not anymore, in certain parts of the country there is actually an issue of under-prescription of narcotics as an overreaction to the opioid crisis we are facing, with painkillers of course being the most difficult to access. Chronic severe pain patients and people with horrendous neurological conditions are going without the medications they need because prescribers are now terrified of heavy-handed medical boards
that said, 20 or so years ago prescribers in the U.S. were in various ways made to believe that painkillers such as oxycodone were not addictive and were these magical drugs that helped pain patients regain their lives in ways we had never seen before. Ended up in so many homes, lots of excess prescription opioids hanging around and as a result a lot of people ended up abusing them. For a significant number of people that led to heroin use, and then fentanyl came into the picture in 2015ish; so that's how we got here. heroin on its own when injected isn't actually that easy to accidentally overdose on- fentanyl however, is.
The death rate from prescription opiates has not budged since 2006[1]. The vast majority of opiate overdoses in America are not prescription opiates, but illicit fentanyl, and to a lesser extent heroin and methadone. Nor do chronic pain patients face any major risk of overdose. The fatal overdose mortality rate for long-term opiate-prescribed patients is 17 per 100,000[2]. And that number doesn't exclude the subset of the population engaged in abusive behavior like mixing with alcohol, snorting pills, or hoarding medication.
Finally the sizable majority of prescription drug abusers in this country do not source from a doctor or the healthcare system at all. The vast majority get their drugs either from the black market or a friend or relative. On the National Drug Use Survey only 18% of prescription drug abusers report doctors as their primary source. And among street prostitutes (a high at-risk group) only 5%[3].
All of this goes to show that there is very little evidence of any sort of over-prescription of opiates in America. To begin with the vast majority of the opiate crisis has to do with fentanyl, not prescription drugs. But even when it comes to prescription drug abuse, the intersection with medical users is vanishingly small.
Yes, restrictions on prescriptions, meant to stop people from getting hooked and cut down on illegal distribution, plus some crackdowns on pill mills have driven people already addicted to cheaper, more available opioids.
"Heroin-related deaths more than tripled between 2010 and 2015, with 12,989 heroin deaths in 2015. The largest increase in overdose deaths from 2014 to 2015 was for those involving synthetic opioids (other than methadone), which rose from 5,544 deaths in 2014 to 9,580 deaths in 2015. One of these synthetic opioids, illegally-made fentanyl, drove the increase. It was often mixed with heroin and/or cocaine as a combination product—with or without the user’s knowledge." [0]
But the rate of increase for death by prescription opioid has been greater than non-prescription so they are nearly half of all deaths.
prescription opiates started the problem with heroin. the history of oxycontin is a sad one for the country. with the recent pharma/biotech explosion, lots of companies are trying to get in on the painkiller game as well. there's really no need for much of it. I've had multiple minor surgeries in the past few years and the doctors have never wanted to give me painkillers. Just take some tylenol.
We've probably had less of a need for legal painkillers than ever - surgery and medical technology keeps getting better and better - minimally invasive and the like - and yet we have more legal painkillers than ever. Something doesn't add up.
Yeah, much of the 'opioid crisis' is entirely manufactured by how we've dealt with things. If doctors had recognized opioids as habit-forming and planned ahead of time to wean patients off of them with a long period of gradual tapering down in dosage (so if it takes 6 months or more, so what?) before quitting. Instead, they decided 'addiction' was a moral failing and simply stopping giving anyone prescriptions no matter how legitimate the need.
One thing that rarely gets mentioned is how abundantly SAFE opiates are. If you know what you're getting, know what dosage it is, and know it's not adulterated with other substances, you can use opiates for decades without significant health complications (aside from constipation). Overdoses primarily happen with people mixing medications, trying to use unfamiliar medications recreationally (nothing can save a stupid person who wants to get high but can't be bothered to figure out what the right dose for that is for their body mass), or, most often now, having to get things from a black market where the supply is unknown potency or contents.
Fundamentally there is one group of people who is angry that other people are using a chemical to feel good because they feel that if other people aren't suffering as much as they have then they were cheated somehow. And they've been driving policy since the 80s, costing countless lives and monumental amounts of resources. Just to make sure no one has an easier time of life than they had.
4 out of 5 pharmacy-filled prescriptions are opioids.¹
In almost every single case, those using these drugs are trying to escape the physical and/or emotional pain. They didn't wake up one day and say "I want to have fun, I'm going to do heroin"
Almost every fentanyl user I've talked to in harm reduction work started out on prescribed painkillers. Whether they got the taste and moved up quick, or just couldn't get their fix and couldn't deal with the horrible weeks of withdrawal and found a place to get it, they didn't just up and start shooting fentanyl one day.
> Patients have told me it's become increasingly difficult to get prescriptions for quite modest doses of opioid agents they've used for years without dose escalation. The tendency to throw babies out with the bathwater is not unique to this situation, but no less problematic.
I have experienced this as well. Not only are doctors now reluctant to prescribe opioids, but you as a patient are suspected to be a drug-seeking addict by everyone in the chain: doctors, nurses, and pharmacists. People complaining that it's too easy to get pills clearly haven't had to manage a chronic pain condition in the past couple of years.
Opiates are also a fun and addictive drug. As long as they exist and are generally available, some percent of the sub-population will abuse them. We can try our best to keep them only for medical use, but once the prescription leaves the pharmacy there's not much you can do. You can't blame the legal manufacturer when that happens, if they took all required steps to keep their drugs in the legal channels. Maybe you think that's true, but that the opiate manufacturers have used their power and influence to over-prescribe their products. That assumes that opiates are over-utilized in American healthcare. And that's a narrative that simply isn't borne out by the data.
Only 0.19% of opiate-treated chronic pain patients without a prior history develop any form of abuse or addiction[1]. And remember these are chronic-pain patients who take tolerance-escalating doses over years or even decades. Virtually no one develops an opiate addiction from following their medically prescribed treatment regiment.
The death rate from prescription opiates has not budged since 2006[2]. The vast majority of opiate overdoses in America are not prescription opiates, but illicit fentanyl, and to a lesser extent heroin and methadone. Nor do chronic pain patients face any major risk of overdose. The fatal overdose mortality rate for long-term opiate-prescribed patients is 17 per 100,000[3]. And that number doesn't exclude the subset of the population engaged in abusive behavior like mixing with alcohol, snorting pills, or hoarding medication.
Finally the sizable majority of prescription drug abusers in this country do not source from a doctor or the healthcare system at all. The vast majority get their drugs either from the black market or a friend or relative. On the National Drug Use Survey only 18% of prescription drug abusers report doctors as their primary source. And among street prostitutes (a high at-risk group) only 5%[4].
All of this goes to show that there is very little evidence of any sort of over-prescription of opiates in America. To begin with the vast majority of the opiate crisis has to do with fentanyl, not prescription drugs. But even when it comes to prescription drug abuse, the intersection with medical users is vanishingly small.
However what there is a major problem in America is untreated chronic pain. 50 million American suffer chronic pain[5]. And 20 million suffer high-impact chronic pain which severely impairs normal life function. More than 10% of suicides are linked to chronic pain[6]. High-dosage opiates are absolutely essential for this group to live any sort of normal life. As long as there are such massive numbers of legitimate pain patients, the law of large numbers guarantees a large supply of diverted opiates. Even under the tightest controls. There's simply no way around that except by denying most of the legitimate patients treatment for their debilitating conditions.
We spent the better part of decade catching and locking up doctors who prescribed opioids out of guidelines, so much so that doctors are now terrified of prescribing them to people who legitimately need them.
The problem is that the prescribing guidelines, which were written by the pharmaceutical companies themselves, described a regimen that would get pretty much anyone physically addicted to their product.
So you had doctors acting in good faith, prescribing medications only when indicated and following their manufacturer's prescribing guidelines, inadvertently creating new addicts where the manufacturer's literature said there would be none.
Not only that, but we spent several decades treating chronic pain patients with opioids, such that they are completely dependent on that class of drugs to manage their condition. Only very recently have prescribing guidelines adjusted to reflect the reality that opioids are not a good treatment for chronic pain. When those pain patients are driven off of their opioid prescriptions, even if their doctor is well-meaning, some of them turn to heroin/fentanyl to manage their pain.
You're perpetuating a myth that drug use is all about personal choice. Many addicts started with prescription opioids, recommended by their doctor, and only moved to more dangerous options once their doctor's supply was extinguished. Doctors themselves over-prescribed these to attack pain, meanwhile they were being lied to by pharma about the addictiveness of opioids. On top of that, you have fentanyl being added to heroin to increase its potency, and also vastly increase the mortality rate.
Finally, it may be hard for those of us who were never addicted to opioids to understand. It no longer becomes a simple choice when your body is extremely sick if you don't get your dose. This is one reason why a drug addict might steal from those they love, their illness is literally the most important physical sensation at any moment, overcoming familial and societal norms. It's a scourge and illness, not merely a choice.
This seems to underestimate the impact of prescription pain killers on the opioid crisis.
"A study of young, urban injection drug users interviewed in 2008 and 2009 found that 86 percent had used opioid pain relievers nonmedically prior to using heroin, and their initiation into nonmedical use was characterized by three main sources of opioids: family, friends, or personal prescriptions (Lankenau et al., 2012). This rate represents a shift from historical trends. Of people entering treatment for heroin addiction who began abusing opioids in the 1960s, more than 80 percent started with heroin. Of those who began abusing opioids in the 2000s, 75 percent reported that their first opioid was a prescription drug (Cicero et al., 2014)."
I think a part of what's driven the opiate epidemic was the massive overprescription of opiate painkillers by doctors and the marketing surrounding them.
People tend to trust that their doctor is right. If the doctor gives you oxycodone, you assume that it's safe.
Tied in with that is the increased availability of heroin and fentanyl, and now decreased availability of prescription painkillers, pushing users from taking relatively safe pills to injecting drugs, which is an order of magnitude more damaging.
Wasn't the problem with opioids in the US that doctors already did prescribe them too freely? The fact that there's now a backlash after it caused a massive problem cannot be the reason that doctors have historically been sceptical about pain (and not just in the US but elsewhere where prescription opioid abuse has not been a problem!)
I was looking through the literature to see if there was good evidence for this, but didn't find much. This paper seems to address the issue most directly, but fails to find much of a causal relationship; indeed, the increase in heroin use predates the reversal in opioid prescription trends.
I don't doubt that prescription opioid abuse is itself a problem, nor that it may exacerbate the heroin epidemic, but the evidence suggests that it does not play a large casual role.
Most people addicted to opioids started with legally prescribed meds. Those meds may not have been prescribed to them, but that's the problem with the fucking stupidly large numbers of opioids being prescribed in the US: there are very many meds lying around to be diverted to recreational use.
So far almost every point you've made in this thread can be directly sourced to Purdue propaganda. Doesn't that worry you?
Here's Purdue Pharma saying, as you are here, that pain meds aren't that addictive and don't we need to use opioids to treat pain (they are addictive, and they don't work for many types of pain): https://www.feinberg.northwestern.edu/sites/ipham/conference...
"The United States makes up only 4.6 percent of the world's population, but consumes 80 percent of its opioids -- and 99 percent of the world's hydrocodone, the opiate that is in Vicodin." [1]
I spend a lot of time listening to podcasts where addiction medicine doctors talk about the state of their industry. Their views and their guests views, are almost in complete alignment and those views are the exact opposite of the comments in this thread. I find that alarming.
If you listen to addiction medicine doctors, they will tell you:
1) There is a massive epidemic of opioid addiction. Opioids are wildly addictive and are negligently / over prescribed.
2) There is little evidence that opioids provide benefit for long term chronic pain and evidence that long-term use of opioids actually causes many problems. Getting off the opioids tends to reduce the chronic pain.
3) Patient surveys rule supreme and patients want pain-killers even if the doctor does not believe they are the solution.
Anecdotally, if you watch the A&E show "Intervention", the number of opioid and heroin cases has shot through the roof since the series started two decades ago. There has been a titanic shift in addiction. It's painful to watch some of these addicts lie to their doctor to get opioids, turn around and sell them, then use the money to get heroin because the opioids aren't strong enough anymore.
I remember that about a decade ago, doctors and others were criticizing the DEA for being draconian in their regulations surrounding opiate prescriptions. They were complaining that doctors often felt that they couldn't prescribe even when there was legitimate need.
I don't know what happened in the interim, whether or how the DEA's policies changed, but if only we had draconian DEA policies aggressively stopping overprescription now.
As someone who used to naively believe in legalizing all drugs for recreational use, this addiction epidemic has opened my eyes to why that's a horrible idea.
On the other hand, opiates are generally not readily available everywhere (and the current opioid epidemic in the US is an example of regulations and healthcare providers failing to work as intended, with Purdue Pharma pleading guilty to 3 Federal criminal charges a while ago as a result) which was not always the case. See also:
that said, 20 or so years ago prescribers in the U.S. were in various ways made to believe that painkillers such as oxycodone were not addictive and were these magical drugs that helped pain patients regain their lives in ways we had never seen before. Ended up in so many homes, lots of excess prescription opioids hanging around and as a result a lot of people ended up abusing them. For a significant number of people that led to heroin use, and then fentanyl came into the picture in 2015ish; so that's how we got here. heroin on its own when injected isn't actually that easy to accidentally overdose on- fentanyl however, is.
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