
Coroner letters changed habits of doctors whose patients died of overdoses - wallflower
http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-overdose-letter-20180809-story.html
======
lesserroneous
I will admit I'm biased: my mother died of an overdose. She was a drug addict.
I, on the other hand, have a painful autoimmune disorder, but I've never taken
medication. Yet every doctor I've met in the past ten years has looked at me
and immediately treated me like a drug addict. Personal experience aside (as
it really is not quantitatively demonstrative of anything larger) I've done my
best to research this issue, and I'm still somewhat at a loss. Based on these
numbers and the 2016 CDC list of leading causes of death _, opiate-related
deaths account for .02% of the population. On the other hand, I would guess we
have quintuple that in people who suffer chronic pain. Though, I can 't say
how many use their medication as prescribed, I would guess it's at least more
than .02% of the population. Addiction is not simple, and even people who
started responsibly taking medication could develop an addiction. I don't
think it's fair, however, to punish the many people who depend on pain relief.
Lax laws in the 80s and 90s have now pendulum-swung to the other side.
Patients are seeing their medication reduced without tapering, they are given
no other option than to "suck it up," and all along, they are variously
demonized or treated as though they are weak. It's a complicated situation
that I am not equipped to solve. I do think there needs to be a middle ground.
There needs to be a better effort that will help the entire patient
population.

_[https://www.cdc.gov/nchs/fastats/leading-causes-of-
death.htm](https://www.cdc.gov/nchs/fastats/leading-causes-of-death.htm)

~~~
DanBC
People think that opioids are an effective treatment for long term pain. They
aren't. They don't work to treat the pain and the patient develops a tolerance
and so ends up taking large quantities putting their health at risk.

> Patients are seeing their medication reduced without tapering, they are
> given no other option than to "suck it up,"

These are both bad, but these are both symptoms of the sometimes terrible
healthcare in the US. People should have access to pain management clinics.

~~~
justinjlynn
> They don't work to treat the pain and the patient develops a tolerance and
> so ends up taking large quantities putting their health at risk.

As you've already asserted in your other comments here and I've asked
elsewhere, could you expand on this assertion?

~~~
DanBC
[https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-
awar...](https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware)

> 1\. Opioids are very good analgesics for acute pain and for pain at the end
> of life but there is little evidence that they are helpful for long term
> pain.

> 2\. A small proportion of people may obtain good pain relief with opioids in
> the long-term if the dose can be kept low and especially if their use is
> intermittent (however it is difficult to identify these people at the point
> of opioid initiation)

> 3\. The risk of harm increases substantially at doses above an oral morphine
> equivalent of 120mg/day, but there is no increased benefit.

> 4\. If a patient is using opioids but is still in pain, the opioids are not
> effective and should be discontinued, even if no other treatment is
> available.

> 5\. Chronic pain is very complex and if patients have refractory and
> disabling symptoms, particularly if they are on high opioid doses, a very
> detail assessment of the many emotional influences on their pain is
> essential.

[https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-
awar...](https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-
aware/condition-patient-context/challenges-of-long-term-pain-management)

> The experience of pain is complex and influenced by the degree of tissue
> injury, current mood, previous experience of pain and understanding of the
> cause and significance of pain. Previous unpleasant thoughts, emotions and
> experiences can also contribute to the current perception of pain and, if
> unresolved, can act as a barrier to treatment. The assessment of chronic
> pain needs to be wide-ranging and comprehensive. The persistence of symptoms
> is particularly relevant in relation to prescribing where patients may be
> exposed to cumulative harms of drugs over prolonged periods. If a patient
> continues to have pain despite taking a number of medications, drugs should
> be sequentially tapered or stopped to establish continued utility.
> Similarly, if a patient reports reasonable pain relief from a medication
> regimen in the longer term, it is also necessary to taper medications
> intermittently to assess whether the symptoms have resolved spontaneously or
> whether the patient is relatively pain free because of continued efficacy of
> medication.

[https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-
awar...](https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-
aware/condition-patient-context/role-of-medicines-in-pain-management)

> Medicines are generally less effective for persistent pain than for other
> types of pain. When medicines are prescribed they should be used in
> combination with other treatment approaches to support improved physical,
> psychological and social functioning.

~~~
justinjlynn
Well, that's a far more nuanced argument than yours. Frankly, you'd be better
off quoting that than making veridical statements such as 'does not' when your
own evidence indicates it 'sometimes' does. Certainly opioids are not a front
line treatment, and never were, but I would avoid going around saying they 'do
not work' when clearly sometimes they do and it's a highly contextual
decision. You may want to say instead that there is little evidence supporting
their widespread use in long term pain management as a primary strategy. That
would be supported by what you've posted and I'd take no issue with that
statement.

~~~
DanBC
The problem is that opioids are a front line treatment, and are being
prescribed by GPs and not only hospitals or pain clinics.

Opioid sales quadrupled in the US between 1999 and 2014, and a lot of those
were family doctors.

------
cm2012
One note: Research pretty thoroughly debunks the idea that a substantial
percent of opioid as addictions come from prescribed pain treatments:
[https://www.fivethirtyeight.com/features/what-science-
says-t...](https://www.fivethirtyeight.com/features/what-science-says-to-do-
if-your-loved-one-has-an-opioid-addiction/)

Now this article is about something different - teaching doctors the warning
signs of when already addicted patients are drug seeking, so they can avoid
prescribing then. The key fact here is that almost all of the deceased had
gotten prescriptions from multiple doctors.

~~~
jeffdavis
What is the predominant mechanism of becoming addicted then?

~~~
cm2012
"Far greater risk comes from simply being young and from using alcohol and
other recreational drugs heavily. Ninety percent of all drug addictions start
in the teens — and 75 percent of prescription opioid misuse begins when
(mainly young) people get pills from friends, family or dealers — not doctors.
Opioids are rarely the first drug people misuse."

~~~
simonbarker87
You could still draw a link: high prescription rates of opioid pain killers
normalises the use of them and as such someone is more likely to be offered
them by family and friends for something minor.

Also, is “throughly” debunked really the case? That makes it sound like there
can be no link at all, but higher levels of these in society legally could
lead to an increase in abuse. On complex topics like this it is rarely
possible to talk in absolutes.

~~~
cm2012
What's debunked is the very common narrative in this thread that poor Uncle
Billy went to the doctor with a bad back and came back a rabid addict. Non
addicts becoming addicts from regular prescriptions is very rare according to
all studies.

There is definitely a big complex drug ecosystem otherwise, though.

------
justinjlynn
It had a direct impact on several doctor's prescription habits. This is a good
thing. Now, did it do so while ensuring doctors maintained the same pain
management outcomes for their patients?

I am dubious and concerned this doesn't appear to have been addressed in their
studies.

~~~
kelnos
As a potential patient, I'm pretty sure I'd prefer to endure a little extra
pain if the alternative is an increased likelihood of painkiller addiction
that could lead to death.

~~~
cm2012
There's almost no chance of you developing an opiate addiction from a
prescribed dose if you don't already have a history of addiction:
[https://www.google.com/amp/s/fivethirtyeight.com/features/wh...](https://www.google.com/amp/s/fivethirtyeight.com/features/what-
science-says-to-do-if-your-loved-one-has-an-opioid-addiction/amp/)

This is a false narrative that needs to go away.

~~~
DanBC
You're pushing a narrative created by opioid manufacturers: "These meds aren't
addictive if used to treat pain".

That's only true (if it is true) if they're used short term. People in this
thread aren't talking about acute pain, they're talking about chronic (long
term) pain.

It's likely that opioids are addictive if used long term to treat long term
pain.

Here's what actual doctors say: [https://www.rcoa.ac.uk/faculty-of-pain-
medicine/opioids-awar...](https://www.rcoa.ac.uk/faculty-of-pain-
medicine/opioids-aware)

EDIT: FFS, your own link says this:

> “Physiological dependence is the normal response to regular dosages of many
> medications, whether opioids or others. It also happens with beta blockers
> for high blood pressure,” said Dr. Wilson Compton, deputy director of the
> National Institute on Drug Abuse.

Your link says that opioids create physical addiction. The physical addiction
to opioids causes all the factors of the newer definition of adddictive:
tolerance, drug seeking, preoccupation, and continuing to take it even though
you know it's harmful.

~~~
justinjlynn
Physiological dependence is a treatment complication to be managed.
Corticosteroids, hormones, and other nonpsychoactive medications feature this
issue too. It is part of the risk/benefit calculation.

What's important is the psychological addiction. You can taper off of a
medication on which you are physiologically dependent. However, if it makes
you psychologically dependent, you can never forget the high.

Turns out not having pain because a medication helps and you experience it
when you stop makes people want to keep taking it. Who knew?

It's when people take more than they need to to address their physical pain,
that they experience psychological addiction, that they chase the high, that a
problem develops.

~~~
DanBC
The psychological addictiveness of opioids is well established.

Turns out not having pain because a medication helps and you experience it
when you stop makes people want to keep taking it. Who knew?

That is not what's happening. People take the medication to treat the pain.
Their pain still exists. They develop a tolerance to opioids (one of the
mechanisms of addiction) and need to increase the dose. Now they're taking
very large -dangerously large- doses of opioids but are still in pain.

------
tehlike
For europeans: [http://archive.is/TN3Uz](http://archive.is/TN3Uz)

------
duncan-donuts
Clearly I'm just a layman but I find it so surprising that the medical
community isn't 100% aware of the over prescribing of opiods by now. I have to
believe they are totally aware of the situation, but don't know what else to
do. Or maybe they're totally fine with it /shrug. I'd love to know more about
the medical community's reaction and reformation efforts around the issues
with opiods and addiction.

~~~
rz2k
Search: “Pain is the fifth vital sign”

There was a very strong campaign to re-educate physicians to not consider pain
as only a symptom. It was suggested that there was liability in not treating
pain for the sake of getting rid of pain alone, but mostly it didn’t just
change prescribing practices out of fear of liability, the focus of attention
on pain changed prescribing habits.

In practice, someone who hardly has enough time for the patients they see, may
subconsciously think that in spite of the prevalence of national opioid
deaths, no one they treat has died or destroyed their lives through addiction,
simply because those who do also stop booking appointments.

These letters sound like a great idea.

~~~
javadocmd
Even for doctors who express awareness of the problem with opioid prescribing,
it's not uncommon to believe that every other doctor is the problem, and not
themselves. Either not realizing their prescribing is above average, or
realizing but justifying it with the thought that they somehow have a patient
population with above average pain needs.

------
orblivion
I found the letter to be crafted very cleverly. "This person died
unnecessarily because of your decisions" then while you're feeling guilty and
vulnerable "Here's a program to show you how you can atone"

------
ewjordan
Opiods have been around forever; pardon my ignorance, but what is different
now that makes so many more people get hooked on them?

Presumably people felt the same levels of pain in the past as they do now,
given the same maladies. Is the situation:

A) More surgeries with extremely painful and long recovery periods are
happening, where these meds are truly necessary

B) Doctors are prescribing opiods more freely for lower levels of pain than in
the past

C) People are faking pain more often

D) People who really do need pain meds are staying on them longer than they
should

B) seems to be the accusation that I usually see, but have doctors really
gotten worse and less careful over time? To an extent that explains the whole
crisis?

My guess is that D) is the real cause, for may different reasons.

~~~
DanBC
Opioid sales quadrupled between 1999 and 2014.

> but what is different now that makes so many more people get hooked on them?

The US VA noticed that pain was not being adequately treated. They created a
campaign to make every HCP ask patients about pain. They looked at the science
of the time which seemed to be saying that opioids were not addictive if you
use them to treat pain. (they're less addictive if used short term for short
term pain (post surgery, for example) but more addictive if used long term.)
Drug companies put out new formulations that they claimed were less addictive
- turns out they were more addictive. US doctors prescribe huge amounts of
opioids.

The tragedy is that pain is still left untreated. The VA campaign meant people
got opioids (cheap, but not particularly effective for long term pain) but
didn't get access to pain management clinics.

[https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital...](https://www.va.gov/PAINMANAGEMENT/docs/Pain_As_the_5th_Vital_Sign_Toolkit.pdf)

[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924634/)

> Routinely measuring pain by the 5th vital sign did not increase the quality
> of pain management. Patients with substantial pain documented by the 5th
> vital sign often had inadequate pain management.

[https://www.cdc.gov/drugoverdose/data/prescribing.html](https://www.cdc.gov/drugoverdose/data/prescribing.html)

> Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to
> 2014,1 but there has not been an overall change in the amount of pain
> Americans report.2,3 During this time period, prescription opioid overdose
> deaths increased similarly.

~~~
mmt
> > Sales of prescription opioids in the U.S. nearly quadrupled from 1999 to
> 2014,1 but there has not been an overall change in the amount of pain
> Americans report

That, there, is the "money" quote. You've been criticized elsewhere in the
thread for the assertion that opiates "don't work" for long-term pain, but
that strikes me as a very reasonable summary in the face of this kind of
evidence.

Sure, there may be exceptions, but they must be quite rare for the above to
remain true. (Some of them may not even be true exceptions, if "intermittent"
use for long-term pain actually looks the same as repeated use for short-term
pain).

------
jaclaz
I believe that this is mainly a US (or actually North America to include
Canada) issue, in most of the EU (Germany being an exception) opioids are not
so commonly prescribed outside hospitals or as generic painkillers (i.e. for
not really serious illnesses) AFAIK.

If you check the maps here:

[https://ppsg.medicine.wisc.edu/](https://ppsg.medicine.wisc.edu/)

the phenomenon seems mostly regional (the colour scale on the map makes very
little sense, you need to check the single amounts as _everywhere_ (both North
America and EU zone is blue but with very different values ) example 2015, "ME
minus Methadone":

Canada 661 mg/capita

US 484

Germany 517

UK 156

France 151

Spain 233

Italy 131

------
ehnto
I have a condition that meant that until my late teens, I was in incredible
pain daily. My parents asked about painkillers, but my doctor at the time
strongly cautioned against them, citing dependence and eventual
ineffectiveness. His decision and my parents bravery to listen, when all signs
pointed toward the need for relief, is likely why I am a fully functional
adult today. That was an insight he had over two decades ago, which is why I
find the opioid crisis so damning toward the prescribers.

------
mnm1
Do the people conducting these studies really think that getting doctors to
prescribe less opiates to existing patients and having patients resort to the
black market where heroin is often cut with fentanyl, carfentanyl, or other
much deadly opiates is really a good idea? Somehow reduced prescriptions are
equated with positive outcomes without any proof. I guess the thinking must be
that if the patient overdoses off of street opiates it's somehow not as big of
a deal as if they overdose off prescribed opiates. At least these doctors
won't feel so bad about patients they are directly killing by cutting them off
their prescriptions. From experience, most doctors don't even care about or
can even fathom the consequences of taking someone dependent on opiates (as
well as other drugs that must be tapered like benzodiazepines) so them
stopping prescriptions without properly tapering patients off is no big deal
while the patients literally scramble to save their lives by getting the drugs
from the black market. But hey, the numbers look good and sound good to a
society that thinks war should be waged on addicts and that they are better
off dead than in recovery. That certainly explains our ridiculous regulations
as regards to methadone, an extremely effective treatment for opiate
addiction, when used to treat addiction (must be taken in liquid form from a
clinic each day etc. etc) vs. when taken for pain. It's almost like these laws
were written by people who want addicts to die rather than recover. They are.
Doctors who stop prescriptions without offering the patient a chance to
recover are essentially sentencing the patient to a possible death penalty
either because the patient goes to the black market or because they can't and
go through withdrawl which can indeed kill both directly and through suicide.
They should really try to remember the Hippocratic oath they are violating and
think about the patients they are directly trying to kill in the name of
prescription reduction and useless, dumb government statistics.

------
sklivvz1971
I can't read that article.

"Unfortunately, our website is currently unavailable in most European
countries."

In common: we can't be bothered respecting your privacy.

OK then.

~~~
MattConfluence
Interestingly, the article is available to me in Norway, where the GDPR is
also in effect, just as in the EU.

And the site does indeed load JS from a horrendous number of domains.

------
icu
LA Times seems to be blocked for the UK, presumably due to GDPR.

~~~
evfanknitram
I assume blocked in all of EU.

~~~
Agentlien
Seems likely. It's blocked in Sweden and the message says it is currently
"unavailable in most European countries".

------
camel_gopher
Real

