Oh, this is a fantastic and beautiful deconstruction of this argument, I LOVE this. The comparison to chronic pain is fantastic, because indeed, chronic pain is a side effect of many conditions, and if we were able to relieve the chronic pain somehow, we certainly would, but being currently unable, we seek means to treat the chronic pain.
I've often held that the most insidious part about clinical depression is its self-reinforcing nature. Deep clinical depression is throwing a person into a deep hole with thorns sticking out of the sides- every attempt to climb out of said hole results in swollen cuts and pain to the arms and body, rendering eventual escape more difficult with each struggle.
Eventually, it becomes like trying to climb out of said hole with no arms at all. It's one of my life goals to discover biochemical methods to help such people regain the use of their arms, or even essentially grow new ones.
I find articles like this one useful ONLY* insofar as they assist those who have gained use of their arms and cut away the brambles on the walls of the pit- for most others, it merely ends up encouraging more struggling, self-recriminations, and effectually a deepening of the hole. :(
I have this wacky idea that maybe, just maybe we should reconsider the point at which opiates would be appropriate for treating depression. I mean maybe make them a 2nd or 3rd line treatment... right now I'm pretty sure they'd only give you opiates once that whole "induce a controlled seizure" thing fails.
Sure, they're addictive, but the "opium cure" was used up until the 1950's[1] and it's not like society was overrun by addicts. (I admit it's possible that the circumstances have changed, but I'd need to hear an argument for that.) Plus the fact that both Buprenorphine and Heroin-Assisted Treatment have been successful... opiates can be given as controlled medicine, and I feel like many people could benefit from them.
Over 40,000 Americans die by their own hand every year.[2] I would much rather have 40,000 opioid-dependent living people if it helped them bear the weight.
each year 19,000 americans die from prescription opioid overdoses and another 10,000 die from heroin overdoses which often start with prescription opioid use.
In my experience (as an anaesthesiologist), people who use opioids as a response to non-pain problems are some of the most miserable people there are. It might work for a couple of weeks, but soon you're tolerant, addicted, intermittently withdrawing and your life becomes a wreck. "The prevalence of suicide attempts among opioid addicts is reported to lie between 8% and 17%, with some studies reporting an even higher rate among special groups of addicts. "
http://www.ncbi.nlm.nih.gov/pubmed/9018906
Using MDMA might be useful as it is non-addictive, but again habitual use leads to decreasing benefits and increasing problems.
Also, don't you think your sample is biased as a doctor? As in: the people you're likely to encounter in your line of work are those that are in need of medical care?
Saying that prescription opioid use is a cause of heroin overdoses ignores the fact that the reason people move to heroin is because of the paranoia about addiction which causes their prescriptions to be cut off in the first place.
In the same vein (no pun intended) I've been looking for stats but not being able to find anything about what percentage of prescription opioid overdoses occur while the patient is being actively prescribed, versus those which occur when the patient is obtaining the drugs illegally once their prescription has been cut off because doctors are afraid they'll become addicted.
There's a piece missing from this argument: opioids were inappropriately prescribed to start with in many cases.
Think of all those folks with back pain. Back pain is complex and difficult to treat, but huge components come from 1) the stupid chairs we sit in 2) at our stupid jobs that encourage hours of sitting 3) in our cities that discourage biking or walking to work, all in the context of 4) a food system that gives us crap to eat that makes us mildly addicted to sugar and salt and makes us unhealthy.
So the real cure for back pain for a lot of people is to go back 20 years in time, make a commitment to taking care of their physical selves, aligning their eating, transportation, work, and recreation with health. The second-best cure is physical therapy. Physical therapy right now! But that costs money and time and no one believes it works (it does!!!) so the pain med is seen as the proximate best answer.
Brings us back to the original original post, actually.
Pretty sure if coffee was outlawed tomorrow you'd see a lot of people moving to illegal substances. Doesn't mean people can't handle the substance, just means people who are cut off from substances they depend on will go out of their way to satisfy that dependency.
This is a tautology. You're not "right" to fear illegal drug use if your reaction to said fear (cutting off access to quality-controlled, measured doses) causes it.
contrary to popular opinion these days, I think pain is undertreated and routinely so. quality of life should take priority over dependence concerns especially in the elderly.
Opioids are not a suitable treatment for long term pain, especially in the elderly.
People need rapid access to pain management clinics, with weight loss and strength building exercise, and access to meds (which in long term pain are often not opioids).
Giving those people opioids increases their risk of accidental death, and suicide. It gives them an addiction. But worse it does not treat their pain - they will still have the pain.
This is ignorant at best and naive at worst. God help anyone you treat, and if you aren't a medical professional its probably for the best. Your comment makes me physically ill.
You seem to think pain control is opioids or nothing, and that's not true. There are a range of meds that should be used before opioids are tried. You also seem to think that pain control is only medication, and that's not true either. Exercise is a powerful intervention that can cure some long term pain (especially long term lower back pain). This strength building exercise is really important for older people too.
Opioids really don't work for long term pain. People develop a tolerance, which means they need to take more to get the same effect, but that means they end up taking dangerous quantities, and not getting pain relief.
> 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 not 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.
Here's a BBC Radio programme about health. They visit a pain management clinic. People who visit that clinic usually have to detox from their opioid addiction before they can start the pain management work. This is because opioids really are not suitable for long term pain, and other meds / interventions should be used. http://www.bbc.co.uk/programmes/b04wv052
But what is the root cause of pain? I used to be depressed and in a lot of pain. I could have got anti depressants and anti pain rXs. Turns out I was just fat and my body was mad at me. Switched to an active lifestyle and everything got better.
Does that mean it would work for everyone? No. But no doctor told me to go run. they either gave me medicine A or B or C, and changed doses to try and minimize side effects. It's terrible but I understand. I can't go to an overweight depressed friend and tell him he needs to fix his life not take drugs for his bad back.
Someone who isn't addicted to highly addictive substances doesn't engage in risky behavior, disregarding consequences and their well-being, by seeking out undosed, more potent and potentially adulterated highly addictive street drugs.
Maybe their doctor has a valid concern. Opioids are rarely an effective treatment for non-cancer and chronic pain if taken regularly for a variety of reasons.
Ideally, if a doctor is going to stop refilling a prescription of an opioid addicted patient, they should be referred to appropriate services. Detoxification, pain management and mental health specialists should be all be involved for the patient's well-being. The patient should never be cut off cold-turkey like that.
I think mushrooms might be a better drug to give people than opiates. Send people to the redwood forest for a week to stay in a small cabin and eat mushrooms/smoke weed/eat good food and see how depressed they are afterwards!
Rofl! These are interesting points, and honestly, cause for deep thought. If these premises are sound, one might argue that a large part of the rise of clinical depression as the problem is presently constituted coincided with the phasing out of the so-called 'opium cure.' XD
(I'm so not willing to commit to that position, but I mean, just looking at only those facts you've popped in right there, it sure looks like a possibility, no real harm in admitting the possibility of any given conclusion! :) )
I'd rather have opioid dependent folk than suicides, as well, mostly because I strongly trend towards any outcome where there continues to be choice and opportunity for betterment. Certainly worth exploring, at least in thought! :)
If you're interested in studying the closest thing to it, look at the rise in popularity of Kratom, a Southeast Asian plant containing opioid alkaloids. It's commonly used by opiate addicts as a replacement therapy, and also by others as self-medication for anxiety, depression, and pain.
I'm not recommending anyone try it... nobody's entirely sure if it's safe, or if it could function as a gateway drug to harder opiates. But it's worth considering the good it may be doing for some people.
> Kratom.. self-medication for anxiety, depression, and pain.
> But it's worth considering the good it may be doing for some people.
The only the good it's doing these people is turing them into opioid addicts with a new problem that has a good chance of eclipsing the original and a certainty of exacerbating it severely in the long-run.
About three years ago I tried kratom and a few hours into it I decided to start an exercise habit and I haven't stopped. I should try kratom again some day.
I don't think prescribing opiates to the right patient is a bad idea, or just make them legal--which will never happen.
That said, you, or anyone else are not going to get opiates from any doctor in the United States. The federal government is comming down hard on doctors who prescribe opiates.
The FDA just sent out prescribing recommendations to all doctors. It is stern. It's basically telling doctors just don't prescribe them--period! Or, only to cancer, and for palliative care.
It will go down like this; patent will go to that rediculious office visit to discuss their pain(a lot of that pain is real. Opoids make you feel better, so the pain is bearable. There are people who stay on their original doses.)
Doctor will just say--no.
Patient will detox, and might die, if old, or has underlying health problems. Just like the way Jerry Garcia died out in Woodacre, CA.
Or, patient will go to herion? If they live in the right area, and they are willing to break the law?
Whatever--getting any opiates will be very difficult. The average patient will be in pain. I really don't like the way the government is telling doctors how to prescribe.
(Bupenorpine shouldn't be thrown in the opiate mix. I have never seen anyone abuse it--period. I know it's opoid like, but so different. I don't even think it possible to OD on this drug.)
There's some research happening recently arpund the use of ketamine as a short term measure to stop suicidal thinking or to get people out of deep treatment resistant depression.
The way I've heard it put is that opiates are an extremely effective treatment for anxiety and depression, with the common and serious side effect of ruining your life. But I hear they're working on eliminating the side effects:
That does seem to be the conventional wisdom. But it's a bit contradictory, don't you think? I mean, crippling depression already ruins your life, and suicide... well, that's the ultimate life-ruiner.
Opioid replacement therapy seems to work, so I'm just not convinced that all opiates inevitably lead to doom... it feels more like FUD rather than anything backed by scientific evidence.
Agreed, that's an interesting take. Do you know if medical professionals differentiate chronic depression from acute depression? Is "clinical" depression related to one or both of those?
I've often held that the most insidious part about clinical depression is its self-reinforcing nature. Deep clinical depression is throwing a person into a deep hole with thorns sticking out of the sides- every attempt to climb out of said hole results in swollen cuts and pain to the arms and body, rendering eventual escape more difficult with each struggle.
Eventually, it becomes like trying to climb out of said hole with no arms at all. It's one of my life goals to discover biochemical methods to help such people regain the use of their arms, or even essentially grow new ones.
I find articles like this one useful ONLY* insofar as they assist those who have gained use of their arms and cut away the brambles on the walls of the pit- for most others, it merely ends up encouraging more struggling, self-recriminations, and effectually a deepening of the hole. :(