3 ms·

My recent experience in the U.S. has been that, at least at major hospitals, it's flipped to the opposite extreme, and doctors are so worried about the backlash

My recent experience in the U.S. has been that, at least at major hospitals, it's flipped to the opposite extreme, and doctors are so worried about the backlash, that they will leave patients in pain and fail to prescribe analgesics sufficient for post-surgical pain control, if they don't have non-opioid options. My partner had a post-cancer DIEP flap reconstruction last month at a top cancer center in NYC, and due to the nature of the surgery, couldn't take NSAIDs, which are typically most effective for her (they have blood thinning side effects and were banned for 2 weeks post-surgery to avoid risk of hematomas). So she was left with taking over the counter Tylenol plus prescription opioids. They prescribed opioids 2 days of pills at a time, which required me to constantly drive to pick up new prescriptions (since obviously she couldn't drive), and it felt like some kind of interrogation each time she'd call up and report her current pain levels. As if they assumed by default she was lying or was a drug addict or something, versus someone recovering from major surgery that doesn't heal in 2 days, and furthermore is not allowed to take anything else that's effective (NSAIDs). Hours spent writhing in pain trying to get some pills prescribed and picked up. It only got resolved once the two-week NSAID ban was up. Then she stopped calling about the opioid-based analgesic and just started taking large ibuprofen doses instead. Problem solved, since you can buy as much ibuprofen as you want. But a pretty shit two weeks up until that point. As a result, I strongly dislike a number of aspects of the anti-opioid backlash. It made our lives worse and caused us more suffering.

jwilber 5y ago
I had open heart surgery in the US and the doctors refused to give me opiates to take home in the few days after. They gave me opiates while I was in the hospital, quite generously, which was for four or five days, but they would not let me take any home. I even asked for just five pills in case the pain was unbearable (they literally had just broke my ribs and sternum and sawed my chest open). I don’t respond much to opiates anyways, but I still find it completely ridiculous.
stef25 5y ago
What you experienced is obviously the pendulum swinging too far (in the right direction). Then again, it should just be accepted that major surgery will always involve some discomfort. There's a big distance between "5 days worth of low dose Tramadol" (+ max dose of Paracetamol) and "2 months worth of Oxycodone". It's really not a hard problem to solve for the medical establishment.
Sophistifunk 5y ago
Yup, there are a lot of people with chronic pain, and the only things that reliably treat pain without being really bad for your system are opiates and weed. Paracetemol (and to a lesser degree ibuprofen) are so bad for you they mix it into opiates so that if you take enough to get high the paracetemol sends you to hospital, and weed is stigmatised at best, and still illegal in most of the world. Ketamine in useful doses has too strong side effects, cocaine-derivatives are only really good locally, and also not great for your system. And that's about all we've got. As a kid I had migraines, and quickly developed an immunity to the pain-relieving aspect of paracetemol, they were basically candy by the time I was a teenager. Luckily they disappeared in my late teens, but now I'm in my 40s and I get weird pains they call "cluster headaches" in my face. I did some tests, got an MRI, and they didn't turn up anything, which is pretty much the end of medicine, pain management is all there is for me. In Australia we need a prescription for any opiates, so I have to be treated like a drug addict to get painkillers the rest of the world can buy over the counter, it's a disgrace.
- panta 5y ago
  > I get weird pains they call "cluster headaches" in my face if you have not already done this, you could consult an "migraine center". There is no cure but there are some effective (for some people at least) options for treating cluster headaches, like triptans and lifestyle changes (regularity in sleep patterns, etc.)
  - Sophistifunk 5y ago
    They're very different from migraines (which I had as a kid), in that there's no visual effects or nausea, and seem to be more localised and less "systemic". I'm always trying to work on my sleep, with very little success overall. I've never tried any of the serious sleeping pills, they seem too risky; but a combination of restavit (an antihystamine) and melatonin can get me to sleep pretty reliably, the problem becomes that it sometimes leaves me a bit too slow and stupid in the mornings.
pkaye 5y ago
Are the only options doctors can prescribe NSAIDs vs opioids? There is nothing else in between?
- _delirium 5y ago
  As far as I know, there surprisingly aren't other options. I also assumed they would have something else up their sleeve that was stronger than OTC ibuprofen but weaker than a morphine analogue. But, the three classes of analgesics really seem to be Tylenol, NSAIDs, and opioids. A few other things are usable for anesthesia but not something you can prescribe as a pill for at-home pain control. There is also some evidence for cannabinoids, but they're stuck in legal limbo. The other thing that comes to mind is that benzodiazepines can also help in some patients. They don't have a direct analgesic effect, but can help people relax or sleep so as to ignore pain (they can also be habit-forming, but probably not to the same extent as opioids).
- otherme123 5y ago
  There are other painkillers coming and going. In my country, the middle ground was, for years, metamizole. This drug is currently baned in some countries (e.g. USA) for its side effects, while is sold nearly OTC in others (e.g. Mexico). Other drugs like flupirtine or nefopam are about the same: middle ground painkillers, but too bad side effects. The good thing about opioids is that you can dosage them precisely, and that you have plenty of opiates in a ladder of potency. Tramadol (sold as Ultram in the US) is a middle-ground painkiller despite being an opiate. Same as codeine. Slightly above is tapentadol. Curious thing is despite tapentadol has not been found addictive (at least as addictive as other opiates), it's still an opiate, and so the FDA put it in the same bucket as fentanyl and morphine. Another analgesic is cannabis. Sadly, it has the same problem as opiates: it was deemed too fun or too good, it seems we must endure pain to make the regulators happy. It turns out people hate pain, so they end up taking fentanyl and heroing under a bridge. The sad thing about all this is that the regulators decided pain is not a bad thing, so you must endure it. But they decided anxiety is a terrible thing, so you can get as much bromazepam as you need. Even when bromazepan and other benzodiazepines create dependence and tolerance (and the withdrawal is terrible), I'm sure you now at least a dozen people taking it cronically (I do). They are as hooked to that thing as it was heroin but, hey, it's legally prescribed, so no problem here: one pill for breakfast, one before bed, and they are 24/7 high while nobody bats an eye.
robbiep 5y ago
That is very different to when I was at BIDMC for my plastic surgery rotation as a medical student - I was shocked at the quantity of opiates people were going home with for simple things, let along DIEPs. I gave a talk to my team when I left on differences and focused on opiate prescribing (this was in 2013)

jwilber 5y ago

I had open heart surgery in the US and the doctors refused to give me opiates to take home in the few days after. They gave me opiates while I was in the hospital, quite generously, which was for four or five days, but they would not let me take any home. I even asked for just five pills in case the pain was unbearable (they literally had just broke my ribs and sternum and sawed my chest open). I don’t respond much to opiates anyways, but I still find it completely ridiculous.

stef25 5y ago

What you experienced is obviously the pendulum swinging too far (in the right direction). Then again, it should just be accepted that major surgery will always involve some discomfort. There's a big distance between "5 days worth of low dose Tramadol" (+ max dose of Paracetamol) and "2 months worth of Oxycodone". It's really not a hard problem to solve for the medical establishment.

Sophistifunk 5y ago

Yup, there are a lot of people with chronic pain, and the only things that reliably treat pain without being really bad for your system are opiates and weed. Paracetemol (and to a lesser degree ibuprofen) are so bad for you they mix it into opiates so that if you take enough to get high the paracetemol sends you to hospital, and weed is stigmatised at best, and still illegal in most of the world. Ketamine in useful doses has too strong side effects, cocaine-derivatives are only really good locally, and also not great for your system. And that's about all we've got. As a kid I had migraines, and quickly developed an immunity to the pain-relieving aspect of paracetemol, they were basically candy by the time I was a teenager. Luckily they disappeared in my late teens, but now I'm in my 40s and I get weird pains they call "cluster headaches" in my face. I did some tests, got an MRI, and they didn't turn up anything, which is pretty much the end of medicine, pain management is all there is for me. In Australia we need a prescription for any opiates, so I have to be treated like a drug addict to get painkillers the rest of the world can buy over the counter, it's a disgrace.

panta 5y ago
> I get weird pains they call "cluster headaches" in my face if you have not already done this, you could consult an "migraine center". There is no cure but there are some effective (for some people at least) options for treating cluster headaches, like triptans and lifestyle changes (regularity in sleep patterns, etc.)
- Sophistifunk 5y ago
  They're very different from migraines (which I had as a kid), in that there's no visual effects or nausea, and seem to be more localised and less "systemic". I'm always trying to work on my sleep, with very little success overall. I've never tried any of the serious sleeping pills, they seem too risky; but a combination of restavit (an antihystamine) and melatonin can get me to sleep pretty reliably, the problem becomes that it sometimes leaves me a bit too slow and stupid in the mornings.

pkaye 5y ago

Are the only options doctors can prescribe NSAIDs vs opioids? There is nothing else in between?

_delirium 5y ago
As far as I know, there surprisingly aren't other options. I also assumed they would have something else up their sleeve that was stronger than OTC ibuprofen but weaker than a morphine analogue. But, the three classes of analgesics really seem to be Tylenol, NSAIDs, and opioids. A few other things are usable for anesthesia but not something you can prescribe as a pill for at-home pain control. There is also some evidence for cannabinoids, but they're stuck in legal limbo. The other thing that comes to mind is that benzodiazepines can also help in some patients. They don't have a direct analgesic effect, but can help people relax or sleep so as to ignore pain (they can also be habit-forming, but probably not to the same extent as opioids).
otherme123 5y ago
There are other painkillers coming and going. In my country, the middle ground was, for years, metamizole. This drug is currently baned in some countries (e.g. USA) for its side effects, while is sold nearly OTC in others (e.g. Mexico). Other drugs like flupirtine or nefopam are about the same: middle ground painkillers, but too bad side effects. The good thing about opioids is that you can dosage them precisely, and that you have plenty of opiates in a ladder of potency. Tramadol (sold as Ultram in the US) is a middle-ground painkiller despite being an opiate. Same as codeine. Slightly above is tapentadol. Curious thing is despite tapentadol has not been found addictive (at least as addictive as other opiates), it's still an opiate, and so the FDA put it in the same bucket as fentanyl and morphine. Another analgesic is cannabis. Sadly, it has the same problem as opiates: it was deemed too fun or too good, it seems we must endure pain to make the regulators happy. It turns out people hate pain, so they end up taking fentanyl and heroing under a bridge. The sad thing about all this is that the regulators decided pain is not a bad thing, so you must endure it. But they decided anxiety is a terrible thing, so you can get as much bromazepam as you need. Even when bromazepan and other benzodiazepines create dependence and tolerance (and the withdrawal is terrible), I'm sure you now at least a dozen people taking it cronically (I do). They are as hooked to that thing as it was heroin but, hey, it's legally prescribed, so no problem here: one pill for breakfast, one before bed, and they are 24/7 high while nobody bats an eye.

robbiep 5y ago

That is very different to when I was at BIDMC for my plastic surgery rotation as a medical student - I was shocked at the quantity of opiates people were going home with for simple things, let along DIEPs. I gave a talk to my team when I left on differences and focused on opiate prescribing (this was in 2013)