: You should start taking it right away, to stay ahead of the pain.
Me: OK, I’ll fill this one.
A few days in, I’m having trouble sleeping because of the discomfort, so I take one pill, have weird dreams, and don’t take any more.

My teenage kids having their wisdom teeth taken out:
Dentist: Here’s an Oxy script for the pain.
One kid tries one and doesn’t like how it makes her feel. Other kid doesn’t even try one.

At this point, we’ve had 5 scripts (only filled two) as a family and have taken two pills. I should have opened up a pharmacy myself to sell some of it off.

Jeez, I wonder why there’s an epidemic.

I’ll just add a #metoo to the excessive prescribing. I got 30 for a minor surgery that cause so little pain I didn’t even need to take one. It’s like they want you to get hooked.

And I had the hardest time getting rid of them. Can’t flush 'em, or send them down the drain. Or the landfill, lest they seep into groundwater. Should have sold them. :slight_smile:

Let me suggest:

  1. Doctor prescribes extra pain medication.

  2. Doctor gets good reviews on Google as “friendly”.

  3. Doctor gets more customers.

  4. Doctor doesn’t prescribe pain medication.

  5. Doctor gets bad reviews on Google as “cranky and mean”.

  6. Doctor does not take on new customers.

As people move around, change doctors, etc. slowly, over the course of a decade, the friendly, understanding doctors take over the market without policy changing at all. And they probably are just friendly, understanding doctors. But in the era of information - but where that information is based on criteria that are more to do with customer service than medical acumen - there’s a strong market feedback component that the Internet ramps up to 20.

Last year I developed excruciating back pain to the point I could barely sleep, much less function normally. I finally had to take a few weeks off work because I was in so much agony. I asked my GP for some Vicodin to keep me while I waited for approval to visit a back specialist. She absolutely wouldn’t do it and not-so-subtley indicated that she thought I was faking pain in order to score opiates. Lady, have I EVER asked for painkillers from you? (Answer: No, not even when I fractured my foot). I was infuriated and went straight from her office to the ER (where I got IV dilaudid and an RX for opiates when it was obvious I was truly in agony).

I finally got to the specialist and had imaging done. I had three herniated cervical disks and spinal stenosis – ta da! That doc prescribed oxycontin, no waffling about it. Fortunately, some low-invasive fixes worked and I was full steam ahead within two months.

I really feel for people who deal with chronic and acute pain in this era of opiate panic, it must really suck if you have to constantly jump through hoops to get RX pain relief. If the level of pain I was in was to become long term and I couldn’t get some pain relief, I’d honestly contemplate suicide.

I have never had a doctor just willy-nilly prescribe oxy or hydrocodone. You kinda have to beg for it if you need it around here. My daughters dental surgeon gave her a prescription for generic Advil, after wisdom teeth removal. I had to call him back to get the real stuff. Then I had to drive over to pick up the paper script, they wouldn’t call it in.
My dog bit hand got me 16 oxy. No chance of getting addicted around here.

Two links:

John Oliver on opioids

Slate on the recent history of pain medicine prescription.

John Oliver says agressive marketing for Oxy by Purdue started in 1996, and was at it’s height in 2000. It was mainly a quick and easy and cheap solution to doctors wanting to help patients when there was little time or other resources to help those patients. Only in 2007 Purdue started to take some responsibility for misleading advertising and overmarketing.

As a physician, a lot of posters experiences above don’t match with mine. So that it’s clear when my training occurred, I was in medical school from 1999-2003, residency was 2003-2006 in family medicine, and I’ve been in practice since then. The situation in the parts of Texas where I’ve worked is not of most doctors handing out narcotics like candy. It’s more like most doctors prescribe them sparingly, with a small handful of doctors well known to the addicts who are the ones that prescribe large amounts of opiates. As an example, after an episode with a kidney stone a few years ago, I was given an Rx for 5 hydrocodone tablets. Most doctors I know are quite careful with how they prescribe, including some specialists that refer their patients either back to their primary care physicians or to pain management rather than writing for the narcotics themselves. The whole oxycodone is not addictive thing may have been before my time, but if a physician were to claim something like that today, his or her colleagues would laugh him/her out of the room. From what I recall that would have been the case even back in 2003 when I was starting my residency. IMHO the problem is pill mills, not regular doctors that overprescribe.

In a graduate level pharmacology course in the mid 90s I did learn that people in pain don’t get addicted to opiates, because the pain interrupts the addiction process. We were told that if you take opiates without pain, that is when addiction occurs. We now know that was completely wrong, and probably should have known at the time, because the research support for it was very slim. The professor was an expert in nicotine addiction, not opiate addiction, but it was the wisdom at the time.

As for my personal experience, I was prescribed some type of opiate when I broke my leg. I only took one, because my leg only hurt when I moved it, drugs or no. It did have the side effect of making me enjoy the Battleship movie. Never again.

While Perdue might have started aggressively marketing their opioid products in 1996, at least some physicians were handing them out indescriminately long before. I was rear ended in a car accident in 1990 which severely injured my knee and I was prescribed Percoset in lieu of effective treatment, primarily because I did not have insurance and my only medical provider was the student health services clinic at the school I was attending. No effort was ever made to monitor my usage of the painkiller and in fact there was little followup to see how the injury was healing. (After several years I did get about 90% usage out of it but it is still prone to problems.) The only caution I got about the potential effects from the drug was the small pamplet that came when I filled the script the first time, and medical services reauthorized my script indefinitely without a doctor’s visit. As casually as this was treated I have to assume this wasn’t unique.

Most physicians are given very little instruction in pain management in medical school and it is largely assumed that pharmicists will monitor usage and counsel patients, something I have never seen happen beyond a brief conversation. General practicianeers rarely interact directly with pharmacists or pharmacologists and so most of their information and ‘training’ on pain medication comes from pharmaceutical company representatives, i.e. salespeople whose job it is to push their product as the cure-all. And even setting aside their self-interest, pharma reps are generally not well-educated in even the basics of medical science much less being experts in pharmacology as the Last Week Tonight story linked above demonstrates.

There is also very poor understanding about addiction by most medical professionals much less the public at large. Most people who are prescribed opioids or opium-derived painkillers will become physically dependant upon the drug but do not become additicted, i.e. do not suffer a life-long affinity for the drug that damages their ability to lead productive lives. Opioid addition is correlated strongly with dysfunction of the SEEKING and FEAR affective systems, acting as a salve to hyperactivity and agitation. These dysfunctions may have natural causes but most are the result of some emotional trauma such as abandonment, intense rejection or humiliation, sudden and inexplicable loss, exposure to extreme violence, et cetera. Unsurprisingly, the opioid epidemic has grown at a rate commiserate with both the incidence of combat-related PTSD from the US Global War on Terror and cycles of economic downturn which have left the areas most affected by the opioid crisis also permanently economically depressed through loss of industry and economic stability.

So while it is easy to call out the pharmaceutical companies and distributors for their part in this self-made crisis (and they deserve criticism for profiteering without concerning themselves as to why these drugs were experiencing such explosive growth) there are a lot of external factors which are also driving the addiction epidemice which encompasses not only opioids but methaphetamines and excessive alcohol consumption, and these tie directly back into the socioeconomics of income inequality, racial disparity, underfunding of public schools and job training programs, and of course, the for-profit medical system which seeks to find the quickest possible fix for patients who cannot afford the costs of long term treatment or for whom ready medical solutions to resolve chronic pain issues do not exist.

The crisis itself has been looming for a long time but received relatively little coverage because it dealt with a legally available drug sold by established companies, and did not have the supposedly simple moral dimensions of the crack cocaine or meth crisis with its clear socioeconomic and racial lines. The resolution should not be to cut off access to opioids to people in chronic pain who need the relief opioid medications can provide and who can self-manage dependant problems with medical oversight but to deal with the fundamental socioeconomic and psychosocial problems which underlie much of the overall addiction crisis.

Stranger

Though finding pill mill docs wasn’t hard. Around here there were billboards for “pain management clinics” which tended to have addresses in lower-income neighborhoods. Even at the time it was difficult to see such blatant exploitation. Fortunately, all these advertisements have gone away now.

The truly sad part is seeing people in agony and unable to get help. Though I have to say since I am not a doctor, it could be the pain is the pain of withdrawal. But I had to sit in the waiting room of our suburban hospital last year waiting for someone to finish up an exam after a car wreck. There were people sitting in that room literally in tears begging for attention from the nurses. And it wasn’t like they were overwhelmed with patients-busy yes but a new emergency got prompt attention. It was sad.

I am in chronic pain. I think about suicide due to the pain at least weekly, sometimes daily. I receive no pain meds. I occasionally ask for a few for quality of life purposes (I would like to go to my daughter’s award ceremony for example). In several years, I think I have gotten a few pills for those purposes twice. Generally my sense is that either my med team does not care, or they hope I won’t kill myself but won’t provide pain relief to prevent it.

It baffles me how anyone gets large quantities of pain pills at this point. My brother-in-law says he is prescribed 7 types for wrist pain. He is in Texas. Maybe we’ve got regional variance? I also strongly suspect there’s a gender bias.

This CDC map on drug overdose mortality is interesting. I’m a tad surprised at how poorly Utah appears to be doing in this area.