Interesting, but I just listened to Econtalk podcast[1] where the guest, author of the book Dreamland about opioid epidemic[2], claims that all this epidemy only started at first place because researchers at the time claimed that opioid based pain relief medicine was disassociated from addiction (and pharma companies gladly played along).
Except it wasnt.
Very worthy your time listening to this guy if you are interested in the topic.
You have to remember like everything, beliefs around addiction to pain medication ebbs and flows over time.
I can remember back in the late 1990s, there was a huge push from the medical community to be more open about prescribing pain medication. A lot of pain wasn't being adequately treated.
As a result, doctors loosened their reigns over prescribing and things moved drastically in the opposite direction. People were getting strong narcotics for pain that they never would have gotten it for in the past.
As a result, we have a huge upswing in addiction.
My concern is that we're now going to swing back the other way and people will get hurt. There are people out there where narcotics are the only thing that works for their pain. Sometimes they need a lot of them as well, we're talking hundreds of milligrams of morphine per day. They will have physical withdrawal symptoms if they were to stop, but they aren't addicted in the way we think. They don't exhibit "drug seeking" behavior.
I'm worried folks like this will get cutoff and have to live a life in terrible pain. All because other patients get addicted.
My girlfriend is in exactly this situation. She has terminal pain from a Whipple and every step of the way the onus is on her to provide evidence that she isn't a drug-seeker. And there are not clear success criterion. Pharmacists can (and have) arbitrarily decide not to fill her prescription, leaving her without pain meds suddenly and unexpectedly (ie baseline pain returns + withdrawal symptoms).
Illinois won't allow sending pain scripts any more, so we have to go to the hospital to pick it up every month. They won't allow you to fill it more than a single day before you need it, and many pharmacies won't have the total number of pills prescribed in stock. If you accept a partial fill - you forego the remainder. Getting the doctors AND insurance (either of which will likely block it) to understand you had to do a partial fill and thus issue your refill before 30 days is a Sisyphean task.
All this means if the pharmacy at the hospital doesn't have enough Morphine on hand to fill her one month description the day we pick it up - we have 24 hours to play Pharmacy Whack-a-mole trying to find one that both does have enough pills and won't just arbitrarily decide to say no. Even better - while sometimes you can call ahead and ask, often they are afraid you are probing for large supplies with intent to rob them, so they won't always tell you if they have it in stock.
It's a huge pain in the ass with multiple able-bodied family members in her corner. I can't even fucking imagine how torturous this whole process is for someone in her situation without that kind of help.
+1. I found this interview highly informative about the background, scale, root causes, and complexities of opium addictions. This episode talks about -
* What role the doctors, drug companies, and even government policies play in causing the epidemic
* How the largest suppliers of heroin came to be, and how they compete based on customer service
* How drug addictions can be caused by supply as much as demand.
* In the USA, heroin overdosing now takes more lives than all homocides
EconTalk almost always has engaging discussions, and this interview is no exception.
In the USA, heroin overdosing now takes more lives than all homocides
I'd been hearing about the heroin epidemic for years. I saw articles about needles in Golden Gate park, I saw discarded needles and black-lit[1] restrooms in Vancouver, but it didn't really have weight until I read that 30,092 people died of opioid overdoses in 2015. In the US alone. Over 30,000!
Anyway, I'm just writing this on the off chance that there are others who are still blissfully unaware.
[1] black light makes it difficult to locate a vein for shooting up.
When I was 18 I had a pretty major surgery (Nuss procedure, to correct pectus excavatum, good times) which required an epidural in my spine.
When I was being prepped, the anesthesiologist joked "ready to feel the best feeling your body will ever experience?"
He wasn't joking - my entire body felt like it was floating, my mind cleared of every negative feeling, and for the 15-20 seconds I remained awake, I honestly thought I was in heaven.
I can totally understand how someone could get addicted to that feeling.
I known what you mean. As a child I had an emergency appendectomy and they gave me intravenous Demerol (synthetic opioid) for the pain. It's literally the best feeling in the world and I can totally understand how people become addicted after prolonged use. So I recommend trying every other option for pain relief before letting a healthcare provider give you an opioid. It's scary how even dentists sometimes hand out codeine prescriptions after minor procedures like wisdom tooth extraction.
My dentist didn't give me Vicodin[0] unless I had more than one or two teeth out.
Even then I never understood how people could like it. I got a little pain relief and a little bit of a relaxing feeling. It was probably a really low dose as well.
Might have just been mine wasn't into giving out prescriptions or they didn't think I would need them.
I have a friend who has so many pain prescriptions after his back surgery that I've lost count of and they either don't work or lose effectiveness or he can't deal with the side effects. The scary part to me is there will never be an end for him unless there is some miracle in medicine that his doctor doesn't know about yet.
This isn't that surprising. Drugs affect people differently and people seek different states of mind.
People talk about how addictive methamphetamine is. I know people who tried and never wanted to try it again. It was the most unpleasant experience. Like you drank way too much coffee and had all the anxiety and jitters to go along with it. For other people, it's like heaven.
This goes back to the idea of "self-medication" as a root cause of drug addiction. People get psychologically addicted to a drug because it solves a psychological issue for them. Depression? It goes away when I take meth. Anxiety? Gone when I take oxy.
Thinking about it that way, we shouldn't really be that surprised when people have trouble beating an addiction. Even with all the negative side effects, would you want to stop taking a drug that cured (imperfectly) a severe problem you've had your whole life?
That's interesting I had the same thing happen to me (around the same age). He phrased it as, "We're going to knock you out let me give you a bit just so you know what it will be like," and instantly my body flooded with warmth. I still to this day remember how good it felt... the mentally addictive properties are obvious even before the physical dependency.
I am so glad I had it done, but I would never have it done again, if that makes sense =)
It was the worst four months of my life after the operation, with basically my entire sternum broken. However, it was amazing what a difference it has made since. I don't remember my number, but the metric I do remember was that my heart was pushing into my left lung, causing about a 35% decrease in lung capacity.
I do miss eating cereal out of my chest, which always made my friends in high school laugh.
I refuse to take opioid pain relievers anymore :( After my knee surgery (subluxated knee cap, hyperextension, multiple tears, loose bodies in joint), I was prescribed oxycodone. I felt very happy, very relaxed (usually I would consider myself high anxiety). But after the dose wore off, it felt terrible and I felt a craving even know my knee necessarily wasn't hurting. That up/down cycle scared me and I realized why people become addicted to these pills and that I'm probably at risk. I flushed the rest and asked the doctor for a NSAID alternative which he was able to find a good one for me. Prescription medicine shouldn't leave you craving more.
I'm not totally sure why that's any better than throwing them into the trash. Are people really digging through garbage just hoping to find opiates?
However, presuming you're not on a septic system, they end up in the river, just like any other form of pollution.
Lots of police departments are taking them no questions asked. The city where I work's police/public affairs building has a big metal box with a one-way lid for unused drugs.
> Are people really digging through garbage just hoping to find opiates?
Where I live? eh... it's not common, but it definitely happens. And it's probably not just for opiates, but anything will probably do. I do get that putting them into the river/ocean is undesirable, though.
I refuse too. I had Percocet prescribed after oral surgery, which I am just learning is a combination of Oxycodone and Acetaminophen. The withdrawal from the Percocets was longer and much more severe than the wisdom teeth pain. I had another gum surgery a year later and never filled the pain prescription - a day of getting used to pain that fades by the end of day three is much better than no pain followed by 2 weeks of headaches, anxiety, and sleeplessness.
My wife recently took two doses of hydrocodone for foot surgery and felt terribly anxious after the 2nd dose. She's not had another. It was hard to watch her in the grip of that anxiety for the better part of an afternoon, mainly because she's never really experienced it and she was so confused.
FWIW, I've had several knee surgeries and have taken everything under the sun. I always feel the ups and down but never have become addicted. I think some of my feeling is anxiety but it wears off after I am active again; I simply don't think about it because I'm off during fun things.
I dont think that everyone who feels anxious taking pain pills becomes addictive. My take is there is a lot more at play.
I think there's more to it than that. Due to a combination of OCD/anxiety/chronic pain, a lot of the things I would enjoy doing aren't currently possible - I rarely leave the house, and I can't cook for myself, for instance. Despite that, each time I've stopped lengthy (>6 months) periods of opiate treatments, I've just stopped (no tapering) and had no ill effects (withdrawal etc.).
It depends on pain levels and duration. If you're in a position to reject them, then you probably shouldn't have been prescribed them in the first place.
The up/down cycle is frustrating... wouldn't it be nice if science could figure out a way to maximize the up and minimize the down? Wouldn't it be great if you could just take a daily pill that brightened your mood and killed your anxiety? Seems like there's a common belief that homeostasis can't be beaten... that the house always wins. Is this really true, or just an assumption?
The root of the problem may be our inability to very accurately remember pain intensity levels over long periods of time. Evolutionarily, it's important to remember that something was painful; but not that it was exactly 6% more painful than some other sensation, or even 40%. So we don't, and we therefore lack the most important bit of information to get us off painkillers.
The CDC says there's no evidence opiods reduce pain (at all) in the long run, and that's been my experience, too. But when you don't remember previous pain clearly enough to be sure you're back where you started (despite the drug) and you know that even partial withdrawal is really painful; it's easy to believe that the drug is still doing you good.
In my experience, this means that most who people taking opiods for long periods end up back at their old pain levels, but aren't able to clearer remember what their pain was like before, whereas they know all too clearly that less painkiller means more pain right away, so they stay on the drugs. Even though they may now be getting no long-term benefit in reduced pain. But once they complete withdrawal they'll tell you that they don't seem to be worse off, for pain now that they've fully quit the opiods. Their pain levels seem about the same.
Evolution has robbed us!
Prove this, and most of the arguments over opiods for chronic illness and pain may end.
For some reason, I kind'of always assumed the act of removing pain was itself the addictive part. But now it seems obvious that a drug could simply make you feel as you did right before hitting your thumb with the hammer.
My layperson's understanding is that the opiates remove the pain and eventually, the person's body re-calibrates its interpretation of pain based on this new state. When they stop with the opiates, normal levels of pain return, which are above and beyond what they're prepared to handle and they'll do nearly anything to make it stop.
One time, I heard a recovering addict talk about his hair hurting. He had been numbing himself for so long, the movement of the hair on his scalp felt agonizing to him.
Based on my conversations with friends who were/are addicted, that seems about right. After stopping long term opiate use, your sensitivity seems amplified. That's why addicts who can't get their fix are often seen scratching themselves - they feel itchy everywhere.
This is part of it, but not the whole thing. Withdrawals will involve pain, but also depending on how much and how long someone had been taking opiates, you will also experience: physical flu symptoms, insomnia, anxiety, induced restless leg syndrome, and more.
Here's an example: Confessions of an English Opium Eater ( http://www.gutenberg.org/files/2040/2040.txt ). Short for a biography, long for an article (couple hours read). The eloquent language itself makes going back to ordinary Internet English a pain. More on topic, he describes a year of abject suffering, 8 years of bliss and 9 years of abject suffering. (In really exceptional language.)
I think that’s a part of the addiction. But then there’s the other part that makes you take the drug even when the pain is gone, and that’s the trouble.
One of the most terrifying descriptions of the effects of certain hard drugs (I believe the one under discussion then was heroin) that I've read (I think on HN a while back?) was something like:
"You're currently in a lot of pain. You don't realize it because you've never not had this pain. The drugs take that pain away, then you know what it's like not to have it and you can't go back."
There's the study on monkeys later on, but that's talking about BU08028, which isn't mentioned as being an active component of Oliceridine (the main drug being promoted in this article). I actually don't see anything here that makes the claim that Oliceridine will be less addictive. It appears to just be a conclusion that people are supposed to assume is implied without a close reading of the article and information.
I'm recovering from a car accident and they gave me plenty of opiates in the hospital. Honestly I didn't see the appeal outside of pain relief.
For pain relief they are great. I went from "I'm being eaten by a bear" to "Meh" pain levels in minutes. But other than that it wasn't too pleasant. There was no euphoria just dizziness and constipation. As soon as I could switch to Ibuprofen, I did.
According to my doctor, there is a genetic component in how people respond to opiates. Guess I was lucky.
I've had various ones prescribed over the years, usually just long enough apart for me to forget how horribly, horribly nauseous they make me feel. They relieve the pain, somewhat, but never completely and there's nothing remotely "euphoric" about the experience.
Over the counter painkillers work just fine on the other hand; never had a problem with ibuprofen, acetaminophen, etc.
Yep. With the exception of some intravenous Valium right before my wisdom tooth surgery, I've been fortunate that opiates and do not get along. The pain relief works, but I also feel like I'm going to throw up. Then about 45 minutes after taking a dose, I fall asleep. No euphoria, no feeling of warmth or comfort. Obviously not everyone has this reaction.
Valium is a benzodiazepine (not an opiate) but don't let that fool you. I've met several people struggling with addiction that swear benzo withdrawal can be as bad or worse than opiates.
They probably had to give you a strong dose to control the pain. Generally if you take too much with a low tolerance you aren't going to have such a good time (even though you definitely won't be in pain anymore). If you hadn't been in so much pain and had been given a smaller dosage at first, you would have probably felt more of a euphoric effect.
What I find weird is that it seems like the body can be in permanent pain, but it isn't able to achieve a permanent state of feeling good.
For instance, there are people with spine damage who feel chronic, unrelenting pain every day of their life. On the other hand, for any drug that makes you "feel good" (oxycodone, morphine, even Adderall), your body eventually builds a tolerance and requires more and more of that substance to achieve the same level of "happy". So why doesn't the body do that with pain — where it eventually gets used to your "average pain state" and requires ever more intense infliction to feel the same level of "hurt"?
At the risk of an evolutionary just so story I think "feeling good" is a larger risk for our animal ancestors.
Not standing in fire is always relevant even if your leg is broken. However, not finding a mate because you just ate, or not eating because you found a mate is counter productive.
Also, as I understand it evolution cares less about edge cases than we do. Improving average outcomes can be worth not regrowing limbs for example.
On a domestic flight I sat next to a physician. During our chats we talked about the opioid epidemic and he pointed to a push by pharmaceuticals to make pain a distinct item that needs to be treated. And how this in part led to the runaway addictions. I had thought it was purely socio-economic reasons, but the big pharama angle was new to me. Curious if there are sources for this.
> push by pharmaceuticals to make pain a distinct item that needs to be treated
It's totally reasonable to treat pain as a distinct item, especially in patients where the cause of pain is vague, or the surgical fix carries high risk - ex: chronic back pain.
Interesting. It would be good to have more ways to relieve pain, and ways to help patients avoid addiction.
One of the best ways to help patients avoid addiction would be to decriminalize these compounds and reduce or eliminate the prohibitions against them. That's a strong statement, so please allow me to make the case.
(1) the iron law of prohibition says this: prohibition drives out all but the most potent, and hence easiest-to-smuggle, formulations of the prohibited substance. During alcohol prohibition in the USA, NOBODY smuggled lite beer. It takes the Busch Clydesdales to move the stuff around, and it's too obvious. It was ALL strong stuff like whiskey and "white lightning." The most potent formulations of opiates are easier to misuse in a way that promotes addiction.
(2) a corollary to the iron law is this: people without training in chemistry or sterile procedure will adulterate the strongest stuff so they can sell more nickel bags, or whatever, on the street. That makes the dosages unpredictable. Unpredictable dosages promote addiction by unpredictably pushing a user's thresholds. Adulterants can be be dangerous and can induce pain.
(3) if the stuff's illegal it's expensive. Then addicts have the incentive to sell some to their friends to help pay for their habits. Teenagers get addicted this way.
(4) offering the substances to addicts at reasonable cost in competently supervised circumstances allows for a variety of treatment options for addiction. At the same time, addicts' lives don't fall apart. Treatment regimes can, brought out of the shadows, be examined for their success rates by agencies like Cochrane: http://www.cochrane.org/CD011117/ADDICTN_opioid-maintenance-... . The current "state of the art" in treatment is cold-turkey twelve-step. It works for some people, but is it evidence-based? Sure it's evidence based, like reducing stress helped people with stomach ulcers until pylobacter was discovered.
(5) if the government stops demonizing addicts as they have been doing for almost a century then they can come out of the shadows and deal with their problems.
(6) decriminalization weakens the incentives for pharmaceutical companies like Purdue Labs to create supposedly "safe" time-release formulas like Oxycontin, and then promote those formulas in ways that lead to addiction. http://www.latimes.com/projects/oxycontin-part1/
(7) We won't have to hear news about people with names like El Chapo any more. Any aura of underworld glamour around this stuff will evaporate. It will become boring and fluorescent-lit like pharmacies should be.
Why is this change difficult? It challenges the narco-industrial complex. Decriminalization means lots of police will be laid off. It will cut profits for big pharma. It will cut government revenues by cutting into civil asset forfeitures. http://www.newyorker.com/magazine/2013/08/12/taken
It's also difficult because of recent successful efforts to decriminalize cannabis. The successful argument in Massachusetts USA and Colorado USA for decriminalization has been one of recreation. "It's safer than alcohol, so go for it." That's obviously a crazy argument to make for decriminalizing opioids : because it's NOT safer, and because it plays into peoples' prejudices (see point 5 above).
It looks like an issue with wording to me, i.e. they may have meant "can in theory be, but usually isn't compared to the high cost compared to lab synthesis", but oversimplified it.
Other way around, synthesis is more expensive (according to wikipedia). But the extraction from poppies doesn't need to involve opium as an intermediary (once again according to wikipedia).
Although may be present in the seeds in minute quantities, they extract it from the seed pod by scarring the pod and then letting it "bleed" (probably not the correct term) and harvesting it later.
I've always wondered about the relationship between america's opiate habit and the afghan poppy harvest. The US army was burning millions (billions?) of dollars worth of poppies every year, to deny profit to the taliban. Could that not have been used to make pain pills? How do the incentives flow here?
There's no shortage of pain pills. GoodRX is a pharmacy benefit manager that doesn't collect any payments from users, it runs on marketing fees, so it gives some information about the real cost of drugs. Several weeks of Oxycodone costs $20 at the pharmacy:
> Could that not have been used to make pain pills?
To my knowledge, the industry has moved away from poppies that produce morphine (they still technically grow p. somniferum, but a special cultivar with low morphine content to discourage theft).
Instead they extract the opioid compound thebaine, which is then converted to powerful name-brand pain meds. This is why they're called "semi-synthetic opioids", because they require thebaine as the primary ingredient.
So yes, those could have been used to produce pain meds the "old-school" way but I doubt they'd be of any use to western pharmaceutical companies.
> The US army was burning millions (billions?) of dollars worth of poppies every year, to deny profit to the taliban.
I'm not sure that's the whole story, if you look at the statistics then it rather looks like poppy production has increased since the US/NATO occupation [0], at least compared to the, very low, numbers in 2000.
Turkey is one example of a country that successfully managed to legalize their poppy production, but it's questionable if that approach would work just as well in Afghanistan [1].
As I understand the talban were opposed to drugs and they did a good job of ensuring poppy was not grown in the country. (they had other problems, but aiding the illegal drug trade was not one)
The withdrawals (if properly tapered) are about as bad as caffeine withdrawals for a heavy coffee drinker. However, they can be mitigated much easier than opiate withdrawals, which is why a lot of people use it as a stepping stone.
It's certainly not free from addiction (it does after all, contain μ-opioid receptor agonists, among other things), but it looks like it's got a lower addiction profile for the level of pain relief it provides. It's worth looking into.
It's also possible it may have applications in addictions management with people who are on harder things.
But yeah, everything with a grain of salt, and it's good to be aware there is a risk.
> It's certainly not free from addiction (it does after all, contain μ-opioid receptor agonists
It's not quite as simple as 'all mu-opioid agonists are bad'.
Mitragynine and 7-OH-mitragyine (the primary alkaloids in kratom) have been shown to be G-protein biased - which is why tolerance doesn't build like it does with almost every other opioid, why the side effects such as constipation are much less, why many people appear to have very mild withdrawals, and perhaps most importantly why it doesn't cause respiratory depression (this is what kills with most opioids)
Psychologically speaking nothing is free from addiction if a person is composed in a way to have such a proclivity. There are people addicted to huffing compressed air duster spray. Though I've never been hooked, I can only imagine the comedown and withdrawls are rather, uh, not fun?
What my point is - that you likely missed - is the innate "harm reduction" pursuit with respect to long-term therapies. Opiates have a use for sure but I think eventually the dosage / toxicity becomes a valid concern. Then up to the next threshold of potency, and on and on. If Kratom has just 50% better results than opiate treatments in equivalent doses, that's a great discovery in my opinion.
All this talk about being "health care consumers" really looks like bullshit when we get down to the nitty-gritty of Doctors still holding power with their pens and pads and saying Yes or No with the DEA looking over their shoulder.
Kratom user here... it's definitely promising, and for the same reason as the other drug in the article: more G Protein activation, less β-arrestin activation.
Here's a study (free access) from Columbia University researchers on the activation patterns of Kratom alkaloids:
There isn't enough research yet. The DEA acted too quickly, to be sure, but I also wouldn't prescribe it to anyone yet. It is associated with withdrawal.
I think we would get far more mileage from alternative pain relief (e.g. cannabis) than we would from alternative detox methods—ensure people don't get opiates unless absolutely necessary.
Except it wasnt.
Very worthy your time listening to this guy if you are interested in the topic.
[1] http://www.econtalk.org/archives/2017/01/sam_quinones_on.htm...
[2] https://www.amazon.com/Dreamland-True-Americas-Opiate-Epidem...