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We also now know that those treatments kill people and users gain dependence and tolerance to opioids. It’s more than just protecting their medical license.

atdrummond 5y ago
The proportion of patients who become addicted from properly prescribed opioids is extremely small. The majority of addicts created were provided with opioids that were not appropriate for their particular medical situation, in doses that were too high, and on a regimen that exceeded in length what was supported by the medical evidence. The proportion of new cancer patients who go on to receive palliative care that includes opioids who end up becoming addicted has always been, and remains, in the low single digits. For patients with a genuine need and who are properly inducted and maintained on them, opioids are a powerful and useful medical tool. Further, the bulk of use in illegal opioids stateside, such as fentanyl and its analogues, is not (at least today) driven by the conversion of the legal opioid user to an illegal drug user. Fentanyl is now commonly found in drugs that never previously would have contained an opioid, such as counterfeit benzos and MDMA. Further, the majority of fentanyl users on the street arrive at its use after consuming other illegal/street drugs. For those who started on other opioids, their first opioid will tend to be the illegally diverted pills or liquid cough treatments containing codeine/hydrocodone called "lean". Very few new users of fentanyl and fentanyl analogues come from legal opioid users, mainly because very few new users are now inducted on reckless prescriptions such as an immediate script for 180 Oxycontin and 240 benzodiazepene pills a month. Your narrative is about a decade out of date at this point. Thomas Kline is a superb resource if you want to take a deeper dive into the actual statistics and how the narrative of a crisis was used to systematically deny law abiding patients the pain treatment they should receive. https://twitter.com/thomasklinemd https://twitter.com/thomasklinemd
- google234123 5y ago
  A meta study of 38 studies from 7 years ago on patients using opioids for chronic pain found that 21-29% of the patients misuse the drugs and 8-12% of the patients are addicted to them. That doesn't seem "extremely small" like you said, though maybe it's better now. I think there are reasons why opioids are no longer recommended for the treatment of most patients with chronic pain that you aren't fairly acknowledging. https://journals.lww.com/pain/Abstract/2015/04000/Rates_of_opioid_misuse,_abuse,_and_addiction_in.3.aspx https://journals.lww.com/pain/Abstract/2015/04000/Rates_of_o...
  - atdrummond 5y ago
    https://www.nejm.org/doi/full/10.1056/NEJMra1507771 https://www.nejm.org/doi/full/10.1056/NEJMra1507771 Volkow is a mainstream researcher, using data from the peak of the crisis, and cites the rate at just under 8%. It is not at all unreasonable to assume that with proper prescribing (unlike what happened in the 90s and 2000s) that chronic pain patients can have opioid misuse and addiction numbers near or matching that of palliative care patients, where addiction rates are closer to 1% than 10%.
  - NineStarPoint 5y ago
    I’ll agree I wouldn’t describe that as extremely small. The misuse stat is pretty bad. The addiction though…essentially for every 10 people who are treated for chronic pain, 1 of them gets addicted? With 9/10 of those people getting to live a more pleasant life…Chronic pain is awful, and the good done by alleviating it might be worth that cost.
    - behringer 5y ago
      And let's not forget the 1/10 very likely would be in extreme pain bordering on torture instead of addiction. It's lose lose for them.
      - google234123 5y ago
        I’m not sure how you figure that this hypothesis is “very likely” true. It’s actually very likely not. The papers don’t mention this at all.
    - atdrummond 5y ago
      Just to be clear - the cohort in his paper is not all opioid users. It is the subset most likely to become addicts, for the following reasons: 1. The meta-analysis occurred during the period of time that pill mills and other unscrupulous prescribing was rampant. See that there was no note regarding patients' (legal) polydrug use or by morphine equivalent dosing, nor was there any modification to the analysis of the data to see how this period in the legal drug market impacted patient outcomes. 2. This analysis selects for chronic pain patients, which tends to mean the long term users of opioids while excluding the acute patients who, particularly among the in-patient subset, pretty much never become addicts during their course of use - which is what we'd expect if these compounds were as addictive as claimed. 3. These cohort selections often do not include some or all palliative care patients. I won't accuse them of doing this to sensationalize their numbers but it does have a significant impact on results, as again palliative care patients very rarely cease their use and carry forward afterwards an opioid misuse disorder. 4. They do not control for or look at the specific impact of the main problematic legal opioid - Purdue Pharma's original OxyContin formula. Because this drug did not have the pharmacodynamic profile claimed by the firm and represented in the safety studies, it was considerably more likely to cause opioid use disorder, as patients would be much more likely to take extra doses to cover the shortfall in the dosing window. This would lead to patients who otherwise would exist on a steady dose asking for increasing doses - or, worse, turning to the street to acquire diverted doses.
- markdown 5y ago
  > properly prescribed opioids They were incentivised to not properly prescribe opioids. Don't be so quick to let the doctors off the hook. They're pleading ignorance isn't going to work. These were highly intelligent people who knew what they were doing and did it anyway in exchange for bribes from "Big Pharma".
exolymph 5y ago
Who fucking cares? This wouldn't be nearly as huge of a problem if people with a physical dependency — inclusive of addicts, but by NO MEANS exclusively addicts — could reliably access safe, reliably dosed opioids instead of getting pushed to street drugs.
- google234123 5y ago
  If these people have access to a doctor/health care then there they definitely have options to treat their addition. Any family physician would be happy to discuss treatment options. The problem of people without health care is a bigger and separate issue.

atdrummond 5y ago

The proportion of patients who become addicted from properly prescribed opioids is extremely small. The majority of addicts created were provided with opioids that were not appropriate for their particular medical situation, in doses that were too high, and on a regimen that exceeded in length what was supported by the medical evidence. The proportion of new cancer patients who go on to receive palliative care that includes opioids who end up becoming addicted has always been, and remains, in the low single digits. For patients with a genuine need and who are properly inducted and maintained on them, opioids are a powerful and useful medical tool. Further, the bulk of use in illegal opioids stateside, such as fentanyl and its analogues, is not (at least today) driven by the conversion of the legal opioid user to an illegal drug user. Fentanyl is now commonly found in drugs that never previously would have contained an opioid, such as counterfeit benzos and MDMA. Further, the majority of fentanyl users on the street arrive at its use after consuming other illegal/street drugs. For those who started on other opioids, their first opioid will tend to be the illegally diverted pills or liquid cough treatments containing codeine/hydrocodone called "lean". Very few new users of fentanyl and fentanyl analogues come from legal opioid users, mainly because very few new users are now inducted on reckless prescriptions such as an immediate script for 180 Oxycontin and 240 benzodiazepene pills a month. Your narrative is about a decade out of date at this point. Thomas Kline is a superb resource if you want to take a deeper dive into the actual statistics and how the narrative of a crisis was used to systematically deny law abiding patients the pain treatment they should receive. https://twitter.com/thomasklinemd https://twitter.com/thomasklinemd

google234123 5y ago
A meta study of 38 studies from 7 years ago on patients using opioids for chronic pain found that 21-29% of the patients misuse the drugs and 8-12% of the patients are addicted to them. That doesn't seem "extremely small" like you said, though maybe it's better now. I think there are reasons why opioids are no longer recommended for the treatment of most patients with chronic pain that you aren't fairly acknowledging. https://journals.lww.com/pain/Abstract/2015/04000/Rates_of_opioid_misuse,_abuse,_and_addiction_in.3.aspx https://journals.lww.com/pain/Abstract/2015/04000/Rates_of_o...
- atdrummond 5y ago
  https://www.nejm.org/doi/full/10.1056/NEJMra1507771 https://www.nejm.org/doi/full/10.1056/NEJMra1507771 Volkow is a mainstream researcher, using data from the peak of the crisis, and cites the rate at just under 8%. It is not at all unreasonable to assume that with proper prescribing (unlike what happened in the 90s and 2000s) that chronic pain patients can have opioid misuse and addiction numbers near or matching that of palliative care patients, where addiction rates are closer to 1% than 10%.
- NineStarPoint 5y ago
  I’ll agree I wouldn’t describe that as extremely small. The misuse stat is pretty bad. The addiction though…essentially for every 10 people who are treated for chronic pain, 1 of them gets addicted? With 9/10 of those people getting to live a more pleasant life…Chronic pain is awful, and the good done by alleviating it might be worth that cost.
  - behringer 5y ago
    And let's not forget the 1/10 very likely would be in extreme pain bordering on torture instead of addiction. It's lose lose for them.
    - google234123 5y ago
      I’m not sure how you figure that this hypothesis is “very likely” true. It’s actually very likely not. The papers don’t mention this at all.
  - atdrummond 5y ago
    Just to be clear - the cohort in his paper is not all opioid users. It is the subset most likely to become addicts, for the following reasons: 1. The meta-analysis occurred during the period of time that pill mills and other unscrupulous prescribing was rampant. See that there was no note regarding patients' (legal) polydrug use or by morphine equivalent dosing, nor was there any modification to the analysis of the data to see how this period in the legal drug market impacted patient outcomes. 2. This analysis selects for chronic pain patients, which tends to mean the long term users of opioids while excluding the acute patients who, particularly among the in-patient subset, pretty much never become addicts during their course of use - which is what we'd expect if these compounds were as addictive as claimed. 3. These cohort selections often do not include some or all palliative care patients. I won't accuse them of doing this to sensationalize their numbers but it does have a significant impact on results, as again palliative care patients very rarely cease their use and carry forward afterwards an opioid misuse disorder. 4. They do not control for or look at the specific impact of the main problematic legal opioid - Purdue Pharma's original OxyContin formula. Because this drug did not have the pharmacodynamic profile claimed by the firm and represented in the safety studies, it was considerably more likely to cause opioid use disorder, as patients would be much more likely to take extra doses to cover the shortfall in the dosing window. This would lead to patients who otherwise would exist on a steady dose asking for increasing doses - or, worse, turning to the street to acquire diverted doses.
markdown 5y ago
> properly prescribed opioids They were incentivised to not properly prescribe opioids. Don't be so quick to let the doctors off the hook. They're pleading ignorance isn't going to work. These were highly intelligent people who knew what they were doing and did it anyway in exchange for bribes from "Big Pharma".

exolymph 5y ago

Who fucking cares? This wouldn't be nearly as huge of a problem if people with a physical dependency — inclusive of addicts, but by NO MEANS exclusively addicts — could reliably access safe, reliably dosed opioids instead of getting pushed to street drugs.

google234123 5y ago
If these people have access to a doctor/health care then there they definitely have options to treat their addition. Any family physician would be happy to discuss treatment options. The problem of people without health care is a bigger and separate issue.