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Opioids are among the best medications for treating severe pain. If we're focusing on patients I'd much rather focus on rehabilitative strategies since the curr

Opioids are among the best medications for treating severe pain. If we're focusing on patients I'd much rather focus on rehabilitative strategies since the current degree of increased scrutiny is already making accessing adequate medication more difficult for groups like the elderly or people with chronic pain. Even more increased oversight is just going to escalate hesitation among doctors.

solinent 6y ago
Opioids don't aid in recovery though--they're not a band-aid, they're simply a veneer. They can prevent recovery since they delays][ physical rehabilitation. I honestly think cannabis is a much better solution long-term, but good luck transitioning an opiate user to cannabis.
- 263943736 6y ago
  Not being in crippling pain is usually considered a good thing. Sure, some things like a broken arm can probably get by with weed and yes some people respond exceptionally well to weed but there is a night and day difference between the two when it comes to treating most forms of severe pain such as what people with significant spinal trauma experience or what the elderly often (for any number of reasons ultimately relating to age) experience.
  - solinent 6y ago
    I agree (it's meaningless though, I'm just pointing out the obvious above, I'm not an expert here) for acute injury it makes sense to use opioids in severe cases like you mention, however, I think we still need to find the best strains and cultivate them for pain use, we've only scratched the surface with cannabis, it's a big genus. Weed ain't what it used to be. For chronic cases, I think chronic makes a lot of sense. Pain helps you get moving. Opioid's don't. Too much pain is debilitating. Surely we can find a formula here (a very very large one). Cannabis never removes all the pain. I think that's the main feature here.
nipponese 6y ago
Check out therapies targeting sodium channels. I found out through my wife that her company (a major pharma corp) is working on therapeutics that can block voltage to certain sodium channels in the brain to suppress pain. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5350027/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5350027/
Aerroon 6y ago
I wonder where most of the harm is coming from with opioids. Do the opioids themselves cause more harm than society does by making them illegal? The cases I've mostly heard about seemed to be that people hot addicted to opioids and the only way to keep it going was to break the law. That eventually got them in trouble. For some drugs it does seem like the government trying to protect you from the drugs do more harm than what the drugs themselves do. Are opioids among them?
- neuroma 6y ago
  Prof Nutt made and published a universal harm scale which accounts for multi dimensional harm of drugs, and potentially allows comparisons to be made between them https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109763/#B29 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109763/#B29. This work got him sacked from his lead advisory role to the UK govt, as it undermined the policy and caused embarrassment. Nutt still works in Imperial College researching psychedelics as novel therapeutics. The money shot is this https://www.researchgate.net/figure/Overall-weighted-scores-for-each-of-the-drugs-The-coloured-bars-indicate-the-part-scores_fig1_47635105 https://www.researchgate.net/figure/Overall-weighted-scores-... A recent article which contextualises the work is here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109763/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109763/
  - ethanbond 6y ago
    Wow this is awesome. I’ve pondered the need for exactly this sort of thing for a while as the obvious desired basis for drug policy. Shouldn’t be surprised the Nutt has done it! Obviously it’s lossy to reduce something with this much complexity down to a single dimension but it’s still a helpful tool nonetheless.
- 263943736 6y ago
  It's very much a value judgement ultimately even if I've obviously been advocating in favor of not shying away from opioids when appropriate. With the judgement being a matter of resolving immediate problems vs. minimizing exposure to potential problems. How you view the probability is important because if you are cautious and wrong you have let your patient suffer unnecessarily, they (or their family) might even seek out street drugs if you are wrong enough about their pain. Most people who are prescribed opioids do not become addicts and even amongst those who develop an attachment to the drugs most who follow their prescription will simply go through an uncomfortable period of withdrawal before moving on (though patient abuse of their prescriptions is a real problem that happens). You also have some groups for whom addiction is a simply not a concern, many elderly deemed near the end of their life for example are provided with morphine if they express a desire to focus on quality of life treatments and people with severe spinal damage can be so debilitated by the pain they can hardly function. That being said, there is still a chance of a severe addiction developing and even if it doesn't many other addicts become addicts because prescriptions often erred on the side of oversupply rather than undersupply (better to have it and not need it as the gun folks say). So for example, a person might ask a partner in their workout group who went to the hospital if they can have a couple of their spare tablets to help with muscle recovery and things then spiral from there. If there were universally acceptable substitutes it would be less of an issue but at present opioids are usually among the most effective treatments for pain even if they carry risks. I do agree that some amount of oversight is important and better methods for evaluating patient pain would be helpful too (see the recent controversey over evaluating pain in black patients) but because it's become a talking point many doctors are being much more conservative not because they think opioids wouldn't be beneficial but simply because they don't want to get caught in the shade if hammers are falling.
adrianN 6y ago
Do you feel like chronic pain patients outside the US don't get adequate treatment? Because where I live opioids are prescribed much less frequently, but I don't think chronic pain patients suffer more than in the US.
- 263943736 6y ago
  I would need a more detailed hypothetical and even then a lot of the devil is in the specifics. By definition their suffering, if not being treated with /something/, is going to be higher. Culture also plays a role, for example Europeans on average dislike pills for some reason and so may simply be more accepting of comparatively light treatments than Americans who are generally much more open to pharmaceudicals.
- watwut 6y ago
  > don't think chronic pain patients suffer more than in the US How would you know who suffers more on average?
raverbashing 6y ago
Doubt it Especially as it is prescribed in the US, where drugs get preferred instead of other interventions. "Back pain? Opioids. No PT, no losing weight, just opioids. No, not even NSAIDS, just go for opioids" Remember that some drug companies pushed for their medication to be in 12h regimens which increased their dependency potential, as opposed to a shorter interval preferred by doctors? As a personal experience, opioids don't seem to work much for me on many types of pain.
DanBC 6y ago
> Opioids are among the best medications for treating severe pain > people with chronic pain. Chronic refers to the length of time the pain exists, it doesn't refer to severity. Here's what the Royal College of Anaesthetists says about opioids https://fpm.ac.uk/opioids-aware https://fpm.ac.uk/opioids-aware > Key Messages > 1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain. > 2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation). > 3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit: tapering or stopping high dose opioids needs careful planning and collaboration. > 4. If a patient has pain that remains severe despite opioid treatment it means they are not working and should be stopped, even if no other treatment is available. > 5. Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detailed assessment of the many emotional influences on their pain experience is essential.

solinent 6y ago

Opioids don't aid in recovery though--they're not a band-aid, they're simply a veneer. They can prevent recovery since they delays][ physical rehabilitation. I honestly think cannabis is a much better solution long-term, but good luck transitioning an opiate user to cannabis.

263943736 6y ago
Not being in crippling pain is usually considered a good thing. Sure, some things like a broken arm can probably get by with weed and yes some people respond exceptionally well to weed but there is a night and day difference between the two when it comes to treating most forms of severe pain such as what people with significant spinal trauma experience or what the elderly often (for any number of reasons ultimately relating to age) experience.
- solinent 6y ago
  I agree (it's meaningless though, I'm just pointing out the obvious above, I'm not an expert here) for acute injury it makes sense to use opioids in severe cases like you mention, however, I think we still need to find the best strains and cultivate them for pain use, we've only scratched the surface with cannabis, it's a big genus. Weed ain't what it used to be. For chronic cases, I think chronic makes a lot of sense. Pain helps you get moving. Opioid's don't. Too much pain is debilitating. Surely we can find a formula here (a very very large one). Cannabis never removes all the pain. I think that's the main feature here.

nipponese 6y ago

Check out therapies targeting sodium channels. I found out through my wife that her company (a major pharma corp) is working on therapeutics that can block voltage to certain sodium channels in the brain to suppress pain. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5350027/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5350027/

Aerroon 6y ago

I wonder where most of the harm is coming from with opioids. Do the opioids themselves cause more harm than society does by making them illegal? The cases I've mostly heard about seemed to be that people hot addicted to opioids and the only way to keep it going was to break the law. That eventually got them in trouble. For some drugs it does seem like the government trying to protect you from the drugs do more harm than what the drugs themselves do. Are opioids among them?

neuroma 6y ago
Prof Nutt made and published a universal harm scale which accounts for multi dimensional harm of drugs, and potentially allows comparisons to be made between them https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109763/#B29 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109763/#B29. This work got him sacked from his lead advisory role to the UK govt, as it undermined the policy and caused embarrassment. Nutt still works in Imperial College researching psychedelics as novel therapeutics. The money shot is this https://www.researchgate.net/figure/Overall-weighted-scores-for-each-of-the-drugs-The-coloured-bars-indicate-the-part-scores_fig1_47635105 https://www.researchgate.net/figure/Overall-weighted-scores-... A recent article which contextualises the work is here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109763/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6109763/
- ethanbond 6y ago
  Wow this is awesome. I’ve pondered the need for exactly this sort of thing for a while as the obvious desired basis for drug policy. Shouldn’t be surprised the Nutt has done it! Obviously it’s lossy to reduce something with this much complexity down to a single dimension but it’s still a helpful tool nonetheless.
263943736 6y ago
It's very much a value judgement ultimately even if I've obviously been advocating in favor of not shying away from opioids when appropriate. With the judgement being a matter of resolving immediate problems vs. minimizing exposure to potential problems. How you view the probability is important because if you are cautious and wrong you have let your patient suffer unnecessarily, they (or their family) might even seek out street drugs if you are wrong enough about their pain. Most people who are prescribed opioids do not become addicts and even amongst those who develop an attachment to the drugs most who follow their prescription will simply go through an uncomfortable period of withdrawal before moving on (though patient abuse of their prescriptions is a real problem that happens). You also have some groups for whom addiction is a simply not a concern, many elderly deemed near the end of their life for example are provided with morphine if they express a desire to focus on quality of life treatments and people with severe spinal damage can be so debilitated by the pain they can hardly function. That being said, there is still a chance of a severe addiction developing and even if it doesn't many other addicts become addicts because prescriptions often erred on the side of oversupply rather than undersupply (better to have it and not need it as the gun folks say). So for example, a person might ask a partner in their workout group who went to the hospital if they can have a couple of their spare tablets to help with muscle recovery and things then spiral from there. If there were universally acceptable substitutes it would be less of an issue but at present opioids are usually among the most effective treatments for pain even if they carry risks. I do agree that some amount of oversight is important and better methods for evaluating patient pain would be helpful too (see the recent controversey over evaluating pain in black patients) but because it's become a talking point many doctors are being much more conservative not because they think opioids wouldn't be beneficial but simply because they don't want to get caught in the shade if hammers are falling.

adrianN 6y ago

Do you feel like chronic pain patients outside the US don't get adequate treatment? Because where I live opioids are prescribed much less frequently, but I don't think chronic pain patients suffer more than in the US.

263943736 6y ago
I would need a more detailed hypothetical and even then a lot of the devil is in the specifics. By definition their suffering, if not being treated with /something/, is going to be higher. Culture also plays a role, for example Europeans on average dislike pills for some reason and so may simply be more accepting of comparatively light treatments than Americans who are generally much more open to pharmaceudicals.
watwut 6y ago
> don't think chronic pain patients suffer more than in the US How would you know who suffers more on average?

raverbashing 6y ago

Doubt it Especially as it is prescribed in the US, where drugs get preferred instead of other interventions. "Back pain? Opioids. No PT, no losing weight, just opioids. No, not even NSAIDS, just go for opioids" Remember that some drug companies pushed for their medication to be in 12h regimens which increased their dependency potential, as opposed to a shorter interval preferred by doctors? As a personal experience, opioids don't seem to work much for me on many types of pain.

DanBC 6y ago

> Opioids are among the best medications for treating severe pain > people with chronic pain. Chronic refers to the length of time the pain exists, it doesn't refer to severity. Here's what the Royal College of Anaesthetists says about opioids https://fpm.ac.uk/opioids-aware https://fpm.ac.uk/opioids-aware > Key Messages > 1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain. > 2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation). > 3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit: tapering or stopping high dose opioids needs careful planning and collaboration. > 4. If a patient has pain that remains severe despite opioid treatment it means they are not working and should be stopped, even if no other treatment is available. > 5. Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detailed assessment of the many emotional influences on their pain experience is essential.