
Researchers are beginning to disentangle pain relief from addiction and overdose - mhb
http://www.smithsonianmag.com/science-nature/new-morphine-180961774/
======
soneca
Interesting, but I just listened to Econtalk podcast[1] where the guest,
author of the book Dreamland about opioid epidemic[2], claims that all this
epidemy only started at first place because researchers at the time claimed
that opioid based pain relief medicine was disassociated from addiction (and
pharma companies gladly played along).

Except it wasnt.

Very worthy your time listening to this guy if you are interested in the
topic.

[1]
[http://www.econtalk.org/archives/2017/01/sam_quinones_on.htm...](http://www.econtalk.org/archives/2017/01/sam_quinones_on.html)

[2] [https://www.amazon.com/Dreamland-True-Americas-Opiate-
Epidem...](https://www.amazon.com/Dreamland-True-Americas-Opiate-
Epidemic/dp/1620402521)

~~~
refurb
You have to remember like everything, beliefs around addiction to pain
medication ebbs and flows over time.

I can remember back in the late 1990s, there was a _huge_ push from the
medical community to be more open about prescribing pain medication. A lot of
pain wasn't being adequately treated.

As a result, doctors loosened their reigns over prescribing and things moved
drastically in the opposite direction. People were getting _strong_ narcotics
for pain that they never would have gotten it for in the past.

As a result, we have a huge upswing in addiction.

My concern is that we're now going to swing back the other way and people will
get hurt. There are people out there where narcotics are the _only_ thing that
works for their pain. Sometimes they need a lot of them as well, we're talking
hundreds of milligrams of morphine per day. They will have physical withdrawal
symptoms if they were to stop, but they aren't addicted in the way we think.
They don't exhibit "drug seeking" behavior.

I'm worried folks like this will get cutoff and have to live a life in
terrible pain. All because other patients get addicted.

~~~
lxmorj
My girlfriend is in exactly this situation. She has terminal pain from a
Whipple and every step of the way the onus is on her to provide evidence that
she isn't a drug-seeker. And there are not clear success criterion.
Pharmacists can (and have) arbitrarily decide not to fill her prescription,
leaving her without pain meds suddenly and unexpectedly (ie baseline pain
returns + withdrawal symptoms).

Illinois won't allow sending pain scripts any more, so we have to go to the
hospital to pick it up every month. They won't allow you to fill it more than
a single day before you need it, and many pharmacies won't have the total
number of pills prescribed in stock. If you accept a partial fill - you forego
the remainder. Getting the doctors AND insurance (either of which will likely
block it) to understand you had to do a partial fill and thus issue your
refill before 30 days is a Sisyphean task.

All this means if the pharmacy at the hospital doesn't have enough Morphine on
hand to fill her one month description the day we pick it up - we have 24
hours to play Pharmacy Whack-a-mole trying to find one that both does have
enough pills and won't just arbitrarily decide to say no. Even better - while
sometimes you can call ahead and ask, often they are afraid you are probing
for large supplies with intent to rob them, so they won't always tell you if
they have it in stock.

It's a huge pain in the ass with multiple able-bodied family members in her
corner. I can't even fucking imagine how torturous this whole process is for
someone in her situation without that kind of help.

------
sharkweek
When I was 18 I had a pretty major surgery (Nuss procedure, to correct pectus
excavatum, good times) which required an epidural in my spine.

When I was being prepped, the anesthesiologist joked "ready to feel the best
feeling your body will ever experience?"

He wasn't joking - my entire body felt like it was floating, my mind cleared
of every negative feeling, and for the 15-20 seconds I remained awake, I
honestly thought I was in heaven.

I can totally understand how someone could get addicted to that feeling.

~~~
nradov
I known what you mean. As a child I had an emergency appendectomy and they
gave me intravenous Demerol (synthetic opioid) for the pain. It's literally
the best feeling in the world and I can totally understand how people become
addicted after prolonged use. So I recommend trying every other option for
pain relief before letting a healthcare provider give you an opioid. It's
scary how even dentists sometimes hand out codeine prescriptions after minor
procedures like wisdom tooth extraction.

~~~
hfsktr
My dentist didn't give me Vicodin[0] unless I had more than one or two teeth
out. Even then I never understood how people could like it. I got a little
pain relief and a little bit of a relaxing feeling. It was probably a really
low dose as well.

Might have just been mine wasn't into giving out prescriptions or they didn't
think I would need them.

I have a friend who has so many pain prescriptions after his back surgery that
I've lost count of and they either don't work or lose effectiveness or he
can't deal with the side effects. The scary part to me is there will never be
an end for him unless there is some miracle in medicine that his doctor
doesn't know about yet.

[0]I know that's not the same as Codeine

~~~
refurb
This isn't that surprising. Drugs affect people differently and people seek
different states of mind.

People talk about how addictive methamphetamine is. I know people who tried
and never wanted to try it again. It was the most unpleasant experience. Like
you drank way too much coffee and had all the anxiety and jitters to go along
with it. For other people, it's like heaven.

This goes back to the idea of "self-medication" as a root cause of drug
addiction. People get psychologically addicted to a drug because it solves a
psychological issue for them. Depression? It goes away when I take meth.
Anxiety? Gone when I take oxy.

Thinking about it that way, we shouldn't really be that surprised when people
have trouble beating an addiction. Even with all the negative side effects,
would you want to stop taking a drug that cured (imperfectly) a severe problem
you've had your whole life?

~~~
hfsktr
"Even with all the negative side effects, would you want to stop taking a drug
that cured (imperfectly) a severe problem you've had your whole life?"

I am not going to go into detail but that really resonates with me[0].

[0]I'm not addicted to anything don't worry!

------
exabrial
I refuse to take opioid pain relievers anymore :( After my knee surgery
(subluxated knee cap, hyperextension, multiple tears, loose bodies in joint),
I was prescribed oxycodone. I felt very happy, very relaxed (usually I would
consider myself high anxiety). But after the dose wore off, it felt terrible
and I felt a craving even know my knee necessarily wasn't hurting. That
up/down cycle scared me and I realized why people become addicted to these
pills and that I'm probably at risk. I flushed the rest and asked the doctor
for a NSAID alternative which he was able to find a good one for me.
Prescription medicine shouldn't leave you craving more.

~~~
mattstreet
Probably a good decision to switch to NSAIDs (at least when possible) please
don't flush meds again though.

~~~
CaptSpify
> please don't flush meds again though.

Curious why you say that? I was always told that this is what you were
supposed to do

~~~
dockd
I'm not totally sure why that's any better than throwing them into the trash.
Are people really digging through garbage just hoping to find opiates?

However, presuming you're not on a septic system, they end up in the river,
just like any other form of pollution.

Lots of police departments are taking them no questions asked. The city where
I work's police/public affairs building has a big metal box with a one-way lid
for unused drugs.

~~~
CaptSpify
> Are people really digging through garbage just hoping to find opiates?

Where I live? eh... it's not common, but it definitely happens. And it's
probably not _just_ for opiates, but anything will probably do. I do get that
putting them into the river/ocean is undesirable, though.

------
Nomentatus
The root of the problem may be our inability to very accurately remember pain
intensity levels over long periods of time. Evolutionarily, it's important to
remember that something was painful; but not that it was exactly 6% more
painful than some other sensation, or even 40%. So we don't, and we therefore
lack the most important bit of information to get us off painkillers.

The CDC says there's no evidence opiods reduce pain (at all) in the long run,
and that's been my experience, too. But when you don't remember previous pain
clearly enough to be sure you're back where you started (despite the drug) and
you know that even partial withdrawal is really painful; it's easy to believe
that the drug is still doing you good.

In my experience, this means that most who people taking opiods for long
periods end up back at their old pain levels, but aren't able to clearer
remember what their pain was like before, whereas they know all too clearly
that less painkiller means more pain right away, so they stay on the drugs.
Even though they may now be getting no long-term benefit in reduced pain. But
once they complete withdrawal they'll tell you that they don't seem to be
worse off, for pain now that they've fully quit the opiods. Their pain levels
seem about the same.

Evolution has robbed us!

Prove this, and most of the arguments over opiods for chronic illness and pain
may end.

------
thinkloop
For some reason, I kind'of always assumed the act of removing pain was itself
the addictive part. But now it seems obvious that a drug could simply make you
feel as you did right before hitting your thumb with the hammer.

~~~
LordKano
My layperson's understanding is that the opiates remove the pain and
eventually, the person's body re-calibrates its interpretation of pain based
on this new state. When they stop with the opiates, normal levels of pain
return, which are above and beyond what they're prepared to handle and they'll
do nearly anything to make it stop.

One time, I heard a recovering addict talk about his hair hurting. He had been
numbing himself for so long, the movement of the hair on his scalp felt
agonizing to him.

~~~
Unklejoe
Based on my conversations with friends who were/are addicted, that seems about
right. After stopping long term opiate use, your sensitivity seems amplified.
That's why addicts who can't get their fix are often seen scratching
themselves - they feel itchy everywhere.

~~~
CoryG89
Generally opiates make you itch while your on them, not while you are
withdrawing.

------
andrewclunn
So the peer reviewed work cited indicates a decreased level of nausea, but
says nothing about addiction:

[https://www.ncbi.nlm.nih.gov/pubmed/24954166](https://www.ncbi.nlm.nih.gov/pubmed/24954166)

There's the study on monkeys later on, but that's talking about BU08028, which
isn't mentioned as being an active component of Oliceridine (the main drug
being promoted in this article). I actually don't see anything here that makes
the claim that Oliceridine will be less addictive. It appears to just be a
conclusion that people are supposed to assume is implied without a close
reading of the article and information.

------
quantumhobbit
I'm recovering from a car accident and they gave me plenty of opiates in the
hospital. Honestly I didn't see the appeal outside of pain relief.

For pain relief they are great. I went from "I'm being eaten by a bear" to
"Meh" pain levels in minutes. But other than that it wasn't too pleasant.
There was no euphoria just dizziness and constipation. As soon as I could
switch to Ibuprofen, I did.

According to my doctor, there is a genetic component in how people respond to
opiates. Guess I was lucky.

~~~
wnissen
Yep. With the exception of some intravenous Valium right before my wisdom
tooth surgery, I've been fortunate that opiates and do not get along. The pain
relief works, but I also feel like I'm going to throw up. Then about 45
minutes after taking a dose, I fall asleep. No euphoria, no feeling of warmth
or comfort. Obviously not everyone has this reaction.

~~~
kkielhofner
Valium is a benzodiazepine (not an opiate) but don't let that fool you. I've
met several people struggling with addiction that swear benzo withdrawal can
be as bad or worse than opiates.

------
throwaway713
What I find weird is that it seems like the body can be in permanent pain, but
it isn't able to achieve a permanent state of feeling good.

For instance, there are people with spine damage who feel chronic, unrelenting
pain every day of their life. On the other hand, for any drug that makes you
"feel good" (oxycodone, morphine, even Adderall), your body eventually builds
a tolerance and requires more and more of that substance to achieve the same
level of "happy". So why doesn't the body do that with pain — where it
eventually gets used to your "average pain state" and requires ever more
intense infliction to feel the same level of "hurt"?

~~~
Retric
At the risk of an evolutionary just so story I think "feeling good" is a
larger risk for our animal ancestors.

Not standing in fire is always relevant even if your leg is broken. However,
not finding a mate because you just ate, or not eating because you found a
mate is counter productive.

Also, as I understand it evolution cares less about edge cases than we do.
Improving average outcomes can be worth not regrowing limbs for example.

~~~
digi_owl
Apparently the prospect of mating can do funny things to mammalian
priorities...

------
siavosh
On a domestic flight I sat next to a physician. During our chats we talked
about the opioid epidemic and he pointed to a push by pharmaceuticals to make
pain a distinct item that needs to be treated. And how this in part led to the
runaway addictions. I had thought it was purely socio-economic reasons, but
the big pharama angle was new to me. Curious if there are sources for this.

~~~
brandonmenc
> push by pharmaceuticals to make pain a distinct item that needs to be
> treated

It's totally reasonable to treat pain as a distinct item, especially in
patients where the cause of pain is vague, or the surgical fix carries high
risk - ex: chronic back pain.

------
OliverJones
Interesting. It would be good to have more ways to relieve pain, and ways to
help patients avoid addiction.

One of the best ways to help patients avoid addiction would be to
decriminalize these compounds and reduce or eliminate the prohibitions against
them. That's a strong statement, so please allow me to make the case.

(1) the iron law of prohibition says this: prohibition drives out all but the
most potent, and hence easiest-to-smuggle, formulations of the prohibited
substance. During alcohol prohibition in the USA, NOBODY smuggled lite beer.
It takes the Busch Clydesdales to move the stuff around, and it's too obvious.
It was ALL strong stuff like whiskey and "white lightning." The most potent
formulations of opiates are easier to misuse in a way that promotes addiction.

(2) a corollary to the iron law is this: people without training in chemistry
or sterile procedure will adulterate the strongest stuff so they can sell more
nickel bags, or whatever, on the street. That makes the dosages unpredictable.
Unpredictable dosages promote addiction by unpredictably pushing a user's
thresholds. Adulterants can be be dangerous and can induce pain.

(3) if the stuff's illegal it's expensive. Then addicts have the incentive to
sell some to their friends to help pay for their habits. Teenagers get
addicted this way.

(4) offering the substances to addicts at reasonable cost in competently
supervised circumstances allows for a variety of treatment options for
addiction. At the same time, addicts' lives don't fall apart. Treatment
regimes can, brought out of the shadows, be examined for their success rates
by agencies like Cochrane: [http://www.cochrane.org/CD011117/ADDICTN_opioid-
maintenance-...](http://www.cochrane.org/CD011117/ADDICTN_opioid-maintenance-
medicines-treatment-dependence-opioid-pain-medicines) . The current "state of
the art" in treatment is cold-turkey twelve-step. It works for some people,
but is it evidence-based? Sure it's evidence based, like reducing stress
helped people with stomach ulcers until pylobacter was discovered.

(5) if the government stops demonizing addicts as they have been doing for
almost a century then they can come out of the shadows and deal with their
problems.

(6) decriminalization weakens the incentives for pharmaceutical companies like
Purdue Labs to create supposedly "safe" time-release formulas like Oxycontin,
and then promote those formulas in ways that lead to addiction.
[http://www.latimes.com/projects/oxycontin-
part1/](http://www.latimes.com/projects/oxycontin-part1/)

(7) We won't have to hear news about people with names like El Chapo any more.
Any aura of underworld glamour around this stuff will evaporate. It will
become boring and fluorescent-lit like pharmacies should be.

Why is this change difficult? It challenges the narco-industrial complex.
Decriminalization means lots of police will be laid off. It will cut profits
for big pharma. It will cut government revenues by cutting into civil asset
forfeitures.
[http://www.newyorker.com/magazine/2013/08/12/taken](http://www.newyorker.com/magazine/2013/08/12/taken)

It's also difficult because of recent successful efforts to decriminalize
cannabis. The successful argument in Massachusetts USA and Colorado USA for
decriminalization has been one of recreation. "It's safer than alcohol, so go
for it." That's obviously a crazy argument to make for decriminalizing opioids
: because it's NOT safer, and because it plays into peoples' prejudices (see
point 5 above).

------
TenOhms
Before the article even begins it gives erroneous information: "Morphine is
extracted from opium, a compound found in the seeds of the opium poppy."

Edit: The research looks interesting though.

~~~
91bananas
Care to clarify what's erroneous?

~~~
maxerickson
The active compounds are not concentrated in the seeds. The seeds are even in
the way of extraction of the opioids from the rest of the plant.

Also, Opium is not really a compound, it's a mixture (which is maybe getting
pedantic, but it's ~8th grade science).

~~~
TenOhms
Correct, the seeds themselves are inert, the latex surrounding the seeds is
what contains the opium.

------
gleenn
This reads like an advertisement. Also, my nurse friend said only older
doctors use morphine. Most hospitals use fentanyl now.

------
oaf357
As someone with irreparable nerve damage (and has to ration pain meds as a
result) this is incredible news!

