For a great many years, they were almost solely for people with serious, chronic pain. Cancer sufferers or people with severe diseases. It wasn't until Oxycontin and the marketing push associated with it that it became so widely prescribed as a regular use pain-killer.

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.

Hydrocodone is an opiate, and was used pretty regularly for pain from wisdom extraction, lacerations, etc. Was used for years with little fanfare before oxycontin and friends. It is now lumped in with them.

Right. The core problem with Oxycontin wasn't that it was an opiate: it was that Purdue sold it as an opiate that resisted addiction. This meant doctors prescribed it more readily and were less concerned about monitoring patients afterwards.

This wasn't the first opiate which was touted to be less addictive than morphine.

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

“Resisted addiction”? Do you have a source for that? My understanding is the FDA would never let the say that.

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

I said they sold it as that, not that it was that and that was the source of the issue.

“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.

Ahhh, that makes sense.

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.

People figured out pretty quickly that if you crush the pills, you absorb the oxycodone quickly. It was the coating that delayed absorption.

This is true, so users were pretty quickly able to get around it.

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

Yes and no.

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.

Are there any slow release drugs that you can't do this with? Shouldn't this be obvious to the doctors?

As a general rule Doctors trust the documentation given to them by the pharmaceutical companies, which in turn is approved after several rounds with the FDA, so one would think that the documentation would be pretty reliable.

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.

I wonder if it is normal for slow release drugs to come with warnings telling you that you can crush them up and abuse them?

the article submitted specifically address this and cites figures that Purdue marketed from one incredibly flimsy sentence to claim 1% addiction rates, when reality according to the article is 8-12%

Right. Purdue claimed opioids in general were less addictive, not that oxycodone itself was less addictive.

No no, Purdue claimed that Oxycontin's time-release formula was believed to reduce it's addictiveness.

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.

This is also partly because more recent studies have determined that for important types of post-surgical pain of this sort, combination ibuprofen+acetaminophen is actually more effective than hydrocodone.

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).

Having been on both, I can say personally hydrocodone seemed more effective.

My anecdotal data says the opposite. I've been prescribed opioid pain killers (Codeine/acetaminophen and Tramadol) a few different times (post regular and oral surgery, after a particularly nasty wrist and ankle sprain, and most recently after getting some second degree burns from a cooking accident). The first couple of times I was prescribed them I remember thinking how bad the pain must have been to have still felt so intense after taking opioids- but eventually I realized that the prescribed opioid pain killers were just not doing much to help at all, and Ibuprofen was far more effective for me. These days I don't even bother filling the prescription and just go straight to advil to manage pain.

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.

Codeine+Paracetomol was available OTC here in Australia until addicts ruined the fun. It was great to have for non-everyday pain like that once a year killer headache.

A doctor should consider the possibility that they are dooming their patient to something far worse than pain. I'm not saying that we should never use opioids ever, but we definitely need to either change how they're used (only administered by professionals in a clinical setting) or change how society deals with users (we decriminalize opioids and work towards better quality control and legal availability.)

Probably just vanishingly. Anyways rare enough that a market for illicit prescription opioids would be difficult to sustain.

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.