7 ms·

How come, the US has an opiate crisis?

by k__ 6y ago

formerly_proven 6y ago
A while ago I posed a similar question and the answers/downvotes made it clear to me why; Americans have a broken model of pain management. Americans think that opiates are necessary to manage the pain from most surgeries, back pain, headaches etc., so, they get opiates to do that, with the obvious and foreseeable catastrophic consequences.
- zdragnar 6y ago
  A friend of mine was very briefly hooked. He had pretty serious leg surgery after an accident at an air force base, and the Veterans Affairs doctor basically wrote him out a prescription for a massive quantity of pills with the instructions to take as needed. So, naturally, he sat around with nothing to do during recovery but to play video games, drink beer and pop pills. Pain management is definitely not taken seriously enough by some doctors, and too many people are too trusting that their overworked doctors and nurses know better. Both myself and my wife also have chronic pain from past injuries (back pain mostly, plus some arthritis for me) but we manage with stretching, liberal amounts of tiger balm, and the occasional ibuprofin.
  - xxpor 6y ago
    I had relatively routine surgery last year that affected my kidneys. It took a few days to recover, and after a few days I wasn't getting any better so they sent me to the ER. I had Percocet that they prescribed me after the surgery, but the ER doctor wrote me a prescription for straight oxycodone because he was concerned that the acetaminophen in Percocet is sufficiently damaging to the kidneys that I really shouldn't be taking them. I have to be honest, I was really hesitant to fill that prescription. I did after a few hours when the pain got unbearable (at 1 in the morning, they filled it in 5 minutes which also makes me worried that pharmacy would be an easy robbery target...), and damn they did work quite well. I only needed them for 2 days, and I didn't get the sense of being high that I expected, and had no issues stopping them. I can't say I didn't wonder what would have happened if I needed them for a week or more, or if I had previously been addicted to opiates. It just seems hard to believe in modern times there's nothing in between NSAIDs/Tylenol and full on opioids for managing pain, especially for this sort of post-op temporary use case.
    - freeone3000 6y ago
      Ibuprofen was already a huge step up from Paracematol, which is another step up from Aspirin. The fact that ibuprofen is also much better tolerated, has fewer side effects, and has to be dosed less often means you're taking the best non-opioid painkiller we know of as your first-line option.
      - jorvi 6y ago
        > The fact that ibuprofen is also much better tolerated, has fewer side effects I'd much rather have the slight load on the liver that paracetemol has than the issues with the stomach that NSAIDs bring.
        freeone3000 6y ago
        Well, lucky for you, both (in fact, all three) are still available. But, as a statistical matter, Ibuprofen is safer. Not only because the liver is such a contentious point for drug elimination, including alcohol, but due to the ability to fix overdoses. Even with minor overdoses (such as mixing with alcohol), paracematol causes permanent liver damage, whereas stomach ulcers can be repaired. More than 100,000 people die annually from Paracematol overdoses. Ibuprofen is sold more, and has fewer than 16,000 deaths.
        rscho 6y ago
        Kidneys cannot be repaired. You'll need hemodialysis if you overdose on ibuprofen. I don't know the state of the research on the topic, but I expect locations offering OTC NSAIDs to have issues with acute and chronic kidney injury that goes pretty much unnoticed. Especially in populations with high diabetes prevalence. One of the reasons for higher paracetamol mortality is because people commit suicide using it (especially common among teenagers).
        hilbert42 6y ago
        "More than 100,000 people die annually from Paracetamol overdoses." The fact is we seem to be damned if we do or damned if we don't. We desperately need a reasonably effective and safe painkiller. If 100,000 actually die from paracetamol per year then there's a reasonable excuse for banning it. But what do we replace it with given that many cannot take NSAIDs for various reasons? - Pharmacists and doctors repeatedly say paracetamol/acetaminophen is very safe if taken according to directions, the trouble is, that in excess, it shuts the liver down and it cannot recover/clear the drug in time before real trouble sets in. Moreover, it's not very effective as a painkiller. - NSAIDs, ibuprofen and aspirin, cause bleeding of the stomach and other major issues, even hearing loss in high doses. - The newer COX-2 selective NSAID Rofecoxib, aka Vioxx, was very effective at certain forms of pain relief but was banned by the FDA after it was found to cause cardiac effects in susceptible people including heard attacks. (Another criticism I have of the FDA is the inordinate length of time it took for the FDA to remove Vioxx from the market after its cardiac effects became known—this was around three years. (I recall reading a paper in the AAAS journal Science that outlined Vioxx's cardiac effects and thinking to myself that the drug would have to be banned. That was some three years before the FDA actually banned it). - Celecoxib, also a newer COX-2 selective NSAID that is in the same class as Vioxx, hasn’t yet been banned but it still has the potential to cause cardiac effects. Moreover, it is not as effective a painkiller as Vioxx was. - Then there's the dangerously addictive opioids. - Once we had another rather effective painkiller but it too has been long banned. APC was a mixture of aspirin, phenacetin and caffeine and it was rather effective except for the fact that it rotted one's kidneys, many instances of kidney disease were attributed to its use Alas, there's precious little else, especially anything that's safe. It's a pathetically inadequate a list, isn't it?
  - acct776 6y ago
    Two people, chronic pain, nobody's had you try CBD edibles, or vaporizing a little CBD herb?
    - zdragnar 6y ago
      Yup. Tried gummies and hemp cigarettes both. I thought the hemp cigs helped the back pain a bit, but not so much the joint pain. The effect was small enough that it wasn't worth the money to keep doing it. We get much more mileage out of stretching and tiger balm- especially the back patches and arthritis lotion formulations.
      - acct776 6y ago
        How long ago was this? Not to keep pestering you, but, recently the prices of medicinal CBD flower have been halved.
        zdragnar 6y ago
        6 months at most, I think. CBD products are becoming trendy out here, but actual flower is much harder to come by, hence attempting the hemp cigarettes (hempettes?). Maybe I'll try again this spring or summer when I get back into doing some light forestry, but I almost prefer to not mask the pain so I know I'm not making things worse.
- dbcurtis 6y ago
  There is a great Freakonomics podcast on the opiate crisis. If you want to get some food for thought about the American approach to pain management, how it is done elsewhere, and some background on the opiate crisis. (Looks like episodes 402 and 403, from a quick search.)
every 6y ago
Regulatory capture can be a significant factor: https://en.wikipedia.org/wiki/Regulatory_capture https://en.wikipedia.org/wiki/Regulatory_capture
meekrohprocess 6y ago
Many American regulatory institutions have crumbled in the past few decades, the FAA being a particularly jarring example. In some cases it seems like peoples' trust in those regulators may be fueled by nostalgia, but the FDA does seem like one of the few agencies that has retained some measure of independence. Looking at what has happened in this nation's other industries and institutions, only one crippling decades-long medical crisis doesn't seem all that bad.
- bordercases 6y ago
  That's not an explanation for why the FDA has failed to address the regulatory aspects of the opioid crisis, but an argument for why we should discount or ignore that failure. At the very least – this is a non sequitur.
  - meekrohprocess 6y ago
    I disagree. Regulatory capture is a clear and present danger to the United States, and it is contributing to a breakdown in accountability across all sectors of the nation's economy and society. So I offered it as an explanation for why the FDA could be well-respected and reasonably functional, while the United States fails to address some acute public health issues. Things could be much worse; at least they don't turn a blind eye when huge sums of money are not involved. It's still very rare for a drug's approval to be pushed through via fraud, and there are a lot of diseases that need treating. They have a solid track record, even now.
- Clewza313 6y ago
  There hasn't been a fatal crash of a US commercial airliner since 2009. Even for the 737 Max debacle Boeing deserves at least as much blame the FAA.
  - sofixa 6y ago
    The FAA are the ones responsible for stopping shit like the 737Max fiasco. Yes, Boeing did it, and many people there deserve to go to prison, but the FAA is supposed to be the guardrail ensuring they can't get away with it in the first place. It was an objective failure, and it has eroded the trust in them - point in case, most other aviation regulators did their own checks on the 737 Max before allowing it back to service, which usually doesn't happen ( EASA trusts FAA's ratings and vice versa).
xxpor 6y ago
That's sort of a different situation. Thalidomide did what it was supposed to, but ended up having horrible unknown (at the time) side effects. The FDA correctly didn't approve it based on the lack of safety data. Opiates also do what they're supposed to, but the fact that they're addictive wasn't a mystery. They're safe if taken and prescribed as instructed. The failure is more on the DEA and other enforcement bodies for not dealing with the obvious prescription abuse. The FDA doesn't make controlled substance decisions.
- maxerickson 6y ago
  There's lots of controversy about opiates being excessively addictive even when used 'on label'. I didn't find it with a bit of searching, but I remember an article about the 'extended release' aspect of Oxycontin tending to encourage addictive use patterns (because it didn't really work for 6 hours). Figuring that out wouldn't necessarily be an up front trial kind of thing though.
- hilbert42 6y ago
  "The FDA doesn't make controlled substance decisions." It never spoke out either. Like Pontius Pilate, it washed its hands of the matter.
Scoundreller 6y ago
The FDA only protects you against novel drugs. Once something is approved for something (or grandfathered!), it’s a free-for-all for prescribing and usually insurance coverage.
mhh__ 6y ago
The FDA doesn't do that kind of regulation if I have read up on it correctly. That and opiates do what they say on the tin - it's more of a policy problem than a specific thing you can just FDA-away.
freeflight 6y ago
That has way more to do with ease of access, due to over-prescription practices resulting from pharma lobbying, than FDA med approval.
rscho 6y ago
The US opiate crisis has its roots deep in US healthcare culture and the blame lies on both sides of the doctor-patient fence. US docs used to prescribe opiates like candies, but US patients expect to feel no pain at all and are extremely aggressive legally speaking. Those two aspects go hand in hand. My 2c.
hilbert42 6y ago
Exactly, the FDA was not only completely incompetent but indirectly responsible for the deaths of thousands. It should have pounced on Purdue at the very outset. Unlike much medical/drug research, knowledge about opioids and opioid addiction is well known. The FDA irresponsibly failed to act on a no-brainer.

How come, the US has an opiate crisis?

by k__ 6y ago

How come, the US has an opiate crisis?

A while ago I posed a similar question and the answers/downvotes made it clear to me why; Americans have a broken model of pain management. Americans think that opiates are necessary to manage the pain from most surgeries, back pain, headaches etc., so, they get opiates to do that, with the obvious and foreseeable catastrophic consequences.

zdragnar 6y ago
A friend of mine was very briefly hooked. He had pretty serious leg surgery after an accident at an air force base, and the Veterans Affairs doctor basically wrote him out a prescription for a massive quantity of pills with the instructions to take as needed. So, naturally, he sat around with nothing to do during recovery but to play video games, drink beer and pop pills. Pain management is definitely not taken seriously enough by some doctors, and too many people are too trusting that their overworked doctors and nurses know better. Both myself and my wife also have chronic pain from past injuries (back pain mostly, plus some arthritis for me) but we manage with stretching, liberal amounts of tiger balm, and the occasional ibuprofin.
- xxpor 6y ago
  I had relatively routine surgery last year that affected my kidneys. It took a few days to recover, and after a few days I wasn't getting any better so they sent me to the ER. I had Percocet that they prescribed me after the surgery, but the ER doctor wrote me a prescription for straight oxycodone because he was concerned that the acetaminophen in Percocet is sufficiently damaging to the kidneys that I really shouldn't be taking them. I have to be honest, I was really hesitant to fill that prescription. I did after a few hours when the pain got unbearable (at 1 in the morning, they filled it in 5 minutes which also makes me worried that pharmacy would be an easy robbery target...), and damn they did work quite well. I only needed them for 2 days, and I didn't get the sense of being high that I expected, and had no issues stopping them. I can't say I didn't wonder what would have happened if I needed them for a week or more, or if I had previously been addicted to opiates. It just seems hard to believe in modern times there's nothing in between NSAIDs/Tylenol and full on opioids for managing pain, especially for this sort of post-op temporary use case.
  - freeone3000 6y ago
    Ibuprofen was already a huge step up from Paracematol, which is another step up from Aspirin. The fact that ibuprofen is also much better tolerated, has fewer side effects, and has to be dosed less often means you're taking the best non-opioid painkiller we know of as your first-line option.
    - jorvi 6y ago
      > The fact that ibuprofen is also much better tolerated, has fewer side effects I'd much rather have the slight load on the liver that paracetemol has than the issues with the stomach that NSAIDs bring.
      - freeone3000 6y ago
        Well, lucky for you, both (in fact, all three) are still available. But, as a statistical matter, Ibuprofen is safer. Not only because the liver is such a contentious point for drug elimination, including alcohol, but due to the ability to fix overdoses. Even with minor overdoses (such as mixing with alcohol), paracematol causes permanent liver damage, whereas stomach ulcers can be repaired. More than 100,000 people die annually from Paracematol overdoses. Ibuprofen is sold more, and has fewer than 16,000 deaths.
        rscho 6y ago
        Kidneys cannot be repaired. You'll need hemodialysis if you overdose on ibuprofen. I don't know the state of the research on the topic, but I expect locations offering OTC NSAIDs to have issues with acute and chronic kidney injury that goes pretty much unnoticed. Especially in populations with high diabetes prevalence. One of the reasons for higher paracetamol mortality is because people commit suicide using it (especially common among teenagers).
        hilbert42 6y ago
        "More than 100,000 people die annually from Paracetamol overdoses." The fact is we seem to be damned if we do or damned if we don't. We desperately need a reasonably effective and safe painkiller. If 100,000 actually die from paracetamol per year then there's a reasonable excuse for banning it. But what do we replace it with given that many cannot take NSAIDs for various reasons? - Pharmacists and doctors repeatedly say paracetamol/acetaminophen is very safe if taken according to directions, the trouble is, that in excess, it shuts the liver down and it cannot recover/clear the drug in time before real trouble sets in. Moreover, it's not very effective as a painkiller. - NSAIDs, ibuprofen and aspirin, cause bleeding of the stomach and other major issues, even hearing loss in high doses. - The newer COX-2 selective NSAID Rofecoxib, aka Vioxx, was very effective at certain forms of pain relief but was banned by the FDA after it was found to cause cardiac effects in susceptible people including heard attacks. (Another criticism I have of the FDA is the inordinate length of time it took for the FDA to remove Vioxx from the market after its cardiac effects became known—this was around three years. (I recall reading a paper in the AAAS journal Science that outlined Vioxx's cardiac effects and thinking to myself that the drug would have to be banned. That was some three years before the FDA actually banned it). - Celecoxib, also a newer COX-2 selective NSAID that is in the same class as Vioxx, hasn’t yet been banned but it still has the potential to cause cardiac effects. Moreover, it is not as effective a painkiller as Vioxx was. - Then there's the dangerously addictive opioids. - Once we had another rather effective painkiller but it too has been long banned. APC was a mixture of aspirin, phenacetin and caffeine and it was rather effective except for the fact that it rotted one's kidneys, many instances of kidney disease were attributed to its use Alas, there's precious little else, especially anything that's safe. It's a pathetically inadequate a list, isn't it?
- acct776 6y ago
  Two people, chronic pain, nobody's had you try CBD edibles, or vaporizing a little CBD herb?
  - zdragnar 6y ago
    Yup. Tried gummies and hemp cigarettes both. I thought the hemp cigs helped the back pain a bit, but not so much the joint pain. The effect was small enough that it wasn't worth the money to keep doing it. We get much more mileage out of stretching and tiger balm- especially the back patches and arthritis lotion formulations.
    - acct776 6y ago
      How long ago was this? Not to keep pestering you, but, recently the prices of medicinal CBD flower have been halved.
      - zdragnar 6y ago
        6 months at most, I think. CBD products are becoming trendy out here, but actual flower is much harder to come by, hence attempting the hemp cigarettes (hempettes?). Maybe I'll try again this spring or summer when I get back into doing some light forestry, but I almost prefer to not mask the pain so I know I'm not making things worse.
dbcurtis 6y ago
There is a great Freakonomics podcast on the opiate crisis. If you want to get some food for thought about the American approach to pain management, how it is done elsewhere, and some background on the opiate crisis. (Looks like episodes 402 and 403, from a quick search.)

every 6y ago

Regulatory capture can be a significant factor: https://en.wikipedia.org/wiki/Regulatory_capture https://en.wikipedia.org/wiki/Regulatory_capture

meekrohprocess 6y ago

Many American regulatory institutions have crumbled in the past few decades, the FAA being a particularly jarring example. In some cases it seems like peoples' trust in those regulators may be fueled by nostalgia, but the FDA does seem like one of the few agencies that has retained some measure of independence. Looking at what has happened in this nation's other industries and institutions, only one crippling decades-long medical crisis doesn't seem all that bad.

bordercases 6y ago
That's not an explanation for why the FDA has failed to address the regulatory aspects of the opioid crisis, but an argument for why we should discount or ignore that failure. At the very least – this is a non sequitur.
- meekrohprocess 6y ago
  I disagree. Regulatory capture is a clear and present danger to the United States, and it is contributing to a breakdown in accountability across all sectors of the nation's economy and society. So I offered it as an explanation for why the FDA could be well-respected and reasonably functional, while the United States fails to address some acute public health issues. Things could be much worse; at least they don't turn a blind eye when huge sums of money are not involved. It's still very rare for a drug's approval to be pushed through via fraud, and there are a lot of diseases that need treating. They have a solid track record, even now.
Clewza313 6y ago
There hasn't been a fatal crash of a US commercial airliner since 2009. Even for the 737 Max debacle Boeing deserves at least as much blame the FAA.
- sofixa 6y ago
  The FAA are the ones responsible for stopping shit like the 737Max fiasco. Yes, Boeing did it, and many people there deserve to go to prison, but the FAA is supposed to be the guardrail ensuring they can't get away with it in the first place. It was an objective failure, and it has eroded the trust in them - point in case, most other aviation regulators did their own checks on the 737 Max before allowing it back to service, which usually doesn't happen ( EASA trusts FAA's ratings and vice versa).

xxpor 6y ago

That's sort of a different situation. Thalidomide did what it was supposed to, but ended up having horrible unknown (at the time) side effects. The FDA correctly didn't approve it based on the lack of safety data. Opiates also do what they're supposed to, but the fact that they're addictive wasn't a mystery. They're safe if taken and prescribed as instructed. The failure is more on the DEA and other enforcement bodies for not dealing with the obvious prescription abuse. The FDA doesn't make controlled substance decisions.

maxerickson 6y ago
There's lots of controversy about opiates being excessively addictive even when used 'on label'. I didn't find it with a bit of searching, but I remember an article about the 'extended release' aspect of Oxycontin tending to encourage addictive use patterns (because it didn't really work for 6 hours). Figuring that out wouldn't necessarily be an up front trial kind of thing though.
hilbert42 6y ago
"The FDA doesn't make controlled substance decisions." It never spoke out either. Like Pontius Pilate, it washed its hands of the matter.

Scoundreller 6y ago

The FDA only protects you against novel drugs. Once something is approved for something (or grandfathered!), it’s a free-for-all for prescribing and usually insurance coverage.

mhh__ 6y ago

The FDA doesn't do that kind of regulation if I have read up on it correctly. That and opiates do what they say on the tin - it's more of a policy problem than a specific thing you can just FDA-away.

freeflight 6y ago

That has way more to do with ease of access, due to over-prescription practices resulting from pharma lobbying, than FDA med approval.

rscho 6y ago

The US opiate crisis has its roots deep in US healthcare culture and the blame lies on both sides of the doctor-patient fence. US docs used to prescribe opiates like candies, but US patients expect to feel no pain at all and are extremely aggressive legally speaking. Those two aspects go hand in hand. My 2c.

hilbert42 6y ago

Exactly, the FDA was not only completely incompetent but indirectly responsible for the deaths of thousands. It should have pounced on Purdue at the very outset. Unlike much medical/drug research, knowledge about opioids and opioid addiction is well known. The FDA irresponsibly failed to act on a no-brainer.