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It had a direct impact on several doctor's prescription habits. This is a good thing. Now, did it do so while ensuring doctors maintained the same pain manageme

It had a direct impact on several doctor's prescription habits. This is a good thing. Now, did it do so while ensuring doctors maintained the same pain management outcomes for their patients? I am dubious and concerned this doesn't appear to have been addressed in their studies.

kelnos 8y ago
As a potential patient, I'm pretty sure I'd prefer to endure a little extra pain if the alternative is an increased likelihood of painkiller addiction that could lead to death.
- cm2012 8y ago
  There's almost no chance of you developing an opiate addiction from a prescribed dose if you don't already have a history of addiction: https://www.google.com/amp/s/fivethirtyeight.com/features/what-science-says-to-do-if-your-loved-one-has-an-opioid-addiction/amp/ https://www.google.com/amp/s/fivethirtyeight.com/features/wh... This is a false narrative that needs to go away.
  - Lxr 8y ago
    Non AMP: https://fivethirtyeight.com/features/what-science-says-to-do-if-your-loved-one-has-an-opioid-addiction/ https://fivethirtyeight.com/features/what-science-says-to-do...
  - DanBC 8y ago
    You're pushing a narrative created by opioid manufacturers: "These meds aren't addictive if used to treat pain". That's only true (if it is true) if they're used short term. People in this thread aren't talking about acute pain, they're talking about chronic (long term) pain. It's likely that opioids are addictive if used long term to treat long term pain. Here's what actual doctors say: https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar... EDIT: FFS, your own link says this: > “Physiological dependence is the normal response to regular dosages of many medications, whether opioids or others. It also happens with beta blockers for high blood pressure,” said Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse. Your link says that opioids create physical addiction. The physical addiction to opioids causes all the factors of the newer definition of adddictive: tolerance, drug seeking, preoccupation, and continuing to take it even though you know it's harmful.
    - justinjlynn 8y ago
      Physiological dependence is a treatment complication to be managed. Corticosteroids, hormones, and other nonpsychoactive medications feature this issue too. It is part of the risk/benefit calculation. What's important is the psychological addiction. You can taper off of a medication on which you are physiologically dependent. However, if it makes you psychologically dependent, you can never forget the high. Turns out not having pain because a medication helps and you experience it when you stop makes people want to keep taking it. Who knew? It's when people take more than they need to to address their physical pain, that they experience psychological addiction, that they chase the high, that a problem develops.
      - DanBC 8y ago
        The psychological addictiveness of opioids is well established. Turns out not having pain because a medication helps and you experience it when you stop makes people want to keep taking it. Who knew? That is not what's happening. People take the medication to treat the pain. Their pain still exists. They develop a tolerance to opioids (one of the mechanisms of addiction) and need to increase the dose. Now they're taking very large -dangerously large- doses of opioids but are still in pain.
    - srinivgp 8y ago
      Repeat after me. Addiction is not dependence. Dependence is not addiction. When I read "dependence is expected", I will not interpret it as "addiction is expected", and I will ESPECIALLY not immediately assume tolerance, drug seeking, preoccupation, or harming oneself just because of dependence.
      - DanBC 8y ago
        Opioids cause tolerance, drug seeking, preoccupation, and continuance even though the patient knows they're harmful This behaviour is long established and well known.
        GordonS 8y ago
  - deleted 8y ago
    [deleted]
- justinjlynn 8y ago
  Imagine having a solution that works for you. It manages your pain. You aren't abusing your medication. Your doctor gets this letter and all of a sudden that option is taken away. Now, that drug hasn't been shown to be unacceptable when taken correctly; and you have been. Now you're in pain again and the solution that had been working for you isn't available for some nebulous reason that isn't directly related to the benefit/risk trade-off you and your doctor already agreed to. So, your doctor takes you through trying some other drugs, again, just as they had before they prescribed you opioids - as is current best practice. Of course, now, for your doctor that option of opioid use is no longer available, even though it is still there - out of reach. How would that feel? Living without pain management because your doctor fears losing their licence or a letter from the coroner more than helping you manage your pain. These studies need to ensure doctors are reserving opioids for worst case management, but still prescribing them when nothing less works. These studies need to be longitudinal. Do patients maintain their quality of life? Are doctors trying less addictive/abusable drugs first? Focusing on reduced opioid prescription is like focusing on reducing antibiotic use. You have to track infection rates to gauge if the ineffective usage has gone down while maintaining outcomes. You can't just track usage to gauge the effectiveness of a program. It's a vanity statistic unless you measure outcomes. Outcomes are the whole point.
- seanmcdirmid 8y ago
  And if its a lot of extra pain?
- GordonS 8y ago
  I felt exactly the same. And then I ended up with chronic, debilitating, unbearable pain in my limbs. Opioids are the only thing that has helped with the pain at all - to flip your comment around, not taking opioids could have led to my death. I only ever take my prescribed dose, and I've been doing this for years. They still have the same efficacy. They don't make me feel good, they constipate me and make me a bit sleepy - I don't know how anyone becomes addicted to them, but amongst many others I guess there are genetic factors at play.
cm2012 8y ago
I'm hoping the doctors just got better at finding out which patients were going to multiple doctors for opiates at the same time, since that was the case for almost all of the deceased. The average decrease was only 10% less new subscriptiona. But I wish they studied that also.
- Broken_Hippo 8y ago
  I think this could be partially solved by changing the pharmacy systems and moving them to robust electronic systems. In the US, when I'd get an electronic prescription, I'd have to specify which branch of which pharmacy I was picking it up on. They don't allow electronic prescriptions for opiods, however. (I worked at a pharmacy). Other pharmacies, even in the same chain, could not see my prescriptions without the pharmacy transferring it over to the other physical location. If the pharmacist or doctor suspects something, they basically have to keep the patient waiting to investigate - and if they deny, hope they are getting something wrong instead of someone just getting bad luck. I now live in Norway. The doctor just does the electronic prescription. I can go to any pharmacy in any location to pick it up. Including the things that aren't allowed to be electronic in the US. This makes such things much easier to be noticed - doctors and pharmacists can get access to this information when filling a prescription.
DanBC 8y ago
> Now, did it do so while ensuring doctors maintained the same pain management outcomes for their patients? Opioids are not effective at treating long term pain, so these doctors were probably maintaining the same pain management outcomes for most patients and avoiding addiction on top.
- justinjlynn 8y ago
  > Opioids are not effective at treating long term pain OK, so, please expand on this asssertion. Also, what does then?
  - jazoom 8y ago
    Not GP but I can expand. Over long periods of use the body develops tolerance to opioids and to get the same level of relief the dose must be increased. This seems to go on forever. Last year I had a patient on 10x what would probably be lethal for me (about 200 times a basic starting dose) and they didn't affect him much at all. He had been on the opiate train for about 30 years.
    - justinjlynn 8y ago
      Indeed, clearly we need to develop a better understanding of the causes of chronic pain and how to treat them directly rather than managing symptoms. My primary concern is maintaining or improving quality of life without impacting the length too negatively. It's difficult to justify saying "sorry, that thing you were taking to make your life bearable makes my colleagues think I'm no better than drug dealer so, uh, you can't have it any more, here's a pamphlet on mindfulness" - if anything it should be buying time for us to find real solutions instead of symptomatic treatment. And that's all opioids really do for those that take it - buy time. If we're going to reduce opioid use we need to treat it as we're treating antibiotics and make sure we're carefully watching outcomes to make sure we're not dropping opioids but raising suicide rates. We owe it to patients to solve their problems and not just treat their symptoms when it's clear they won't heal on their own. Not a GP either.

kelnos 8y ago

As a potential patient, I'm pretty sure I'd prefer to endure a little extra pain if the alternative is an increased likelihood of painkiller addiction that could lead to death.

cm2012 8y ago
There's almost no chance of you developing an opiate addiction from a prescribed dose if you don't already have a history of addiction: https://www.google.com/amp/s/fivethirtyeight.com/features/what-science-says-to-do-if-your-loved-one-has-an-opioid-addiction/amp/ https://www.google.com/amp/s/fivethirtyeight.com/features/wh... This is a false narrative that needs to go away.
- Lxr 8y ago
  Non AMP: https://fivethirtyeight.com/features/what-science-says-to-do-if-your-loved-one-has-an-opioid-addiction/ https://fivethirtyeight.com/features/what-science-says-to-do...
- DanBC 8y ago
  You're pushing a narrative created by opioid manufacturers: "These meds aren't addictive if used to treat pain". That's only true (if it is true) if they're used short term. People in this thread aren't talking about acute pain, they're talking about chronic (long term) pain. It's likely that opioids are addictive if used long term to treat long term pain. Here's what actual doctors say: https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-awar... EDIT: FFS, your own link says this: > “Physiological dependence is the normal response to regular dosages of many medications, whether opioids or others. It also happens with beta blockers for high blood pressure,” said Dr. Wilson Compton, deputy director of the National Institute on Drug Abuse. Your link says that opioids create physical addiction. The physical addiction to opioids causes all the factors of the newer definition of adddictive: tolerance, drug seeking, preoccupation, and continuing to take it even though you know it's harmful.
  - justinjlynn 8y ago
    Physiological dependence is a treatment complication to be managed. Corticosteroids, hormones, and other nonpsychoactive medications feature this issue too. It is part of the risk/benefit calculation. What's important is the psychological addiction. You can taper off of a medication on which you are physiologically dependent. However, if it makes you psychologically dependent, you can never forget the high. Turns out not having pain because a medication helps and you experience it when you stop makes people want to keep taking it. Who knew? It's when people take more than they need to to address their physical pain, that they experience psychological addiction, that they chase the high, that a problem develops.
    - DanBC 8y ago
      The psychological addictiveness of opioids is well established. Turns out not having pain because a medication helps and you experience it when you stop makes people want to keep taking it. Who knew? That is not what's happening. People take the medication to treat the pain. Their pain still exists. They develop a tolerance to opioids (one of the mechanisms of addiction) and need to increase the dose. Now they're taking very large -dangerously large- doses of opioids but are still in pain.
  - srinivgp 8y ago
    Repeat after me. Addiction is not dependence. Dependence is not addiction. When I read "dependence is expected", I will not interpret it as "addiction is expected", and I will ESPECIALLY not immediately assume tolerance, drug seeking, preoccupation, or harming oneself just because of dependence.
    - DanBC 8y ago
      Opioids cause tolerance, drug seeking, preoccupation, and continuance even though the patient knows they're harmful This behaviour is long established and well known.
      - GordonS 8y ago
- deleted 8y ago
  [deleted]
justinjlynn 8y ago
Imagine having a solution that works for you. It manages your pain. You aren't abusing your medication. Your doctor gets this letter and all of a sudden that option is taken away. Now, that drug hasn't been shown to be unacceptable when taken correctly; and you have been. Now you're in pain again and the solution that had been working for you isn't available for some nebulous reason that isn't directly related to the benefit/risk trade-off you and your doctor already agreed to. So, your doctor takes you through trying some other drugs, again, just as they had before they prescribed you opioids - as is current best practice. Of course, now, for your doctor that option of opioid use is no longer available, even though it is still there - out of reach. How would that feel? Living without pain management because your doctor fears losing their licence or a letter from the coroner more than helping you manage your pain. These studies need to ensure doctors are reserving opioids for worst case management, but still prescribing them when nothing less works. These studies need to be longitudinal. Do patients maintain their quality of life? Are doctors trying less addictive/abusable drugs first? Focusing on reduced opioid prescription is like focusing on reducing antibiotic use. You have to track infection rates to gauge if the ineffective usage has gone down while maintaining outcomes. You can't just track usage to gauge the effectiveness of a program. It's a vanity statistic unless you measure outcomes. Outcomes are the whole point.
seanmcdirmid 8y ago
And if its a lot of extra pain?
GordonS 8y ago
I felt exactly the same. And then I ended up with chronic, debilitating, unbearable pain in my limbs. Opioids are the only thing that has helped with the pain at all - to flip your comment around, not taking opioids could have led to my death. I only ever take my prescribed dose, and I've been doing this for years. They still have the same efficacy. They don't make me feel good, they constipate me and make me a bit sleepy - I don't know how anyone becomes addicted to them, but amongst many others I guess there are genetic factors at play.

cm2012 8y ago

I'm hoping the doctors just got better at finding out which patients were going to multiple doctors for opiates at the same time, since that was the case for almost all of the deceased. The average decrease was only 10% less new subscriptiona. But I wish they studied that also.

Broken_Hippo 8y ago
I think this could be partially solved by changing the pharmacy systems and moving them to robust electronic systems. In the US, when I'd get an electronic prescription, I'd have to specify which branch of which pharmacy I was picking it up on. They don't allow electronic prescriptions for opiods, however. (I worked at a pharmacy). Other pharmacies, even in the same chain, could not see my prescriptions without the pharmacy transferring it over to the other physical location. If the pharmacist or doctor suspects something, they basically have to keep the patient waiting to investigate - and if they deny, hope they are getting something wrong instead of someone just getting bad luck. I now live in Norway. The doctor just does the electronic prescription. I can go to any pharmacy in any location to pick it up. Including the things that aren't allowed to be electronic in the US. This makes such things much easier to be noticed - doctors and pharmacists can get access to this information when filling a prescription.

DanBC 8y ago

> Now, did it do so while ensuring doctors maintained the same pain management outcomes for their patients? Opioids are not effective at treating long term pain, so these doctors were probably maintaining the same pain management outcomes for most patients and avoiding addiction on top.

justinjlynn 8y ago
> Opioids are not effective at treating long term pain OK, so, please expand on this asssertion. Also, what does then?
- jazoom 8y ago
  Not GP but I can expand. Over long periods of use the body develops tolerance to opioids and to get the same level of relief the dose must be increased. This seems to go on forever. Last year I had a patient on 10x what would probably be lethal for me (about 200 times a basic starting dose) and they didn't affect him much at all. He had been on the opiate train for about 30 years.
  - justinjlynn 8y ago
    Indeed, clearly we need to develop a better understanding of the causes of chronic pain and how to treat them directly rather than managing symptoms. My primary concern is maintaining or improving quality of life without impacting the length too negatively. It's difficult to justify saying "sorry, that thing you were taking to make your life bearable makes my colleagues think I'm no better than drug dealer so, uh, you can't have it any more, here's a pamphlet on mindfulness" - if anything it should be buying time for us to find real solutions instead of symptomatic treatment. And that's all opioids really do for those that take it - buy time. If we're going to reduce opioid use we need to treat it as we're treating antibiotics and make sure we're carefully watching outcomes to make sure we're not dropping opioids but raising suicide rates. We owe it to patients to solve their problems and not just treat their symptoms when it's clear they won't heal on their own. Not a GP either.