If there's enough overreaction to opioid dependency, it does impede the use of opioids to treat pain. Making it harder to get opioids also, typically, makes it harder to get opioids to treat pain. Bureaucratic systems, put simply, suck.

Whenever you talk about the "opioid epidemic", a large part of what you're talking about is people buying heroin and fentanyl from drug dealers. Making it harder to get oxycodone does zero to stop people from buying heroin and fentanyl on the street. It does a hell of a lot to stop the use of oxycodone to treat pain.

So the protocols changed, and doctors in many areas of practice started treating opioids like ibuprofen. Hydrocodone or oxy isn’t the best choice for chronic pain, and as chronic users take it, their tolerance increases and their ability to get an effective, legal prescription slowly goes away.

The black market offered cheaper, but more dangerous alternatives.

Somehow there's no egg on the medical community's face. Is medically checking the doctor now the responsibility of patients?

At google's scale it doesn't take much bureaucratic indifference to have an outsized effect.

I would be surprised if google wasn't-- but it's spread out over thousands of distinct causes. Like maps effectively directing people to turn onto railroad tracks and google being unwilling to do anything about it (https://www.theverge.com/2019/8/12/20802036/google-apple-mic...), or maps and especially waze directing highway level flows of traffic through residential neighborhoods.

Now ordinary people with ordinary aches and pains can't get effective painkillers without visiting a doctor (or a quick trip to NZ where they're still available).

Is the threshold for visiting a doctor that high in Australia ? From my European perspective, seeing your GP is a routine and cheap thing to do, and definitely warranted before starting an addictive drug.

PS: That’s not to say it’s purely the drug companies issue. While recovering from surgery in the hospital and on an clicker IV drip I had a doctor suggest I try ‘upping my dose’ for the fun of it.

Many doctors and pharmacies in the US have swung the pendulum to that end. Probably for liability reasons.

That's of course when the addiction rate for opioids went through the roof. Entirely disconnected I'm sure.

I don't know if they should be used for pain. I'm not educated enough on it to make a statement like that, for or against. What I can say with absolute certainty is Purdue Pharama created a disaster on the scale of natural events by selling legal medication. Every facet of that should be analyzed so we can make sure it never happens again.

That would be heroin. Our institutional memory is woefully short.

My understanding is that they said opioid addiction (in general) was a relatively minor problem and it shouldn’t stop doctors from prescribing them.

“Delayed absorption as provided by OxyContin tablets, is believed to reduce the abuse liability of a drug.”

That's what the FDA allowed them to publish. Possibly the most dangerous single sentence in the history of medicines.

It is actually true though. Delayed release would be expected to reduce abuse liability.

That doesn’t mean OxyContin is not addictive, it just means it’s expected to be less addictive than immediate release oxycodone.

Although manufacturers have created a tamper proof version, but that just led users to move to heroin.

The first fault is that even the studies done by Purdue prior to release did not indicate anything close to the 1% addiction rate they advertised, it was more like 8-12%.

The second, most Oxycontin users who aren't well off eventually move to heroin, because the effects are very similar, and the street price for Oxycontin is much higher. Ironically, where Marijuana was demonized for a nonexistent gateway property in the original war on drugs, Oxycontin was actually demonstrably a gateway drug for heroin.

There's a very well researched episode of the podcast "Behind the Bastards" hosted by Robert Evans that drills down exactly into all of Purdue's dirty little secrets surrounding Oxycontin. Once you realized just how many numbers were fudged, how many studies fiddled with, it becomes clear just how much had to be made to go wrong in order for this epidemic to really kick off. It's quite damning.

The source of the issue really is just how hard Purdue was fudging their data. And I mean, you can say that a drug company shouldn't be the sole tester of it's own drugs and I'd agree with you, but good luck getting average people to want to pay for it by funding the FDA.

Which yes, is a pretty logical follow through, but also you'd expect more rigorous proof than "we think it'll do that" for medicines.

https://www.aafp.org/afp/2018/0301/p348.html

is one example, for patients presenting in the ER with extremity pain, and one that's specific to impacted wisdom tooth extraction is:

https://www.ncbi.nlm.nih.gov/pubmed/28586638

("CONCLUSION: Codeine 60 mg added to a regimen of paracetamol 1,000 mg and ibuprofen 400 mg does not improve analgesia after third molar surgery.")

There's a study I'm very curious to see the results of for this question for post-caesarian patients: https://clinicaltrials.gov/ct2/show/NCT03372382 (study is still underway).

And there's been really promising results for other forms of post-surgical pain management. One great example is the use of a QL nerve block administered during surgery to manage post-caesarian pain:

https://sci-hub.tw/https://rapm.bmj.com/content/early/2019/1...

"QL block has been associated with reduced postoperative opioid consumption and pain scores in patients undergoing cesarean delivery, [... but more study is needed because the studies weren't big/comprehensive enough ...]"

There are lots of caveats here (in other words, don't believe some random schmuck on the Internet over your doctor) -- different types of pain may respond differently, different people may respond differently, etc., etc. Ibuprofen impairs clotting and is inappropriate for use with some patients and some types of injury. Acetaminophen has to be dosed carefully to avoid liver toxicity. No free lunch. But it's certainly promising from the perspective of non-narcotic pain treatment _in some circumstances_.

(Please don't misconstrue what I'm saying, of course, as suggesting we can or should eliminate opiates. There's a place for everything in our arsenal. But there's been a lot of progress in the last decade that open up alternatives in some cases.)

Glossary, in case it's helpful: acetaminophen (US) = paracetamol (UK) = tylenol (brand name). ibuprofen = motrin = advil. oxycodone/acetaminophen = percoset (brand name; ratios may vary).

I'm certainly not well educated in medicine, so it's hard to say whether my experiences can be generalized to the broader population, but if my experiences are at all common it does make me wonder why the are so broadly prescribed, and why I was never advised to even try NSAIDs before escalating to opioids with their associated side effects and addiction risk.

I had a bone marrow biopsy, where they can’t anesthetize you and sure burrowing into my bone with a scalpel hurt. But whatever. Life is pain.

It must be that elsewhere doctors more frequently say “yes, your condition is painful, but if normal painkillers don’t help, the next alternative is worse than the pain”.

It’s not clear to me why this discrepancy exists. Pharma can’t be the only reason. Maybe the private insurance system is a factor (“I paid a lot for this healthcare now fix my pain or I’ll take my business elsewhere”)?

Keep in mind that not only insurance is a factor, but also the fact that many hospital systems themselves are private and have lots of cost pressures. A fair amount of advertising I've seen is for hospital systems.

Also, most hospitals in the US are nonprofits, though that doesn't free them from cost pressures or the need to advertise.

America's fear of regulation results in more workers being injured and developing chronic pain.

America's broken healthcare system means that people are less likely to have access to alternatives such as physical therapy, meditation, counseling, etc.

America's weak social safety net means that people have to relieve their pain so that they can continue working.

Cultural factors result in people being less accepting of pain as part of their lives.

My mom ran different units in busy NYC hospitals in the 80s. At that time, the protocols for most pain events were Tylenol and/or Motrin. Getting more than 600mg of Motrin was unusual.

When I had back problems in the early 2000s, the protocols were totally different. If you had back pain, once the newer NSAIDS like Vioxx and Celebrex were mostly removed from the market, the substitute was an opioid. In my case, physical therapy, motrin/aleve, etc helped until surgery was required. I know a few people who went to opioid route, and a couple of them have struggled with dependency.

Sure, no one can reasonably disagree with that. I don't think folks defending opioids are staking that claim. To your earlier question,

> I mean, nobody is suggesting that opiods shouldn't be used to treat pain, are they?

Kinda, yes, actually. Or rather, since regulators and doctors cannot actually tell the difference between someone in pain and someone not in pain, the response to a perceived overprescription crisis has been to swing towards underprescribing — restricting access to and increasing the difficulty of obtaining opioids for everyone.

Literally everyone is suggesting this. Not sure if you had any surgeries/medical producers these days. You will now get prescription strength ibuprofin or something like that instead of opioids.

My father in law spent one month straight of sleeping < 1 hr /night due to post op pain but the doc refused to prescribe opioids.

So yes, lots of people are suggesting not using opioids for pain. Perhaps you are using a different/extreme definition of pain in your sentence.

That is incorrect. "You will" is not the same as "You are more likely to". They still give intraveneous delotin when your appendix bursts or your gall bladder duct is blocked in the short term. It should come as no surprise, that major medical surgery (eg some pain from open heart surgery), is not mitigated by ibuprofin and the like.

Yes you are right. That's what i meant. thank you.

Well...yes. Some are quite explicit about it, but even the ones who aren't are advocating for a policy where that is an inevitable result at the margins, yes. It's not like there's a box with a switch that says "dispense opioids responsibly for real issues" on one side and "just hand them out like candy" on the other, and we're debating toggling it.

If you make opioids harder to get, then some people who should get them will now not (which is bad), and some people who should not get them now won't (which is good), but the correct balance is deeply unclear, and unlikely to be determined in the middle of a moral panic.

Note in the linked article, especially, the offhand discussion of "pseudo-addiction".

> If patients reported withdrawal symptoms like nausea or the shakes, the reps were trained to call this “pseudo-addiction.” A doctor who was skeptical of this concept could find studies to back it up — many of them conducted by J. David Haddox, Purdue’s scientific adviser. His research claimed that these symptoms resembled drug-seeking behavior but were actually caused by unrelieved pain. This pain, of course, could be treated by increasing the opioid dosage; these patients should not be diagnosed with addiction. Though “pseudo-addiction” became a popular term in medical literature, there has been no empirical evidence backing up the concept.

This is, frankly, absurd. Are we really questioning whether under-treated pain can sometimes exist, or can cause nausea or shaking? Are we really going to go down the "let's see empirical evidence" road when discussing, effectively, the concept of pain? Here's some empirical evidence; go kick a wall, now your foot hurts. That isn't the feeling of painkiller withdrawal.

For a lengthy discussion of this, I recommend the inimitable Scott Alexander: https://slatestarcodex.com/2019/09/16/against-against-pseudo...

In particular check out his "case 1". Yes, the push against over-prescribing opioids mean real people in real pain will not get the treatment that our current understanding of medical science says they should receive. The costs may be worthwhile, but they exist.

It checks a box. Whether or not the long term result is actually positive or "good" for that individual seems far less clear, particularly if your plans only extend as far as cutting off their supply.

> but the correct balance is deeply unclear, and unlikely to be determined in the middle of a moral panic.

I feel like drug abuse is indicative of other more serious underlying problems, and unless you address those, you're just shifting problems from one domain to another.

The answer is "none".

"Harm reduction" has a specific meaning im the context of addiction (such as needle exchange programs, etc). Cutting people off from their access to legal opiods does not qualify as "harm reduction", but the opposite as it pushes people to unsafe street drugs.

As I grow older, I've become way more conservative about legalizing drugs.

SSC had a good piece on that: https://slatestarcodex.com/2019/09/16/against-against-pseudo...

My mom had surgery recently and the oxycodone had her nauseous and vomiting through the night the first night after her surgery. After which she decided to just not take them.

Not to mention that opioids put your digestive tract basically to sleep, leading to severe constipation.

Paracetamol and ibuprofen are the right choice in a lot of cases, but I don't think any medical professional would dream of suggesting they're the only painkillers that you'll ever need!

This suggests to me that opioids are not needed nearly so often as they are prescribed, even if they are warranted in certain situations.

If I have a severely painful joint bleed (common in my condition) or surgery, I'm taking the opioids.

Availability of illicitly manufactured synthetic opioids (e.g., fentanyl) that traditionally were prescription medications has increased. This has blurred the lines between prescription and illicit opioid-involved deaths. In one study in 27 states, Gladden et al. examined data on drug products obtained by law enforcement that tested positive for fentanyl (fentanyl submissions) and deaths involving synthetic opioids other than methadone (referred to as synthetic opioids). From 2013 to 2014, fentanyl submissions increased by 426%. The increases were strongly correlated with increases in synthetic opioid deaths but not with pharmaceutical fentanyl prescribing rates, suggesting that the increases were largely due to IMF. In a recent report, fentanyl was detected in at least half of the opioid overdose deaths from July to December 2016 in 7 of the 10 states examined. [0]

0. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5844400/

The CDC describes overdose deaths as occurring in three waves [1]. Normal pharmaceuticals are involved in wave one, starting in the 1990s. Clearly pharma co.s aren’t involved in wave two, heroin. What’s their culpability for wave three, the synthetic opiods starting in 2013? NIH above says not majorly. If pharma cos aren’t the source of fentanyl and wave two’s heroin, why are they the media focus point?

1. https://www.cdc.gov/drugoverdose/epidemic/index.html

Can anyone comment on the validity or invalidity of that argument?

~90% of people who are prescribed opioids never develop addiction problems. [1]

Despite being in the midst of an opioid crisis with skyrocketing mortality rates, the mortality rate from prescription opiates has been ~stable for the last ~15 years. [2]

[0] https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTab...

[1] https://www.ncbi.nlm.nih.gov/pubmed/25785523

[2] http://www.ncsl.org/portals/1/documents/health/APeeples0118_...

Something like 6% of american adults abuse alcohol -- and alcohol is less "addictive" than an opioid for most of the population.

I knew of people buying oxycodone on the street a decade ago, and it was clear their dealers had a supply of name brand pills beyond "pills stolen from the medicine cabinet".

I seem to recall earlier stories linking the rise of prescription opiates in general to a resurgence in what had been declining heroin abuse, but I'm not finding anything.

[0] https://www.latimes.com/local/lanow/la-me-oxycontin-20170109...