Never even the tiniest sign of dependence. Sometimes I go months between uses.

I am also a chronic pain patient and I worry that benzos are going to get the opioid treatment.

There was a period in the mid to late 2010s where patients who depended on opioids for any sort of quality of life were taken off of their medication without any sort of alternative. It’s something that people love to gloss over when they talk about the opioid crisis, but if you knew someone personally who went through that, you know that we collectively subjected those people to torture.

people should only ever take opioids VERY TEMPORARILY to get through surgeries or other such things. Opioids are not for long term pain management.

Same thing with benzos and anxiety.

Nearly all opioids present the hazard of dose escalation over time to maintain their efficacy. Hence the dose escalation commonly seen with morphine, oxycontin, etc.

Most opioids, in addition to interacting with mu-opioid receptors (the mechanism of pain relief), also activate NMDA receptors, which enhance pain sensitivity. So for most opioids, there's an adverse dynamic in which analgesic activity competes with nociceptive activity, leading to dose escalation.

Methadone is one of two opioids that don't activate the NMDA receptor system. (The other is dextromethorphan, the OTC cough suppressant.) Methadone has been used very successfully to treat chronic pain, and does not exhibit dose escalation issues. Methadone has slow kinetics and does depress respiration, so when putting patients on it, dosages should be titrated slowly to avoid hazardous or fatal events. This is easily managed in ordinary clinical practice.

A close family member has been treated with methadone for chronic refractory migraines for >20 years. She transitioned to methadone from morphine SR after experiencing the classic need for increased dose. With methadone, she's had no dose escalation, no impairment due to psychotropic effects...it's simply given her a life to live.

(If you read my reply to the above comment, you'll note the significant rebound effect I suffered from codeine in that it significantly increased the frequency of my headaches.)

It has only just occurred to me to ask this question after reading your comment and my logic for doing so is thus:

(a) Compared to certain other opiates, codeine isn't a particularly powerful painkiller, presumably this is why it's been licensed for inclusion in weak amounts in combination with NSAID painkillers in a number of countries (although I realize that in some places the rules concerning the sale of these OTC drugs have been tightened in recent years).

(b) The codeine 'rebound problem' (presumably caused by its activation of NMDA receptors) could be eliminated if codeine were to be substituted with low-dose methadone in these combination painkillers.

(c) As it has little or no NMDA activity, substituting low-dose methadone may alleviate or reduce some of the overdose problem from paracetamol overdoses (paracetamol poisoning occurs when people overdose on it in their attempt to get a bigger hit from the codeine component - or when they find that the painkillers are no longer working effectively and increase the dose above recommended amounts).

(d) Again, as methadone doesn't have any NMDA activity, its effective level could be increased in comparison to that which has been traditionally considered safe for OTC codeine preparations. In essence, for an equivalent level of risk/narcotic side effects, OTC low-dose methadone/NSAID combination painkillers could be made more effective than their codeine equivalents.

Thinking quickly through this some objections are immedately clear, the most obvious being that (from memory) methadone has a similar analgesic threshold to morphine (albeit its overall effectiveness is somewhat less for other reasons).

As methadone's analgesic threshold much higher than that of codeine (perhaps by as much as five times) it's traditionally said to be highly addictive in its own right and thus significantly more so than codeine.

The question arises that given its lack of activation of NMDA receptors how effective would it be in low-dose preparations. If there is little NMDA response one would expect little addictive risk at these low leveks. Of course, the argument against that is that the higher analgesic threshold would negate the benefits as consumers could actually get bigger hits by taking larger amount of these painkillers (that argument is used correctly with other opiates such as heroin which has an analgesic threshold of about three times that of morphine).

However, as you point out, this shouldn't happen with methadone given its lack NMDA action (especially so in small amounts).

Even if it did, would we be faced with methadone addiction kicking in first or would abusers of these painkillers succumb and die from paracetamol poisoning (as they often do now with codeine combinations)?

There's another option that is also worth considering in this debate and that's the inclusion of a small quantity of atropine in OTC preparations that include narcotic drugs such as with the anti-diarrhea drug diphenoxylate (aka Lomotil). The inclusion of atropine has proved highly effective in discouraging deliberate overdosage of diphenoxylate, as beyond a certain threshold level it makes one feel quite I'll.

No doubt, the wider use of opiates such a methadone is both a complex and very emotive subject. Moreover, it worries me that the very mention of the word 'opiate' is enough to close down sensible debate on the subject. We need a much more sophisticated and nuanced approach to the use of opiates than we have at present and I can't help feel that we're not getting it because of a silly non rational approach to the problem. Mentioning methadone for instance has widespread connotations with drug abuse and these are usually negative - even though the drug is usually used to improve the lives of people.

BTW, let it not be said that I'm advocating a wider more laissez faire approach to opiate use, I'm certainly not. What I want to see is more science and less emotion in the debate.

Moreover, if you look back on my old HN comments about such matters, you'd find few other posters whose comments were more critical over the opioid epidemic than I have been. In my opinion, the behavior of Purdue Pharmaceuticals and the Sacklers has been nothing short of criminal and the fact that they have been let off lightly is a national disgrace.

I can only speculate at the absence of methadone as a replacement for codeine pain meds. Two things come to mind.

One is the known respiratory depression hazard presented by methadone. This is complicated by the fact that methadone's clearance rate varies by more than an order of magnitude among individuals. In clinical practice, this means that the effective analgesic methadone dose must be established slowly. This isn't a problem in controlled clinical settings with patients who comply with treatment regimens. It's another story entirely in patients who are immersed in street drug polypharmacy situations. So there may be an element of caution, well-placed or not, that biases against use of methadone in place of other opiates.

The second is what you touched on - methadone (and all opiates, really) is a complex and emotionally-laden subject. Methadone has a poor reputation from its use in detoxing opiate addicts. Mentioning that you're being treated with methadone nearly never elicits even a neutral response. I think methadone's negative reputation is a serious impediment to its use in situations where it would otherwise be the logical choice.

I don't know about addictive properties of methadone. I know that my family member, who has been treated with methadone for chronic refractory migraine for ~17 years, doesn't show withdrawal symptoms when she misses her meds. Her headaches return, but there's none of the sweating, feverish shivers that characterize withdrawal from other opioids. She doesn't experience psychotropic effects, positive or negative. The principal side effect is constipation. In at least this anecdatum, there's no evidence of addiction even after a very long term of use.

I agree there's a shortage of rational thought and a great excess of emotion around opioids. I wish the emotional charge could be more directed to Purdue Pharma, the Sacklers, and the like, who have not only killed people in multitudes, but who also have compromised progress in getting effective and safe pain relief to the very many who would benefit. Sometimes, one can only live in hope of better times.

Thanks again.

I would happily trade 10 to 20 years off of my life to live the remaining ones pain-free and functional.

Edit: One of the most frustrating things I experience are doctors who don’t understand topics that guide “no tolerance” policies; for example, they are aware they hyperalgesia exists — much like the GP — but don’t really know what it is or what it’s like for the patient.

From peronal albeit limited experience, I don't doubt that opioids can cause pain they purport to relieve.

I used to take an OTC painkiller for headaches that was a combination of 500mg acetaminophen (aka paracetamol) and 10mg codeine and whilst it was somewhat effective the frequency of my headaches actually increased.

It eventually dawned on me that the painkiller and or the frequency of taking it was causing some rebound effect and that the likely culprit was the codeine - given that it was an opiate and thus potentially addictive.

I then switched to acetaminophen-only tablets and although less effective as a painkiller than the combination, the frequency of my headaches decreased quite dramatically.

I never exceeded the recommended daily dose nor did I take the tablets every day (as I've always been aware of acetaminophen's potential to cause life threatening liver damage on overdose), so my codeine intake would have been within acceptable limits (especially given the painkiller's OTC status).

That said, I abruptly switched to the non-codeine formulation without any noticeable withdrawal symptoms.

The fact that codeine could cause headache pain when taken at dose levels below that which would be considered potentially addictive has never been lost on me. I'm very surprised that the public hasn't been warned more widely about this issue.

Or realize that people should follow their doctor's advice and realize that opioids definitely can be a part of long-term pain management. Not all long-term use is equal. You can have long-term pain and long-term use of opioids without needing to take them daily just like you can use benzos for years without needing to take them daily for that entire time.

When she passed, her cocktail included 12 prescriptions. One of her doctors had prescribed her medication to lower her blood pressure while another had her on medication to raise it.

There is no way I’m going to any appointment (including my dentist) without a printed list of everything, including the dosages, instructions, and reason for being on it.

Edit: I apologize for the poor phrasing. It comes off being flippant. The reality is the American system is often broken, and it’s up to the patient to manage their own care. And for many reasons, people don’t or can’t.

What I was trying to say is, I have to do this and be diligent about it because no one else will. :(

Of course they are, that's why they seek professional help from people who have spent years studying medicine and who can presumably be trusted to understand the intricacies of the issues involved.

People are bad at handling their own auto repairs, that's why we have mechanics. They're bad at handling their own legal issues, that's why we have lawyers. Etc etc etc

It seems pretty harsh to react so flippantly to someone facing negative consequences to the advice given to them professionals. It's nothing other than victim blaming in my view.

And much like doctors, mechanics have a massive conflict of interest. If you're not careful, the mechanic will propose a bunch of unnecessary work on your car just to earn more money.

I'd say medical care is an exception where we try to mandate (by law) that they act in our best interest.

I propose we call them, "Doctors," from the Latin word for "teacher," by reference to their role in instructing patients on the things they need to know about their health.

All people who complete a doctorate program are entitled to be addressed as "doctor". This includes everything from a Ph.D. (the original "doctor"), to M.D.s and D.O.s (medical doctors), and yes, D.C.

The chiropractors aren't having folks call them doctor because they have the right to (as someone with a PhD would do). They are doing it to make folks think they are medical professionals in the same manner as an M.D.

In other words, posing as a medical doctor.

And this kills folks when you consider the sort of scam practices that a lot of chiropractors tend to practice. Honestly, I think it is too bad that we've decided to use the same word for all of these and I'd be happy to change things legally to protect folks from this sort of sham.

Well, we have three choices. Either:

1. We change this social norm

2. we come up with a better title for people who didn't get a degree in quackery from an online program, or

3. most people lose all trust in doctors.

Beyond old age, the vast majority of people are bad at taking care of themselves. So many people that it is not a moral issue. It is a systemic issue.

The problem is, you don’t need to take care of yourself, until you do. Society doesn’t prepare us for that. (I got to learn the hard way.)

All it takes is one accident or affliction to change this ability. Unresponsive due to a car accident, for example, or simply not having your list of information when you got rushed to the hospital. Confusion due to a high fever. A stroke due to an undiagnosed and hidden condition. Heck, simply age or winding up with a complicated health situation can do it.

In short: You really only can trust yourself if you have enough luck.

They’re called “teachers” because their degree qualifies them to teach medical students.

It has its origin in the medieval academic degree system.

But it’s not in any way about their instruction of patients.

Hold on. We have computers and networks. In most other countries I've been in, records are computerized and there's no need to write a piece of paper that you hand to new doctors and 'get good at handling your own health care.' Even here I see some exchange across providers on a "Mychart" like app. That's a start.

But what you're seeing is inefficiency - a computerized world where you're telling people they should bring printouts of everything to all appointments seems really unnecessary a burden.

In France there's a similar system being rolled out currently, Dossier médical partagé, which is opt-in, and contains all of your diagnosis, tests, prescriptions, so that doctors can quickly see your medical history and present.

Unfortunately listening to average doctor is a recipe for illness. Doctors belong to a medieval-style guild that managed to make it illegal to heal other people if you aren't its member, and extremely hard to buy needed drugs for yourself because of prescription (fortunately it's possible now because of internet pharmacies) - the latter of which is borderline slavery.

Against all 'expert' opinion, I'm pretty on average everyone would be better off trying to cure themselves using information from the internet - or at the very least everyone on hn.

My mother had hypothyroidism and got prescribed levothyroxine. She didn't like the idea of taking it forever, and after researching the internet found out selenium deficiency can cause it too. Directed blood test found a severe deficiency. After a month of taking selenium supplements thyroid hormones normalized. Internet self-diagnosis > average doctor.

Yes, why would it take more than an internet search or two to diagnose and fix one of the most complex systems known to man? Having people spend half a decade or more studying this is an obvious absurdity, tantamount to slavery!

Beyond the sarcasm, just like you wouldn't expect StackOverflow to help you fix your company's complex bugs, you can't realistically expect to be able to treat yourself if you don't spend a good year or two researching your specific health issues.

Sure, it's a good idea to read about it and not blindly trust your doctor - sometimes they do make mistakes, assume diagnoses without testing, or even actively seek to prevent you receiving the best care for various biases. Sometimes you have a simple issue and the solution is to simply take a targeted medicine or supplement.

But a lot of the time, the problems are complex, and they interact in complex ways with other issues. For a lot of diseases there are no treatments without serious side-effects, and drugs to address those side-effects can have other side-effects and so on. A lot of symptoms are common to many illnesses, so you need a wide array of information to arrive at a correct differential diagnosis (quickly). Sometimes the differences between symptoms are subtle, and you need experience telling them apart.

Not to mention, while classes of life saving medications are highly addictive, so patient's access to them must be carefully managed to avoid making their lives even worse. Benzodiazepines, as in TFA, are a good example.

There's a big difference between trying to learn everything and about some specific issue. Every doctor would destroy anyone self-taught on general medical knowledge, of course, but in areas that are specifically relevant to that person - anyone of above average intelligence can definitely become more competent than an average doctor, just because the person with a problem is motivated to spend hours or even days finding relevant information. Then there's of course the whole area of surgery where self-treatment is borderline impossible - which is a major part of medical studies.

>For a lot of diseases there are no treatments without serious side-effects, and drugs to address those side-effects can have other side-effects and so on. A lot of symptoms are common to many illnesses, so you need a wide array of information to arrive at a correct differential diagnosis (quickly).

This describes an absolute best case and presents it as the average. Chances are if you go to a doctor with a viral infection you will get a prescription for antibiotics, an obvious absurdity. Why? Because a patient expects 'something', so doing that makes the uninformed patient happier - while in reality, at best it's minimally harmful.

This is so prevalent there are multiple studies about this, eg:

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5093394/

"More than half the GP respondents to the survey in Australia self-reported that they would prescribe antibiotics for an URTI to meet patient expectations. Our qualitative findings suggest that ‘patient expectations’ may be the main reason given for inappropriate prescribing, but it is an all-encompassing phrase that includes other reasons."

More than half! That's the actual quality of care that's being delivered, it's worse than doing nothing at all. Risk of side effects is completely ignored. Millions of people have allergy to amoxicillin, one of the most commonly prescribed one.

My opinion based on my experiences, experiences of others and studies like that - is that advice from an average doctor is completely worthless. Of course there are competent doctors - but there's a contradiction here: for any specific problem, the only way to determine competency is to become competent yourself, but the moment you do, you stop needing the advice. Therefore, as long as you're capable of doing research based on symptoms, and the situation isn't an emergency - going to a doctor is pointless. Yet the law system is doing everything it can to force me.

>Not to mention, while classes of life saving medications are highly addictive, so patient's access to them must be carefully managed to avoid making their lives even worse. Benzodiazepines, as in TFA, are a good example.

This is paternalism and it's abhorrent. In fact I have another related real life story: my grandma has extreme sleep problems and no OTC supplements helped. After some research I decided that etizolam is the safest and most likely to help drug - which turned out to be right, as it worked perfectly for over 2 years, along with a very strong increase in general mood (etizolam itself is mildly anxiolytic - but probably mostly due to more sleep) and mental capability. No side effects reported. Unfortunately it became a controlled substance here (even though in some countries it's a normal prescription drug - at least Japan and Italy) and she definitely didn't want to break any laws. As the daily dose was small (0.7mg before sleep - chosen experimentally as the minimum one that worked), there were no noticeable withdrawal symptoms. Went to a doctor, eventually got a prescription for zolpidem. Result: works for sleep, but also caused an enormous increase in depression symptoms and noticeable memory problems. Real life result from "managing access".

Of course, it seems that in this case that assumption (if indeed that happened) was tragically wrong, and instead the cocktail was a product of doctors disinterested in communication. But such complex treatments can be intentionally prescribed.

I also tried a few many years ago, but they didn't really do anything for me. I think they only work if you got anxiety or something, so some underlying issue which -if chronic- is probably not a good fit. Never had any cravings since.

Probably something to that. I didn't feel much at the prescribed dose. Being curious and foolish, I took 3x. Did feel that. Socially effusive. Good sleep. There was a physical aspect. A warm glow, muscles that felt relaxed rather than stiff. Like waking up in warm sun after a particularly good night's sleep.

People without anxiety, who aren't literally and metaphorically tense, probably get far less of that. But that's what it does for a really anxious person like me, especially with a bit too much. So of course I did it again the next day.

You quickly come to long for, or believe that you're just better off, in that state all the time. But there is tolerance. It stops working like that at the same dose after a few days in my experience. So, take more. I was in big trouble within a month. That's the psychological addiction in my experience, the strong desire or preference for being in that state, emotionally.

I couldn't stop. No physical consequences but intolerable withdrawal mostly of rebound anxiety and insomnia. I eventually got off them with a very long taper. ~5 months with the dose adjusted weekly. No significant physical withdrawal. At the right dose of a long-lasting benzodiazepine, I felt like before I had started taking them, more or less. I did have to learn to deal with the psychological need to be more disinhibited than normal. If I could do that, and not escalate doses, getting off would be possible. It was, and I haven't taken any since the last dose of the taper. I think about that state and sometimes I do long for aspects of it, but they're not really cravings anymore. Only get those for nicotine.

I tend to see it a bit like “medication stabilizes; therapy heals”.

I tend to see the opioid epidemic (which is comparable to the current benzo problem) as a systemic failure. You were handed a loaded gun and no one taught you how to use it.

Our medical system is designed to be transactional, but the experience of a chronic condition is a narrative.

Psychoactive medications are fun…

Now that I think of it, a benzo actually did help me once, when I got my wisdom teeth removed. Made me a bit more calm about it. But it was fairly tolerable overall anyways.

I trust the person who told me that, but have heard a lot of benzo horror stories.

(I'm not afraid of flying)

Even such a small dose I feel restores a sense of normality that I haven't experienced in over 10 years without them, I'm able to rationalise what I want to say, conversation flows, I feel in control. With all that said, I've been doing this for a while and have never come close to addiction and no noticeable side effects. I continue to work on the underlying causes but without them I would be much worse off.

Propranolol blocks the physical symptoms of anxiety. It stops your hear rate and blood pressure from rising. It stops those uncomfortable adrenaline rushes. It stops stress-induced trembling / shaking.

It's completely safe, any doctor will happily prescribe it, it's not addicting, and unlike benzos, it doesn't affect your cognition.

I take it a few times a week as needed, small doses (2-5mg) and I feel that I am in control of it and could go off any time.

I think it also helps that edibles take 60-90 mins to kick in, vs smoking which is pretty immediate gratification.

I would argue that taking a drug to cover over something like anxiety is exactly the sort of circumstance that usually ends up with people being addicted/dependant. If I were you, I'd start addressing those root causes ASAP.

How do you know a person you're advising over the Internet hasn't already tried?

How do you know they weren't abused as a child, or a veteran suffering from PTSD, or a rape victim or any other number of things where the root cause is probably never going to be fully resolved, just managed.

There's a tragic amount of hate for doctors in this thread, and I really mean tragic because it's going to result in someone out there not getting the help they need, because they think they and the Internet are smarter than a doctor.

The medical profession has the right answer here, which is that in general for serious psychiatric disorders, you use a combination of drugs and therapy in order to get results. Drugs get you immediate results with a higher degree of reliability. Therapy is less consistent, expensive and slow, but when it works the effects are mostly permanent and side effect-free.

Now does the US system over-prescribe drugs and is it fucked up by cost pressures? The answer is way too often 'yes,' but people are conflating this with "doctors are awful."

There are people who need the drugs now as well as people who will need them forever.

There are also worse fates than addiction.

This isn't my experience with cannabis: it does relieve anxiety but it also makes me unable to get anything done, which defeats the purpose.

If you have been taking benzos for 20 years you might have an addiction. Parent poster was talking about cravings a year later.

https://www.ama-assn.org/press-center/press-releases/ama-ana...

https://www.healthcarefinancenews.com/news/nearly-70-us-phys...

https://www.webmd.com/health-insurance/news/20210527/more-an...

Yes but easier comes with a greater cost.

This is widely true for broader society where we are all busy taking the convenient solution over the harder, proper way, because screw long-term.

Sometimes, you have to realise that what pharma companies list as 'side effects' are not that at all, they're effects. Think about that.

It isn't like we are choosing easier because we are lazy. The reason it is easier to say is because with a lot of diseases and afflictions, we simply do not know the cause or do not know how to treat it. And honestly, it is Much better to treat symptoms than to treat nothing at all. Heck, sometimes it might mean death - like in the case of diabetes - or more suffering and disability - like with MS.

It isn't just because we are taking the convenient solution, in other words, and I find it disingenuous not to remember that we have a lot of holes in our medical knowledge and to realize that our imperfect knowledge leads to much of this.

And redefining side effects isn't really helpful. Sure, the medicine causes them, but it isn't like any researcher or doctor is trying to make you have unwanted effects. They are there because we don't yet know how to do the treatment without unwanted effects, and we still do it because sometimes those are better than the disease.

I don't think "big pharma" is innocent, mind you, but it doesn't help anyone to focus on conspiracy theories when you could be looking at things that actually happen and including other organizations that allow the abuse to continue (for profit medicine, for example).

It’s harder to clear trauma, teach emotional regulation and to build a life that is healthy, yes. And, it’s a path worth walking down.

Have you been hiding under a rock? American doctors are completely corrupt and in the pockets of "big pharma". They've gotten millions of Americans addicted, and caused countless deaths and unimaginable human suffering.

Would that not mean the same to your own?