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OxyContin's 12-hour problem (latimes.com)
565 points by sergeant3 on May 7, 2016 | hide | past | web | favorite | 359 comments

Sensible doctors do not believe drug company marketing.

I get large amounts of ad-junk from drug companies that ends up unread in the bin. I refuse to meet with drug company representatives. I smile politely at them if I bump into them in the corridor and suggest that they leave their ad-junk with my secretary. My staff then file their ad-junk in the trash bin.

On Friday, I had a drug company representative attempt to tell me ( he was hanging around my coffee area ) about the joys of Targin, a fixed-dose combination of oxycodone and naloxone. I gently shook him off, and directed him to my secretary.

Drug company representatives are usually decent human beings with lives and families. However they are poorly educated, poorly informed salesmen and women with sales targets to meet and product managers to keep happy. Even worse, they and the drug company have no accountability if a patient dies because of their recommendations. If avoidable death supervenes or if there are non-lethal complications or even just therapeutic failure, I am accountable.

Instead of relying on marketing, I rely on information from good, well performed randomised controlled studies published in reputable peer reviewed journals ( I like the NEJM ) and on meta-analyses of these. I view the results of these through a filter of scepticism, cynicism, pragmatism and a modicum of hope.

Many of my colleagues do likewise. I trust that you do the same in your respective vocations. Regrettably, there is a bell curve. I am sure that the drug companies find enough gullible prescribers out in the wild for their purposes.

Have you read Bad Pharma by Ben Goldacre? One of the more interesting findings discussed in the book is that doctors were convinced they were personally not affected by drug company PR/goodies (3 day conferences in Bahamas, etc) but they were all worried that their colleagues were.

It's an excellent book and I highly recommend it.

It's a standard reaction, like how most people believe that they aren't affected by TV/newspaper advertising but they worry about how it affects other people.

I am well aware I am affected by advertising, but I am responsible for its effect on me.

The problem is that there's absolutely no incentive for doctors to act ethically. You don't win any points for ignoring drug company marketing.

Vendor marketing exists in all fields, technology included. The difference is that when I'm spending money on a vendor as a tech manager it's coming out of my budget. I have an incentive to make sure that the spending is intelligent and the solution is effective.

Where is the incentive for doctors to do that? They're spending other people's money on other people's problems.

That comparison doesn't work.

As a tech manager, you're not using your personal funds, either, you're using your employer's money.

Further, if a doctor's prescription doesn't work, or is too expensive, the patients can get a second opinion, and the doctor can lose the person as a patient. An employer may not even have that option with a tech manager.

> As a tech manager, you're not using your personal funds, either, you're using your employer's money.

Right, but I am spending the money of my company. They control my salary and advancement, and I also have a fixed pool to draw from.

Doctors are spending money for insurance companies.

How is it different?

The insurance company can investigate the efficacy of prescriptions and stop paying for ones that don't work. The article says some of them have done exactly that with Oxycontin.

At the other end, if the pain killer isn't working, a patient can go to a different doctor who will prescribe something else.

Just a different perspective: maybe give other doctors more of the benefit of the doubt? I have a family friend who's I guess what you'd call "on the bell curve" and he described to me the process. Basically he says that the representatives are paying for the doctor's time/attention with fancy dinners and whatnot. Doctors are busy people and can't read about every drug and study that's being released. He, just like you, takes in the information skeptically and ask for what studies have been performed etc. etc. Like you say, the representatives aren't scientists so often they won't know the answer and they will take notes and have their company send the doctor a custom made document answering everything he wanted to know (as you know, the marketing budgets are insane).

It's sorta similar to the function congressional lobbying is supposed to fulfill. Ie. It'd be ideal if the congressmen/doctors did all the research themselves but that's not possible so you basically have a whole research team at your disposal (who's agenda is very obvious...)

Out of curiousity: how do you find out about new stuff then? I know there's a lot of messy incentives, but if a company wants to at least show that they have a new drug, how could they get you to read about it?

> how do you find out about new stuff then?

"Instead of relying on marketing, I rely on information from good, well performed randomised controlled studies published in reputable peer reviewed journals ( I like the NEJM ) and on meta-analyses of these. I view the results of these through a filter of scepticism, cynicism, pragmatism and a modicum of hope."

> how could they get you to read about it?

I'd assume by performing a sensible clinical trial that proves its efficacy beyond a reasonable doubt.

Advertising is how you're sold things whether or not you need them. It is not how you learn about what's best for your patient. There are other avenues of information that aren't tainted by the motivation to sell a product despite the consequences.

"a fixed-dose combination of oxycodone and naloxone"

That sounds similar to Suboxone, just with OxyCodone instead of Buprenorphine (i think they also make bup. minus the naloxone under the brand name Subutex). The naloxone mixture never quite made sense to me. Isn't that counter-productive? Is naloxone (aka "Narcan") not an opioid-antagonist at low doses or something?

The naloxone is not well absorbed when taken orally. It's in the Suboxone to deter injection.

This marketing says it's in the Targin to reduce constipation:


I see. I didn't know that, that's interesting. Question you may be able to answer: The naloxone/Narcan sticks that EMTs and some police have, they also pass them out at needle exchanges, etc. is that why are those applied in the nasal passage?

I'm a layman, but if i'm guessing right the term for this might be 'bioavailability' of the drug, is that correct? for example drug A may be absorbed faster and more easily through the digestive system over snorting. And then of course IV is the quickest way for just about anything, yea?

You used the correct term - bioavailability describes the fraction of a drug dosage that can enters the bloodstream.

Your example however makes an incorrect assumption. Bioavailability from snorting a powdered drug is higher than oral ingestion. When snorted, the drug passes through the thin lining of the nose and enters the bloodstream directly. When ingested orally, the drug has to make it through the chaos of the stomach and small intestine, get through the hepatic pathway (stomach and intestinal lining to liver to general bloodstream) before it reaches the rest of the body.

Depends on what you mean by "Sensible doctors". Clearly, doctors are influenced by marketing, otherwise pharmaceutical companies would not have spent and continue to spend, multiple millions of dollars targeting doctors.

It's not about conversion rate, it's about LTV.

Even if they only influence 1 doctor in a hundred, but that doctor brings enough revenue, it's worth it.

Want to see if you doctor has been taking money from pharma for meals/consulting/speaking/etc? Look them up in ProPublica's Dollars for Docs: https://projects.propublica.org/docdollars/

> he was hanging around my coffee area

What? Are they allowed to just enter hospitals as neither doctor, patient, nor visitor, and hang around promoting their companies' drugs? If so, why??

Have you read about ULDN? I know some addicts who've had a lot of success keeping tolerance down with this method.

Naltrexone != Naloxone. ULDN is incredibly dose sensitive. According to studies, 2 micrograms of naltrexone is effective, yet at 4mcg it begins to lose its efficacy.

One of my questions when interviewing a new physician is to ask their opinion on "detail people".

My mother works for a doctor, she's gotten some drug company swag and passed it on. I have (had?) a pen somewhere with a floating viagra pill, and a notebook in the form of a Cialis box.

Hardcover, I assume

Armchair Policy Wonk:

* Make FDA approval double blind. Can't bribe who you can't see.

* Before starting a study, if you want to include it with a future application you need to register it. All registered studies need to be included with an application. Can't cherry pick studies.

* You may only use approved claims stated in the application in marketing or product descriptions. (which I thought was already the case)

* Make it illegal to advertise or market any drug that requires a prescription.

Hell yah. It's not a coincidence that America is the only country that allows direct to consumer advertising of medication.

Here's another one: ban all forms of compensation from drug companies to doctors. No more bribes^Wconference trips.

False, there are three (western?) countries that allow it: USA, New Zealand, and Brazil [1]. Here in NZ, there are not very many ads on TV for prescription mediation. "Ask your doctor" is a common phrase, but I get the impression that the large majority of advertised drugs are non-prescription. (But I watch little TV and I certainly avoid watching TV ads)

[1] https://en.wikipedia.org/wiki/Direct-to-consumer_advertising

I didn't know about NZ. Also, I think the Brazil info is out of date.

The hilarious thing is that the US has the Foreign Corrupt Practices Act through which we can punish multinationals - usually BigPharma - for bribing doctors in other countries, where direct-to-customer advertising is prohibited.

I've seen ads (either in the US or UK) that didn't market drugs directly, didn't name any brands or anything, but was basically "If you have erectile dysfunction, go see your doctor, there may be something for you".

That sort of ad seems common for conditions they're trying to "popularize", like "restless legs syndrome", especially when the drug they're selling isn't approved for that use. Hypochondriacs go to the "official site" and learn from sockpuppets what drugs to pester their physicians about.


The argument for these ads is that many conditions are very undermedicated. People don't know they have treatable conditions and suffer needlessly.

People are not qualified to judge. If they are suffering they should see a doctor, who is qualified to determine if they have a treatable condition.

That is exactly what these ads tell people to do.

Not quite ... they tell people to ask about a certain, non-generic, drug.

What about the first amendment?

You can almost certainly restrict it on public broadcast TV, which would be a good start. The FCC has pretty broad powers to regulate broadcast TV and radio compared to other kinds of speech. For example:


What about it? I can't show pornography on TV or slander someone on a newspaper and call freedom of speech.

Legally, it's not really an issue. Commercial speech can be broadly regulated by Congress.

Free Speech doesn't really factor into a huge portion of what you see from the FDA, FTC, SEC, CFPB, and hundreds of state-level organs focused on regulating deceptive business practices.

What about it? Not all speech is protected and there is a case to be made of the harm such speech poses. This is why we can't yell "fire!" in a crowded theater. Schenck v. United States, 249 U.S. 47 (1919)

The bar for prior restraint based on content is pretty high. I believe it's "clear and present danger". You're likely to have a difficult time making the case that ads for allergy medications present a clear and present danger.

The bar for prior restraint on public airwaves is much lower. We'd be much better off if drug marketing were relegated to the shady corners of the internet for advertising.

I agree - this could be tricky.

One solution for restricting advertising would be to allow consumers to sue drug companies for false claims or for misinforming doctors.

No, it's commercial speech. The FDA already regulates what they can say in drug advertisements. There's not really a legal issue there.

I think your second bullet is already partially true [0]. The broader question of cherry picking in scientific studies is pretty interesting [1].

[0] https://clinicaltrials.gov/ct2/manage-recs/fdaaa#WhichTrials... [1] http://www.npr.org/templates/transcript/transcript.php?story...

> Before starting a study, if you want to include it with a future application you need to register it. All registered studies need to be included with an application. Can't cherry pick studies.

That's similar to Ben Goldacre's project http://www.alltrials.net/

Richard Taite of Cliffside Malibue was on Bill Maher last night and he said that there was a study that recently (within the last month) came out done by I think the FDA that concluded that oxycontin was only to be prescribed to people for 7-12 days maximum. And he said that everyone was on board, but then the prescription drug lobby totally squashed it.

The United States has 5% of the world’s population & consumes 75% of the world’s prescription drugs.[0]


The problems derive from the prohibition, which takes several forms. The forms add up for big profits and bad incentives, for which the consumer pays.

FDA approval is the first layer of prohibition. Very expensive, this keeps a lot of competitors out. Lots of market (read: pricing) power is conferred to the winners. Great incentive is provided for regulatory capture.

The second layer is patent protection. Again, competition becomes illegal, with outcomes similar to above.

Third is scheduling it as a prescription drug. The incentives of the drug company are now to influence doctors, in ways that may be more or less overt. Docs get a cut of the outsize profits, de facto.

The fourth layer is opiates being illegal in general. Competitors out.

Of course there are legitimate reasons for prohibition, even if I don’t agree with them. One can make an argument for protecting people from harming themselves.

But these arguments are naive and static. By “dynamically scoring” the cost of prohibition – following the incentives and the outcomes – we might choose differently.

Can you explain more how competition, availability, and legality will stop the more addiction-prone (low-income, chronic pain among other health problem) parts of society in America from doing drugs and becoming addicted? If I read your argument correctly, it's that the pharma firms will not market it as much and not profit as much. In my mind that's not enough reasoning that people who simply have a bad situation won't reach out (to their doctor, guy next door with a prescription) and find the drug

I see the experimental results in other countries that have taken steps forward on legalizing various drugs, but they also have a much better social welfare, schooling, and support system.

I just don't see the connection between making a drug more available, making more versions of it, deregulating it and having less people taking it. Without your further explanation, that is.

I don’t think legalization will reduce addiction (though would defer to empirical studies here). It would make the economic cost of addiction lower for the individual – one problem instead of two.

More importantly, it would make doctors (and regulators) more honest participants. If a doctor wants to recommend opiates, it would largely remove their economic incentives for doing so. We don’t think of doctors having much economic incentive for prescribing acetaminophen or ibuprofen, by comparison.

I have to agree! The bad floats with the good and likewise.

From the New York Times: "Actually, Prohibition Was a Success By Mark H. Moore; Mark H. Moore is professor of criminal justice at Harvard's Kennedy School of Government."

"... Second, alcohol consumption declined dramatically during Prohibition. Cirrhosis death rates for men were 29.5 per 100,000 in 1911 and 10.7 in 1929. Admissions to state mental hospitals for alcoholic psychosis declined from 10.1 per 100,000 in 1919 to 4.7 in 1928.

Arrests for public drunkennness and disorderly conduct declined 50 percent between 1916 and 1922. For the population as a whole, the best estimates are that consumption of alcohol declined by 30 percent to 50 percent.

Third, violent crime did not increase dramatically during Prohibition. Homicide rates rose dramatically from 1900 to 1910 but remained roughly constant during Prohibition's 14 year rule. Organized crime may have become more visible and lurid during Prohibition, but it existed before and after. ..."


> Second, alcohol consumption declined dramatically during Prohibition. Cirrhosis death rates for men were 29.5 per 100,000 in 1911 and 10.7 in 1929. Admissions to state mental hospitals for alcoholic psychosis declined from 10.1 per 100,000 in 1919 to 4.7 in 1928.

From http://www.slate.com/articles/health_and_science/medical_exa...:

> In 1926, in New York City, 1,200 were sickened by poisonous alcohol; 400 died. The following year, deaths climbed to 700

The poisonous alcohol was a direct result of prohibition. So I think focusing on just cirrhosis deaths paints an unfair picture of the actual health effects.

> It would make the economic cost of addiction lower for the individual

Isn't a low cost of addiction a bad thing?

I'm also not just talking about legalization, but mainly the thing about deregulation/competition. I see your logic though, I hope it's not too wishful to assume that less doctors pushing drugs on patients will solve the issue. I suppose it definitely will cut it back some.

No, it's a good thing. It means people that are addicted (by choice or not) don't need to resort to crime or desperation to buy essential medicines.

Less doctors "pushing" really means more doctors being very critical of patients. Which means more people in pain, scared to make too big a fuss, lest they be labeled an "addict" or "seeker".

We don't accept (in theory) a legal system that condemns innocent people to suffer, why should we accept a health system that does the same?

A number of people in this thread are saying the answer is either to prescribe opiates, or to leave people in pain.

People who need opiates should be able to get them, but that's a small number of people. Giving opiates to the rest does very little to treat their pain, and leaves them with an opiate addiction.

Most people with long term pain don't need better access to opiates. They need better access to pain clinics with the range of meds and physical therapies they have. (And yes, opiates if those are needed.)

> No, it's a good thing. It means people that are addicted (by choice or not) don't need to resort to crime or desperation to buy essential medicines.

This seems twisted to me. Okay, so they don't do crime, but they get their stuff easier and stay addicted/get worse/die. Isn't it best to eliminate the motivation for doctors to overprescribe, but still force people to see their doctors for a fix? This way maybe the doctors can intervene and help them out.

Don't understate the "do not do crime". I've known addicts and the biggest damage they cause (apart from dying when they OD on unknown-quality junk) is that they become thieves and liars. No one trusts them and it tears relationships apart. Both are fixed by having more legal availability. If they were simply able to get opiate as easily as pot, then addicts for the most part would be just like potheads. Perhaps being useless, perhaps seen as a drain or whatever, but not dangerous, not bad people like some junkies turn into.

With proper availability, opiates are very well tolerated. Being addicted, by itself, is not a big deal. Apart from the negative pieces you see like this one, opiates are still a huge success for many people. Not just physical pain, but emotional pain, depression, and stress. Keep an eye out for pinned pupils and notice how many professionals have them.

There's this stigma that addiction is inherently bad. Yet it only applies to "fun" drugs like opiates. No one, in general, goes on about the terribleness it is to be addicted to antipsychotics or insulin or antidepressants. At best, you hear how annoying it is, having to always make sure you've got your gear - but I've not seen people go on about the intrinsic badness of addictions lifesaving medications cause.

What should be available is more public health awareness, and a cultural shift. People should be free to get addicted, but easily obtain services to help with it, without being labelled or criminalized. You don't need to rob people of liberty and cause suffering by requiring a paid gatekeeper to watch over everyone.

"Being addicted, by itself, is not a big deal." - As someone with an en extensive amount of first-hand knowledge, I disagree very very much. It is in fact so big of a deal that it becomes your one and only deal.

The worst part is, if you use opiates for a long period of time consistently - you WILL become reliant upon them. Your body will be chained to them, physically dependent, and I don't care who you are, where you come from, or how much money you have. 100% of the time, no exceptions willpower be damned.

And as far as using opiates as a means to heal emotional pain and depression? That's is possibly the worst idea ever. You're flat out asking for a long, long slow death in which you probably kill yourself in the end anyway but in the meantime you disappoint anyone who has ever cared about you even slightly.

Well I guess we have two different sets of people and experience then. I've seen people do rather successfully in business, all while using opiates on the side. (I've seen a few people die too, but that was pretty much caused by illegal supply and lack of regulation/QC.) The actual addiction part, without supply constraints, becomes very, very simple logistics.

Those logistics are not as simple as it may seem. 2 bags of dope/pills/caps/doses a day becomes 3, 4, 6, 8 twice a day + 9 on Sundays. Happens to everyone given a long enough usage period. There's that proverbial slippery slope there, and once you're over the hump it's checkmate. Wait until something happens to these successful folks - and it will. there's a weak link somewhere in the chain and when it breaks they will act like every other junky.

And what is "acting like every other junkie" mean? Göring was a morphine user for what, 2 decades? Didn't stop him from becoming extremely powerful (misguided, but he accomplished a lot).

I mean the guys who are successful you mentioned, i assume they have nice jobs, families, maybe children -- the good stuff. Once shit hits the fan and they get a taste of dopesickness they will ignore all of that, the drug becomes priority #1 hell with everything else. Then they will do whatever and screw over whoever to fix the link of the chain that broke (ie, where to get them or how to pay for them, how to hide it, or whatever the problem may be) just like every other junkie. You will eventually look in their eyes and see nothing, like every other junkie. It's a short ride from having it all to having nowhere to sleep.

It's a cycle and story told time and time again. If your friends want to stay successful and keep the good stuff in their lives they should get off the shit is all i'm saying. That's nowhere near easy to do, but it's gotta be done or they will crash & burn. Opiates don't really cure the pain anyway, just mask it.

Goring had the advantage of being in a prominent position close to the leader before he got hooked and fell off. I'm sure any other lower nazi officer would've been cast off if they weren't buddies with the fuhrer. He also was in the advantageous (but bad) position of being able to tell his doctor "you're going to give me this dope when i ask for it or i'm going to toss you in the fucking oven"

So it sounds like you're saying that the issue is availability, pricing, and legality. We're in agreement.

Those things (except legality, because that's not stopping anyone) can be part of the problem, sure but it's a lot more than that. It's such a fragile house of cards you're describing with that situation and I don't know if you just don't believe me or you're taking it WAY too lightly.

Those people who are successful are headed for disaster, even if they have the money to mitigate supply issues/price. If you care about these people, tell them rich people go to Passages in Malibu. It costs $80,000 and i can prove that. but maybe they can afford it?

I am 100% reliant upon, chained to, and physically dependent on both water and oxygen.

But since they are cheaply and abundantly available, I can live a full happy life anyway.

Alcohol is cheap, legal and abundantly available, and plenty of addicts destroy the lives of themselves and others around them. One part of it is true though: legalisation does reduce crime dramatically. You don't hear of alcoholics breaking into houses to feed their habit.

I'm sorry I don't understand your point?

I mean, heroin is cheap and abundantly available.

Heroin isn't that cheap, and the availability is sporadic, if you take quality control into account. Factored into this is the legality aspect, meaning a patient might not be able to buy when the need arises. It should be as easy to get as alcohol or Tylenol.

Look at the prices of morphine on goodrx: I don't think unlicensed manufacturers and retailers approach the low cost legit ones do.

I've enjoyed the discussion we've had here and in the other thread as well- and I mean no disrespect, but I take it that you're not used to the streets (if i've missed the mark, i apologize). It sounds like that world is unfamiliar to you - which isn't a bad thing, but in that underworld people don't think the same way. It also sounds like you're someone who has never experienced withdrawal symptoms of a severe opiate addiction (which is definitely not a bad thing). Legality isn't stopping anyone. There is not a dopefiend on the planet who, given the opportunity, wouldn't do just about anything for a fix in dire straits. It is that bad, regardless of your place in life or social status. I don't know if you are taking into account how incredibly easy it is to go from "i'm getting these from a doctor, and have a prescription" to shooting dope in places you wouldn't come within miles of otherwise.

Price - It depends on location and other factors, but i can tell you from personal experience that as a user, as far as pure numbers go, heroin ends up being much cheaper than prescription pills (which are the most popular form of opiates). it was pretty close in price on either coast and the midwest, in big cities and smaller towns. (except Florida, surprise! pills are dirt cheap there and it's deadly. there are pharmacies on top of pharmacies on top of shady doctors offices in Florida, it's like goddamn Mexico. not an exaggeration). I've been out of the game for a while, but I hear through the grapevine there are recent shifts in the market as Govt. officials crack down on Docs who they perceive as writing too many scripts. This immediately takes a major source of Rx meds out of the game, which is the ideal opportunity for heroin dealers to move in - and as soon as that happens, on day 0, it's too late to fix in the current system we have in place in the US.

Availability for 'street drugs' right now isn't really an issue in my experience. Opiate addicts are a subset within a subset of drug addicts and they tend to flock together. An addict of many years on the streets can spot another addict (or a corner boy) easily, and they all know where to go to get it.

There is also quality control on the streets, it's messed up but it's true and works: If a dealer sells a new batch to a group of 5 users and 3 of them overdose word will get around that it's killer shit and then that's what all the other users WANT because they figure it's potent. I've seen dealers with Narcan nose injections on them at all times, specifically with the intention of saving a dope fiend's life when they OD just so he goes out and tells the other users it's good shit. Then he can either cut it to stretch it out and make more money, or continue giving out the goods to build loyal clientele.

The converse of that works as well, if you sell a faulty product then you become the LAST option on the addict's go-to list. The fact that someone who sells a faulty product intentionally is even still on the list at all is a testament to how fucked up opiate addiction is.

And I'm all for legalizing, controlling, and even taxing weed (for recreation and ESPECIALLY medicinally) -- but if heroin ever becomes as easy to get as alcohol.... man, unless someone discovers how to drastically change how opiate receptors in your brain work, that would be the modern day equivalent to the zombie apocalypse. We'd be doomed, everyone.

My point is that there is nothing inherently bad about being reliant upon, chained to, and physically dependent on a substance.

Couldn't the opposite be said as well? Isn't being completely bound by ANY substance at all, be it air or narcotics or whatever, inherently a negative? Reliance on oxygen makes the whole space thing difficult, chained to opiates makes you a monster, etc.

We're not talking about inherent bad, or about oxygen. We're talking about addiction to opiates, which ruins lives and kills people.

I've seen it first hand. Stop this nonsense.

Opiate specific arguments could be reasonable.

But the post I responded had no such arguments.

Then go to a thread about oxygen and water. This one's about opiates.

Heroin has been illegal for a hundred years. We still have junkies.

You can say the same about alcohol. Does alcohol ruin lives? Yes. But we limit many of the social impacts by treating it as a regulated substance vs a controlled substance.

Even with heroin being illegal, I've seen people get it without a problem. They have to resort to no crime to get it other than getting it itself being a crime. But this hurts no one.

What hurts people isn't getting it, it's what they do as addicts. Throw their lives away, resorting to crime to live day to day, get housing and food… They partly ruin the lives of those close to them too.

Legalization would do nothing to help this, it would just hurt a little. They'd get it a bit easier, but since they didn't resort to violent crime to get it in the first place it would be meaningless. The crime and disaster they cause after getting it and becoming addicted would remain.

But like you said in the other branch, we have seen different people and have had different experiences.

I've seen friends destroy their relationships and careers over addiction.

I've also seen a burned out house where a dealer set fire to it with the occupant inside to incentivise future debtors to pay up faster.

I've seen the grey market involved in buying such things suck far harder on somebody's lifeblood than buying alcohol would an alcoholic.

So ... my gut feeling is that, overall, legalisation would probably be an improvement. But I think that, if so, it would be an improvement overall, and that doing the math carefully beforehand is a really good idea.

Or: I think you and MichaelGG both have valid points, and that any opinion on this subject that doesn't include both is probably going to fall short of the mark.

(to be clear, I'm replying to this specific comment largely because of your last line, since I'm seeking synthesis, not antithesis, by this line of thought)

> With proper availability, opiates are very well tolerated.

This just is not true. With proper availability people develop tolerance, and require higher doses. That does becomes high enough to become dangerous, and so they need to change to a different, stronger opiate. They develop a tolerance to that too.

Eventually they're cycling through 2 or three different opiates (sometimes at the same time) at very high dose. And their pain is not being managed.

> addicted to antipsychotics or insulin or antidepressants

No tolerance, no seeking, no preoccupation, no continuing to take them when you know they're doing you harm -- those things are not addictive.

What you keep saying in these threads is that opiates aren't effective. Why then do people continue to use them? Certainly if you're in pain, you're not taking a gram of morphine-equivalent per day just because. If there are effective alternatives, why are they not used? Then with pain under control, you can slowly (over a year, say) taper down.

I'm not saying it. National organisations are saying it - Public Health England (part of government); the Faculty of Pain Medicine (part of the Royal College of Anaesthetists); NICE (The National Institute for Health and Care Excellence, a non-departmental public body) all say it. So, unusually, do the CDC: http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html

If they were effective and if addiction could be safely managed you wouldn't see increasing rates of people addicted, taking dangerous amounts, and dying of overdose. http://www.theguardian.com/us-news/2016/mar/17/cdc-guideline...

People take opiates because doctors inappropriately prescribe them (in some countries); because the word "opiate" is well known; because people reject other treatments; and because people stick to the med they know. That's why co-proxamol (and very dangerous, ineffective medication, is still being prescribed today even though there are many other better meds).

They continue taking them, at massive doses, because they're addicted. And that's the problem - if they were addicted but getting pain relief we could understand the continued use of opioids as first line treatment, but most people don't get good pain control with opiates for long term pain. They end up having to mix different meds, these combinations are often dangerous. https://www.theguardian.com/science/2014/dec/09/us-patients-...

This would be basically why after breaking my hip and having it reassembled around a Dynamic Hip Screw, every week I dropped my dose of codeine so that the pain was back to being as bad as I'd been dealing with a week ago. I do wish people being prescribed opiates for situations where that's possible (i.e. the pain will lessen over time anyway) basically got a guide on doing that, not everybody's an ornery bastard like I am.

The only time opiates for control of pain that wasn't going to lessen over time seems like a good idea is in the case of palliative care for the dying; my father got several months of mostly-pain-free end of life out of it, and whether it was increased pain from the cancer or decreased effectiveness due to addiction that eventually meant the maximum dose allowable didn't help, he was dead within a week after that so even given all the obvious caveats I think he picked the right set of trade-offs.

This is what I've seen firsthand from the treatment facility I've volunteered at. Long term use becomes a problem for many patients and eventually they have pain even with dangerously high doses of opiodes.

There are multiple, large studies of rest home patients on opoids.

The conclusion, patients did not build up a tolerance.

(I know Dr. Dean Edell cited these studies many times, when he was on the air. He wasen't the typical media Doctor.)

You're talking about acute, short term, pain. I have repeatedly said that I am not talking about short term pain. I am talking about chronic, long term, pain.

Controlled legalization of other currently illegal drugs may or may not have benefits that can't be proven yet due to research of these drugs being illegal. There is empirical evidence that certain psychedelic drugs may reduce or eradicate opiate addiction. Even if these drugs were also addictive, it may be that the harm they cause is orders of magnitude less than opiates or similar. Replacing one problem with a lesser one is indeed a better outcome than what we have now.

None of this will be known, though, until certain deregulation and controlled legalization occurs.

It's not just making it more available. Legalization has to bring better treatment and a shift in public perception to it being perceived as what it really is- a mental and physical health problem. If nothing else, people would be far more likely to seek help if they weren't treated as criminals for doing so. Also, truth in education makes a big difference. See Portugal for a good example.

Addiction can be managed, it's only a catastrophic problem for the patient in limited circumstances: the dosage is too strong or you can't get it.

Where are you getting the goal of fewer people taking it, and why is the number of people taking it a concern at all? Pain management is the issue at hand.

Opiates are usually not a good option for long term pain relief for many patients. They can work well in the short term but long term use can ruin a person's life (I've seen it happen, it's awful) and they lose effectiveness long term and end up causing more problems than they solve. Switching opiodes from a short term option to a long term one in the 90s was a huge (and largely failed) experiment.

Long term pain control is a complicated and multi facaded beast. We need to invest in it. "Just take a pill" is clearly not the solution that works.

I am not sure what "addiction can be managed" is supposed to mean.


The prevailing medical notion was that there was this bright line involving the opioids — that they were great for patients but the problems happened when they went out on the streets and were abused by kids and others. But today it’s clear that the long-term use of these drugs can not only be ineffective for chronic pain, but they also create bad side effects for patients. Not just addiction but powerful psychological dependency, depression of hormone production, lethargy and listlessness and sleep apnea, among others. These drugs do work well for some patients, but for many other patients, they’re not working well at all.

One leading expert said: “We thought the big problem with these drugs is addiction. Now we realize the problem is with patients who take them and basically opt out of life.” There is a general realization that while they do work for some patients, using them on a massive scale to treat chronic pain has had really disastrous consequences.

For instance, back pain is probably the leading workplace injury. What insurers and workers’ comp agencies are discovering is that when workers are treated with high doses of opioid drugs fairly soon after these injuries, it’s the leading predictor for them not coming back to work for long periods of time, or ever.

When you take a narcotic painkiller it sets off a natural reaction called tolerance, which means your body adjusts to it. You have to take more of the drug to get the same painkilling effect. Patients would come back to doctors and say, “This drug was working really well for me, but now I’m feeling pain again.” The doctor would increase the dose. The prevailing ideology during the war on pain was that these drugs had no ceiling dose. You could keep increasing them. The doctors kept boosting them every six months. People started taking higher and higher doses of these drugs. At a certain point it appears they create a change in the neurological system where people develop hyperalgesia and they become far more sensitive to pain than when they started out on these drug

What he meant was that dependency can be maintained.


I disagree that opiates are not a good choice for short-term pain relief, and I also disagree that they are not a good choice for long-term pain relief.

If anything, pain is currently being under treated on a massive scale thanks to the new-wave crusaders against opiates, flying a flag of the same type of study they decry as flashy science only meant to gun for the headlines as proof undeniable.

There will always be opiate abuse. A moral backlash against abuse should not deny people in pain the quality-of-life increase they can get in return from opiates. Dependency be damned.

>Long term pain control is a complicated and multi facaded beast. We need to invest in it.

I do agree with this.

>"Just take a pill" is clearly not the solution that works.

It's the solution we have right now, though.

My grandparents, bless them, couldn't function without narcotic painkillers. without narcotics, there is no quality-of-life to speak of for them, and for a lot of people like them. Dependency be damned.

Until something as affordable and available as opiates come around, that can give them equipotent pain relief, traditional poppy derivatives can and should be used to treat pain in those who live each day in pain. Tolerance be damned.

I said opioids are a good option for short term pain. They are also usually (not always) a bad option for long term pain.

Please go to a treatment facility (volunteer please) and talk to the patients there. It is beyond eye opening, I volunteered at one myself. I've seen pain medicine literary ruin lives, and it's so sad. These are people who have been through hell with their injuries, some of the worst I've ever seen, and then they go through hell again with the opiodes.

They can work on a long term basis for SOME (but not the majority) of patients.

Psychological treatments are also an important part of pain management.

Yes, opiates can ruin lives. That is not the trump card you want it to be, sorry.

If anything, the pushback against opiate prescribing has resulted in a lot of dependent patients (and addicted abusers) looking at heroin as a more potent, widely available, cheaper alternative.

opiates have been around a long time for a good reason. they can give an unrivaled increase in the quality of life of those suffering.

there will ALWAYS be opiate abuse. taking prescription painkillers out of the picture doesn't even put a dent into it.

do you think it makes more sense to spend time and money demonizing prescription opiates and prosecuting those who prescribe them, or use that time and money to implement programs and services that can help those who have become dependent or addicted?

As someone who has chronic pain, tapentadol has been a godsend for me. Its an opioid which also has norepinephrine agonist effects to help reduce pain in a multi mechanistic way. It was developed as a 2nd generation version of Tramadol, which is also a very amazing drug. Tapentadol is brand name Nucynta and cost 1500 for a 30 day supply compared with morphine at <$50. But tapentadol is an engineered alkaloid..designed to be less addictivr, more selective for the mu opiod receptor and norepinephrine agonism for better medicinal use than morphine. I agree with other posters about prices necessarily harming those who are poor and more inclined to abuse drugs due to a dismal outlook on life. On the other hand, having taken various opiates and seen how effective and therepeutic Tapentadol is, makes me want to reward Depomed who researched and developed an improved version of their already very successful Tramadol. They took on an endeavor that needs to be justified by some type of risk rewarding lucrativity. Its not all carnal..

My energy levels and ability to be active during an entire day was borderline geriatric before I started taking tapentadol. Opiates are addictive but are also the gold standard for pain relief. Pain reduces energy levels, its fatiguing. I would sometimes want to just cry out of how weak I felt. No one should have to 'just deal with it' when it comes to nerve splitting pain.

To counter your anecdote, tapentadol (Nucynta) leaves me extremely foggy and out of it at doses below the required dose for pain relief -- far loopier than hydrocodone, oxycodone or oxymorphone.

I'm the same, as I was with straight SNRIs too. I think some people just can't tolerate SNRIs and SSRIs. But for those who can, they can make a big difference to pain levels

I feel more awake and stimulated from it. A laser focus. And the pain relief is far better than Tramadol or conventional opiates that lack an adrenal boost. I would guess you are right and it can definitely be a genetic variability. Its actually difficult for me to sleep on Tramadol or Nucynta .. so exactly the opposite of drowsy.

You're putting words in my mouth that I didn't say.

It's often used inappropriately, which is one reason to use less of it and use other better alternative.

It's a significant cause of death in suicide so that's another reason to use less of it. It accounts for a lot of accidental death, so that's yet another reason to use less of it.

Right, that's the moralistic part. However, physiologically it remains an actual treatment path. How are opiates a significant cause of suicide? How do they compare to the antidepressants I see advertised on TV that mention an increased likelihood of suicidal thoughts?

There are actual people with actual suffering involved here, remember that. Don't let your misconceptions of junkies determine public heath policy.

>There are actual people with actual suffering involved here, remember that. Don't let your misconceptions of junkies determine public heath policy.

Go to any treatment facility and actually talk to the patients there. Your attitude will change. I used to volunteer at one so I knew a lot of people who went from pain patients to addicts who were still in pain. Amputees, people with disfiguring injuries, chronic diseases. These aren't people who are seeking drugs on the streets - these are doctor prescribed drugs. The effects of the medication are terrible for quality of life and they just plain stop working!

How is it moralistic?

We know in the UK that self poisoning is the second most common method of suicide after hanging, strangling and suffocation. (and that's likely to change with the next release of numbers - self poisoning is likely to overtake hanging strangling and suffocation).

the list of meds used in self poisoning is something like

  1) Opiates
  2) Anti-psychotics
  3) Tri-cyclics
  4) Paracetamol
  5) Paracetamol and opiate combination
> However, physiologically it remains an actual treatment path

But that's the point, it doesn't.

> are actual people with actual suffering involved here, remember that

That's entirely the point! Opiates are not effective for most of those people. Opiates work in the short term, but the patient develops tolerance and needs to take more. Opiates are not suitable for long term use. A patient can very quickly build up to dangerous harmful levels of opiate use, and they're not getting pain relief.

Calling a medication dangerous and ineffective, and pointing out safer more effective alternatives, is not moralising, unlike your "remember there are people suffering" comment.

I forgot the cites! Sorry.

The first is the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness http://www.bbmh.manchester.ac.uk/cmhs/research/centreforsuic...

The second are the Office for National Statistics mortality data. Here's deaths: http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdea...

And here's suicide: http://www.ons.gov.uk/peoplepopulationandcommunity/birthsdea...

(Watch out. They count slightly different things. But they should both be clear enough about what they're counting).

Here's a map showing medications that are prescribed across England. You can noodle around with the data to see what's prescribed or not, and how much, and by what doctors offices: https://openprescribing.net/

The same could be said for guns.

Addicts are going to get fucked up on whatever they can find. If they can't find opiates or whatever, they're going to get fucked up on cough syrup, or booze or huffing paint or whatever.

In general, though, addicts don't necessarily go straight to the hard stuff or inevitably to the hard stuff, if other options are available. Prohibition actually encourages people to go to the hardest purest forms, though.

When you're moving around contraband, you want the most expensive high you can get in the smallest volume. It's easier to move around heroin or crack than something like codeine or coca wine, so that's what's going to be available on the street.

> Addicts are going to get fucked up on whatever they can find. If they can't find opiates or whatever, they're going to get fucked up on cough syrup, or booze or huffing paint or whatever.

While this is reminiscent of something Matt Dillon's "shameless dopefiend" character from Drugstore Cowboy said, I'm not sure if this is true.

There is another thread of addiction research that establishes the notion of "addiction as self-medication," in which users seek the drugs that work to alleviate their symptoms, be they physical or psychological. Anecdotally, I've experimented with a lot of substances, and opioids are the only class of compounds that I have sampled that work for me.

In addition, while it's certainly true that, if you attach two acetyl groups to morphine you end up with something 2-3 times more potent by weight, I wonder if people's conception of the "hardness" of drugs is somewhat artificial.

> addiction-prone (low-income

Are low-income people more likely to become addicted? I'd like to see some statistics.

A few thoughts:

* There are many more low-income people than wealthy people, so low-income addicts may be greater in sheer numbers but not in rate.

* I expect that addition tends to reduce income, so people who started wealthier may become low-income

* Prescription opiods are by reputation the wealthy person's heroin. Given the high cost of presecription drugs, and that low-income people sometimes can't even afford drugs necessary for their health, I wonder if Oxycontin is widely abused in low-income groups.

There is no correlation. People of all incomes become addicted to all sorts of things. And it was perhaps wrong of me to phrase myself that way.

I suppose the motivation for that parenthetical was just subconscious--as I've seen some people who happened to be lower income have their lives ruined by their pain meds, whereas in the higher income circles I've seen, they're more addicted to strictly recreational drugs.

What a classy response! And perhaps I put too much weight on one short parenthetical phrase.

At the some time, income is inversely correlated with impulsiveness, which is correlated with being addiction prone. (The old one/two marshmallow experiment.)

The Marshmallow experiment fails to take into account the findings of previous experiments that the author of the original experiment conducted. Mainly, that a child's belief about whether or not the stated outcome would happen influenced how long they would wait before acting 'impulsively'.


> income is inversely correlated with impulsiveness, which is correlated with being addiction prone

I'm sure many people think this, but do we know if it's actually true? Is there any research or data?

For example, as a completely speculative alternative hypothesis, people with more money could be more impulsive because they can afford it.

> Third is scheduling it as a prescription drug. The incentives of the drug company are now to influence doctors, in ways that may be more or less overt. Docs get a cut of the outsize profits, de facto.

Hi! I'm a non-trad physician, with a history in health policy and managed care before moving onto the provider side. Please, tell me more about this, in a way that is more nuanced than the urban myth of "free golf trips and speaker fees for everybody!"

Urban myth? This probably varies from place to place, but certainly all the physicians I'm close to are treated to very good food every day, and will accept occasional invitations to attend fun events with sales reps. Drug companies do their best to create an informal quid pro quo atmosphere. Many drug companies are involved, so they are clearly seeing returns from their physician influence.

More overtly, drug companies pay for fancy physician association dinners, and a rep will give a presentation on their drug and hand out business cards and brochures.

First, and I want to make clear that I am strongly against any drug rep presence in any medical institution, and have advocated against it in institutions I've been affiliated with: let us draw a hard line between three levels of behavior, because conflating them is ... well, not ridiculous, not quite, but misleading. It's not ridiculous to group "slapping someone" with "beating them with a baseball bat," but it loses something.

Additionally, I'm putting a firm "no" on "informal quid pro quo." Though you, I, and ever psych major on the planet knows better, most physicians firmly believe they're just being advertised to, but are not swayed by the pharmaceutical company ads. Very few of my colleagues believe they're susceptible to this sort of shenanigans. Very few would knowingly consent to partake in a "quid pro quo" arrangement of fringe benefits for prescriptions, and most would be earnestly outraged at any such suggestion. You can claim the outcomes are the same, but they're not - it speaks entirely different volumes of the characters of the people involved, and approach needed to reform.

So, 3 levels:

1) Direct pay-offs from drug companies to docs This is something that has never been as commonplace as people seem to believe (eg, speaker fees), and is very nearly dead since physicians that get this money are now publicly monitored for it. It's always been rare, and remains so. So when we say "docs profit," which implies this level 1, well, let's not.

2) Physician frills paid for by drug companies This used to be quite common, and has grown much less so. It used to be "let us subsidize your trip to the bahamas for a 5-day medical conference (during which you will be pitched regularly)." That's been on the down-trend for about 2 decades, and is generally pretty rare these days. You're pretty much down to getting lunch brought to your office - and you had better believe this isn't ubiquitous, but depends on your practice (good private insurance practice of patients with lifelong autoimmune disease, and your co. has a new mAb out? Why, yes, lunch will be arriving soon. Standard PCP w/ 50% medicare, 20% medicaid, 30% private blend, general population of disease? eh, not so much). And, sure, occasionally dinner - subject to the above. Again, these have grown increasingly rare since these are now public numbers subject to scrutiny. No one wants to show up on that database, and definitely no one wants to be one of the docs that shows up in the local papers as one of the top 10 pharma whores for the year. More common is:

3) Drugs in the background Branded pens. Branded clipboards. Bullshit journals of carefully curated studies. Donations to org. meetings, which result in huge banners and the like. The chance to "educate" docs on new results: these are carefully put together study analyses meant to show the drug in its best light, not overt pitches. They're generally very well done studies earnestly presented, with their biases baked in deep in the fundamental study design (e.g., subject selection), so there's nothing for casual audience members to be able to nitpick at. It takes an old hand to catch the trickery here.

3 is really the big one. It's the tickle at the back of your brain; the easy prescription of familiarity, avoidance of the discomfort of getting that sad look from your local rep. But it's reasonably subtle, and unless you think docs are making bank on those free pens, it's not really what you'd call "profiting" in any meaningful sense.

1 & 2 are profiting, and inflammatory, and mostly a relic of the 80s and early 90s. They're also a shit-ton less effective than #3.

In a transparent environment, advertising is a lot more effective than bribery. As a strong advocate for complete absence of pharma-to-MD relationships, I don't worry about the occasional bit steak lunch that most docs sit through playing on their phones; I worry about the never-ending barrage of advertisements. If you look at where pharma drops their big bucks, you'll see they share my priorities.

> physicians that get this money are now publicly monitored for it.

> Again, these have grown increasingly rare since these are now public numbers subject to scrutiny.

Where can I access this information?

> FDA approval ... patent protection ... scheduling it as a prescription drug ... opiates being illegal

These things provide not only prohibition and costs, but also many essential services, a matter of life and death in some cases. The free market is a useful tool, but not the solution to every situation; not every issue is a nail for the free market hammer. I don't want to see how many of my neighbors die from a drug before I decide whether or not to take it.

> One can make an argument for protecting people from harming themselves.

I don't have an opinion on legalization, but I don't think that's quite the argument against (even if some people express it in this way). Not all people are free to make choices in the same way, and drugs -- similarly to fast food -- hurt some communities more than others. Drugs have a social dynamics, they're not like choosing which toothpaste to use. Of course, prohibition may make matters worse instead of better, but as you say, that requires empirical study (I don't know the findings, which is why I don't have an opinion, except that the enforcement situation now is far from good).

There is a difference between marketing and actual use. Its a synthetic opioid, which means it has all the variability of opioids. Any decent doctor should know this, and the guides, if they were any good will indicate it.

For example codamol is now not prescribed in a hospital setting for under 5s, after one child died because they had large amounts of the enzyme required to processes it all at once. This caused respiratory arrest.

the BNF has prices: https://www.evidence.nhs.uk/formulary/bnf/current/4-central-...

and some basic advice: https://www.evidence.nhs.uk/formulary/bnf/current/4-central-...

also a big fat warning saying its a fucking opiate. If a doctor is surprised that a synthetic slow release diamorphene derivative has variable outcomes, is deeply upsetting. Its their fucking job to monitor the outcome of drugs. Its pretty much half of being a doctor.

One of the many advantages of the NHS is the chances of getting hooked on painkillers if miniscule, mainly because drugs are prescribed for the purpose of helping you, not because you've seen an advert, or you want to make a bit more money.

Sure, it's an opioid. That's not the point. The point is that it's made from an inexpensive generic opioid feedstock: oxycodone. The supposed value-add isn't the painkiller, it's the timed-release agent.

Unless these reporters are simply lying, there's evidence of great variability in the effectiveness of that timed-release agent. But the company's market position depends on the 12-hour dose. If the drug's needed every six hours, the only difference between it and the cheap stuff is price. In that case, most doctors won't prescribe and most payers won't reimburse the expensive stuff.

So, a doctor can ask a patient, "are you willing to take a pill every six hours?" If the patient agrees, the prescription can be very inexpensive and effective. And, wide swings in blood concentration are controllable, which helps avoid both grogginess and withdrawal struggles.

A friend who develops instruments for anesthesiologists has told me that a well-controlled minimal effective dose of pain med works, and manages risk very well. Peoples' rates of clearing these compounds vary a lot, and the timed-release compound doesn't appear to reduce that variability, contrary to the what the marketer is implicitly claiming.

If the treatment is for acute short-term pain (post-op, etc) a six-hour regime isn't a big burden, and the reduced risk of addiction justifies some inconvenience.

If the treatment is for chronic pain, a wise patient and doctor might start by trying the more frequent doses, and move to "time-release" doses if the first treatment doesn't work. Patients and doctors tune their meds all the time. Why not start trying for minimal effective dose, and move to a more addiction-prone regime if the first one desn't work?

But that would foul up the business of Oxycontin's marketer.

A weekly Narcotics Anonymous meeting just moved out of the hall of a church I serve to a bigger hall, because they're gaining members fast. That's not good.

Isn't NA mandated by courts? Even for pot sometimes? A growing group could easily just mean a change in law enforcement or sentencing.

It could, but I guarantee you it's not. In case you haven't heard, there is a very real heroin epidemic in a large part of the country. (largely caused by the over prescription, and then cutting off, via a change in regulations and practices of prescribed painkillers).

But I wasn't being (intentionally) being an asshole when I say "In case you haven't heard." It's being reported in the news, but it is largely a local story, and even in a lot of cases, its kind of like "There's a Heroin Epidemic, it's now affecting white rich kids, nobody knows what to do." I don't know if it is a function people being tired of the drug war or what, but it just seems like there's a quiet epidemic that's tragically killing (and/or negatively affecting) millions of Americans out there.

The emergence of drug courts in many parts of the country has actually led to a sharp decrease in people attending NA and AA meetings because a court ordered them to.

I'm very active in the recovery community in Madison Wisconsin, and holy smokes, it's all junkies these days! Not complaining, the experience is similar enough to mine as an old fashioned booze hound with occasional forays into meth addiction that I can help them, but man - it's never been like this before!

Which is a terrible intrusion upon people voluntarily there for actual support and help.

Sort of - we don't really mind if people come to get their court thingies signed after the meeting. The thing is, most people who don't want to be there quickly realize that they can just have anyone sign them. There's no way for a court to verify that people are going to meetings.

Not around here.

This last bit is very true. Same thing in canada. Doctor shopping is very hard because there is no benefit to the Doctor, only risk.

> Any decent doctor should know this

It sounds like they did, at first, and the manufacturer (ostensibly the experts on this particular drug) pushed back hard.

More like "nagged" than "pushed". The responsibilities of a salesman vs. doctor are clearly delineated. The salesman sells. The doctor must not outsource his decision making to the salesman.

What people underappreciate is that salespeople provide a vital role. Their job is to aid buyers in choosing what to do with their money. If doctors were susceptible to fraud of other underhanded sales tactics, that'd be alarming — they're the smart ones, are they not? But it's not that. They're not being duped. They succumb to corruption, or actively seek it.

> One of the many advantages of the NHS is the chances of getting hooked on painkillers if miniscule

You have got to be kidding. The UK might be behind the US, but the trendlines are pointing up, not down. The UK working hard to close the gap. "Miniscule" please.

You'll need data to back that up.

So long as opiates are used for acute pain, not long term chronic pain, the chances of addiction are pretty low.

It does happen, with about 30K people addicted in the UK total.

The reason why its much harder is that unless you have lots of money you'll have to persuade your GP that there is a medical reason for continuing. This is much harder in the UK where patients are patients, not customers that must be pleased.

What about their push for higher, instead of more frequent, doses?

But that's standard opiate management. Long term usage leads to resistance which must be managed. Its a well understood pathway.

The best part of the article:

"Dr. Curtis Wright, who led the agency’s medical review of the drug, declined to comment for this article. Shortly after OxyContin’s approval, he left the FDA and, within two years, was working for Purdue in new product development, according to his sworn testimony in a lawsuit a decade ago."

Says it all doesn't it?

What does it say?

It is the appearance of impropriety, straight out of any corporate anti-bribery ethics training. In this case, it appears they offered a cushy job to a government official in exchange for favorable regulatory treatment, leading a very lucrative business. It appears dirty but maybe can't be proven.

Another way to look at it was in working with Purdue, he was able to demonstrate his ability to define and walk around FDA approvals by understanding and guiding product language to get approval.

This is a valuable skill. Purdue probably wanted someone like that on their product development team who could influence drug design early on which would make it less costly and more efficient to get drugs approved in the future.

It's all business. Every actor wants more money and power, and are willing to play to their strengths to get there. No malice, obvious corruption, or bribery would even need to take place. Just smart motivated people trying to make a ton of money .... (without caring about the consequences).

> Another way to look at it was in working with Purdue, he was able to demonstrate his ability to define and walk around FDA approvals by understanding and guiding product language to get approval.

Isn't subverting the system like that almost as improper as doing it from the other side? Not as obviously, possibly not as strongly, but from having been in research myself, knowing the little details like that is often good enough to get things through all by itself, completely without regard for whether your research works.

I don't think so because the government created a regulatory environment that requires drug companies to find people like this that know how to get their drugs approved.

> a regulatory environment that requires

the regulatory environment only "requires" this if your drug doesn't work as advertised. The other way to get your drug approved is to, you know, not make phony claims about its efficacy.

If you don't know how and when and where and exactly what format to file your documents, you don't get approval. Simply working isn't sufficient. It's a complex process and having well connected experts is of extreme value.

Happens ALLLLLLLL the time, though. Improper or not, look around at corporate America and you'll find a lot of people who were regulating a company as a government agent, then soon there after, work for the firm they were regulating.

Of course it does. If you've got two organizations competing for the experts, you'll get a lot of back and forth.

I don't disagree that it creates the appearance of impropriety, but I'm not quite sure how'd you'd avoid it. Force people at the beginning of their career to chose one or another?

another way of looking at it is, working at the FDA means he is capable and qualified individual. Why would a pharmaceutical company not hire him? Let's not put 100% confidence level into guilt by insinuation. Did he do something specifically improper?

FDA approval shouldn't be determined by your ability to write product language effectively, but by your ability to do valuable research and to produce a useful product.

If the FDA is approving drugs based on their advertising budget or methodology, then they're worthless.

Just like your salary compensation should be determined by the value you bring to your company, instead of how well you negotiate and get people to identify you as "one of us".

Just like presidents should be decided by issues instead of how good looking they are. http://paulgraham.com/charisma.html

The other agents in all of our interactions are humans. Fallible, emotional creatures, guided by an unimaginably complicated, overlapping, self-contradicting set of heuristics optimized over millions of years to make us as effective as possible at creating more humans.

View any behavior approaching rationality as something to be treasured and appreciated, rather than the norm-- _Even within ourselves_. Even very smart people need prolonged introspection/mindfulness practice to become aware of how rarely we actually act as a rational being.

Wishing things were one way has no bearing on whether they are that way. We do ourselves a disfavor if we act as if the world worked the way we want it to rather than the way it does.

All true, but I think a good measure of "brokenness" of a regulatory apparatus is the extent to which you need someone on the inside in order to understand what you need to do to get approval, as opposed to being able to find that information from easily discoverable documents as an outsider.

So yes, humans are fallible, but the extent of this reliance on "knowing the right people" is the extent of the fallibility.

> Another way to look at it was in working with Purdue, he was able to demonstrate his ability to define and walk around FDA approvals by understanding and guiding product language to get approval.

Well, he was working for the FDA at that point. So that would have been a fail.

Had he denied the application it could just as easily be said to have shown his expertise in the regulatory approval process by detecting and rejecting a dangerous drug.

And yet, I don't think that display of competence would have landed him a job at Purdue.

It strongly implies he received favoritism in hiring after a Purdue drug was approved. It's a revolving door problem between regulators and industries they regulate.

Quid pro quo. You scratch my back and I'll scratch yours 2 years later.

That the revolving doors work well.

The pervasiveness of OC provided by doctors is amazing. Even as of a year ago, I went into the hospital for back pain and left with a script for two fist fulls of oxy. I looked at the doctor and legitimately thought he was trying to get me hooked. And this was at a world renowned hospital.

I have to wonder if Purdue is involved in some kickbacks to Dr's who (over)prescribe.

I fractured my tibia recently and the urgent care gave me a short prescription for Percocet (which contains oxycodone like Oxycontin and also acetaminophen). I didn't end up picking it up as I don't have a car and mobility is understandably limited when you've fractured your tibia, but the past the first day the pain wasn't bad enough to need it anyway, and ibuprofen sufficed. And I am a wimpy person who does not do well with pushing through pain.

I think we need to re-evaluate how often we're prescribing this stuff. Experiencing pain has a limited risk potential in most people, especially when the pain is linked to a temporary condition. The potential for addiction has nearly unlimited risk. Much better in my opinion for someone to suffer through temporary pain using over-the-counter pain meds than risk throwing your life away to drug addiction.

In a similar vein, I got an entire bottle of vicodin prescribed to me after having Lasik surgery. There was virtually no pain, merely discomfort similar to having a dirty contact lens in your eye, which went away after a day. I never used any of the vicodin.

I don't get this mentality at all. I would guess a majority of adults in the US have had Vicodin or similar and I don't know anyone personally who ever got addicted.

In some it causes nausea. You don't like it, fine. But I don't understand how people can be so pro marijuana on one hand, and so anti-opiates on the other. It's pain. It's not noble to suffer needlessly.

It's complete BS that it's harder for a dentist to prescribe a dozen Vicodin after a root canal these days. Or that many doctors will try to pass off 800mg of ibuprofen as a substitute for Vicodin for throwing you back out. That turns a couple of days of "be careful and taken it easy" into a couple of days of laying around on the couch in pain instead.

These drugs are inexpensive, very effective for short term pain management, and the vast majority of people have mild to no side effects, and almost no one has an addiction issue from using them.

It feels like the modern equivalent of Reefer Madness.

> But I don't understand how people can be so pro marijuana on one hand, and so anti-opiates on the other. It's pain. It's not noble to suffer needlessly.

Weed is not addictive, or even if it is in some people, to nowhere near the same level as opiates. It's also not responsible for thousands of overdose cases per year. It seems to me that THC pills would be better for pain management in these situations than opiate pills.

I also don't think you have much personal experience people who have been addicted to opiates. I have. It's not pretty. It's certainly worse than people who are merely potheads. The potheads I knew, when their source dried up or they ran out of money, were irritated, but were otherwise whole, and just waited until they could get their hands on more weed again. People addicted to opiates suffer severe withdrawal, and will do anything to get more pills. They can't simply stop using for a week.

Weed is not physically addictive like opiates are, but people do become psychologically dependent upon it to avoid dealing with stress and anxiety in healthier ways. And it can become difficult to stop if you haven't resolved the underlying problems that you're treating with it.

Oh yes, just like chocolate then.

> I also don't think you have much personal experience people who have been addicted to opiates.

I said as much. Which is a good enough reason to be suspicious of prohibition for me.

And to be clear, I'd find it very difficult to believe anyone gets a two week supply of opiates after surgery and goes all Reefer Madness after following the directions on the prescription. You're talking about people who abuse the drug. Most people who drink don't become alcoholics.

Now maybe you also want to abolish alcohol, in that case I just don't see any common ground.

I've tried pot for a migraine before and it only made me more nauseous. I'd be willing to try it for other types of pain but it certainly wouldn't be my first choice. I find the side effects mostly unpleasant.

I find opiates far more effective at relieving pain (tooth, back, eye pain after PRK surgery, mouth surgery after a car accident), with the fewest side effects. (I've only had light nausea once.) Running out of medication at the end of a course is a non-issue (I actually almost never finish it), and I notice lower levels of impairment than even a single beer.

But I don't abuse it. I take the larger dosage (500 vs 325? I forget exactly), in a maximum of 4 hour intervals (IIRC), and usually whatever the reason for taking them has subsided to the point ibuprofen alone works fine after about 48-hours.

And you would suggest that should end, without a viable alternative, because some other people abuse it? That seems like a very puritanical position to me.

> You're talking about people who abuse the drug. Most people who drink don't become alcoholics

The article is specifically about the effects of withdrawal when a 12 hour dose doesn't last 12 hours - when people are taking it by the prescribed schedule.

Exactly. The article rambles a bit, but the primary point is that when the effects wear off before the 12 hour interval but the patient keeps taking the drug as expected, it causes a cycle of pain and relief, which fosters addiction.

You're arguing against a strawman. I'm not in favor of banning opioids and I don't know where you even got that impression from.

I assumed you were replying to my comment you quoted. Sounds like we misunderstood each other.

Other way around. You replied to me and turned it into a different topic.

> But I don't understand how people can be so pro marijuana on one hand, and so anti-opiates on the other.

It's probably the hundreds of thousands of dead people from opiate overdoses vs the 0 dead people from marijuana overdose.

> I would guess a majority of adults in the US have had Vicodin or similar and I don't know anyone personally who ever got addicted.

You almost certainly know someone who has been addicted, you just didn't know. It is shockingly common.

It's not like I've never taken it.

Like I said, feels very hyperbolic.

It's like you're suggesting marijuana has no negative downsides at all when millions of people risk their freedom on a routine basis to consume it. Physical/physiological, doesn't make much difference when you're sitting in a cell and your family's financial future is in jeopardy. And I do know some people like that. It is shockingly common.

I don't think drug users in general should be in jail. Even if I think in general people would be better off without them outside of a medical reason.

When you start restricting people's freedom because you think you know what's best for them, and inflict needless suffering in the process, I have a hard time telling you apart from any other prohibitionist.

Is there a higher rate of opioid addiction amongst opioid users than marijuana addiction amongst marijuana users?

One of these is not like the other, opioids cause a clinical chemical dependency very quickly (as mentioned by the article, if you 12 hour dose doesn't last the full 12 hours) while the [chemical dependency of marijuana](https://en.wikipedia.org/wiki/Cannabis_use_disorder) is much more subtle.

I can't comment on that, but I'd be confident in saying the rate of death is higher~

My point, which mirrored the point of the post to which I responded, wasn't that Vicodin wasn't useful in some cases. It was that it was overprescribed relative to the amount of pain of the particular procedure.

I find this isn't true at all. Especially after the new rules on it a couple years ago. What used to be routine now is looked at with suspicion IME.

And if you have any pain at all after a medical procedure, I see no good reason responsible adults need to suffer at all if there's an inexpensive, effective, safe treatment for the vast majority of them.

You might want to have a look at the first couple of graphs here: https://www.drugabuse.gov/related-topics/trends-statistics/o...

I'm not saying we should ban opioids. I have found them useful on occasion too. But to suggest there's no problem with people abusing them is not a helpful stance either.

I don't mean to suggest people abusing them isn't something to address. I just don't think the answer is to make it difficult or inconvenient for people who don't have that issue.

I suppose in the same way I think having to pick up Sudafed from the pharmacy these days is silly.

I'm not a libertarian by any stretch but for me this is a sort of sacrificing freedom for security issue. Assumption of guilt and pre-crime is bad and I don't see any reason why people should be forced to suffer needlessly after a medical procedure, even if it's only temporary, and even if someone else found the pain tolerable.

But I think I've beat this horse to death. ;-)

I got some of that crap years ago. I felt good for about a half an hour, then got really nauseas, which is not something you want after surgery. Switched to ibuprofen. Pre surgery morphine had the same effect. I am not a fan of opioids.

I'm the same way. After watching a friend deal with an opioid addiction I feel lucky to have that problem.

I'm fortunate to have the same problem with alcohol. I can get up to drunk (though I won't feel 100% the next day), but anything beyond that stage and I start to feel ill. Especially back in college, I remember other students regularly getting to stages well past drunk (e.g. "wasted", "trashed", "black-out", etc.), and enjoying it, but I only ever did a few times and was always completely miserable.

In the end it was just my body protecting itself from the stupidities of the brain running it.

> Experiencing pain has a limited risk potential in most people, especially when the pain is linked to a temporary condition.

People living with long term pain are at increased risk for death by suicide.

That doesn't mean we should just hand out opiates (which should not be used for chronic pain), but that we should take pain relief a bit more seriously.

Living in pain sucks.

I illegally use marijuana, not for the pain relief, it's not any more effect in my case than a bottle of Jack. But it gives me a pocket of time where I can just feel okay, mentally, knowing that I will never live another day without pain.

The medical community focuses too much on symptom/treatment, and not enough on quality of life. I'm not saying that marijuana is an answer here, and I completely accept anyone who says I'm just using my pain as an excuse to get high, but it lets me feel emotion again, something you wrap up so tight in order to deal with the pain, you forget how to laugh and cry.

I'm sorry that it's illegal for you (it's not here in Oregon). I'm hopeful that we are on the verge of widespread legalization and I'm hopeful that you will, one day soon, enjoy all the benefits of it's legalization. Hang in there...

I feel most prescription drugs are about numbing down feeling, whereas weed unleashes a lot of bottled up feeling. Which is why so many people say they don't like feeling high. But it can help a lot with emotional healing.

We're talking about different things. I was talking about how opiates are over-prescribed for temporary pain, like dental procedures or bone fractures, whereas you are talking about long-term management of chronic pain. I specifically didn't say anything about the latter case.

If you're in your twenties, and you fracture a bone, the really bad pain will last for a day or two max. It's better to take over-the-counter pain meds and suffer through what pain remains than to jump immediately to the dangerous opiates and potentially risk your life going a lot more off-course than just dealing with some pain.

And to reiterate, I am a wuss as far as pain goes. I'm not the kind of person who pushes himself to suffer through pain. But in these kinds of situations, I look at the various paths, and potential opiate addiction is way more frightening than temporary pain.

"Especially when the pain is linked to a temporary condition."

I think that's the important point in the original comment.

Most of the responses to my post have argued against various incorrect interpretations of it, not what I actually said. It's frustrating. Thank you for your reading comprehension.

Then what should chronic pain sufferers take? Opiates may not be ideal, but it is one of the best options available.

Personally I do not believe that GP's should prescribe pain killers. They either under prescribe (fearing everyone will become an addict) or over prescribing (often the wrong drugs).

Pain is a very complex subject (people of different thresholds and biological responses), it should be left to specialists.

Depends on the pain.



I'm not saying "Don't ever prescribe opiates". I'm saying "Don't prescribe opiates as a first option".

> Personally I do not believe that GP's should prescribe pain killers. [...] it should be left to specialists

I agree. I didn't point it out, but that's what the guidance that I posted earlier says.

Chronic pain sufferers should try Cannabinoids

Agreed, but they should also be allowed to use opiates. Canniboids do not operate on the same receptors that opiates do, and the mechanism of pain relief is different.

They are not substitutes. Just options that may work for patients depending on just what manifests the pain and how they need to manage or cope with it.

One significant consideration is how well a person can function in a cognitive sense on both options. This varies extremely widely among people, and it's not simple to understand what will work for who.

They (opiates) are effective, but do require education and management. I am short on time, but one thing near completely ignored in this discussion is the pain trigger for medication and how that differs from other triggers and addiction.

Secondly, there are natural and effective addiction treatments out there that can work extremely well to get people off opiates. We don't talk about these because money and morals...

I have got myself off them, right along with a dozen others. The tolerance, once understood, and combined with things that work to marginalize withdrawl, is a solvable problem for most people.

Frankly, I've been asked to publish by medical practitioners and so far have not for fear of a legal option being scheduled away for profit.

Just know this dialog is not inclusive. There are powerful interests aligned against making this all workable.

The oxy manufacturers want to sell. The moral authority don't want people to get high, and cannot differentiate that from legit pain management.

Both do not want to face remedies and education needed to keep people out of trouble, and society contributes with an irrational dialog about these things.

In the 90's, I ended up there, did research, solved it for myself and to date, many others.

The dialog is broken. We can manage this to a net benefit for the vast majority of problem cases today. That we don't have THAT discussion is the problem, not the drug.

BTW, it has a 4 hour effective life, not 12. This is widely known. The whole 12 hour relief line of discussion is avoidance. True. 4 hour relief being bad is also avoidance, given there are meaningful, workable options out there today.

Agreed. I've had severe nerve pain for 6 months now, and I honestly don't know how the hell I would have coped if I hadn't found something that worked for me. Opioids.

I've tried gabapentin, pregabalin, duloxetine etc, but had terrible side effects with them all. I was at my wits end before I was put on opioids.

Do you have any support for your claim that "[t]he potential for addiction has nearly unlimited risk."? Given that the majority of the population has been prescribed an opioid at some point (wisdom teeth removal, broken bone, etc.) and yet hasn't developed an "addiction", it seems as though the opposite of your claim would be true.

Let me clarify my point. Let's say you just have an every day simple bone fracture (that didn't pierce your skin, so there's no risk of infection). You're almost certainly going to be fine.

Contrast with getting hooked on opioids and entering a downward cycle of addiction -- the potential outcome there is the very loss of your life, with a higher chance than losing your life from a simple bone fracture. A lot of people die from opiate overdose every year in the United States; it's actually a few thousand more than from being murdered with a gun. http://www.cdc.gov/drugoverdose/data/overdose.html

The problem with opiate addiction is that a lot of people are introduced to it through benign means, like starting off with a prescription from their doctor, or their friend giving them some for a legitimate pain-related reason. The gateway drug argument for weed is bunkum, but the gateway drug argument for some opioid use sometimes leading to more opioid use is very real, and is borne out with the statistics. The CDC has lots of information you can read. It's the biggest and deadliest drug epidemic in the US right now.

> Experiencing pain has a limited risk potential in most people, especially when the pain is linked to a temporary condition

While I may have agreed with this years ago, I'm pretty sure the research shows otherwise.

Also, I'm not sure why pain is considered less important than other medical outcomes. For example, would you rather live in constant pain or lose a pinkie finger? I'd lose the finger and get on with my life.

You seem to have glossed right over my use of the word "temporary". Does it suck that my tibia is fractured? Yeah. It's going to heal though. I sure as hell would not rather lose my foot for the rest of my life than wait for this to heal, just the same as I would rather deal with some pain now than risk a life-altering addiction to opioids.

So to answer your hypothetical, yes, I absolutely would rather deal with some temporary pain and get on with my life in another week than lose a body part for the rest of my life. Who would make the other choice?!

They gave me percocet after my appendectomy. I really only needed it the first day after the surgery, and then to get to sleep the next two days. I think I took 4 or 5 of the big 'ol bottle of pills they gave me.

I think this is a natural outcome of a system where drugmakers can spend billions on advertising, marketing, and sales reps. Those are three activities with basically no ethical standards; their only job is to make the graph go up and to the right.

My solution: ban all of that. Let doctors learn about new drugs via means funded by the doctors themselves. Before the Internet, that would have been difficult. But now you can imagine specialist medical journals, or special AMA committees. Manufacturers would still try to manipulate that, but doctors wouldn't be grossly outgunned.

It's kind of scary how quickly doctors seem to prescribe it. I've had a doctor prescribe me some for everything from the flu to a mild ankle sprain.

That being said, I always used to wonder if it was because I can't take any NSAIDs- it's acetaminophen or nothing for me. This usually means where they could get away with a big dose of Ibuprofin for pain and anti-inflammatory I wind up with oxycodone and prednisone. Which means I usually just gut it out after the first day or two.

And acetaminophen has its own set of problems. It's at least a reasonable question whether it would have been approved as an over the counter drug had its level of liver toxicity been known at the time.

It's extremely toxic - opioids are a much safer option.

It seems to be very rare to prescribe opioids for self-administration in the UK. One friend of mine was given some sort of opioid (i forget which) after having surgery on his leg. But for everyone else, diclofenac seems to be the thing that GPs like to spray everywhere.

>The pervasiveness of OC provided by doctors is amazing.

I've also heard just the opposite: dr's being afraid to prescribe them or being skeptical of patients' claims of pain out of fear they are just trying to score some pain pills.

'fist fulls' is a rather strange unit of measurement for pills!

Really the duration can vary quite a lot. I was put under on fentanyl for having my wisdom teeth taken out and woke up in the middle of the operation in extreme pain as someone was digging my teeth out with a metal instrument. I moaned at him, through a mouth stuffed with gauze pads, to get the fuck off me and let me out of there if he wasn't giving me more meds. He proceeded to angrily accuse me of taking dope, which I had, quite a few times, but never that much, in high school a few years before. I had already explained this before the procedure and assumed they had adjusted the dose. Explaining this again, with tears of pain rolling down my face, the nurse told me it's okay and, I assume out of some attempt to comfort me, that she'd taken dope too. They gave me the fentanyl and I passed out again. My opiate use in high school was infrequent and I'd never experienced withdrawals in the slightest, though I'd say I probably took a double or triple dose a few times, mostly because it never seemed to do that much for me. I was probably 16 when I started my experimentation and it ended by the time I was 17. Freshman year of college I was suffering stomach pain and headaches, so the doc at school prescribed Reglan and a small amount of Vicodin. Painkillers for a headache? By the end of the next day I had taken them all, in total 25mg Hydrocodone spread out over a day and a half. I take ibuprofen for headaches anyway. That was probably 8-12 months before my wisdom teeth procedure, but somehow either that one time recently or the times I took opiates in high school years before were enough for the fentanyl to wear off and for me to get yelled at by a doctor for it. I can't figure out if I always had a high tolerance or if opiate tolerance never goes away. I'm looking at this chart of equivalent potency https://en.m.wikipedia.org/wiki/Equianalgesic and it seems like I probably took the equivalent of a 15 mg oxycontin at the highest dosage I ever took, 22.5mg Hydrocodone, so it's really a mystery to me why I would have an effect like that. In my opinion, the problem here is that a higher dose was recommended instead of a longer acting opioid. However, I think people should always research their medication and talk to their pharmacist. I never took the Reglan because there's a risk of Parkinsons. My friend was prescribed a huge dose of antidepressants and ended up in the hospital with serotonin syndrome. Doctor knows best is a lie when it comes to medication. Pharmacist knows best. Always ask the pharmacist.

I woke up when I was having my wisdom teeth extracted but promptly went back to sleep when they suggested it.

My recollection is that I was briefly aware of them working in my mouth but not in any pain.

It's remarkable that in the US the much more dangerous general anesthesia is used for routine things like wisdom teeth when anesthetic shots (lidocaine) are significantly safer and simpler. This leads to additional complications due to anesthesia itself, or worse. [1] [2]

If your dentist proposes things like this, please, switch to someone else.

(For those unfamiliar, after the shots you feel not much other than some tugging. And you can get up and walk immediately after.)

[1] http://www.medicaldaily.com/baby-girl-cavity-filling-dental-...

[2] http://wgntv.com/2016/02/23/dentists-license-suspended-after...

As I recall, when I had my wisdom teeth out (around 1999-2000) the oral surgeon offered three options - local anesthetic only, local + some anesthetic gas (I remember he called it the "la-la land option"), or a full "you're totally out" anesthetic. I took the middle option, and I have some vague memories of people standing over me pulling on something in my mouth, but that's it. That would've been a pretty damn unpleasant experience if I was fully conscious, even if there was no pain.

I went to an oral surgeon who offered general anesthetic because he was digging out 4 impacted wisdom teeth at one and I don't do well with any kind of dental work.

Without the general I would still have the teeth today.

The fentanyl mentioned in the GP (probably also what I had) is an anesthetic shot.

Yikes, I was only referring to lidocaine (i.e. more typical choice for dental work.)

Right, I think I shouldn't pretend to define what the various words mean.

Still, I don't think the procedure used for wisdom teeth in the US has the same risks as the general anesthesia used in more involved surgeries. It's probably still reasonably described as sedation (in my story, I'm obviously still conscious, just not very aware. I didn't include it above, but I actually asked How much longer? and they just told me to go back to sleep).

Meanwhile, 4mg of codeine will make me drowsy and seriously impair my rationality; 8mg will send me right to sleep.

Human bodies are not even vaguely consistent in their response to medications.

Are you a redhead?

Care to explain why this would make a difference, or else what it's a reference to?

Sorry, I should have included the link; https://en.wikipedia.org/wiki/Red_hair#Pain_tolerance_and_in...

When I had my appendix removed when I was about 12 I awoke and tried to sit up in the middle of the operation. I remembered it and confirmed it with the doc in post-op. The OP's story of waking up during the wisdom tooth extraction reminded me of my experience. Years later I learned of the connection between pain tolerance and red hair, which I have.

My late father was addicted to Percocet / Percodan for much of his life after being severely wounded in the Korean War and then followed by the prostate cancer that was his ultimate demise. In the 90s, his doctor switched him to Oxycontin because of its ease of dosage (it's hard to remember when you took your last pill when you're high). Neither I nor his doctors knew that this 12 hour claim was just so that Purdue could defend its patent, despite the studies (according to this article) that pointed to it lasting far less than 12 hours.

Reading this article now helps me to better understand the pain and suffering he endured from these drugs and now give me insight into the lengths he went to for "rescue" medication, which included doctor shopping and paying retail price for more than half of his meds so that his insurance company wouldn't report him to the state or DEA (he did get caught eventually).

It boggles my mind to think how an industry whose purpose is to help people can become so corrupt and I wonder whether there is any hope of this getting better before it gets much worse. With the mainstream media playing enabler, it's doubtful it will ever happen (name the last news broadcast that wasn't wrapped end to end in big pharma advertising).

I can't believe how doctors apparently routinely prescribe addictive painkillers in the US. Here in Europe, as far as I know, doctors only prescribe non-opioid painkillers. I don't know anyone who was prescribed an opioid drug outside of an ICU.

Ibuprofen is surprisingly effective for many types of pain, I don't see why doctors immediately prescribe something as dangerous as OxyContin.

You can buy opioids over the counter in France. Codoliprane for example has 500mg of paracetamol combined with 30mg of codeine. Codeine is not the hardest opioid, but still...

Sadly many people die from accidental paracetamol overdose.

My experience with family in the UK and Ireland is that it's not hard to get the equivalent of Tylenol with codeine. Antibiotics seem to be perscribed more often as well, but that's off topic.

Yes, Co-codamol (paracetamol and codeine) is cheap and available over the counter in the UK. They have "Three days use only" in large letters on the front, like cigarette packet warnings.

I've seen a wide variety of opiates prescribed in England. They were all for short temr pain though.

That 80mg oxy pill is a sad symbol of modern American life.

We idealize pills. We talk about a future where all food could be replaced with a pill. We attribute the starting gun of women's liberation to... THE pill. So many pills have captured our imagination and our culture: viagra, valium, adderall, prozac, mothers little helpers, morning after pills To us medicine often means pills.

We live lives that are too busy with artificial constraints, without enough time connected to relationships and leisure and nature. We live accelerated lives and have no time to be unhealthy. A pill that you take home and take just once every twelve hours -- at the start of your work day and the end -- is the only kind of cure we have time for.

There is a reason Americans consume the vast majority of pills. Far far more than other rich countries.

I had three orthopedic surgeries in 2014. Each time I got a vial of OxyContin. Figured I'd use 'em since I'm not much into pain. But the pain was not so bad. Once I tried an OxyContin to see if I could tell the difference. I could not.

A colleague tells me that they have a street price of like $40/pill. So then I'm wondering how many people know that I have a thousand dollars worth of street drugs in my house. I dropped them off at the local drug disposal facility.

If you are prescribed 60x80mg monthly, you could sell them for $2,400 per month quite easily. Not a bad ROI on a $20 co-pay.

Won't do that. But I would like to be able to donate them to someone for whom that copay would be burdensome. My point is that these things are VALUABLE and that violent people may want to steal them. It is another way that over-prescription can do harm.

A perfect storm:

- Corporate misinformation pushing a significant set of users on a repeated and addiction forming schedule.

- Morphine (one of the proven and cheaper alternatives) perceived as problematic / cancer drug

- Doctors having less hassle and financial incentive to prescribe OC on q12 schedule than alternatives

- shame on user side and war on drugs policies that make it hard to reach out for help

The good news is that the internet makes it harder to spin misinformation over the long run.

I have generally found that the internet is a double-edged sword. The information available makes it much easier to find information supporting ones cause and thus reinforcing it, even if that cause is ludicrous.

It's pretty depressing how casually people's lives are thrown away for money. I can't imagine how angry I'd be if I was dealing with a family member who was prescribed these increasingly higher doses of Oxycotin and going to doctor who refused to prescribe anything else because Purdue repts insisted it was safe and effective at 12 hour doses.

Guess the jokes on us though the Sackler family gets knighted and modern institutions like MoMA let them slap their name on buildings for $$$ so who's really any better.

It seems lots of pain was inflicted on many people because of the patent system. Usually drugs are upheld as the prime example of why patent systems are necessary. This seems more than questionable, given this example. Combined with the fact that companies have no conscience, it would be nice to have better ways to do expensive research than a) in companies and b) for patents.

Medically reasonable alternatives have been on the market since 1950 (hydrocodone for example). Patents didn't drive the use of Oxycontin.

The article is even about the supposed justification of choosing Oxycontin, the 12 hour dosing, not being sufficient or even harmful.

The entire reason the manufacturer was pushing Oxycontin's 12-hour dosing so hard was because they had a patent on it, and if it required more frequent dosing the patent gave no advantage over the cheaper patent-free formulations. That's why it was so important to them that doctors stuck to the official 12-hour dosing interval even if it led to a higher overall dosage and ineffective pain relief.

Yes, I understand the dynamic.

I refuse to see doctors as the hapless victims of a corporation.

Your dismissiveness is unwarranted and wrong. The whole reason the drug was developed because their patent on their current flagship drug was expiring. It's right there in the article.

Oxycontin is essentially hydrocodone with a time-release mechanism. You need to demonstrate significant distance from existing medication in order to get a new patent.

The entire debacle, soup to nuts, was driven by the patent system. Without it, a) the drug wouldn't have even gotten developed, and b) the 12 hour marketing claim would not have been politically and economically necessary for Purdue.

The patent and the marketing didn't make hydrocodone less viable as an alternative.

I mean, the doctors can see that information coming from the company can be problematic and be cautious of it. I guess they ideally shouldn't have to be, but that's not the world.

Personally, I'd be fine dismantling Purdue for something like this. We need to start recognizing that large institutions make mistakes for reasons that can't be fixed.

I'm not opposed to that, but you also need to fix broken systems, otherwise the problem will recur.

To me the big flaw is that FDA approval and the associated studies were enough to drive the prescriptions. It would be pretty easy for the healthcare system to systematically run their own comparative studies on new drugs (during the course of normal care). There's some ethical mumbo jumbo around best possible care to look at, but I think being cautious about unfamiliar products is probably a nice offset to those concerns.

I find myself thinking back to this discussion: https://news.ycombinator.com/item?id=11627213

Where I quoted Peter Pronovost (the checklist guy) saying:

The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is ensuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine.

This is literally a case of boxes 1 and 2 being checked, with little attention to box 3.

OxyContin is oxycodone, which is actually a good deal stronger than hydrocodone.

The patent system drove that company to develop something to stay ahead of the game, and when it wasn't good enough on its own merits, they cheated.

So yes, it was partially the fault of the patent system.

Another problem is all the anti abuse so called safeguards like timed release so the pills can't be crushed. That means you can't take half the pill and a few hours later the other half which is what some people did to get around the false 12hr relief advertising before the DEA and other government meddlers got involved.

As for the FDA guy materializing at Perdue this is par for the course of all gov positions. A cabinet minister here was instrumental in vetoing the Bank Act which saved banks millions in taxes. Of course that minister materialized on a bank's board of directors after being kicked out of office by the voters as a thank you. When that bank started making large party donations they appointed the same ex minister as dean of a local university where immediately upon being parachuted into the role credit card tables were set up by the same bank on campus to rope students into applying for them. Plenty of city employees and councillors that allowed unpopular developments ended up on the board of developer corps too only later to be appointed to special environment advisory committees that of course pushed for pro development regulations. I'm sure this ex FDA pharma shill will end up somewhere else so he can further manipulate the system to the benefit of his patron too.

The timed release portion wasn't for anti-abuse, it was the whole point of the drug. It is supposed to meter out the opiate so you get an even dose, instead of peaks and valleys. If it worked, this would be great.

They don't go into the mechanism in the article, but my assumption is that some peoples bodies dissolve the costing more quickly than others, and those people get the dose in a shortened time period.

Parent is referring to the anti-crushing design that was later introduced. It's in the article, grep for "crush".

> That means you can't take half the pill and a few hours later the other half which is what some people did to get around the false 12hr relief advertising before the DEA and other government meddlers got involved.

can you elaborate on this? I'm not sure how the mechanism works to prevent splitting the pill in two. (I'm not sure how the mechanism works at all, really.)

I found this article: http://www.popsci.com/science/article/2013-05/science-un-cru...

edit: read through it, splitting should still be possible.

Pills in tablet form typically consist of the active ingredients mixed with a buffering agent and a caking agent, followed by a coating. Those agents and coating hold the pill together as a tablet, but are not particularly strong and can easily be cut, crushed, or shaved.

The "abuse-resistant" tablets are made by mixing the active ingredients with a polymer, a plastic- or glue-like substance that, when dried, is very hard and slightly malleable. Typically, attempts to crush these tablets simply flatten them out rather than pulverize them. They can still be cut in half, but doing so is more difficult and dangerous than with a standard tablet (you need a very sharp knife/razor to cut them, and you need considerably more effort as well, which increases the risk of injuring yourself while attempting the cut).

Patients who wish to pulverize these pills can still do so using a Dremel or similar power tool, but direct insufflation tends to result in gunking up their nostrils: when the powder mixes with mucous, it turns into a thick goo that clogs the nasal passages. This can be circumvented by cutting the powder with the powder of a crushed over-the-counter medication (typically acetaminophen/paracetamol). At a ≥50% paracetamol ratio, the resulting mucous goo can be avoided entirely.

Patients who wish to inject the substance will also run into the goo problem when trying to dissolve the powder in water or other liquid. The goo is too thick to inject with a typical syringe. I'm almost 100% certain there's a way around this as with insufflation, but I'm not sure what such a method would be. I guarantee you that users who inject already know.

It seems to me that pharmaceutical companies are constantly being surprised by the lengths to which drug addicts will go to get their fix. The only effective way to "combat" drug abuse would be to decriminalize possession and (ab)use of these substances (in the sense that perpetrators will not be regarded as criminals), to start viewing users as sufferers of an illness / mental health problem rather than as criminals, and to make treatment for their addictions readily available without stigma. Slapping addicts with a felony and sending them to prison is the current practice, and it is absolutely ineffective at combating drug abuse. In terms of government funding, I seriously doubt that treatment for addiction will be any more expensive than imprisonment, and it may even be cheaper. Of course, medical providers can do their part by prescribing such addictive substances only as a last resort, and only at the smallest effective dosage.

What do addicts crush/shoot drugs, instead of just eating them?

Higher bioavailability, and faster action. From memory, morphine (as an example) has 100% bioavailability when I'D, but only around 20% orally.

Faster action, more intense high.


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