15 ms·

Drug users use a lot of drugs

178 points by feross 5y ago

rogerclark 5y ago
"The most important reason meth makes your teeth fall out and ruins your life but Adderall just makes you study a little harder is that the meth users are taking 50x higher doses" The reason meth addicts have bad teeth isn't because of the dosage of the drug. It's because stimulants make you want to eat candy and drink sugar water, because meth addicts lose track of oral hygiene in favor of doing meth or something else more interesting, and because they're smoking it (along with other drugs).
- canary1 5y ago
  Regardless, I think the author's point is that the massive dose is more responsible for that negative outcome than the chemical is itself.
- peanut_worm 5y ago
  Stimulants suppress your appetite but they also make you clench you jaw and grind your teeth involuntarily.
  - beebeepka 5y ago
    You mean amphetamines, not stimulants in general. I've seen people do much worse when they mix this shit with alcohol, the worst offender that is still perfectly legal
    - peanut_worm 5y ago
      What non-amphetemine stimulants are people doing recreationally?
      - MagnumOpus 5y ago
        Cocaine? MDMA?
        peanut_worm 5y ago
        MDMA is an amphetamine, short for Methylenedioxymethamphetamine I don’t know how I forgot cocaine, but it has the same jaw clenching problem
      - loves_mangoes 5y ago
        2C-B. Cathinones and other pyrovalerones. Some people even seem to enjoy absorbing Coffee through their nose.
        Stevvo 5y ago
        Cathinones are amphetamines.
        loves_mangoes 5y ago
        Sure, cathinones are a sub-category of amphetamines, but only in the same way that amphetamines are technically phenetylamines. But cathinones differ from "pure" substituted amphetamines by a ketone group at the Beta-position, which is what I mean here. And regardless, the point stands for substituted phenethylamines like the 2C family, which are clearly not amphetamines.
        randomopining 5y ago
        How do you do coffee through your nose lol
        milkytron 5y ago
        I would imagine snorting really fine grounds, similar to how people use tobacco snuff.
- bawolff 5y ago
  Adderall is also a stimulant(?) The authors suggestion is it would cause the same effect if taken in the same dosage.
  - skummetmaelk 5y ago
    They are both amphetamines.
  - treeman79 5y ago
    I was on Adderall 10mg a day. Worked as advertised. ADHD under control. Chronic fatigue fixed. Every portion of my body felt like it was being burned from the inside. I had to start tramadol to counter act the pain. It also upped cranial pressure. Causing a lot of secondary problems. This was made much worse as dosage went up. I had to stop it before downward spiral completely destroyed me. Vyvanse was a mild version of all this. Can’t imagine anything more intense.
    - anon9001 5y ago
      I've never heard of anything like that before. I wonder if you'd get the same reaction from ritalin.
    - astrange 5y ago
      I've never heard of this symptom! Maybe you were allergic? It does sound like SJS, in which case you should definitely quit it, but I thought that could only happen with modafinil.
      - treeman79 5y ago
        I am hypersensitive to most medications. Runs in the family. Benadryl will cause me and my kids to go completely nuts. Like climbing the ceiling of the hospital level. Was describing that to one nurse and she almost started crying. Apparently she had same reaction and no one would believe her.
    - QuadmasterXLII 5y ago
- TX0098812 5y ago
  ...because they're taking 50x the dose?
- shredprez 5y ago
  Also: dehydration and dry-mouth secondary to stimulant use, classic accelerators of bacterial overgrowth and consequent tooth decay.
  - KingMachiavelli 5y ago
    Truth. It's highly variable but even Adderall will accelerate tooth decay. It's quite necessary to drink water very frequently.
- Nuzzerino 5y ago
  Street meth also has a lot of adulterants, contaminants, or byproducts that can accelerate the damage.
- whymauri 5y ago
  The reason there's confusion in this thread about dosage is that the author didn't use precise terminology (the author is technically correct, but there's ambiguity). I'm pretty sure he means that the recreational dose is relatively larger compared to the effective dose (ED) with meth than with Adderall.
- kingTug 5y ago
  This isn’t correct. Meth, when smoked, is incredibly toxic. The toxic smoke that causes “meth mouth”
  - volkl48 5y ago
    While I am certainly willing to believe that illicit meth is...bad for you/toxic and the smoke is as well, I'm not finding much to support the idea of it being the primary cause of (or major contributor to) "meth mouth" in a quick search. In contrast, every source I find cites the things the prior poster mentioned as the causes. For example: https://www.drugabuse.gov/publications/research-reports/methamphetamine/what-are-long-term-effects-methamphetamine-misuse https://www.drugabuse.gov/publications/research-reports/meth... > The dental problems may be caused by a combination of poor nutrition and dental hygiene as well as dry mouth and teeth grinding caused by the drug. I would think they would be mentioning that the toxic smoke is a cause or contributor if there was evidence to support it.
  - robocat 5y ago
    People get meth mouth even if they don't take it orally (or smoking) i.e. your thesis is wrong AFAIK.
- newbie789 5y ago
  Meth does not make you crave any type of food. If that were the case Desoxyn would not be FDA approved for weight loss. “Meth mouth” is caused by the fact that it dries your mouth out, you grind your teeth a LOT, and is often observed in people that have used drugs long/hard enough to find themselves no longer taking care of their health in general, let alone oral hygiene. This often is coupled with financial ruin and utter alienation from society. Somehow, mysteriously, all of the rich house wives and Silicon Valley coders that use it develop meth mouth at a lower rate.
  - yerwhat01010 5y ago
    Wait, are you saying that meth is popular among Silicon Valley coders and rich house wives? This is news to me.
    - FeepingCreature 5y ago
      Adderall. I can't find a Wiki cite for the specific use among coders, but it's stereotypically widespread as a nootropic.
      - astrange 5y ago
        Adderall is not meth. It does promote jaw clenching some, but it's not nearly as bad for you (as the article says, mostly because prescribed doses are smaller) and in fact is neuroprotective. I don't think housewives would enjoy abusing it, unless they're studying for the GRE.
        kragen 5y ago
        Right, Adderall is near-racemic amphetamine, not methamphetamine. Amphetamine and methamphetamine are very similar in their effects, as discussed here, and both can easily be used at neurotoxic levels. Among their effects in therapeutic doses are weight loss and, yes, being good at memorizing things, like if you're studying for the GRE. I'm not a big fan of any of the drug family.
        5y ago
- refurb 5y ago
  It's purely due to a dry mouth. People that get radiation therapy for head and neck cancers get severe dry mouth as well (salivary glands affected) and severe tooth decay is common unless you use artificial saliva.
zafka 5y ago
Thank you. While there is no data to back up some of these numbers, at least they are offered up. I have often wondered what amounts Meth addicts were using do cause their severe issues.
- wincy 5y ago
  My neighbors teeth are falling out. Salesman, honestly pretty successful guy, making 6 figures. Apparently he takes 120mg if Adderall to wake up in the morning. At that dose, he’s basically just getting Walter White quality meth for his morning pick me up.
  - throwaway0a5e 5y ago
    His teeth are far more likely to be falling out because of bad oral hygiene for a decade earlier in life than they are because of a low dose of Adderal or anything. If 120mg of Adderal made your teeth fall out then tons more people would have their teeth falling out.
    - wincy 5y ago
      To be clear, 120mg is what he takes first thing in the morning. He takes more throughout the day. I’d guess he takes 500+ in a day.
      - arthurcolle 5y ago
        That is impossible. There is no one someone's heart would be able to take that. I take 60 mg daily of Vyvanse and I'm pretty wired all day. I can't even fathom the effects of that on a human body. Is he like 300 lbs?
        cwkoss 5y ago
        500mg/day was the figure cited for heavy users in the OP article. You're right that 500mg is far into overdose territory for novice users. But, he probably has been using for a long time and has a very high tolerance.
canary1 5y ago
This article is mostly weak opinion. There was one important takeaway, which is notable to anyone interested in ketamine: > I hesitate to say the risk of bladder injury from a normal psychiatric dose of ketamine is literally zero
- daperor630 5y ago
  >I hesitate to say the risk of bladder injury from a normal psychiatric dose of ketamine is literally zero. The author's hesitation to make such a claim is very important to this quote.
deleted 5y ago
[deleted]
Impassionata 5y ago
It's hard to read Scott once you hear about how he courted the alt-right on purpose and his communities became full of open racists as a result.
- arijun 5y ago
  Do you have a source for that? Beyond the NYT piece, which is so laughable it does hit pieces a disservice by being grouped with them.
  - wizzwizz4 5y ago
    The NYT piece didn't even say that; it said that he supported genocide (??), which is similar, but I don't remember it saying that he courted neo-Nazis. (Or was that one of the heavily-implied things I was oblivious to?)
    - arijun 5y ago
      Perhaps it was more implying they were welcomed? > The voices also included white supremacists and neo-fascists. The only people who struggled to be heard... were “social justice warriors.”
  - Impassionata 5y ago
    There's some leaked emails where he plainly states he's chasing that audience. https://web.archive.org/web/20210217195335/https://twitter.com/TopherTBrennan/status/1362108632070905857 https://web.archive.org/web/20210217195335/https://twitter.c... I wouldn't say he's racist but it's almost worse. He didn't think about how this would go down, which is to say, when you court an audience that has a reputation of being overtly racist, your audience will become more and more racist, driving good people out.
    - arijun 5y ago
      I couldn't read Scott's email at your link but I could here: https://twitter.com/arsonatdennys/status/1362153191102677001 https://twitter.com/arsonatdennys/status/1362153191102677001 I don't think his reasoning is that crazy here--I certainly don't see it as the smoking gun that you or the person who tweeted it do. I also haven't noticed a huge amount of racists in his comment section, although I have to admit I haven't spent all that much time on the blog.
droopyEyelids 5y ago
This is a great article, and it could be also be expanded to include the 'whale' effect. I'm not just talking about how a small percent of users spend the most on loot-box games, but also how the top 10% of drinkers consume 50% of all the alcohol sold in the USA. I also believe it must apply to people who use cannabis, as a 'dab' setup allows a heavy user to inhale in one breath what would literally be 50 sessions worth of doses for an infrequent smoker. This isn't necessarily the same topic as what the author wrote, but I'd like to see someone explore the connection.
- oogetyboogety 5y ago
  I mean, not literally 50. Like 3 times the potency, maybe 5 or 6 times the potency of whatever your state average black market, grey market, or illegally grown crop is. It's important to clear up the FUD here because it has led to some backwards progress for legalization in states like Colorado recently.
  - droopyEyelids 5y ago
    Let's say you use a 0.5 g dab which has a THC content of 70% (most dabs are either 1-gram or 0.5 g). The wax has 0.35 g (350 mg of THC), but you could lose up to one-third of it when vaporizing. If this happens, you’ll end up with roughly 235 mg of THC per hit (if you can finish the whole dab in one hit). Someone without a THC tolerance will be completely satisfied with a 5mg dose, total. Thats 47 doses out of the 236mg the stoner _absorbed_
    - sgspace 5y ago
      I don’t know anyone who is doing half gram dabs lol. That’s like $25 in one hit. A gram of concentrate is supposed to last a while (20+ dabs) not a single hit or two.
      - notional 5y ago
        A gram of wax lasts me probably 50+ hits. It seriously lasts a long time. A tiny little crumb you can pinch out of the jar is more than enough for a big hit
trestenhortz 5y ago
I watched a documentary about ketamine use by party people. It profiled a young guy who had destroyed his bladder and needed to use a pump and hole in his belly to urinate. Really disturbing.
- vmception 5y ago
  My problem with that, and this article, is that it doesn't say what dosage does that? It just skips right on to meth, and dosages, and never mentions Ketamine again. We get that 280mg a month mostly doesn't, and 90,000mg a month can. But are these "party people" the same as the people doing that higher amount prorated to daily? More specifically, are the "party people" I've been around secretly having bladder problems and getting a hole in their belly and not really ubering home but ubering to the hospital? Let me know when you, or anyone passing by, find that article
  - kriskrunch 5y ago
    I've known many users over the years, many OD while others decay over a few years. One customer in particular used ketamine heavily. Due to a string of poor decisions, he was on federal probation and subjected to random drug tests. He determined two drugs were not detectible by the tests at that time: ketamine and GHB. And he frequently consumed them. I remember him stumbling around my store, sipping caps of G every so often... sniffling behind tall pallets to suck up another key bump. Over a year or so, he developed severe problems with his bladder, but wouldn't / couldn't stop his drug use, even after I broke it down to him plainly; "Bro, you are killing yourself." From what I can tell, users don't keep track of doses, or much of anything. Their objectives are short term in nature: get high asap. I suspect any such article that provides hard numbers like what you want will provide guestimates at best.
    - vmception 5y ago
      So we can improve the data by regulating the supply chain, serving sizes, and points of sale Doesnt seem to support enforcing varying levels of prohibition
newbie789 5y ago
Former meth addict here. > The average crystal meth addict uses about 500 mg a day. And they snort it, which probably produces about double the peak plasma level as taking it orally. So they're getting the equivalent of 1000 mg oral amphetamine daily... 500mg sounds about right, but from my experience the most common route of administration (in the western United States at least) is smoking, not snorting. Because so many people smoke meth rather than snort it, a lot of meth is sold as methamphetamine base rather than methamphetamine hydrochloride. This means that it’s often not particularly water soluble, which makes it a poor choice for snorting since it doesn’t get through your nasal mucosa and actually kicks in after it drips down into your stomach. It’s not actually much different from eating it in many cases. I like this article overall but I get irritated when I read stuff about drug users that is clearly written by somebody who hasn’t done a lot of drugs. Edited for spelling. Also if anybody has any questions for me, I’m pretty knowledgeable on this topic (though no expert), so feel free to ask away!
- tomcam 5y ago
  Might be a regional thing? I was raised in Southern California, where is smoking is also the preferred method. I believe OP is from New York City. For all we know perhaps inhaling what his upper middle class cohort does.
  - marton78 5y ago
    OP is from California.
- sharken 5y ago
  Must admit the specifics of doing drugs is not that interesting to me, it's more interesting to ask the question: How does someone stop doing drugs?
  - agentdrtran 5y ago
    You may get the best answer to that question from people who have stopped rather than never started.
grawprog 5y ago
This article isn't bad, but it's a very shallow, narrow view of things. In general it seems to make no distinction with addicts using high doses to overcome tolerance levels with recreational drug users in general. Methamphetamines and amphetamines are not the same chemical, despite being similar. https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=172 https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=1... The small differences between the molecules allow it to penetrate the blood brain barrier more efficiently, has longer lasting toxic effects and acts more as a central nervous system stimulant and >less peripheral nervous system and cardiovascular stimulation activity. Another difference between amphetamine and MA is that amphetamine stimulates the CNS indirectly by activating the release of catecholamines and inhibiting their breakdown and storage. In contrast, MA stimulates the postsynaptic catecholamine receptors directly.[2] Increased dosage is only one part of the difference between Methamphetamine and Amphetamines. Street meth is also far more likely to have fillers, leftover solvents and a bunch of other things that are not good for you. >In general, recreational drug users take their drugs at doses so much higher than psychiatric patients that they're basically two different chemicals Recreational drug users come in a wide range. The first two sections of the article speak about addicts doing extremely large doses, then seems to lump 'recreational drug users' altogether with that.
golergka 5y ago
There's recreational drug users, and then there's recreational drug users. Turns out some people I know who microdosed amphetamine took doses exactly in the ballpark of what doctor would prescribe them.
- dnate 5y ago
  There always are, for any drug. There is the person that uses amphetamines to get high SAT scores, high college grades and stops after landing a FAANG job. There is the person using alcohol as "social lube". Never drinks alone, never gets wasted. There is the person using LSD and other party drugs few times per year or less in a controlled setting And then there are the extremely addicted people. And everything in between. It's a sliding scale. People need to be educated to learn the risks and recognize harmful behavioral patterns. Simply telling people "drugs are bad for you" might be the abridged version of the truth. But is as effective as the "war on drugs" in reducing drug abuse.
- austhrow743 5y ago
  If they're microdosing amphetamine at medicinal dosage levels are their intentions even recreation?
  - stuntkite 5y ago
    That's an interesting question. Sometimes I experiment with my meds into micro dosage levels if I have a long weekend. Sometimes I'll even keep a journal and sometimes I'll mix with other agents like microdosed psilocybe or LSD and run tests on neuroplacticity. Some times on the weekends I'll take 2mg or less of my ADHD meds just to clear the noise out of my head so I can get a nap. It works a treat, I wake up feeling refreshed and I can tackle some chores or do nothing at all with only muted versions of my normal symptoms. I wouldn't say this is not recreational. It's my body and am curious about how it works and also I think it's always good to experiment with making very low doses or even medication fasts (in relation to stims specifically THIS IS NOT MEDICAL ADVICE) part of any regimen. Testing out strategies on my free time and not at work is just responsible. My ADHD medication makes me employable and has helped tremendously with my ability to maintain valuable relationships, it's crucial for me to make my way in a world designed around shit that is nearly torture for me, but I really hope to not be on the stims one day and I think it's going to take some work to figure that out. I'm a long time psychonaut so what is recreation to you might not be the same thing it is to me but I consider the observations and experiments to be recreational.
heisenbit 5y ago
Drug processing in the body can sometimes be surprising. I learned recently about first pass effect which means the drug heads first to the liver and only what passes through is available to the body. So if one ups the dose and the liver processing is saturated a double dose can deliver much more punch than two single ones. The body has many non-linear features and extrapolating several orders of magnitude is often not possible.
- cwkoss 5y ago
  Yep, this is why "boofing" (intrarectal) dosing has found rising popularity in the 'research chemical' scene over the past couple decades. The liver's effects on drugs is really fascinating. Grapefruit has a chemical that can inactive liver enzymes, so some drug addicts regularly drink grapefruit juice to 'get more bang for their buck'. Plain old black pepper (in large doses) inactivates a different enzyme IIRC. There are also some interesting anecdotal cases of people who claim to have found regimens of essential oils, which when consumed at the right schedule saturate liver enzymes to the extent that otherwise inert substances can produce recreationally psychoactive effects. Source: i have a morbid fascination with the 'frontier non-medical drug use' communities and follow their subreddits (/r/researchchemicals and /r/peptides being among the most interesting). There a lot of people who choose to make themselves guinea pigs quite recklessly and, thankfully for scientific advancement and future harm reduction, post in-depth reports of how these novel chemicals or preparations effected them. Recently, broad cheap availability of novel benzos have led many posters to deep addictions of such great magnitude that they struggle to convince doctors assisting with detox that they've actually been consuming equivalents of 1000x typical prescribed doses... until the doctor gives them massive doses of valium to detox and they still have severe seizures.
  - whymauri 5y ago
    >There are also some interesting anecdotal cases of people who claim to have found regimens of essential oils, which when consumed at the right schedule saturate liver enzymes to the extent that otherwise inert substances can produce recreationally psychoactive effects. Are essential oils literally oils? Because I doubt they can have a metabolic effect due to their size and lipophilicity. My main concern is adsorption. But if they're small and greasy, then they may be promiscuous binders. Or do the essential oils carry other molecules along? Edit: I see now that individual oils carry many diverse constituents, including some small-to-medium sized lads. That's a pretty interesting shotgun strategy for controlling your metabolism, lol.
Alex3917 5y ago
Somehow he managed to ignore the data showing that a non-trivial percentage of people with KLUTS get it after only doing doses comparable to the psychiatric dose, and sometimes after only doing it once or a handful of times. https://erowid.org/chemicals/ketamine/ketamine_article2.shtml https://erowid.org/chemicals/ketamine/ketamine_article2.shtm...
- loves_mangoes 5y ago
  I'll add my anecdote to the pile. I don't use ketamine a lot (it is not very good for headaches, pretty good for dulling a mosquito bite until it fades away naturally, excellent for dancing). I've taken about 1000mg over the course of several months, at irregular intervals. While it is somewhat higher than Scott's 280mg/month, it's not an order of magnitude higher. Certainly nowhere near 90,000mg/month. I can report one event of pain while peeing, a few days ago. So it looks like my body is not built to handle even moderate levels of ketamine use, and I'd have to stay closer to 100mg/month or lower to be on the safe side. That said, let me reiterate, this is anecdote. I only think it's interesting because there is no other reasonable explanation for my recent urinary pain, and I didn't expect such low doses of Ketamine to have noticeable effects.
  - Alex3917 5y ago
    Yeah I think I gave myself some minor bladder damage just by drinking iced mint tea (since it's such a strong diuretic), so I can't imagine I'd react well to ketamine even in small doses.
    - kaybe 5y ago
      Wow, how much did you drink?
      - Alex3917 5y ago
        Only one glass a day, so maybe 20oz. I was working out of a coffee shop, and would have an iced coffee or a latte in the morning but then wanted something non caffeinated in the early afternoon. I think the combination of the large coffee and the large iced tea was just too much diuretic for whatever reason. Fortunately the problem seems to have resolved itself after a couple years.
cwkoss 5y ago
I think another major factor that this article didn't point out is drug purity - and what those specific impurities are. Particularly with drugs like meth, which can be manufactured clandestinely by people who don't understand chemistry well, there are a lot of intermediates or potential reaction byproducts which are orders of magnitude more cardiotoxic or otherwise more harmful than pure methamphetamine. And that's before you get into the potential toxicity of any intentionally-added cutting agents. I think ketamine synthesis is more involved, so it's likely that illegally manufactured ketamine is comparatively cleaner than illegally manufactured meth, but illicit ketamine is still probably harder on your body than pharmaceutical grade for the same reasons. Illegal drug manufacturers have a moderate economic pressure to increase purity, but - short of not immediately killing users and losing your customer base - they have little economic incentive to ensure that the impurities that remain in the final product are safe or inert. Yes, 500mgs of meth a day is almost certainly not good for your health. But these studies are usually not able to control for purity of the meth that is consumed, so I expect for these studies finding adverse effects of chronic use - at least some portion of this effect size is a result of purity issues rather than purely based on dosage.
- Smithalicious 5y ago
  AFAIK almost all street ketamine is just diverted medical supply. Might be cut with something, but other than that it is pharmaceutical grade.
  - deleted 5y ago
    [deleted]
- varispeed 5y ago
  > Illegal drug manufacturers have a moderate economic pressure to increase purity, but - short of not immediately killing users and losing your customer base - they have little economic incentive to ensure that the impurities that remain in the final product are safe or inert. From the time of alcohol prohibition, it was the government that was introducing contaminated batches that killed people. It was done for propaganda, to solidify the message "drugs are bad". When I read articles about another teenager died of bad Ecstasy batch, this always comes to my mind. It always accompanies PSA saying that bad batches are circulating in the area etc. but somehow nobody else dies. Then when you read article almost always it turns out the drug wasn't actually Ecstasy, but that information is hidden deep in the article. It's disgusting how such tragedies are used for propaganda purposes and it is never investigated if it was actually government involvement in the killings.
psysharp 5y ago
Holy shit the bias just reeks out of this paper.
mxxc 5y ago
hooray another article that focuses on the heavy tail of severe addiction and generalises it to the general public who uses drugs. humanity really needed this!
- Broken_Hippo 5y ago
  You know, I thought it was going that way when I started reading it - but by the end, I really didn't feel like you do. But realistically, it compared dosages of drugs in heavy users compared to regular use at medical doses and the side effects of them. It never stated these were normal users, just stating the things that happen with a lot of use. I was surprised. Sure, it could have went on to say that occasional recreational use probably won't hurt you, but that's difficult when it could be seen as promoting drugs and a lot of places have pretty draconian drug laws.
  - mxxc 5y ago
    the title says "drug users use a lot of drugs". either it's shamelessly clickbaiting or it's what the author thinks. we move to the ketamine section, again, "two studies on users". one clicks on the chinese one and the word "chronic" is in the title. the study focuses on them only. the english one is on "addiction research" but the study is more complex than this dude's summary. he says that "both find that they [the users] take about 90mg". this is, of course, not what the UK paper says, as one can check in the paper. and to your point: some places have draconian laws about possession of MA in the same amounts that get prescribed in the US. if i were from thailand i would argue that this person is shamelessly drugging his patients. there is nothing wrong with telling the truth about occasional recreational use, and yes, "drug addicts use a lot of drugs". that's a necessary condition for "addiction".
blablablerg 5y ago
3g ketamine, daily?? If that is recreational then drinking a bottle of vodka a day is also recreational.
splithalf 5y ago
The point is valid but I am not so sure the line between recreation and use is so clear cut. Take pain patients for example. If they are not getting enough pills from their doctor they’ll get them on the street. Is that person a patient or an addict? At what specific dosage does one crossover? Obviously everyone in the medical profession has a huge stake in dividing the world into two groups, patients and druggies, and so most will set the cutpoint low. The incentives all reinforce such behaviour; you could go to jail for being too liberal in handing out pain meds. So, despite the appearance of there being two groups, heavy use addicts and low use patients, I don’t think reality is so simply bifurcated. I think the appearance of two groups is largely an artifact of the system. Doctors restrict dosages artificially and if someone claims to need more pain pills and maybe seeks another doctors to proscribe them, that person will be reclassified by his doctor from being a legitimate patient to being a drug addict. Scott implies there are no edge cases but that’s because the system starts with that assumption. Definitions are everything.

178 points by feross 5y ago

"The most important reason meth makes your teeth fall out and ruins your life but Adderall just makes you study a little harder is that the meth users are taking 50x higher doses" The reason meth addicts have bad teeth isn't because of the dosage of the drug. It's because stimulants make you want to eat candy and drink sugar water, because meth addicts lose track of oral hygiene in favor of doing meth or something else more interesting, and because they're smoking it (along with other drugs).

canary1 5y ago
Regardless, I think the author's point is that the massive dose is more responsible for that negative outcome than the chemical is itself.
peanut_worm 5y ago
Stimulants suppress your appetite but they also make you clench you jaw and grind your teeth involuntarily.
- beebeepka 5y ago
  You mean amphetamines, not stimulants in general. I've seen people do much worse when they mix this shit with alcohol, the worst offender that is still perfectly legal
  - peanut_worm 5y ago
    What non-amphetemine stimulants are people doing recreationally?
    - MagnumOpus 5y ago
      Cocaine? MDMA?
      - peanut_worm 5y ago
        MDMA is an amphetamine, short for Methylenedioxymethamphetamine I don’t know how I forgot cocaine, but it has the same jaw clenching problem
    - loves_mangoes 5y ago
      2C-B. Cathinones and other pyrovalerones. Some people even seem to enjoy absorbing Coffee through their nose.
      - Stevvo 5y ago
        Cathinones are amphetamines.
        loves_mangoes 5y ago
        Sure, cathinones are a sub-category of amphetamines, but only in the same way that amphetamines are technically phenetylamines. But cathinones differ from "pure" substituted amphetamines by a ketone group at the Beta-position, which is what I mean here. And regardless, the point stands for substituted phenethylamines like the 2C family, which are clearly not amphetamines.
      - randomopining 5y ago
        How do you do coffee through your nose lol
        milkytron 5y ago
        I would imagine snorting really fine grounds, similar to how people use tobacco snuff.
bawolff 5y ago
Adderall is also a stimulant(?) The authors suggestion is it would cause the same effect if taken in the same dosage.
- skummetmaelk 5y ago
  They are both amphetamines.
- treeman79 5y ago
  I was on Adderall 10mg a day. Worked as advertised. ADHD under control. Chronic fatigue fixed. Every portion of my body felt like it was being burned from the inside. I had to start tramadol to counter act the pain. It also upped cranial pressure. Causing a lot of secondary problems. This was made much worse as dosage went up. I had to stop it before downward spiral completely destroyed me. Vyvanse was a mild version of all this. Can’t imagine anything more intense.
  - anon9001 5y ago
    I've never heard of anything like that before. I wonder if you'd get the same reaction from ritalin.
  - astrange 5y ago
    I've never heard of this symptom! Maybe you were allergic? It does sound like SJS, in which case you should definitely quit it, but I thought that could only happen with modafinil.
    - treeman79 5y ago
      I am hypersensitive to most medications. Runs in the family. Benadryl will cause me and my kids to go completely nuts. Like climbing the ceiling of the hospital level. Was describing that to one nurse and she almost started crying. Apparently she had same reaction and no one would believe her.
  - QuadmasterXLII 5y ago
TX0098812 5y ago
...because they're taking 50x the dose?
shredprez 5y ago
Also: dehydration and dry-mouth secondary to stimulant use, classic accelerators of bacterial overgrowth and consequent tooth decay.
- KingMachiavelli 5y ago
  Truth. It's highly variable but even Adderall will accelerate tooth decay. It's quite necessary to drink water very frequently.
Nuzzerino 5y ago
Street meth also has a lot of adulterants, contaminants, or byproducts that can accelerate the damage.
whymauri 5y ago
The reason there's confusion in this thread about dosage is that the author didn't use precise terminology (the author is technically correct, but there's ambiguity). I'm pretty sure he means that the recreational dose is relatively larger compared to the effective dose (ED) with meth than with Adderall.
kingTug 5y ago
This isn’t correct. Meth, when smoked, is incredibly toxic. The toxic smoke that causes “meth mouth”
- volkl48 5y ago
  While I am certainly willing to believe that illicit meth is...bad for you/toxic and the smoke is as well, I'm not finding much to support the idea of it being the primary cause of (or major contributor to) "meth mouth" in a quick search. In contrast, every source I find cites the things the prior poster mentioned as the causes. For example: https://www.drugabuse.gov/publications/research-reports/methamphetamine/what-are-long-term-effects-methamphetamine-misuse https://www.drugabuse.gov/publications/research-reports/meth... > The dental problems may be caused by a combination of poor nutrition and dental hygiene as well as dry mouth and teeth grinding caused by the drug. I would think they would be mentioning that the toxic smoke is a cause or contributor if there was evidence to support it.
- robocat 5y ago
  People get meth mouth even if they don't take it orally (or smoking) i.e. your thesis is wrong AFAIK.
newbie789 5y ago
Meth does not make you crave any type of food. If that were the case Desoxyn would not be FDA approved for weight loss. “Meth mouth” is caused by the fact that it dries your mouth out, you grind your teeth a LOT, and is often observed in people that have used drugs long/hard enough to find themselves no longer taking care of their health in general, let alone oral hygiene. This often is coupled with financial ruin and utter alienation from society. Somehow, mysteriously, all of the rich house wives and Silicon Valley coders that use it develop meth mouth at a lower rate.
- yerwhat01010 5y ago
  Wait, are you saying that meth is popular among Silicon Valley coders and rich house wives? This is news to me.
  - FeepingCreature 5y ago
    Adderall. I can't find a Wiki cite for the specific use among coders, but it's stereotypically widespread as a nootropic.
    - astrange 5y ago
      Adderall is not meth. It does promote jaw clenching some, but it's not nearly as bad for you (as the article says, mostly because prescribed doses are smaller) and in fact is neuroprotective. I don't think housewives would enjoy abusing it, unless they're studying for the GRE.
      - kragen 5y ago
        Right, Adderall is near-racemic amphetamine, not methamphetamine. Amphetamine and methamphetamine are very similar in their effects, as discussed here, and both can easily be used at neurotoxic levels. Among their effects in therapeutic doses are weight loss and, yes, being good at memorizing things, like if you're studying for the GRE. I'm not a big fan of any of the drug family.
      - 5y ago
refurb 5y ago
It's purely due to a dry mouth. People that get radiation therapy for head and neck cancers get severe dry mouth as well (salivary glands affected) and severe tooth decay is common unless you use artificial saliva.

zafka 5y ago

Thank you. While there is no data to back up some of these numbers, at least they are offered up. I have often wondered what amounts Meth addicts were using do cause their severe issues.

wincy 5y ago
My neighbors teeth are falling out. Salesman, honestly pretty successful guy, making 6 figures. Apparently he takes 120mg if Adderall to wake up in the morning. At that dose, he’s basically just getting Walter White quality meth for his morning pick me up.
- throwaway0a5e 5y ago
  His teeth are far more likely to be falling out because of bad oral hygiene for a decade earlier in life than they are because of a low dose of Adderal or anything. If 120mg of Adderal made your teeth fall out then tons more people would have their teeth falling out.
  - wincy 5y ago
    To be clear, 120mg is what he takes first thing in the morning. He takes more throughout the day. I’d guess he takes 500+ in a day.
    - arthurcolle 5y ago
      That is impossible. There is no one someone's heart would be able to take that. I take 60 mg daily of Vyvanse and I'm pretty wired all day. I can't even fathom the effects of that on a human body. Is he like 300 lbs?
      - cwkoss 5y ago
        500mg/day was the figure cited for heavy users in the OP article. You're right that 500mg is far into overdose territory for novice users. But, he probably has been using for a long time and has a very high tolerance.

canary1 5y ago

This article is mostly weak opinion. There was one important takeaway, which is notable to anyone interested in ketamine: > I hesitate to say the risk of bladder injury from a normal psychiatric dose of ketamine is literally zero

daperor630 5y ago
>I hesitate to say the risk of bladder injury from a normal psychiatric dose of ketamine is literally zero. The author's hesitation to make such a claim is very important to this quote.

deleted 5y ago

[deleted]

Impassionata 5y ago

It's hard to read Scott once you hear about how he courted the alt-right on purpose and his communities became full of open racists as a result.

arijun 5y ago
Do you have a source for that? Beyond the NYT piece, which is so laughable it does hit pieces a disservice by being grouped with them.
- wizzwizz4 5y ago
  The NYT piece didn't even say that; it said that he supported genocide (??), which is similar, but I don't remember it saying that he courted neo-Nazis. (Or was that one of the heavily-implied things I was oblivious to?)
  - arijun 5y ago
    Perhaps it was more implying they were welcomed? > The voices also included white supremacists and neo-fascists. The only people who struggled to be heard... were “social justice warriors.”
- Impassionata 5y ago
  There's some leaked emails where he plainly states he's chasing that audience. https://web.archive.org/web/20210217195335/https://twitter.com/TopherTBrennan/status/1362108632070905857 https://web.archive.org/web/20210217195335/https://twitter.c... I wouldn't say he's racist but it's almost worse. He didn't think about how this would go down, which is to say, when you court an audience that has a reputation of being overtly racist, your audience will become more and more racist, driving good people out.
  - arijun 5y ago
    I couldn't read Scott's email at your link but I could here: https://twitter.com/arsonatdennys/status/1362153191102677001 https://twitter.com/arsonatdennys/status/1362153191102677001 I don't think his reasoning is that crazy here--I certainly don't see it as the smoking gun that you or the person who tweeted it do. I also haven't noticed a huge amount of racists in his comment section, although I have to admit I haven't spent all that much time on the blog.

droopyEyelids 5y ago

This is a great article, and it could be also be expanded to include the 'whale' effect. I'm not just talking about how a small percent of users spend the most on loot-box games, but also how the top 10% of drinkers consume 50% of all the alcohol sold in the USA. I also believe it must apply to people who use cannabis, as a 'dab' setup allows a heavy user to inhale in one breath what would literally be 50 sessions worth of doses for an infrequent smoker. This isn't necessarily the same topic as what the author wrote, but I'd like to see someone explore the connection.

oogetyboogety 5y ago
I mean, not literally 50. Like 3 times the potency, maybe 5 or 6 times the potency of whatever your state average black market, grey market, or illegally grown crop is. It's important to clear up the FUD here because it has led to some backwards progress for legalization in states like Colorado recently.
- droopyEyelids 5y ago
  Let's say you use a 0.5 g dab which has a THC content of 70% (most dabs are either 1-gram or 0.5 g). The wax has 0.35 g (350 mg of THC), but you could lose up to one-third of it when vaporizing. If this happens, you’ll end up with roughly 235 mg of THC per hit (if you can finish the whole dab in one hit). Someone without a THC tolerance will be completely satisfied with a 5mg dose, total. Thats 47 doses out of the 236mg the stoner _absorbed_
  - sgspace 5y ago
    I don’t know anyone who is doing half gram dabs lol. That’s like $25 in one hit. A gram of concentrate is supposed to last a while (20+ dabs) not a single hit or two.
    - notional 5y ago
      A gram of wax lasts me probably 50+ hits. It seriously lasts a long time. A tiny little crumb you can pinch out of the jar is more than enough for a big hit

trestenhortz 5y ago

I watched a documentary about ketamine use by party people. It profiled a young guy who had destroyed his bladder and needed to use a pump and hole in his belly to urinate. Really disturbing.

vmception 5y ago
My problem with that, and this article, is that it doesn't say what dosage does that? It just skips right on to meth, and dosages, and never mentions Ketamine again. We get that 280mg a month mostly doesn't, and 90,000mg a month can. But are these "party people" the same as the people doing that higher amount prorated to daily? More specifically, are the "party people" I've been around secretly having bladder problems and getting a hole in their belly and not really ubering home but ubering to the hospital? Let me know when you, or anyone passing by, find that article
- kriskrunch 5y ago
  I've known many users over the years, many OD while others decay over a few years. One customer in particular used ketamine heavily. Due to a string of poor decisions, he was on federal probation and subjected to random drug tests. He determined two drugs were not detectible by the tests at that time: ketamine and GHB. And he frequently consumed them. I remember him stumbling around my store, sipping caps of G every so often... sniffling behind tall pallets to suck up another key bump. Over a year or so, he developed severe problems with his bladder, but wouldn't / couldn't stop his drug use, even after I broke it down to him plainly; "Bro, you are killing yourself." From what I can tell, users don't keep track of doses, or much of anything. Their objectives are short term in nature: get high asap. I suspect any such article that provides hard numbers like what you want will provide guestimates at best.
  - vmception 5y ago
    So we can improve the data by regulating the supply chain, serving sizes, and points of sale Doesnt seem to support enforcing varying levels of prohibition

newbie789 5y ago

Former meth addict here. > The average crystal meth addict uses about 500 mg a day. And they snort it, which probably produces about double the peak plasma level as taking it orally. So they're getting the equivalent of 1000 mg oral amphetamine daily... 500mg sounds about right, but from my experience the most common route of administration (in the western United States at least) is smoking, not snorting. Because so many people smoke meth rather than snort it, a lot of meth is sold as methamphetamine base rather than methamphetamine hydrochloride. This means that it’s often not particularly water soluble, which makes it a poor choice for snorting since it doesn’t get through your nasal mucosa and actually kicks in after it drips down into your stomach. It’s not actually much different from eating it in many cases. I like this article overall but I get irritated when I read stuff about drug users that is clearly written by somebody who hasn’t done a lot of drugs. Edited for spelling. Also if anybody has any questions for me, I’m pretty knowledgeable on this topic (though no expert), so feel free to ask away!

tomcam 5y ago
Might be a regional thing? I was raised in Southern California, where is smoking is also the preferred method. I believe OP is from New York City. For all we know perhaps inhaling what his upper middle class cohort does.
- marton78 5y ago
  OP is from California.
sharken 5y ago
Must admit the specifics of doing drugs is not that interesting to me, it's more interesting to ask the question: How does someone stop doing drugs?
- agentdrtran 5y ago
  You may get the best answer to that question from people who have stopped rather than never started.

grawprog 5y ago

This article isn't bad, but it's a very shallow, narrow view of things. In general it seems to make no distinction with addicts using high doses to overcome tolerance levels with recreational drug users in general. Methamphetamines and amphetamines are not the same chemical, despite being similar. https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=172 https://methoide.fcm.arizona.edu/infocenter/index.cfm?stid=1... The small differences between the molecules allow it to penetrate the blood brain barrier more efficiently, has longer lasting toxic effects and acts more as a central nervous system stimulant and >less peripheral nervous system and cardiovascular stimulation activity. Another difference between amphetamine and MA is that amphetamine stimulates the CNS indirectly by activating the release of catecholamines and inhibiting their breakdown and storage. In contrast, MA stimulates the postsynaptic catecholamine receptors directly.[2] Increased dosage is only one part of the difference between Methamphetamine and Amphetamines. Street meth is also far more likely to have fillers, leftover solvents and a bunch of other things that are not good for you. >In general, recreational drug users take their drugs at doses so much higher than psychiatric patients that they're basically two different chemicals Recreational drug users come in a wide range. The first two sections of the article speak about addicts doing extremely large doses, then seems to lump 'recreational drug users' altogether with that.

golergka 5y ago

There's recreational drug users, and then there's recreational drug users. Turns out some people I know who microdosed amphetamine took doses exactly in the ballpark of what doctor would prescribe them.

dnate 5y ago
There always are, for any drug. There is the person that uses amphetamines to get high SAT scores, high college grades and stops after landing a FAANG job. There is the person using alcohol as "social lube". Never drinks alone, never gets wasted. There is the person using LSD and other party drugs few times per year or less in a controlled setting And then there are the extremely addicted people. And everything in between. It's a sliding scale. People need to be educated to learn the risks and recognize harmful behavioral patterns. Simply telling people "drugs are bad for you" might be the abridged version of the truth. But is as effective as the "war on drugs" in reducing drug abuse.
austhrow743 5y ago
If they're microdosing amphetamine at medicinal dosage levels are their intentions even recreation?
- stuntkite 5y ago
  That's an interesting question. Sometimes I experiment with my meds into micro dosage levels if I have a long weekend. Sometimes I'll even keep a journal and sometimes I'll mix with other agents like microdosed psilocybe or LSD and run tests on neuroplacticity. Some times on the weekends I'll take 2mg or less of my ADHD meds just to clear the noise out of my head so I can get a nap. It works a treat, I wake up feeling refreshed and I can tackle some chores or do nothing at all with only muted versions of my normal symptoms. I wouldn't say this is not recreational. It's my body and am curious about how it works and also I think it's always good to experiment with making very low doses or even medication fasts (in relation to stims specifically THIS IS NOT MEDICAL ADVICE) part of any regimen. Testing out strategies on my free time and not at work is just responsible. My ADHD medication makes me employable and has helped tremendously with my ability to maintain valuable relationships, it's crucial for me to make my way in a world designed around shit that is nearly torture for me, but I really hope to not be on the stims one day and I think it's going to take some work to figure that out. I'm a long time psychonaut so what is recreation to you might not be the same thing it is to me but I consider the observations and experiments to be recreational.

heisenbit 5y ago

Drug processing in the body can sometimes be surprising. I learned recently about first pass effect which means the drug heads first to the liver and only what passes through is available to the body. So if one ups the dose and the liver processing is saturated a double dose can deliver much more punch than two single ones. The body has many non-linear features and extrapolating several orders of magnitude is often not possible.

cwkoss 5y ago
Yep, this is why "boofing" (intrarectal) dosing has found rising popularity in the 'research chemical' scene over the past couple decades. The liver's effects on drugs is really fascinating. Grapefruit has a chemical that can inactive liver enzymes, so some drug addicts regularly drink grapefruit juice to 'get more bang for their buck'. Plain old black pepper (in large doses) inactivates a different enzyme IIRC. There are also some interesting anecdotal cases of people who claim to have found regimens of essential oils, which when consumed at the right schedule saturate liver enzymes to the extent that otherwise inert substances can produce recreationally psychoactive effects. Source: i have a morbid fascination with the 'frontier non-medical drug use' communities and follow their subreddits (/r/researchchemicals and /r/peptides being among the most interesting). There a lot of people who choose to make themselves guinea pigs quite recklessly and, thankfully for scientific advancement and future harm reduction, post in-depth reports of how these novel chemicals or preparations effected them. Recently, broad cheap availability of novel benzos have led many posters to deep addictions of such great magnitude that they struggle to convince doctors assisting with detox that they've actually been consuming equivalents of 1000x typical prescribed doses... until the doctor gives them massive doses of valium to detox and they still have severe seizures.
- whymauri 5y ago
  >There are also some interesting anecdotal cases of people who claim to have found regimens of essential oils, which when consumed at the right schedule saturate liver enzymes to the extent that otherwise inert substances can produce recreationally psychoactive effects. Are essential oils literally oils? Because I doubt they can have a metabolic effect due to their size and lipophilicity. My main concern is adsorption. But if they're small and greasy, then they may be promiscuous binders. Or do the essential oils carry other molecules along? Edit: I see now that individual oils carry many diverse constituents, including some small-to-medium sized lads. That's a pretty interesting shotgun strategy for controlling your metabolism, lol.

Alex3917 5y ago

Somehow he managed to ignore the data showing that a non-trivial percentage of people with KLUTS get it after only doing doses comparable to the psychiatric dose, and sometimes after only doing it once or a handful of times. https://erowid.org/chemicals/ketamine/ketamine_article2.shtml https://erowid.org/chemicals/ketamine/ketamine_article2.shtm...

loves_mangoes 5y ago
I'll add my anecdote to the pile. I don't use ketamine a lot (it is not very good for headaches, pretty good for dulling a mosquito bite until it fades away naturally, excellent for dancing). I've taken about 1000mg over the course of several months, at irregular intervals. While it is somewhat higher than Scott's 280mg/month, it's not an order of magnitude higher. Certainly nowhere near 90,000mg/month. I can report one event of pain while peeing, a few days ago. So it looks like my body is not built to handle even moderate levels of ketamine use, and I'd have to stay closer to 100mg/month or lower to be on the safe side. That said, let me reiterate, this is anecdote. I only think it's interesting because there is no other reasonable explanation for my recent urinary pain, and I didn't expect such low doses of Ketamine to have noticeable effects.
- Alex3917 5y ago
  Yeah I think I gave myself some minor bladder damage just by drinking iced mint tea (since it's such a strong diuretic), so I can't imagine I'd react well to ketamine even in small doses.
  - kaybe 5y ago
    Wow, how much did you drink?
    - Alex3917 5y ago
      Only one glass a day, so maybe 20oz. I was working out of a coffee shop, and would have an iced coffee or a latte in the morning but then wanted something non caffeinated in the early afternoon. I think the combination of the large coffee and the large iced tea was just too much diuretic for whatever reason. Fortunately the problem seems to have resolved itself after a couple years.

cwkoss 5y ago

I think another major factor that this article didn't point out is drug purity - and what those specific impurities are. Particularly with drugs like meth, which can be manufactured clandestinely by people who don't understand chemistry well, there are a lot of intermediates or potential reaction byproducts which are orders of magnitude more cardiotoxic or otherwise more harmful than pure methamphetamine. And that's before you get into the potential toxicity of any intentionally-added cutting agents. I think ketamine synthesis is more involved, so it's likely that illegally manufactured ketamine is comparatively cleaner than illegally manufactured meth, but illicit ketamine is still probably harder on your body than pharmaceutical grade for the same reasons. Illegal drug manufacturers have a moderate economic pressure to increase purity, but - short of not immediately killing users and losing your customer base - they have little economic incentive to ensure that the impurities that remain in the final product are safe or inert. Yes, 500mgs of meth a day is almost certainly not good for your health. But these studies are usually not able to control for purity of the meth that is consumed, so I expect for these studies finding adverse effects of chronic use - at least some portion of this effect size is a result of purity issues rather than purely based on dosage.

Smithalicious 5y ago
AFAIK almost all street ketamine is just diverted medical supply. Might be cut with something, but other than that it is pharmaceutical grade.
- deleted 5y ago
  [deleted]
varispeed 5y ago
> Illegal drug manufacturers have a moderate economic pressure to increase purity, but - short of not immediately killing users and losing your customer base - they have little economic incentive to ensure that the impurities that remain in the final product are safe or inert. From the time of alcohol prohibition, it was the government that was introducing contaminated batches that killed people. It was done for propaganda, to solidify the message "drugs are bad". When I read articles about another teenager died of bad Ecstasy batch, this always comes to my mind. It always accompanies PSA saying that bad batches are circulating in the area etc. but somehow nobody else dies. Then when you read article almost always it turns out the drug wasn't actually Ecstasy, but that information is hidden deep in the article. It's disgusting how such tragedies are used for propaganda purposes and it is never investigated if it was actually government involvement in the killings.

psysharp 5y ago

Holy shit the bias just reeks out of this paper.

mxxc 5y ago

hooray another article that focuses on the heavy tail of severe addiction and generalises it to the general public who uses drugs. humanity really needed this!

Broken_Hippo 5y ago
You know, I thought it was going that way when I started reading it - but by the end, I really didn't feel like you do. But realistically, it compared dosages of drugs in heavy users compared to regular use at medical doses and the side effects of them. It never stated these were normal users, just stating the things that happen with a lot of use. I was surprised. Sure, it could have went on to say that occasional recreational use probably won't hurt you, but that's difficult when it could be seen as promoting drugs and a lot of places have pretty draconian drug laws.
- mxxc 5y ago
  the title says "drug users use a lot of drugs". either it's shamelessly clickbaiting or it's what the author thinks. we move to the ketamine section, again, "two studies on users". one clicks on the chinese one and the word "chronic" is in the title. the study focuses on them only. the english one is on "addiction research" but the study is more complex than this dude's summary. he says that "both find that they [the users] take about 90mg". this is, of course, not what the UK paper says, as one can check in the paper. and to your point: some places have draconian laws about possession of MA in the same amounts that get prescribed in the US. if i were from thailand i would argue that this person is shamelessly drugging his patients. there is nothing wrong with telling the truth about occasional recreational use, and yes, "drug addicts use a lot of drugs". that's a necessary condition for "addiction".

blablablerg 5y ago

3g ketamine, daily?? If that is recreational then drinking a bottle of vodka a day is also recreational.

splithalf 5y ago

The point is valid but I am not so sure the line between recreation and use is so clear cut. Take pain patients for example. If they are not getting enough pills from their doctor they’ll get them on the street. Is that person a patient or an addict? At what specific dosage does one crossover? Obviously everyone in the medical profession has a huge stake in dividing the world into two groups, patients and druggies, and so most will set the cutpoint low. The incentives all reinforce such behaviour; you could go to jail for being too liberal in handing out pain meds. So, despite the appearance of there being two groups, heavy use addicts and low use patients, I don’t think reality is so simply bifurcated. I think the appearance of two groups is largely an artifact of the system. Doctors restrict dosages artificially and if someone claims to need more pain pills and maybe seeks another doctors to proscribe them, that person will be reclassified by his doctor from being a legitimate patient to being a drug addict. Scott implies there are no edge cases but that’s because the system starts with that assumption. Definitions are everything.