Thank the Drug War For This

My elderly neighbor had all of her pain medication stolen by someone who was doing some yardwork and household chores for her. But since we are idiot nation and have decided to launch a multi-decade war on drugs that has achieved nothing other than clog our prisons and ruin more lives than the drugs themselves, she can’t simply get a new prescription from her doctor. Why? Because he is terrified of the DEA and the DOJ going after him for being a pill pusher. That isn’t an unreasonable fear on his part.

So, thanks to our stupid war on drugs, I get to drive this poor old woman, unmedicated for two days and in excruciating back pain, down bumpy curvy roads 20 miles away to the hospital, so we can waste an emergency room visit just so she can get some pain relief.

Stupidity defined.






67 replies
  1. 1
    cathyx says:

    Do you know how much money is to be made with this war on drugs? It can’t end, ever.

  2. 2
    Seebach says:

    Feds are ordering the CA medical marijuana dispensaries to close up:

    http://abclocal.go.com/kgo/sto.....id=8381783

  3. 3

    Facts don’t matter in this war. Human misery doesn’t matter. Doesn’t matter if the cops kick in the door to the wrong house, put two in the family dog, and taze grandma with her heart condition, because no matter how many good useful facts you present to some people, they’ll just counter with how everyone from kindergarten up to the old folks home would immediately charge out to CostCo and buy heroin in bulk if we legalized it.

  4. 4
    licensed to kill time says:

    The irony of this drug war is that apparently it wasn’t too difficult for someone like, say, Rush Limbaugh to obtain all the oxy he wanted by sending his maid out to cop in a parking lot. Money and connections…

    Yet your neighbor suffers because the doc is afraid of the alphabet dudes. It’s sick.

  5. 5
    Villago Delenda Est says:

    @cathyx:

    Um, what you said.

    There is a LOT of money to be made in the War on Some Drugs (particularly, those Drugs that cannot be patented and are used, at least in part, as recreation). A hell of a lot of money.

    Oregon put a screeching halt to some of this shit a few years back when they banned drug infraction related civil forfeiture, which was being used by our local branches of the Kripo to finance their ongoing operations.

  6. 6
    twiffer says:

    yeah it’s fucking stupid. just like the only possible reason i’d want sudafed (the original pseudoephidrine kind) is to cook up some meth. not, you know, the mucus oozing out of my nose. so now you have to give the pharmacist your fucking SSN or DL to get sudafed, or buy the replacement shit that doesn’t work as well.

    treating everyone like a potential criminal is so effective and has completely eradicated illegal drug use!

  7. 7
    Belafon (formerly anonevent) says:

    I also file this in the war on reasonableness that this country has been having since its inception. Most people are binary in this country: It’s either all right or all wrong, no ability to handle anything that is not absolute. (Did you make it this far before you realized I was also referring to three posts earlier?)

  8. 8
    twiffer says:

    @cathyx: it seems to me there would be even more money to be made by actually selling the drugs though. it’s not like tobacco and alcohol corps are hurting for cash.

  9. 9
    Villago Delenda Est says:

    @Seebach:

    Specifically, the IRS is doing this.

    If you can’t get them to them via the regular Kripo, by all means, use the guys from Treasury, ala Elliot Ness, to do so.

    On edit: aha! Clicking on the link is your friend…this is a separate action by four US attorneys. I had read of the IRS determination earlier, this may be followup to it.

  10. 10
    singfoom says:

    But but, someone might have fun in the comfort of their own home without alcohol! We can’t allow that.

    Harm reduction, how does it work?

  11. 11
    Death Panel Truck says:

    The War on Drugs.

    Dick Nixon’s biggest mistake!

  12. 12
    dr. luba says:

    Been watching Ken Burns’ series on Prohibition. We, as a nation, are incapable of learning from our past mistakes.

  13. 13
    Morzer says:

    @Belafon (formerly anonevent):

    It’s kind of hard to semi-assassinate someone, you know, just as it’s hard to semi-execute a mentally ill man or semi-abort a fetus. There are quite a few issues where you really can’t split the difference, despite the endless cries for centrism by the MSM and their acolytes. Reasonable judgment is not the same thing as mushy compromise.

  14. 14
    Less Popular Tim says:

    I get to drive this poor old woman, unmedicated for two days and in excruciating back pain, down bumpy curvy roads 20 miles away to the hospital

    Christ, Cole, you stole her freakin pain meds, it’s the least you can do

  15. 15
    Shade Tail says:

    @Death Panel Truck:

    “Mistake”? I think it’s gone pretty much exactly as Nixon et. al. intended.

  16. 16
    Chris says:

    Funny how the right doesn’t mind the federal government intrusion and overregulation AT ALL when it takes the form of security agencies targeting (mostly ) poor and nonwhite folk.

  17. 17
    Redshift says:

    Yup. The pharmacy screwed up one of Ms. Redshift’s prescriptions, so she got a replacement one, which earned her doctor a visit from the DEA (thanks, we’re pretty sure, to an overly-suspicious pharmacist, so we no longer go to that pharmacy or the entire store.)

    And the result of making people sign for sudafed is that meth dealers are paying homeless people to buy it, people who were never before involved in criminal activity. Way to fight crime!

  18. 18
    singfoom says:

    @Chris: Real Murkins drink alcohol and smoke tobacco. They don’t need drugs to have fun.

  19. 19
    djork says:

    @Shade Tail: This. Minorities and hippies get arrested and disenfranchised? Sounds like it’s working just as Nixon intended.

  20. 20
    Seebach says:

    I just feel utterly hopeless about the war on drugs. Does anyone see any way out of this before we end up going to war with Mexico over the cartels?

    I thought Obama would help end this, but he hasn’t.

  21. 21
    Villago Delenda Est says:

    @singfoom:

    ROFL.

    Sad thing is, Poe’s Law strikes again.

  22. 22
    Belafon (formerly anonevent) says:

    @Morzer: Oh, I know. It’s hard now to go back in the past and undo all the waiting we did while everyone got their ducks in a row while he planned the attacks at Fort Hood.

  23. 23
    Belafon (formerly anonevent) says:

    @Chris: Heck, the only reason they’re resorting to voter supression laws is that blacks are starting to become equal to whites anyway. The whole point of throwing them in jail was to keep them down.

  24. 24
    flukebucket says:

    I suffered more than I have ever suffered in my life due to that bullshit. Treated by doctors who were just sure that I was only trying to get pain medication while I waited and waited for a damn MRI to prove to them that I needed an anterior cervical discectomy and fusion. They would give me 14 5 mg Lortabs and expect it to last a week.

    Thankfully I had the surgery and while I do not feel great and have accepted the fact that I will never, ever feel right again at least I do not have to grovel at their feet to get some piddly ass amount of pain medication.

  25. 25
    jibeaux says:

    Did she file a police report? The pain doctor should have written her another Rx if she had a police report, I think.

  26. 26
    The Dangerman says:

    @Seebach:

    Feds are ordering the CA medical marijuana dispensaries to close up.

    Not entirely surprising; I fully support MM (indeed, I support full legalization), but it was hijacked by some corrupt MD’s and their customers. It was a racket…

    …which, in turn, had to be supported by quasi-legal growers that were ruining some communities (I’ve heard some horror stories about a little town up on the Mendocino Coast).

    Now, I wouldn’t know how hard it is to grow the stuff, but, as I have, um, researched the issue, one can have 6 plants without penalty. This may have changed, but, if these dispensaries go away, not much will change.

  27. 27
    angela says:

    Her doctor needs a new spine. My cat is on Valium and my vet was afraid to give me scrips for 100 pills at a time (which was so much cheaper per pill for me, since i’m paying full price for her meds). I got the pharmacist to call him and tell him it was okay. Now, no problems.

    The doctor obviously doesn’t make a habit of this, so he’s just being a coward. Pussy.

  28. 28
    Svensker says:

    Had the same thing happen to my MIL. She or the pharmacist somehow screwed up a prescription but it couldn’t be fixed because this 83-year-old 85 pound lady was prolly doin’ teh drugs! She had to do without until the next cycle came along.

    Wonder what Sarah “Death Panels” thinks about that?

  29. 29
    The Dangerman says:

    @Less Popular Tim:

    Christ, Cole, you stole her freakin pain meds…

    May or may or not have been Cole; do you recall that Bill the Cat pose from a couple days ago? I’m thinking we have the potential culprit in his house, at least.

  30. 30
    Morzer says:

    @Belafon (formerly anonevent):

    I just know that there’s an obvious connection to your previous remarks, but it’s a little hard to see why compromising would have changed anything at Fort Hood. If anything, you seem to be arguing for some hard and fast determination one way or the other.

  31. 31
    Scott P. says:

    Likewise, my neighbor lost his job at a coal plant that was shut down for pollution violations, thus proving that all environmental regulations are wrong.

  32. 32
    Van says:

    The sad thing is from a scientific standpoint narcotic pain meds are pretty safe. And they are also cheap. But instead they’ll give you all sorts of new medicines with long lists of side effects and high prices. Sheesh.

  33. 33
    evinfuilt says:

    @Death Panel Truck:
    Tea Party says it’s the EPA, but I agree with you, he screwed the country on that one.

  34. 34
    Gilles de Rais says:

    Looks like Eric Holder needed to punch some hippies and sick people in California to earn a get out of jail card.

    Silly Holder. When will he realize that Democrats never get those cards?

  35. 35
    Gilles de Rais says:

    …which, in turn, had to be supported by quasi-legal growers that were ruining some communities (I’ve heard some horror stories about a little town up on the Mendocino Coast).

    @The Dangerman: Let me guess. Either Fort Bragg or Fortuna.

  36. 36
    Anne Laurie says:

    “Phhhft, it’s not like she was doing anything useful anyway. Why should my tax dollars pay for expensive prescriptions just so some little old lady can tie up traffic driving 35 in the passing lane? Let her stay home and suck it up!”

    Almost word-for-word statement from a capital-L Libertarian acquaintance concerning a similar incident. He had decided, using his mighty Randian gifts, that if it weren’t for grannies “abusing” pain meds and Those People smoking crack, the federales would be totally cool with his own personal self-reliant, home-grown self-medication. Thinking like this gave him a dual hit of sweet, sweet social resentment — these parasites were spoiling his fun, and doing it with “his” money, too.

  37. 37
    Less Popular Tim says:

    @The Dangerman:

    do you recall that Bill the Cat pose from a couple days ago? I’m thinking we have the potential culprit in his house, at least

    maybe…But I can’t really see Tunch doing alot of yardwork or household chores.

  38. 38
    Auguste says:

    @Scott P.:

    Right, because there’s no other evidence for the damage the War on Drugs is doing to this country but this anecdote.

  39. 39
    Rita R. says:

    She’s lucky she has you. You’re really a mensch, John Cole.

  40. 40
    kindness says:

    I thought Obama had promised not to have the Feds go after Clubs that operate within the guidelines of the state they are in.

    Maybe the IRS & the US DOJ Federal Attorneys aren’t Feds. Or maybe Obama has been taken over by the pod people and their plan is to elect President Perry. Why would the Pod People want that? I can’t figure.

    Sure would suck for Obama to lose the 2012 Presidential election because if he starts going after the miniscule legal pot clubs we do have, I will be moving to Canada and wishing all you well with President I shot a coyote while walking my dog.

  41. 41
    The Other Chuck says:

    Dear Mr. Obama:

    Get rid of Eric Holder or I stay home in 2012. Don’t threaten me with Republicans: let them burn the entire fucking country to the ground for all I care. You’re letting them do it anyway.

  42. 42
    Mattminus says:

    @Less Popular Tim:

    LOL!

    reminds me of a joke I heard once on the difference between drunks and junkies.

    A drunk will steal a friends purse to get some money for a drink and then be racked by guilt over it.

    A junkie will steal a friend’s purse to get some money for dope and then help look for the purse.

  43. 43
    wrb says:

    Holder has been disappointing.

  44. 44

    I’m having pronoun problems with this post.

  45. 45
    Gilles de Rais says:

    I thought Obama had promised not to have the Feds go after Clubs that operate within the guidelines of the state they are in.

    @kindness: This was my understanding as well. Apparently the promise has been…altered.

    Dear Mr. Obama:
    __
    Get rid of Eric Holder or I stay home in 2012. Don’t threaten me with Republicans: let them burn the entire fucking country to the ground for all I care. You’re letting them do it anyway.

    @The Other Chuck: Holder is a fucking menace and now a fairly large political liability. Not sure if he’s gone rouge on the White House or what…but he needs to go regardless.

    I too am past the point where I can be threatened with Republicans. Obama simply needs to do a better job, period. I understand there are a lot of legislative things he has no control over, but the Justice Department, Eric Holder, and which cases they choose to persecute is most assuredly something that he does have control over. He needs to put an end to this bullshit today.

  46. 46
    Death Panel Truck says:

    @Shade Tail: I was being facetious. Sorry you didn’t get that. It’s a reference to an episode of King of the Hill. Connie wants to join Bobby’s wrestling team. The coach’s response: “Title IX! Dick Nixon’s biggest mistake!”

  47. 47
    wrb says:

    @Gilles de Rais:

    the Justice Department, Eric Holder, and which cases they choose to persecute is most assuredly something that he does have control over. He needs to put an end to this bullshit today.

    As one of my most savage complaints about the Bush Admn (or the Nixon Admn, for that matter), was their politicization of the DOJ, it is hard for me to criticize Obama for seeming to show scrupulous respect for its independence.

    But I sure wish Holder had cleaned house more aggressively. Is Luara Canary still drawing a paycheck? WTF?

    But how does Obama replace him, or Geithner? No replacement will be confirmed.

  48. 48
    kindness says:

    If any one had the guts to tell the DEA that they have to change the marijuana classification from Schedule 1 to anything less I would be much obliged. But I know in Washington where it took Nixon to go to China it will take Harry J. Anslinger to legalize pot.

  49. 49
    wrb says:

    Ummm… Looks like the Fed jack-boots may only be crunching the gravel outside dispensaries located within a prohibited distance (1000′) of schools.

    An article linked from the first:

    http://abclocal.go.com/kgo/sto.....id=8379212

    The U.S. Attorney’s office declined to be interviewed, but a spokesperson said they are targeting dispensaries which are operating within 1,000 feet of schools.
    “That is a legitimate rule and it makes sense when it’s so close to a school,” Mission District resident Dave Blair said.

  50. 50

    Why? Because he is terrified of the DEA and the DOJ going after him for being a pill pusher.

    Dear Gawd, true and unqualified stupid DEA

  51. 51
    Odie Hugh Manatee says:

    @cathyx:

    Do you know how many careers are made, political and professional, and how much money is to be made with this war on drugs? It can’t end, ever.

    Improved. :)

  52. 52
    WereBear says:

    I’m very very sick of the whole country being run in a way that soothes the rabid paranoia and dysfunction of the stupidest and least helpful segment of the public.

  53. 53
    Pococurante says:

    At risk of sounding like a PUMA… at least with a non-Obama we must deal with a stark reality as opposed to a pussy version.

  54. 54
    Anonymous About This says:

    @Pococurante: Because stark reality worked so well during Bush II.

  55. 55
    The Dangerman says:

    @Gilles de Rais:

    Let me guess. Either Fort Bragg or Fortuna.

    Actually, neither one; I know of the recent killings in Fort Bragg, haven’t heard anything about Fortuna.

    The city I chose not to name is way, WAY out of the way; without confirming, I’d say it’s even the end of the road (obviously, your guesses have significant highways running through them).

  56. 56
    Chris says:

    @WereBear:

    I’m very very sick of the whole country being run in a way that soothes the rabid paranoia and dysfunction of the stupidest and least helpful segment of the public.

    Kindness’ comment @ 49 sums up the problem.

    There’s a moment in the West Wing when Toby goes on this minute-long rant (hard to believe, I know) about Arab resentment towards the U.S. and how he’s tired of “having to take them out for an ice cream cone.” That entire rant comes to mind frequently when I’m thinking about American conservatives (the “stupidest and least helpful” you mentioned).

  57. 57
    Glen Tomkins says:

    The War on Drugs has many sins to answer for, no doubt, but this story is not among them. This is a case of prescribed opioids, not illegal drugs, and the arguable overreaction and overcaution we see now in the oversight of opioids prescribed for chronic pain, is a natural swing of the pendulum back from the overly enthusiastic use we saw 5-20 years ago. That period of laxity, in turn, was a reaction to an earlier period of caution and uptightness.

    I can’t trace it back further from my own memory, because that earlier period of uptightness was when I went to medical school, but it’s worth remembering that the orginal impetus for having prescription control over the dispensing of any medications, was the abuse of opioids under the old system, where people could just go to the druggist and ask for opioids without any prescription. And the problem back then wasn’t opium addicts. Only a minority of people are prone to true addiction, and society, frankly, doesn’t give a damn about this minority, and wouldn’t have bothered to create the prescription system just to keep them from harm. The problem with opioids is that they have the potential to harm large numbers of people. They are “good for what ails you”, across the whole spectrum of pain, from broken bones and head hurts, all the way to the pain of not loving Jesus. But, if used chronically, they dial down the body’s own endorphins, and users progressively habituate, even to doses that don’t produce recreational pleasure, but simply control pain.

    Now, I don’t know the particulars of the case of this woman you helped out. But many people on opioids for chronic pain conditions such as low back pain have worked themselves into really high doses. Maybe her doctor is an uncaring idiot, but I suspect that her physician would not have been so reluctant to replace her opioids unless she was indeed someone on really whopping doses. Such really whopping doses are not something that even a non-paranoid and/or puritanical system would treat lightly. If the person who stole her supply is not knowledgable about reasonable dosing, and is not as habituated as this woman is to large doses, he could easily kill himself and the folks he parties with just by taking the dose on the label that barely controls this woman’s pain. And if this person stole her supply for profit, such whopping doses represent a huge amount of money. No system can treat carelessness with such sums lightly.

    You’re right that this last point does bring us back to the War on Drugs, because at least this part of the problem, the fact that whopping doses of Oxycontin practically need to be handled in a Brinks truck and a high-security vault because of their high street value, does relate back to the War on Drugs. But you have to distinguish the clearly foolish attempt to control drugs that aren’t dangerous and don’t need to be controlled, such as marijuana (okay, wouldn’t be dangerous unless we allow free commercial exploitation in addition to legalization, in which case we get a plague of lung cancer 20 years after legalization), from the necessary attempt to control drugs like the opioids that are quite dangerous. With marijuana, the cure of the attempt to control is clearly worse than the disease because marijuana use isn’t a disease at all. But uncontrolled opioid use is a very real and very serious problem, and not just to addicts. There is definitely a price to be paid for the cure, but the price of not trying, of just giving in and letting everybody have as much oxycontin as they wanted, would clearly be higher.

    We started requiring prescriptions for all meds a century and a half ago because sweet little old ladies were killing their nephews on a regular basis by leaving fatal doses of opioids lying around where they could be stolen. What your sweet little old lady did letting her meds get stolen was extremely irresponsible, and would be no matter what legal regime we lived under.

  58. 58
    Baron Jrod of Keeblershire says:

    @Glen Tomkins: And the proper punishment for such carelessness (i.e. being robbed) is a month of horrific pain.

    Fucking listen to yourself. Jesus.

  59. 59
    Jennyjinx says:

    Something similar happened to me last year. My husband accidentally threw out my prescription refill for my pain meds and the doctor couldn’t write a new for 6 months. I could’ve probably driven to another town to get a new one, but since it’s a controlled substance I’m pretty sure there’s a database. It was an absolute miserable 6 months, too.

    ETA: Fuck off, Glen who-the-fuck-cares. Seriously.

  60. 60
    Glen Tomkins says:

    @Jennyjinx: Your needs have to be met, no matter what the cost to anyone else, and anyone who points out the costs of a system that would meet your needs effortlessly and instantly should be dismissed with an expletive?

    If you had read what I wrote before dismissing it because it obviously didn’t contribute to the free the opioids chorus, you would have noted that I said that the pendulum has swung too far towards rigidity in prescribing opioids. My point is that it’s important to realize that this is not driven by the War on Drugs, but is a reaction to where the pendulum was 5-20 years ago, a system that was too loose, didn’t control rigidly enough. That system resulted in piles of dead bodies, and plenty of people habiutated to large doses of opioids, because that’s what happens when no one and no institution shows any rigidity with these medications. I assume that none of these dead bodies wound up on your doorstep. Now, if that means they, and the system that killed them, don’t figure in your personal moral universe, fine, stop reading right here, what I have to say is of no interest to you. But some of us the-f-care about the world beyond our doorsteps.

    In a perfect world, your physician would be a rigid enough asshole that he could be trusted to separate out the people whose husbands accidentally threw out their rx from the dog-ate-my-homework drug seekers. But, assuming you’re not a heavy user, he isn’t a sufficiently rigid asshole. I know he isn’t because he’s worried enough about a DEA (or other enforcement body) audit if his opioid prescribing pattern that he wouldn’t rewrite your rx, which I’m presuming was for occasional use of small doses. His practice won’t bear objective scrutiny, or he’s a user himself, or both.

    Now, if you are a heavy and regular user, then you are clearly not a rigid enough asshole to be trusted with opioids, because you left that scrap of paper where someone who also can’t be trusted could get his hands on it. Regular, heavy users are on doses that could kill an opioid-naive person. Is it your practice to leave loaded weapons where 2 year-olds can get their hands on them?

    Not that you or your physician should feel bad. In your failure to meet the standard of rigidity needed to handle opioids, you are completely typical. That last period of laxity in prescribing opioids showed over and over again that relying on physicians and patients to self-police the use of opioids would result in widespread and systematic failure. So we have swung into a period of impersonal, institutional rigidity. Yes, that has its costs. The costs of doing nothing are greater.

    The right answer to the War on Marijuana is to just end it, just walk away from a high-cost attempt to control a non-problem that isn’t imposing any appreciable cost itself. But we can’t just walk away from the real need to control opioids. Refusal to control is a known killer.

    None of us controls the wider universe, which will continue to visit stupidity and injustice on all in a random fashion. Overcontrol, overly rigid and insitutional control, of opioids is far from the worst of these stupidities and injustices. But you are perfectly free to live sensibly and justly within your corner of the universe. That would include recognizing that the scrap of paper with your rx on it was important enough to either not leave where your husband might clean it up, or that you would explain to him its importance to you. Any rx is dead serious, because we only put dangerous drugs under prescription control. An opioid rx is doubly so, and would be no matter whether we had a War on Drugs giving opioids an artifically astronomical street value or not.

  61. 61
    Winston Smith says:

    Earlier this year, a dear friend of mine lost her license to practice medicine over something like this. Shortly after, her husband made a trip to her office to move some of her stuff out and when he returned home, he found she had killed herself.

    I’m pretty pissed off at her for leaving a husband and two kids traumatized, but what about a system that took away everything from someone who was only trying to help her patients?

    It was in Massachusetts, if that makes any difference.

  62. 62
    Glen Tomkins says:

    @Baron Jrod of Keeblershire: The proper punishment for the kid who walked off with a lethal dose of opioids, and kills himself partying with them because he reasonably figures that a little old lady dose couldn’t hurt, is death?

    Jesus, just listen to yourself.

  63. 63
    phoebesmother says:

    @Glen Tomkins: Time for the Wikipedia protest sign: “Citation please.”

    Like to see some studies on how Cole’s elderly neighbor is going to need increasing, very dangerous doses of her Oxy or Vicodin or whatever. I’ve been taking opioids for two years after a crippling accident and haven’t experienced this tolerance-leading-to-very-dangerous-doses reaction. Hell, I don’t experience anything like a high at all, just enough relief to stay somewhat mobile on my crutches.

    And I ran into this unwarranted fear of doctor-shopping by medical professionals when I went to a rehabilitative medicine doctor seeking advice on what more I could do to regain the ability to walk. The first words out of her mouth were “I don’t see how I can help you” before I’d said anything to her, before she’d asked me a single question. It wasn’t until I left the office that I realized that she thought I was seeking pain meds — though I hadn’t said anything like that in the nurse pre-interview. She just assumed person-with-pain equals drug addict.

    You know that on the suicide sites they say it’s very hard to kill yourself with opioids because you’d probably vomit before you take enough to kill yourself. The tylenol in most prescription opioid compounds might kill your liver before the hydrocodone kills you.

    And Mr. Tomkins, mary jane is not quite as harmless as you say it is; I’ve known some pretty paranoid habitual users.

  64. 64
    Glen Tomkins says:

    @phoebesmother: Large chunks of medical practice never make it into any sort of literature because you can’t do randomized control trials on the issues involved. That limitation certainly isn’t confined to pain medicine.

    There actually is a lot of evidence from the lab bench about daily use of exogenous opioids causing a clear and substantial depression in the production of endogenous opioids. But that doesn’t really prove anything about the clinical reality. We think this explains habituation, but facts first, theories later. And there really are no facts to the point you raise except anecdata, the experience of clinicians.

    The very best we often can do when we operate under the limitation that anecdata is the best data we have, and what we therefore have to do, is acknowledge the sources of bias in the experiential data base we rely on. No doubt, my bias that chronic, daily use of opioids tends, over time, to ever-escalating doses as patients habituate, is influenced by recall bias. Florid and dramatic train wrecks definitely make a stronger impression than low-drama cases, and I have certainly tried to sort through the wreckage of many such train wrecks. But part of what you do in such a case is to try to understand these extreme cases in terms of your experience dealing with chronic pain patients who perhaps used opioids, but at lower and more stable doses. The idea is to try to get someone who has gotten to unsustainable doses down to some regimen that will still control the pain, but be stable over the long-term. But it’s not an idea that works very often. The best I can usually do is halt further progression, stop at the current doses. If those are too high, even this strategy doesn’t work, because doses that are too high are addling, despite habituation. My point is that the chronic pain patient who can use opioids daily and not habituate, just isn’t that common, because those of us who deal with the train wrecks on a daily basis would treat such cases as the Holy Grail. Their secret, if we could only find it, would make our lives much easier — but we just don’t have them around to learn from.

    I definitely have seen patients who can stop at a level of chronic use that is shy of daily use. What they do is use other means most days, and only pull out the opioids on relatively rare bad days. The theory is that they never depress endogenous opioids because they don’t take exogenous every day, so no habituation. But this really is not, in my experience, that common. One pattern for the deterioration is that the patient hits a rough patch, either in the medical condition causing the pain, or in their emotional life, or both (the medical condition, or the pain it causes, are of, course inherently depressing), and the lowered pain threshold produced by the depression makes them need the opioids every day, and soon they are on the habituation treadmill.

    The other way patients on less-than-daily use go, is that they get off the opioids altogether because they habituate to their illness. The same physiologic derangement will, over time, cause less pain. They get better help treating the underlying cause. They learn to live around the disease, avoid things that worsen the pain and replace the lost activities with new things. If you have been on a stable dose of opioids, are you sure you realy still need that level? You should at least consider a trial of reduction in dose levels.

    Which brings up one thing you say that has me a bit concerned about your use of opioids. You say that you don’t get any sort of high off of opioids. Well, it’s bad enough for the general public to labor under the misconception that the reason patients seek opioids in escalating doses is some sort of weakness of character, some sort pleasure seeking. But someone who uses really needs to avoid thinking moralistically about these medications. The threat they pose to you is that you will escalate in order to deal with very real pain, but pain that, because it occurs daily for long periods, is no longer safe for opioids. If you’re worried about the wrong threat, you won’t be worried about the right threat

    As for your experience with that rehab medicine doctor, sadly, shoot-from-the-hip superficiality of assessment is not limited to chronic pain cases. I can imagine all sorts of very good reasons the doctor in John Cole’s story might have for not wanting to give his neighbor a refill on her opioids, but there simply is no excuse for what she said to you. For what it’s worth, what you would have been at very great risk of experiencing during the recent period of opioid laxity, would have been a rehab provider who would have replaced a careful and time-consuming assessment of what you individually needed, with a prescription for opioids. They’re good for what ails you, no matter what ails you. I always begin my assessment of people started on opioids during that era with a careful relook for reversible causes overlooked when the patient was just labeled as a chonic painer and fobbed off with opioids because that was the path of least resistance.

    Any system or regime will foster its own little maggot paths of least resistance. You ran into the “opioid users not welcome here” path of least resistance the current regine fosters. The old “everyone with pain whose cause isn’t obvious on first sight gets opioids” path of least resistance was worse. Of course, the right way under any regime is to look at the patient in front of you, but that takes work. If you are interested in dose reduction, you would be best served by finding someone who will do that work from the physician side.

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    Baron Jrod of Keeblershire says:

    @Glen Tomkins: And the only possible way to deal with that is to lock up doctors? For fuck’s sake, was there no other solution but to start throwing people in prison and crushing lives that way? Is it somehow better that doctors fear a visit from the DEA that could end in hard prison time because a patient misplaced their prescription?

    Good god, how can you be so blase about that?

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    Glen Tomkins says:

    @Baron Jrod of Keeblershire: If you’re referring to the VillageVoice article that Cole links to, I have to confess that the first go round I didn’t make it past the first paragraph. I went back and tried again, and read through the second page before writing this response, but found nothing to shake the impression that first para gave me that the author knows nothing about the subject of pain and opioids.

    His poster child, the example he advances that he thinks has a story that most cogently and succinclty makes the case against tight opioid control, actually tends in the exact opposite direction. Darlene’s case illustrates the violation of three general rules whose violation would be expected to result in the failure that they indeed have produced. First, back surgery generally shouldn’t be done for pain, only for motor impairment or threatened impairment. This is not because motor impairment is more worthy of attention, while “mere” pain is not worth a surgey, it’s because back surgery for pain makes the pain worse more often than it makes it better. Secondly, multiple back surgeries are generally a bad idea. If you don’t get it done at your first crack, you’re most likely to only make it worse. And finally, opioids are not good for daily use on pain present every day. They just create habituation in that setting, leaving the patient with, at best, a stable dose level that still leaves them struggling with daily unrelieved pain, but now they also have an opioid problem. At worst, there is no stable level the patient or her providers can establish, and use spirals out of control until the patient is dead.

    Of course, all three are just general rules, all three have exceptions, and Darlene may be one of those exceptions for whom back surgery for pain made sense, repeat surgeries made sense, and is clearly better off at some completely stable level of daily opioids so high that pharmacists show concern when she fills her prescriptions. My point is that no one who understood the problems with chronic opioid use would see in her case anything but the worst case scenario for the free opioid position the worst case they have to explain away as the inevitable occasional failure of their approach. She looks like the classic case of someone foolishly given unnecessary, harmful, surgeries that didn’t cure her peoblem but only added new problems, and is now getting equally foolish chronic opioids, apparently high dose, that still leaves her in pain, but adds the new problem of opioid habituation. The underlying pain couild actually be gone, and she will never know, because once you’re habituated to high doses, coming off them produces pain resulting from lack of endorphins. Physicians who let their desire to do something for her pain, let themselves be led into making it worse because they let their desire to do good blind them to the realities. Again, the author doesn’t tell you enough to be sure that’s the real story here, my point is that if he knew anything of his subject, he would know that instead of a poster case for his side, this is a really tough case for his side, that this case requires a lot of explaining that he clearly doesn’t understand is needed, if it is not to be read as an indictment of the ideas he wants to advance.

    As for the case Cole presents. I really don’t see any threat at all of any sort of DEA action arising just from filling the rx of of a small dose, occasional user. You don’t get your license revoked over 10 Percocets, well, not unless you have hundreds of these patients on your panel, and many of them often “lose” their rx. The VillageVoice article isn’t about physicians who write 10 Percocet a month regimens. If that’s the neighbor lady’s dose level, she is mistaken or not being truthful with Cole about her doctor refusing to replace the rx based on fear of legal repercussions.

    There are plenty of reasons a doctor in his place would not want to write any opioids for this neighbor lady that become even more important if she is, as Cole’s account implies, elderly and no longer quite capable of managing her own affairs (she needs to be driven to the ER, she has people clean her yard, she has people clean her yard who steal stuff from her). Opioids can either cause themselves, or badly worsen, cognitive problems in the elderly, dementia or even lesser problems. Opioids can cause falls in the elderly, and this person may have a history of falls the doctor knows about but Cole doesn’t.

    If this neighbor lady is instead a daily user, then we get into territory that might actually make her doctor reasonably fear an audit of his practice. These people tned to be on higher, sometimes very high, doses. The doctor very likely has a contract with the patient in which the absolute, categorical need to protect these dangerous meds from theft or any other diversion is spelled out. Breaking that contract is a serious matter, letting patients break those contracts is a serious matter, and doing so on a systematic basis is a real, not just a DEA-imagined, problem.

    This is not John Cole at his best. If he had any understanding of what’s at play when opioids are used for chronic pain, he would have known to differentiate between a neighbor lady with a 10 Percocet a month level, and the very different case of a neighbor lady on Oxycontin. She proablby just has the 10 Percocet level, but if so, Cole would have made the piece that much stronger, it would have been that much clearer that she was the vicitm of a stupid system, if he had said that. He either didn’t understand he could make it stronger that way, or this lady is on dosing levels that undercut his outrage, and he doesn’t understand that. He just settled for a hit piece to push a certain take on a topic that, if he has any understanding of, he’s not showing it to us here.

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    The reversal of the onus of proof in drug-possession cases is incompatible with the rule of law and is therefore unconstitutional in ALL jurisdictions.

    More: http://is.gd/noreverse .

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