Let's Talk About The Opioid Problem

[old goat]

I don't disagree with most of your post, but I do with this part. The drug companies were bribing docs and the docs were telling everyone that oxy and the like weren't addictive. Even after Oxy was shown to be as addictive as other opiates and Purdue Pharma paid a $600m penalty in 2007, they continued bribing docs to prescribe it for chronic pain (which it was shown didn't work) because they made so much money on it. So no, a lot of people didn't really know they were doing something wrong. They were in pain, and a trusted medical professional may have told them it was safe. Once they got hooked, then the nastiness of addiction takes over, but at the start, they were just like anybody else.

https://www.govinfo.gov/content/pkg/...6hhrg43010.htm

They certainly bribed docs--especialy the ones they hired to give talks about Oxycontin to other docs, but they didn't need to bribe all the docs or even most of them. Chronic pain is very frustrating to treat and docs were happy to convince themselves that oxycontin was different.

And if you work in healthcare, you'll also know that Joint Commission in 2001 urged (demanded) us to consider pain as "the fifth vital sign" and that pain was "what the patient tells you it is" and that treating this pain was a "patient right". They had patient survey's that included "How often did the hospital or provider do everything in their power to control your pain?” This bullshit was thought to at least contribute to the opioid crisis, so much that the Joint Commission even published a "It wasn't our fault" memorandum of sorts.

Is big pharma to blame, yes. Are providers to blame.....yes, but placating a drug seeking patient isn't easy. Placating is easy now, because we just say fuck off, not prescribing narcotics for your XYZ diagnosis. And yes, I think Joint Commission is also to blame.

It was the JC and a whole lot of other people. But the JC evaluates hospitals, not outpt practice; they were talking about hospitaized patients with things like surgery and broken bones. The physiologic benefits of adequate analgesia are well documented--it alows good respiratory hygiene, eary mobilization, decreased cardiovascuar stress, decreased cortisol levels, less pneumonia, less blood clots, earlier return of bowel function due to mobilization (until you want to take a shit). I never bought in to the 10 point scale but I tried to make sure my patients had adquate analgesia (that doesn't mean no pain) before the JC statement, after it, and after the opioid epidemic was front page news. Acute inpatient pain management and the outpatient management of chronic pain are night and day.

Rare to get declined opioids in ambulance transfers for legit reasons. I dislocated my shoulder skiing, alone, couldn’t drive manual transmission and called medics. They gave me morphine 2mg and I said that won’t go shit give me more, and they did. Required no sedation for reduction at arrival to ED…no further meds.

Time and a place.

When I dislocated mine it was relocated--painlessly-- by the ER nurse working in the patrol shack. Then I went to the ER for an xray and saw a guy with a dislocated shoulder getting just Toradol for reduction. It ddn't sound like he was having a good time. I was very glad that nurse was so good. (I was told to tell the ER doc that the shoulder popped back in when they took off my coat.)

[ötzi]

That 10-point scale has cost me some pain. I'm always like, well, I don't know how much something can possibly hurt, but this is clearly less than that, so I dunno, 5? 6? From now on I'm going the Spinal Tap route.

[Touring_Sedan]

I ate shit on the mountain bike a few years ago and ended up getting with a bunch of broken ribs and half a collapsed lung. Knowing my family history and all I've encountered at work I was pretty frank with my doctor and told him that I wanted the bare minimum when it came to the pain pills. I don't remember the specifics, but I do remember that I was grossly over prescribed with an equally absurd number of refills. I understand the doctor / patient satisfaction metrics he was operating under, but I was a young guy, he was a young guy and I thought we had an understanding. I don't know what the disconnect was.

[Dantheman]

Rare to get declined opioids in ambulance transfers for legit reasons. I dislocated my shoulder skiing, alone, couldn’t drive manual transmission and called medics. They gave me morphine 2mg and I said that won’t go shit give me more, and they did. Required no sedation for reduction at arrival to ED…no further meds.

Time and a place.

FWIW, at equivalent doses there's no functional difference morphine and heroin. Heroin is a brand name for diacetylmorphine. Upon crossing the blood-brain barrier the acetyl groups get cleaved off and the active agent is morphine. Experienced users cannot tell the difference between heroin and morphine at equivalent doses under blind conditions.

That 10-point scale has cost me some pain. I'm always like, well, I don't know how much something can possibly hurt, but this is clearly less than that, so I dunno, 5? 6? From now on I'm going the Spinal Tap route.

I'll happily take all the drugs I can get when they're being legally offered to me. Oxy is great. 5 mg and a movie is a lovely chilled out Friday evening. Taking more than that, every day? Fuck that, never had the slightest desire. I once had to take them for a week when I shattered my clavicle. I couldn't wait to get off them and could barley look at the bottle for at least a month afterwards.

[riser4]

That 10-point scale has cost me some pain. I'm always like, well, I don't know how much something can possibly hurt, but this is clearly less than that, so I dunno, 5? 6? From now on I'm going the Spinal Tap route.

Ya, im not a woman who has given birth nor have I passed out from the pain yet, so it's obviously not a 10.

[ötzi]

"This Pain goes to Eleven!"

[Buzzworthy]

"This Pain goes to Eleven!"

When I dropped a cinder block on my left toes one July wearing flip flops, I’ve definitely said this.

[bennymac]

It's fucking pathetic that this is even a matter of debate.

its more complicated for an ER doc to prescribe suboxone when compared to just saying "here take one of these pills once a day for a week for your sore throat". There is training involved for the doctor, there is timing the start of the medication, there is dosing it properly for the particular patient, there is considering what clinic is going to followup with the patient and monitor it etc - logistics that aren't needed in a lot of ER cases. And the patients that need suboxone often don't have a reliable method of ongoing medical care.

I am in no way saying it can't or shouldn't be done - it's a travesty that as a society we aren't pulling out all the stops on par with say our covid response. Just want to be clear this isn't just as simple as saying "ER docs just don't want to prescribe it"

Dan you may know all this - my response is not directed at you specifically.

[Trackhead]

Old goat….agree with all and we all come at this discussion from our own life/work experience. I’m ER mostly, and we certainly dealt with a shit ton of drug seeking behavior. Your world in surgery/post op is obvious very different. It’s not like we’re withholding dilaudid from femur fractures, but we’re also mostly not giving it to every migraine that walks through the door (like we used to),

And for those with skepticism and disdain for prescribers…regarding suboxone or XYZ controlled substance. We are essentially required/encouraged to check your “background” via multi-state database before prescribing controlled substances. It gives the prescriber a handy summary of past prescriptions, prescriber, quantity, and essentially overdose score. And what Bennymac said, it’s a nuanced discussion that is patient specific. I still write for small quantities of narcotics but far less frequently than the days of old. By enlarge, patients in the ER or outpatient setting seem to understand the limits we place on prescribing controlled substances, far different than say late 90s early/mid 2000s.

DTM, I’ve given enough intravenous, intranasal, oral, and intramuscular narcotics (Demerol, hydromorphone, morphine, fentanyl, sufentanil, methadone, nalbuphine, butorphanol, etc) to have a pretty solid grasp on efficacy across a diverse group of adult and pediatric patients, including addicts of all persuasions

[Jacques Strap]

Opioids are indispensable in pain management, nothing else works like them.

A variety of opioid receptor sub-types are important for analgesia, but opioid dependence is strongly correlated with mu-reception agonism.

I don’t think it’s crazy to imagine a selective opioid receptor agonist or mixed agonist/antagonist that could inhibit pain without such high addiction potential. But yeah, probably shouldn’t believe you’re being sold the magic bullet when oxy looks like morphine (with all those tasty functional groups in all those perfect places)

[Trackhead]

Bring back the Demerol! Patients loved it! Put a smile on everyone’s face. And killed a coworker of mine on the job (dead in the bathroom).

[old goat]

Early in my career I tried to kill a young woman with Stage 4 ovarian cancer and repeated bowel obstructions with Demerol. The metabolite normeperedine causes seizures and other neurotoxicity. That was the last time I used it and I haven't seen anyone else getting it since then. (That was one of those cases I can't get out of my mind, not because of the Demerol reaction but the whole situation.)
TH--I know you know.

One thing that needs to be discussed more are the side effects of NSAIDS and Tylenol. They're not benign either. Liver and kidney failure, GI bleeding. Increased risk of heart attacks. And IME the neuroactive pain reiievers like Neurontin are crap.

[skaredshtles]

Early in my career I tried to kill a young woman with Stage 4 ovarian cancer and repeated bowel obstructions with Demerol. The metabolite normeperedine causes seizures and other neurotoxicity. That was the last time I used it and I haven't seen anyone else getting it since then. (That was one of those cases I can't get out of my mind, not because of the Demerol reaction but the whole situation.)
TH--I know you know.

One thing that needs to be discussed more are the side effects of NSAIDS and Tylenol. They're not benign either. Liver and kidney failure, GI bleeding. Increased risk of heart attacks. And IME the neuroactive pain reiievers like Neurontin are crap.

There's always weed, man...

[MontuckyFried]

Interestingly enough, on the OTHER end of the spectrum, there are also people who have undergone major pain relief and as a result want nothing to do with it ever again due to the side effects they experienced. Person close to me who was intubated and ventilated for a long time then went through a VERY long and painful recovery at the hospital was on heavy doses of fentanyl, morphine, and all the rest. The right course of treatment, as the pain was so severe and agonizing, it may have been almost lethal without the relief. Anyway, they told me that even though they were "knocked out" for most the initial months long recovery, they were very much dreaming a bunch of vivid nightmares they couldn't escape or wake from. They remembered all sorts of nightmarish things they thought were real until we had to tell them that no such things happened, much to their relief. Anyway, long story short, she told me that she will NEVER touch the stuff recreationally or ANY such drug that should be reserved for medical treatment. Even if her body/brain was telling her she "needed" it as she continued recovery and therapy at home, her logic dictated "no effing way." An awful experience for her, and for many others. I know everybody's different though, so maybe some get more of the euphoric effects without the scarier feelings, thus the temptations to use it outside of the hospital or beyond recovery.

[Trackhead]

Early in my career I tried to kill a young woman with Stage 4 ovarian cancer and repeated bowel obstructions with Demerol. The metabolite normeperedine causes seizures and other neurotoxicity. That was the last time I used it and I haven't seen anyone else getting it since then. (That was one of those cases I can't get out of my mind, not because of the Demerol reaction but the whole situation.)
TH--I know you know.

Yeah, this nurse had a seizure at work, was admitted, discharged, no tox screen. Three weeks later dead in bathroom while at work in ER. We coded her for 30 minutes. Pants around ankles, slumped on floor. Demerol toxicity, likely seizure, cardiac arrest. Years ago had ICU nurse collapse while at work, in patient bathroom, 20cc syringe propofol found on floor. Suicidal??? We bagged him for a minute or two, woke up. Obviously he didn't finish his shift. I've known countless good nurses who have been drug diverters. It's sad.

Patients loved demerol.....apparently has norepi/dopamine inhibition and a better buzz. I haven't seen it since about 2006 or so. People used to request that shit by name, like dilaudid now. And ortho loved it.

[Boissal]

Opioids are indispensable in pain management, nothing else works like them.

Nonsense. Opioids are a great tool for acute pain management but don't do shit for chronic pain. And NSAIDs are equally efficacious for management of acute low to mid grade pain (however you want to define that). Since both are biochemical hammers, not refined tools, you get a whole lot of off-target effects and associated toxicities. Pick your side effect profile and go with it, NSAIDs will trash your gut and metabolism/excretion systems but won't kill you on the spot or turn your into a fiend.

A variety of opioid receptor sub-types are important for analgesia, but opioid dependence is strongly correlated with mu-reception agonism.
I don’t think it’s crazy to imagine a selective opioid receptor agonist or mixed agonist/antagonist that could inhibit pain without such high addiction potential. But yeah, probably shouldn’t believe you’re being sold the magic bullet when oxy looks like morphine (with all those tasty functional groups in all those perfect places)

It's crazy enough that it hasn't been done yet, and that's not for lack of trying. There's a massive amount of money being poured into this line of research, and it's a lot more complex than balancing agonism/antagonism against a pair of receptors. Biologically, we understand pain just about as well as we understand neurodegeneration or depression: barely at all, and half of what we thing we know is most likely wrong.
Contrary to popular belief pharma is not omniscient. If we could generate the silver bullet, we would. And we'd sell it for ALL THE FUCKING $$$$.

[Dantheman]

its more complicated for an ER doc to prescribe suboxone when compared to just saying "here take one of these pills once a day for a week for your sore throat". There is training involved for the doctor, there is timing the start of the medication, there is dosing it properly for the particular patient, there is considering what clinic is going to followup with the patient and monitor it etc - logistics that aren't needed in a lot of ER cases. And the patients that need suboxone often don't have a reliable method of ongoing medical care.

I am in no way saying it can't or shouldn't be done - it's a travesty that as a society we aren't pulling out all the stops on par with say our covid response. Just want to be clear this isn't just as simple as saying "ER docs just don't want to prescribe it"

Dan you may know all this - my response is not directed at you specifically.

Sure, there are logistics involved. What's pathetic is that we're still debating whether MOUD is a legitimate treatment. Switzerland has had heroin clinics for decades now and AFAIK they're very successful.

DTM, I’ve given enough intravenous, intranasal, oral, and intramuscular narcotics (Demerol, hydromorphone, morphine, fentanyl, sufentanil, methadone, nalbuphine, butorphanol, etc) to have a pretty solid grasp on efficacy across a diverse group of adult and pediatric patients, including addicts of all persuasions

That was more of a general comment. I don't think most people understand that pharmacologically heroin = morphine. From an evidence-based perspective it's clear that heroin should be a Schedule II drug just like morphine, fentanyl and every other opioid. The side effect profile is actually better than morphine.

Interestingly enough, on the OTHER end of the spectrum, there are also people who have undergone major pain relief and as a result want nothing to do with it ever again due to the side effects they experienced. Person close to me who was intubated and ventilated for a long time then went through a VERY long and painful recovery at the hospital was on heavy doses of fentanyl, morphine, and all the rest. The right course of treatment, as the pain was so severe and agonizing, it may have been almost lethal without the relief. Anyway, they told me that even though they were "knocked out" for most the initial months long recovery, they were very much dreaming a bunch of vivid nightmares they couldn't escape or wake from. They remembered all sorts of nightmarish things they thought were real until we had to tell them that no such things happened, much to their relief. Anyway, long story short, she told me that she will NEVER touch the stuff recreationally or ANY such drug that should be reserved for medical treatment. Even if her body/brain was telling her she "needed" it as she continued recovery and therapy at home, her logic dictated "no effing way." An awful experience for her, and for many others. I know everybody's different though, so maybe some get more of the euphoric effects without the scarier feelings, thus the temptations to use it outside of the hospital or beyond recovery.

Among the general population this is the norm, not the exception. Most people do not experience euphoria from opioids (https://www.livescience.com/opioid-e...ly-a-myth.html) and most people who try heroin do not become addicted (https://www.livescience.com/62701-od...ependency.html).

Addiction is a complex psychological phenomenon of which the drug itself is just one component (hence why behaviors can become addictions). Things like a high ACE score and/or PTSD/depression/anxiety all dramatically increase the likelihood that someone will develop clinical substance use disorder, which requires uncontrolled use of a substance despite harmful consequences. Opioids are extremely effective at treating psychological pain, in the short term until they stop working and you're addicted. Look at that Reddit post from earlier. Watch junkie interviews on Soft White Underbelly. Look at clinical data on OUD. The common thread in studies and anecdotes is that these people are self-medicating to relieve psychological pain from untreated trauma. Opioid addiction is a symptom of society's inability to treat that trauma.

[bennymac]

agreed - which is why having an infinite number of Narcan kits handed out for free will save lives (often just temporarily) but will do nothing on it's own to change the situation - that's the wrong end of the problem

[SumJongGuy]

^^^^Just like the actual drug, the first one's free? Send one per household but no bottomless supply because these are tests you're only allowed to fail once before being require to go to treatment..


I just had a morbid thought.. How often do you hospital maggots see people who clearly injured themselves, and BADLY to get more opiates from the doctor/hospital? I'm imagining someone gets told no more refills PERIOD then just goes and does something really stupid and dangerous to go back to the hospital with a new injury..

[Trackhead]

I just had a morbid thought.. How often do you hospital maggots see people who clearly injured themselves, and BADLY to get more opiates from the doctor/hospital? I'm imagining someone gets told no more refills PERIOD then just goes and does something really stupid and dangerous to go back to the hospital with a new injury..

I've seen it a handful of times with males under the age of 30 with frequent shoulder dislocations. Like dudes coming in with 10+ dislocations, and they don't go to surgery/orth consult. But they love getting sedated with XYZ drugs.......then hope for a discharge including narcotics. Sounds odd, but we do see it in ER. That's the only pattern I've seen. Demographic is always the same.

[Jacques Strap]

efficacious

Sure. But I didn’t say anything about chronic pain.

And I know it’s a difficult MoA and set of properties to achieve, even though there are tons of candidates in the pipeline, which is why I said it wasn’t necessarily crazy to think maybe this new compound had done it… until you take one look at the thing. After which, any MD should’ve been demanding some extraordinary evidence for these extraordinary claims.

Still, I’m glad you said your comments, because I agree with all of them.

[Trackhead]

Perhaps more interesting than opioid addiction and a bigger public health crisis is the concept of endogenous opioid release after consumption of “hedonistic” foods. Lotta studies looking at naloxone and reduction in binge eating/weight loss…Hence Contrave, the Wellbutrin/naloxone combo FDA approved weight loss med with a hypothesis of blocking “anticipatory food reward”….

A bigger public health crisis involving opioid receptors/obesity….[/thread drift]

[Dantheman]

Didn't you see that 60 Minutes a few weeks ago? It turns out that obesity is mostly genetic

Naloxone has also been shown to block the antidepressant effect of ketamine despite ketamine having no direct action on the mu opioid receptor. Weird shit that really shows that we don't fully understand the mu opioid receptor's function.

[Trackhead]

Yeah human reward system is pretty interesting and often destructive.

[SumJongGuy]

So fructose corn syrup is the fentanyl of the food world?

Ya I know that's the worst hyperbole ever. End of the day, fat shaming is no different than alcohol or drug shaming..