Who's at Fault for the Opioid Epidemic?

[rb]

My understanding is that for heroin and all opioids its pretty difficult to have a fatality without also using alcohol or some other drug.

 

People can survive without overdosing for years. The problem is nearly always mixing drugs.

I'm pretty sure you can overdose if you use enough but people don't cause they know their dosage and tend to OD when they move away from their dosage by adding alcohol or some other drug. It seems we have MDs on this thread so maybe they can answer this better than me.

 

But further to your point, let's say you have Leanne the suburban housewife who's zonked on xanax with a side of chardonnay. Nobody has a problem with that cause they probably don't know and this way she's pleasant and bakes cookies so they don't ask many questions. Now say that the Xanax producer replaces the alprazolam with some fentanyl. Now she's taking fentanyl with a side of chardonnay and no opioid tolerance. She overdoses.

 

This is not a totally unrealistic scenario as they did find plenty of Xanax and other drugs that were really fentanyl. Check the picture below that is relevant to my previous post as well. It sure looks like something significant happened to fentanyl around 2013.

 

[mrholty]

This is a hard thread for me to read right now.  My niece just lost her boyfriend to a heroin overdose this week. 

 

What blows me away is that my county has had 2 deaths this week from heroin.  Both drugs were cut with elephant tranquilizers.  What?  How does one get elephant tranquilizers and decide that is what you are going to use to cut. 

 

 

[LC]

My condolences, mrholty. That is tragic.

 

There was a person in an old neighborhood of mine who worked in a horse stable. There were always shady characters in and out of her apartment. My guess was she was supplying people with horse tranqs, probably for the same reason you mention.

[rkbabang]

This is a hard thread for me to read right now.  My niece just lost her boyfriend to a heroin overdose this week. 

 

What blows me away is that my county has had 2 deaths this week from heroin.  Both drugs were cut with elephant tranquilizers.  What?  How does one get elephant tranquilizers and decide that is what you are going to use to cut. 

 

That has more to do with it being illegal than it does the heroin itself.  I think the fact that they are illegal kills far more people than these drugs would if they were simply sold like Tylenol over the counter.  A huge reason people OD is that they don't really know what they are taking or the proper dose for the purity/mixture they have just purchased.  Is it cut with elephant tranquilizers, rat poison?  Does it have fentanyl in it?  Is it more pure than the stuff you bought yesterday or less?  How would you know?  It isn't like you can sue the manufacturer if it isn't what you expected.  I know that the Advil I buy at CVS isn't cut with elephant tranquilizers just like I know the vodka I buy at the liquor store isn't going to make me blind or kill me.

 

[mrholty]

This is a hard thread for me to read right now.  My niece just lost her boyfriend to a heroin overdose this week. 

 

What blows me away is that my county has had 2 deaths this week from heroin.  Both drugs were cut with elephant tranquilizers.  What?  How does one get elephant tranquilizers and decide that is what you are going to use to cut. 

 

That has more to do with it being illegal than it does the heroin itself.  I think the fact that they are illegal kills far more people than these drugs would if they were simply sold like Tylenol over the counter.  A huge reason people OD is that they don't really know what they are taking or the proper dose for the purity/mixture they have just purchased.  Is it cut with elephant tranquilizers, rat poison?  Does it have fentanyl in it?  Is it more pure than the stuff you bought yesterday or less?  How would you know?  It isn't like you can sue the manufacturer if it isn't what you expected.  I know that the Advil I buy at CVS isn't cut with elephant tranquilizers just like I know the vodka I buy at the liquor store isn't going to make me blind or kill me.

 

you are correct in that if it is cut and what it is cut with causes many issues and if it was sold via a prescription it would be safer.  I'm pretty liberal with regards to much of our drug laws/customs but I cannot support and think its incredibly naive to think that if Opiods were legal we'd be better off. 

 

Your last comment in that you cannot sue the manufacterer is somewhat incorrect.  In the case of a HS classmate of mine who lost her brother to a heroin overdose the police found the dealer and he was charged with manslaughter as he was selling heroin that was pure and not cut which is not the standard.  They made the argument that he knowingly put peoples lives at risk by selling a more pure substance.

 

 

[Guest cherzeca]

This is a hard thread for me to read right now.  My niece just lost her boyfriend to a heroin overdose this week. 

 

What blows me away is that my county has had 2 deaths this week from heroin.  Both drugs were cut with elephant tranquilizers.  What?  How does one get elephant tranquilizers and decide that is what you are going to use to cut. 

 

That has more to do with it being illegal than it does the heroin itself.  I think the fact that they are illegal kills far more people than these drugs would if they were simply sold like Tylenol over the counter.  A huge reason people OD is that they don't really know what they are taking or the proper dose for the purity/mixture they have just purchased.  Is it cut with elephant tranquilizers, rat poison?  Does it have fentanyl in it?  Is it more pure than the stuff you bought yesterday or less?  How would you know?  It isn't like you can sue the manufacturer if it isn't what you expected.  I know that the Advil I buy at CVS isn't cut with elephant tranquilizers just like I know the vodka I buy at the liquor store isn't going to make me blind or kill me.

 

you are correct in that if it is cut and what it is cut with causes many issues and if it was sold via a prescription it would be safer.  I'm pretty liberal with regards to much of our drug laws/customs but I cannot support and think its incredibly naive to think that if Opiods were legal we'd be better off. 

 

Your last comment in that you cannot sue the manufacterer is somewhat incorrect.  In the case of a HS classmate of mine who lost her brother to a heroin overdose the police found the dealer and he was charged with manslaughter as he was selling heroin that was pure and not cut which is not the standard.  They made the argument that he knowingly put peoples lives at risk by selling a more pure substance.

 

many suppliers are users, who sell to finance habit.  they are selling without warranty, as it were, since they do not know for sure what they are selling, but they are forced to sell economically...which gets at the legalization point...if every seller was with warranty since the whole supply process was regulated, then would we as a society be safer.  no clear cut answer as to optimal path

 

again, i say this without skin in the game, and i respect your views mrholty more than my own for this reason

[rkbabang]

This is a hard thread for me to read right now.  My niece just lost her boyfriend to a heroin overdose this week. 

 

What blows me away is that my county has had 2 deaths this week from heroin.  Both drugs were cut with elephant tranquilizers.  What?  How does one get elephant tranquilizers and decide that is what you are going to use to cut. 

 

That has more to do with it being illegal than it does the heroin itself.  I think the fact that they are illegal kills far more people than these drugs would if they were simply sold like Tylenol over the counter.  A huge reason people OD is that they don't really know what they are taking or the proper dose for the purity/mixture they have just purchased.  Is it cut with elephant tranquilizers, rat poison?  Does it have fentanyl in it?  Is it more pure than the stuff you bought yesterday or less?  How would you know?  It isn't like you can sue the manufacturer if it isn't what you expected.  I know that the Advil I buy at CVS isn't cut with elephant tranquilizers just like I know the vodka I buy at the liquor store isn't going to make me blind or kill me.

 

you are correct in that if it is cut and what it is cut with causes many issues and if it was sold via a prescription it would be safer.  I'm pretty liberal with regards to much of our drug laws/customs but I cannot support and think its incredibly naive to think that if Opiods were legal we'd be better off. 

 

Your last comment in that you cannot sue the manufacterer is somewhat incorrect.  In the case of a HS classmate of mine who lost her brother to a heroin overdose the police found the dealer and he was charged with manslaughter as he was selling heroin that was pure and not cut which is not the standard.  They made the argument that he knowingly put peoples lives at risk by selling a more pure substance.

 

The police happened to catch that one.  There are many the police didn't catch.  When I go to the liquor store the bottles are labeled with the exact percentage of alcohol they contain and I know exactly who manufactured it.  I know that I can't drink as much of a 100 proof spirit as I can a 60 proof.  There is no guesswork involved.

That wasn't the case in the 1920s.

 

[Vish_ram]

UNF explained it well, the root cause was making Pain as a vital sign.

 

But there were several forces at play to make it worse:

1) Unscrupulous docs who practice general medicine, but keep operating a pain clinic in disguise. I personally know docs who make millions until they are caught.

2) Medical reps who push docs hard and give them incentives to prescribe more opiods

3) The legal system that criminalizes drug addiction

4) Pharma companies (insys in particular) that push the boundaries. Take fentanyl, that is 100 times more addictive than cocaine. it is given to end stage cancer patients who live for few months only. Slowly it creeps into broader population

5) FDA that takes years to get a drug approved. Any anti-addiction medication will take billions to develop and 10+ years to get approved.

6) Stupid politicians who enacted laws that made medicine like Ayahuasca illegal. Ayahuasca can cure a person of opiod addictions. It is used in Amazon regions for 1000's of years.

7) Society that looks down on addicts, this is a medical issue not a moral one.

 

PS

Not to mention, most Americans dont have a safety net when they lose a job. In the last 20 years we witnessed a tremendous upheaval all over small towns, where jobs were lost due to automation, outsourcing, offshoring etc.

[lschmidt]

All of the above is true. However, saying that the establishment of pain as a vital sign is a product of first-order thinking.

Second-order thinking brings us to the question of "how did pain become a vital sign?" The answer to this takes you through another slew of organizations and influence in medical education and physician oversight, from the AMA, various professional physician pain medicine organizations, patient advocacy groups, CMS (Centers for Medicare and Medicaid services), and the Joint Commission. There was a lobbying and influence compaign that accomplished its goal. You will find that the cascade of influence that introduced the importance of pain monitoring may have been a chain of self-serving biases with another set of players at the root. Some of it was pharma (influencing the physician and patient groups) and some of it was misguided beliefs on the part of physicians and patients, blieving much would be relieved with more use of opiates. Multiple groups were blinded to the risk of addiction, with some contributions from the misinformation compaigns from pharma. Complicated web.

 

 

"UNF explained it well, the root cause was making Pain as a vital sign.

 

But there were several forces at play to make it worse:

1) Unscrupulous docs who practice general medicine, but keep operating a pain clinic in disguise. I personally know docs who make millions until they are caught.

2) Medical reps who push docs hard and give them incentives to prescribe more opiods

3) The legal system that criminalizes drug addiction

4) Pharma companies (insys in particular) that push the boundaries. Take fentanyl, that is 100 times more addictive than cocaine. it is given to end stage cancer patients who live for few months only. Slowly it creeps into broader population

5) FDA that takes years to get a drug approved. Any anti-addiction medication will take billions to develop and 10+ years to get approved.

6) Stupid politicians who enacted laws that made medicine like Ayahuasca illegal. Ayahuasca can cure a person of opiod addictions. It is used in Amazon regions for 1000's of years.

7) Society that looks down on addicts, this is a medical issue not a moral one.

 

PS

Not to mention, most Americans dont have a safety net when they lose a job. In the last 20 years we witnessed a tremendous upheaval all over small towns, where jobs were lost due to automation, outsourcing, offshoring etc. "

[rkbabang]

UNF explained it well, the root cause was making Pain as a vital sign.

 

But there were several forces at play to make it worse:

1) Unscrupulous docs who practice general medicine, but keep operating a pain clinic in disguise. I personally know docs who make millions until they are caught.

2) Medical reps who push docs hard and give them incentives to prescribe more opiods

3) The legal system that criminalizes drug addiction

4) Pharma companies (insys in particular) that push the boundaries. Take fentanyl, that is 100 times more addictive than cocaine. it is given to end stage cancer patients who live for few months only. Slowly it creeps into broader population

5) FDA that takes years to get a drug approved. Any anti-addiction medication will take billions to develop and 10+ years to get approved.

6) Stupid politicians who enacted laws that made medicine like Ayahuasca illegal. Ayahuasca can cure a person of opiod addictions. It is used in Amazon regions for 1000's of years.

7) Society that looks down on addicts, this is a medical issue not a moral one.

 

PS

Not to mention, most Americans dont have a safety net when they lose a job. In the last 20 years we witnessed a tremendous upheaval all over small towns, where jobs were lost due to automation, outsourcing, offshoring etc.

 

+1.

 

I think of all of them the root of the problem is #7.  The way society views drugs in general.  Anything proscribed by a doctor must not be harmful, while anything you do for personal reasons must be the work of the devil.  All of the government laws/regulations and doctors/drug company actions are simply reflections of our warped puritan culture.

 

[Guest cherzeca]

pain as a vital sign.  i'm not sure i get that.

 

my mom died recently at 95.  for about her last 5 years, she had pain that was treated well enough with tramadol (an opitate).  for this i am grateful.  i am not a fan of opiates but i am also not a fan of pain, especially her pain. i am also not a fan of her having an ability to buy what seemed like 100 pills of tramadol at a time. 

 

i also recall having had surgery (1974) and being in severe pain afterwards in the hospital, and the nurse telling me that he would come right back after he cut the narcotics for me.  i remember not feeling good about this statement, but feeling much better about it after receiving the injection.

 

there is life pain and there is PAIN.  i think there is a distinction that makes a difference.

[Liberty]

[Cigarbutt]

An evolving problem.

https://www.healthsystemtracker.org/brief/a-look-at-how-the-opioid-crisis-has-affected-people-with-employer-coverage/#item-start

[doughishere]

I recently had double inguinal hernia surgery (done in 2 stages, 3 weeks apart.)

 

I was prescribed x40 Oxycodones after each procedure.

 

The 1st procedure, I took all but about 8 or 10 of the pills which I found out was unnecessary.

For the 2nd surgery, I quit taking the pills on day 3 following the procedure & started taking Motrin.

 

This was perfectly adequate to control the pain (nothing but time would take care of the discomfort.)

 

I had a follow up exam recently & asked the surgeon why they prescribe x40 pills & got what I thought was a bullshit answer.

(I totally trust this guy with regards to the procedures performed but believe that he & others are a bit aggressive with the prescription pad.)

 

I still have a full bottle from the 2nd prescription & a few pills from the 1st one.

(gotta Google how to dispose of these properly.)

 

Here's a quick article on all the finger pointing going on.

 

http://www.bradenton.com/news/local/article191485574.html

 

and another one re: the Cherokee nation filing suit.

 

http://www.tahlequahdailypress.com/news/local_news/pharm-companies-seek-to-thwart-cn-opioid-suit/article_2531e7fe-47c4-5c7c-82b2-66f4e7ebd60d.html

 

I just can't help but think that everyone is pointing in the wrong direction.

 

Just smoke weed.

[LongHaul]

Pretty sad thread to read. 

 

~64k deaths from drug overdoses in 2016.

https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

 

Something from Charlie's Almanack that stuck me the other week.

 

"One should stay far away from any conduct at all likely to drift into chemical dependency.  Even a small chance of suffering so great a damage should be avoided."

 

I completely agree with this.  As I get older I see more people die and ruin their lives with drugs, alcohol etc.

When I was young I only had a vague sense of it.

[LongHaul]

 

https://en.wikipedia.org/wiki/History_of_opium_in_China

 

Under Mao

The Mao Zedong government is generally credited with eradicating both consumption and production of opium during the 1950s using unrestrained repression and social reform.[citation needed] Ten million addicts were forced into compulsory treatment, dealers were executed, and opium-producing regions were planted with new crops. Remaining opium production shifted south of the Chinese border into the Golden Triangle region.[38] The remnant opium trade primarily served Southeast Asia, but spread to American soldiers during the Vietnam War, with 20 percent of soldiers regarding themselves as addicted during the peak of the epidemic in 1971. In 2003, China was estimated to have four million regular drug users and one million registered drug addicts.[39]

[Guest Schwab711]

LA Times has done some great reporting on Purdue.

 

http://www.latimes.com/projects/oxycontin-part1/

[LR1400]

I don’t know, I had multiple medical issues when I was younger and was prescribed all

kinds of narcotics, very strong ones unavailable now. I recall kind of wanting them, but being able to not take them and just making myself make sure I didn’t become addicted to them beause I knew I could become addicted.

 

Really the bottom line is: people like to get a buzz and this is one method. I believe in little regulation and personal choice. People are going to do whatever they want to get a buzz. The drugs will vary over time.

 

Opiates work better than most things like Tylenol and ibuprofen and they will be restricted to the masses beause of some idiots.

[LC]

I believe in little regulation and personal choice. People are going to do whatever they want to get a buzz. The drugs will vary over time.

Every time I hear this argument I wonder, where do you draw the line? Curious to hear your thoughts.

[LR1400]

It’s a tough call. Marijuana, alcohol should totally be legal, no question.

 

I honestly could see a decrease in drug use over time were most of the legal, or at the very least not so severely punishing to the user.

[rb]

I believe in little regulation and personal choice. People are going to do whatever they want to get a buzz. The drugs will vary over time.

Every time I hear this argument I wonder, where do you draw the line? Curious to hear your thoughts.

It's not my thoughts you've asked for but i'll share them anyway. Blame the open forum. :P

 

The way I see it legalization will lead to an increase in use - it may be small (i don't see a lot of non users lining up for smack if it suddenly became legal) or large (alcohol). But a share of substance users are actually high functioning. That share I imagine depends on the substance. But I also believe it's a lot larger than we think. Furthermore the way the laws are setup now we have the state basically ruining more lives related to substances rather than the substances themselves.

 

Right now we seem to be in possibly the worst position possible. Even with the laws in place now demand is strong. We haven't been able to really do anything about the supply despite spending enormous amounts of money. Then we spend even more piles money to catch drug users and small time retailers and incarcerate them. Given that it's illegal it breeds more criminal behaviour and we spend more money to police that. Then the proceeds of the drug trade go to fund organized crime and terrorism. So we need to spend even more money on dealing with organized crime. Then spend stupendous amounts of money on military and intelligence to deal with terrorism. Though I suspect that if it all gets fixed the US would find some other reason to shower money on the military.

 

So where do you draw the line? I think nobody knows. Maybe there should be no line. But I think a smart way to do it is one step (substance) at a time and see how things develop. I honestly think that any change is good because we can do no worse than we are right now.

 

Some final points:

 

1. We're just whistling Dixie out of our ass here. The US has a horrendous record on this going back a really long time. That's not at all likely to change.

 

2. None of what I wrote here matters to you if your kid is a heroin addict.

[nodnub]

I don’t know, I had multiple medical issues when I was younger and was prescribed all

kinds of narcotics, very strong ones unavailable now. I recall kind of wanting them, but being able to not take them and just making myself make sure I didn’t become addicted to them beause I knew I could become addicted.

 

Really the bottom line is: people like to get a buzz and this is one method. I believe in little regulation and personal choice. People are going to do whatever they want to get a buzz. The drugs will vary over time.

 

Opiates work better than most things like Tylenol and ibuprofen and they will be restricted to the masses beause of some idiots.

 

Just because you or I have a certain experience, doesn't mean that anyone else in the world has the same experience (with avoiding addiction).  I think they found genetic components to addiction.

 

It's easy for me to avoid getting addicted to Alcohol... but some people do become addicted.

 

Purdue also lied about the time length effectiveness of the time release version of oxycontin, which led to patients being in pain before their next dose.  In those situations, Purdue sales and marketing pushed Doctors to bump up the dose from 20mg to 40mg, and from 40mg to 80mg... leading to drug tolerance and addiction..  but what patients really needed was to take the small dose every 8 hours instead of 12 hours. The sales team was adamant that they maintain the 12 hours dosing regimen and raise the dose amount. The whole reason for this lie about the 12 hour effectiveness was so Purdue could get another patent and extend revenue stream before facing generic competition.  I'm sure I got some of the details above wrong, but there was a long and well-written expose on this topic.  It made Purdue and rivals look really dirty.

 

TLDR: The opiod addiction triggered by OxyContin is probably not as simple as you think, and your personal experience is not universal.

 

 

 

 

 

 

 

[rkbabang]

I believe in little regulation and personal choice. People are going to do whatever they want to get a buzz. The drugs will vary over time.

Every time I hear this argument I wonder, where do you draw the line? Curious to hear your thoughts.

 

I don't draw lines.  And who gave you the power to draw them?  You do whatever you want to your body and let me do whatever I want to mine.

 

[jmp8822]

I believe in little regulation and personal choice. People are going to do whatever they want to get a buzz. The drugs will vary over time.

Every time I hear this argument I wonder, where do you draw the line? Curious to hear your thoughts.

 

I don't draw lines.  And who gave you the power to draw them?  You do whatever you want to your body and let me do whatever I want to mine.

 

Not much to add to this thread, but "do whatever you want to your body and let me do whatever I want to mine" isn't the best argument.  There are too many real world externalities.  Who pays for the hospital stays, police force, etc. etc. for people who are drug addicted non-productive members of society? Drugs users don't exist in a vacuum.

[Dynamic]

I heard a good description on ep 661 of the Skeptics Guide to the Universe podcast recently about opioids, and from the show notes, I think this story was brought about by a recent study summarized in an LA Times article.

 

The gist seem to be that over a year-long clinical trial it appeared that over a year, i.e. for condition where pain is chronic (long-term) rather than acute (short-term spike) opioids offered no advantage over everyday non-opioid painkillers (I believe they referred to Tylenol, which I have understood is a US name or brand-name for paracetamol).

 

I think in the short term, opioids may be superior for pain relief and not caring, but over time their effectiveness at pain suppression lessens, requiring increase doses, and greatly increasing the likelihood of dependence and withdrawal symptoms, and long term non-opioids are at least as good. For end-of-life palliative care, opioids are very helpful, and dependence isn't really a problem.

 

As the evidence base changes I suspect that the best practice needs to be redefined and new guidelines for the default interventions issued across the medical community for long term (chronic) pain management in light of the best available evidence of benefits and side-effects. It may be that opioids still provide the best combination of effectiveness and reasonable safety for short-term use in certain categories of acute pain, but should be avoided for chronic pain management.

 

The SGU team made clear certain limitations of the trial, but it adds to a body of evidence that change may be required.