Popping prescribed pills

Earlier this week, the LA Times had a good article on a study that traced where people who overdosed on prescription drug opiods got their pills:

The study, published Monday by the Journal of the American Medical Assn., echoes a 2012 Times investigation that found drugs prescribed by doctors caused or contributed to nearly half of the prescription overdose deaths in Southern California in recent years. The Times also revealed that authorities were failing to mine a rich database of prescribing records to identify and stop reckless prescribers…

Prescription drugs — mostly narcotic painkillers, such as OxyContin and Vicodin — contribute to more than 16,000 fatal overdoses annually and are the main reason drugs have surpassed traffic accidents as a cause of death in the U.S.

If drugs are being prescribed, this implies a good proportion of the drugs are being paid for by some insurance program.  The question is what can insurance companies and state/federal insurance programs do to minimize overprescription of opiod pain mdiciation?

There are two classes of actions that can be taken.  Medicaid has a system in place to identify patients who doctor shop for extra pills.  Doctor shopping means they frequently go to different providers for the same diagnosis, or show up to the emergency room with a pain complaint that can not be otherwise specified.  Medicaid or managed care organizations managing Medicaid patients perform statistic analysis for outliers, and then have a system that locks a patient to a single primary care provider at a signle location who can prescribe to only a single pharmacy.  This type of care-lock can last for several years.  It has been shown to reduce diversion and overdoses by making several classes of drugs far less available.

Commercial programs have this as an option.  However, since they are in the member satisfaction as well as the health provision/maitenance business, restricting member options even when it is for their own long term good is not popular.  I think there is an opportunity on the provider side of changing the opiod prescribing culture which would be far more effective in limiting diversion. 

Right now, opiod prescription culture is extraordinarily varied.  When my wife gave birth to Kid #2, she was sent home from the hospital with a bottle of 800mg Motrin and a prescription for twelve Vicodins.  When I had my vasectomy, I came home with a bottle of 800mg  Motrin and a prescription for fifty Vicodins. 

I do  not care how much I overestimate the relative pain of the two scenarios, I was in significantly less pain and less damage than my wife was three days after giving birth.  I never filled the prescription as a bag of frozen peas, rest and Motrin was sufficient.  When I returned to work, I talked with a pharmacy auditor, and she said that this disparity was well within normal treatment routines. 

Insurers could put into place policies that they will only pay for a short initial prescription of opiod painkillers with a follow-up visit within a week for a larger prescription.  This would eliminate the fifty pill prescription that I received as a prophylactic against potential pain and replace it with an eight or twelve pill prescription to cover the option of pain treatment needs. 

The biggest problem with this system is two fold.  First, it will increase member complaints.  In a group market, this might not matter all that much if the complaints are randomly distributed as one more person complaining to Jan in HR won’t change the decision structure at renewal time.  However in an increasinly individual market where insurance is not tied to employment (a net good thing), this will lead to membership loss if only one insurer in a region limits opiod prescription.  Here would be a good case for government regulation to solve a collective action problem.

The larger problem is a cost effectiveness issue from an insurer’s point of view.  Opiod painkillers are cheap.  Percocets cost, at a retail pharmacy, less than a dollar a pill, or ten cents per miligram of oxycodone.  Other opiate pain killers are similarly priced.  Going to a short regimen, follow-up visit, long regimen scenario means paying for a lot of additional follow-up visits.  There will be cost savings as may fill an eight pill prescription instead of a forty pill prescription that they otherwise would have received and never go for a follow-up to get an additional thirty five pills.  However, there are increased costs of the follow-up visits.  These individuals will cost the insurance company an extra hundred dollars or so for the office visit plus the regular prescription drug costs.  This is counterbalanced by whatever the decreased probability of overdose treatment costs thgat are avoided by a new system of opiod pain medicine management.  

This is probably a situation where the net social benefits of reducing overdoses and deaths from overdoses are much higher than the benefits that are received by the payers.

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149 replies
  1. 1
    Wendy says:

    I am genuinely shocked at how many times doctors and dentists (!) have tried to prescribe opiods, even for my daughter after an impacted tooth extraction (she was only 13!). I have never needed them, but I always feel as though the doctors are pushing them on me. I keep two in the house in case of emergency (well, they’re probably expired now), but I can imagine some people have stockpiles.

  2. 2
    raven says:

    Why do the saleswomen dress like hookers?

  3. 3
    aimai says:

    I’ve had the opposite experience. We have never been over proscribed –or maybe its that we never accepted–any scripts for vicodin or percocet until my husband came down with excruciating back pain, spent six hours on the floor of our house, was taken twice to the ER and endured substandard ER care and then was hospitalized for four days on massive muscle relaxants and pain killers.

    One of the reasons he went right back into the ER after the first ER visit was that they underprescribed the pain killers the first time and I couldn’t get the scrip filled at midnight as I was taking him home. So they essentially sent us home with nothing and he was frozen again by morning and unable to unfreeze without going back ot the ER.

    I have vowed never to be without an emergency stash again. Neither of us take any pain killers above an ibuprofen or have any addictions and I keep the remaining pain pills locked up. But I would never permit us to be without something in the house again for fear of dickering with the doctors/pharmacies in an emergency situation.

  4. 4
    Richard Mayhew says:

    @raven: Opiods basically sell themselves so they are sold by middle age schmucks. The lookers are selling the higher cost long term maitenance drugs, or the patented brand name which has a slightly different molecular twist than the seventeen generic versions already on the market.

  5. 5
    Patternmaker says:

    Your post addresses a serious problem, but please remember that when a solution requires more doctor visits, it puts a significant burden on the many people whose work and childcare responsibilities make it difficult and expensive to get to the doctor. I spent years as a CNA, and I speak from (ironic) experience when I say this.

  6. 6
    Yatsuno says:

    When I was getting ready for the hip surgery, it was decided to put me on a very low dose of Percocet so that when I went into the surgery the much higher dosage of opioids I would be getting would be more effective. This turned out to matter more as I was on a primarily oral pain control regimen immediately afterwards. And damn if that didn’t work well. I didn’t need the morphine pump once! The hospital had it on my chart just in case but I was rather proud of not having to request it. Do you know how much this is becoming prominent Richard and shouldn’t this lower costs and free morphine for immediate pain victims?

  7. 7
    Patternmaker says:

    Your post addresses a serious problem, but please remember that when a solution requires more doctor visits, it puts a significant burden on the many people whose work and childcare responsibilities make it difficult and expensive to get to the doctor. I spent years as a caregiver, and I speak from (ironic) experience when I say this.

  8. 8
    pontiac says:

    It would be a great start to ensure that every ‘new’ prescription to opiates comes with a short (like 5 minutes with a nurse) counseling session on pain management. People need to be told how to use NSAIDs and other techniques for maintenance to avoid breakthroughs, and opiates to tamp back breakthroughs. Taking opiates steadily or only using them when the pain becomes agonizing only leads to trouble.

    Labeling is of little help either. The little ‘don’t take with alcohol’ sticker appears on /lots/ of things, and I know that people generally do not understand and are not informed about exactly what this means in various cases (you will hurt your liver vs you will REALLY hurt your liver vs you will pass out).

    Simply focusing on the opiates as ‘bad’ is only going to worsen the other common problem of many providers being reluctant to prescribe adequate pain relief medication. It’s a matter of getting with the patient and making sure they are adequately informed *before* as well as afterward.

  9. 9
  10. 10
    raven says:

    @pontiac: ” Taking opiates steadily or only using them when the pain becomes agonizing only leads to trouble.”

    I don’t get this?

  11. 11
    Richard Mayhew says:

    @Patternmaker: It’s a trade-off — more PCP short visits for fewer ER/ICU visits (how many fewer ICU days across the nation or an MSA, I don’t know)

  12. 12
    cmorenc says:

    There’s also the case of folks like me whose bodies are very poorly tolerant of most opoids, and if we’re given them for post-op pain, might take one pill before we’re reminded of that fact by the intense nausea and vivid opium nightmares that we’d rather take the pain than this. The last Vicodan prescription for 12 I had, 11 pills sat in thir bottle for several years before I finally tossed them.

    Count me among those who cannot wait until the day when really potent medical marijuana is available as an anelgesic. Incidentally, Tylenol (another painkiller strongly preferred while in-hospital due to not risking induction of bleeding) is absolutely worthless as a painkiller in my body at even the mildest level. Give me ibuprofin – which works magnificently in my system (though not enough for post-op pain, and certainly not as well as some really good mj).

  13. 13
    aimai says:

    @Patternmaker: I want to second this observation-and its as true for young families and single parents as it can be for older families and single elders. Having someone to come in and watch over your children/elderly parent while you chauffeur the sick patient back to the doctor can be a nightmare and very high cost. When my husband was sick–which lasted for two weeks after the four day hospital stay–I sent my children to live with a relative and I had to ask one of my parents to come in and watch my husband when I needed to get a refill of his prescriptions, or to refill them for me so I could care for my husband. And I wasn’t working at the same time, as well. IF I had been I don’t know what would have happened.

  14. 14
    JVader says:

    I’d bet a paycheck that most of the deaths cited in this article are due to the fact that tylenol is part of the vicodin or percocet pill. There really isn’t a household OTC drug that can do more damage to a person than tylenol. Many, many Doctors feel that it should be taken out of existence in the US. Yes, people abuse opiates, but there isn’t any reason to put tylenol in with the opiate in order to kill people.

  15. 15
    raven says:

    I have a buddy that is a counselor and he said that pain killer addiction is an insanely awful problem here.

  16. 16
    cmorenc says:

    @JVader:

    There really isn’t a household OTC drug that can do more damage to a person than tylenol.

    Tylenol is also completely worthless as a painkiller for a significant portion of users. I won’t take it, period because for me, there is no upside – there’s only the potential toxic side-effects on kidney and liver.

  17. 17
    RSA says:

    @aimai:

    One of the reasons he went right back into the ER after the first ER visit was that they underprescribed the pain killers the first time and I couldn’t get the scrip filled at midnight as I was taking him home.

    This happened to my wife several years ago, the night I brought her home from a brain surgery operation. I was very angry at the doctors.

    A few things make this a difficult issue. We have this War on Drugs, which leads in many cases to doctors under-prescribing pain meds. The medical profession further has a long history of not understanding pain, in particular women’s pain. I think the quoted text oversimplifies things.

  18. 18
    pontiac says:

    @Richard Mayhew: @raven:

    This doesn’t apply in all cases or to everyone, certainly. But it can work sometimes – suppose you’ve just had your wisdom teeth pulled, done a knee, or some similar sort of thing. It’s far better to use ice and ibuprofen (or tylenol some similar drug that doesn’t develop such a tolerance) constantly to try to maintain comfort, and take an opiate only if the pain just starts to become troublesome, than to either take the opiate constantly by itself, or to try to avoid taking the opiate too long, get a ‘breakthrough’, and need to take a larger dose than you otherwise would need to regain comfort.

    The first (more tactical) way of using the medication is possible and it can work for a lot of people, but they need to be told how to do it.

    Speaking for myself, I managed a (mildly) herniated disk for several months in this manner until the situation resolved – and it was the kind of thing where for the first few months I really couldn’t be sitting up for more than an hour or so at a time.

  19. 19
    Omnes Omnibus says:

    I am sure that another factor that comes into play here is that different people have different tolerances for pain and different responses to painkillers. Pain management must necessarily be individualized.

  20. 20
    FlyingToaster says:

    @JVader:

    I’d bet a paycheck that most of the deaths cited in this article are due to the fact that tylenol is part of the vicodin or percocet pill.

    Doubtful. Tylenol contributes to liver failure, not ODs. Overall deaths due to prescription misuse, sure, but not overdoses per se.

    Tylenol w/Vicodin has one specific target; it’s really good for head-area pain such as a tooth’s nerve death (root canal time) or impacted molars.

    You’re taking these for about 3 days until the thing is outta there. Not long enough to destroy organs in someone who doesn’t normally take any painkillers.

    Adding Tylenol for any other purpose is nuts. I wouldn’t accept the scrip (and I doubt either my doctor or dentist would prescribe it).

    We only use Tylenol (or generic acetaminophen) for fevers and earaches/toothaches. It’s useless for our bumps-n-bruises pain, where we’re using ibuprofin. If I need something for arthritis, it seems that enteric-coated aspirin does a better job that anything else.

    My PCP cautions against regular painkiller use; if something is in chronic pain, we need to figure out the underlying cause and deal with it, instead of treating the symptom. YMMV.

  21. 21
    Trabb's Boy says:

    I can’t see a private insurance approach that wouldn’t be a huge pain in the butt for consumers. The idea of identifying doctors that fill frequent prescriptions or routinely fill large prescriptions sounds like an easier route to fixing the problem, using education, then disciplinary action if that doesn’t work.

  22. 22
    Gex says:

    What concerns me about this is the effects our drug wars and protecting people from themselves have on the people who need pain meds. It was a goddamn nightmare getting the meds Kate needed to manage pain during her cancer treatments. All in the name of keeping addicts from getting them.

    Have we learned nothing from Portugal? Has my need to fill out a form and show my ID for cold meds stopped the use of meth?

    I’m all for using the data in order to identify patients with problems and trying to get them help. And looking for doctors that are careless bordering on criminal with their scripts. But I am very nervous about what effect these approaches to the drug war have on medical care and patient pain management.

    I’d rather not force people who need the meds to suffer just so we can ramp up what seem to be ineffectual approaches to fighting drug abuse.

  23. 23
    Origuy says:

    My housemate has Ehlers-Danlos Syndrome, arachnoiditis, and osteonecrosis of the hip (like Yusanto ). Her pain level would be intolerable without Percocet and methodone in pill form. She had to sign a contract to agree to stick to one pharmacy. The prescriptions have to be written out, picked up at the doctor’s and physically taken to the pharmacy. They can’t be called in or faxed. They can’t be dated more than a day or two before she’s due to run out. The pharmacies don’t always keep these in stock, so if they are out when we bring in the script, someone has to call around to other locations of the same chain. She’s on MediCal, which arbitrarily sets the limit of prescriptions they will pay for without authorization at six. She’s on more than that for other things wrong with her. I sometimes end up paying for something and waiting for MediCal to get around to reimbursing me, which doesn’t always happen.

  24. 24
    randomworker says:

    People like their pills. Over 4 billion (!) prescriptions were written last year in the USA. Over 200 million of those for opiate pain killers. Between psychic pain and physical pain we are quite well medicated. Zoloft and Celexa alone count for 265 million scrips. It is totally insane. Out of control. Not to mention a massively profitable business. 326 billion dollars a year.

    Good luck!

  25. 25
    maximiliano furtive, formerly known as dr. bloor says:

    @aimai:

    I’ve had the opposite experience. We have never been over proscribed –or maybe its that we never accepted–any scripts for vicodin or percocet until my husband came down with excruciating back pain, spent six hours on the floor of our house, was taken twice to the ER and endured substandard ER care and then was hospitalized for four days on massive muscle relaxants and pain killers.

    This is the flip-side of the same coin that Richard is talking about. The central problem is that pain management training for doctors is generally somewhere between terrible and horrible. I was working on a psych consultation and liaison team for a few years, and undertreatment of pain was one of the more common issues we encountered. Docs routinely underprescribed–even with terminally ill paitients–due to fear of OD, some sort of moral hangup, or their inability to wrap their brains around the limited correlation between objective findings and subjective experience.

    ERs are a particularly tough nut to crack, since they deal with drug seekers on a regular basis. I was once more-or-less accused of same during an ER visit one time–when the doctor seemed not to have noticed the hospital ID I was wearing on my belt. It’s reflexive.

    A scrip for 50 Vicodins, though? Insane.

  26. 26
    elm says:

    @raven: I’m not a health care professional, but here’s what I’ve gathered from friends who are.

    1) It’s more effective to head-off pain than to try to bring it under control once it’s become very bad.
    2) Human bodies fairly quickly develop tolerance for opiates (and opiate dependency).

    Because of point 1, a person in pain/at risk for pain should be taking some painkiller regularly. Because of point 2, that should not be an opioid.

    Therefore, a good solution is to:

    1) Take ibuprofen or another NSAID at regular intervals (every 6 or 8 hours, as directed).
    2) Take an opioid in addition when the pain exceeds what the first drug can handle.

    Also, know that many popular prescription opiate pills contain acetaminophen (Tylenol), and that too much of that drug will damage your liver.

  27. 27

    Bad ideas in large doses. It’s too hard to get medication to control pain as it is; adding accountability at the HMO level will simply result in sick people suffering more.

    I can’t get the red pills that work for my allergies anymore because dumb shit speed freaks make them into druuuuugs. That’s an inconvenience that costs me about 10 workdays a year. If I had bone pain from cancer, as I watched someone die from recently, and couldn’t get effective medication because some addicts were careless with their drug abuse…I would burn shit down as soon as I got back out of bed.

    It’s funny that your PPO thinks men are too delicate to handle vasectomy pain, but it’s also not how medicine is practiced in this country.

  28. 28
  29. 29
    MomSense says:

    Seems to me like a person who is prescribed a large quantity of narcotic painkillers would benefit from a home health visit. Obviously that would add expense but considering how many overdose deaths there are–it sounds like a worthwhile expense.

    A home health visit would alleviate the cost concerns of scheduling additional office visits and a good home health professional would sniff out a drug dependence situation in a way that a primary care doc could not. Just a thought.

  30. 30
    Gex says:

    @maximiliano furtive, formerly known as dr. bloor: under prescribing may also be due to fear of the DEA. Kate could only get a script from someone with a DEA number on special watermarked paper that looked like a check. It was clear to me that these doctors were ready being monitored for their opiate prescriptions.

    AND we already had the first prescription refused by the insurance company. I’m not sure what more could have been done to us to make pain management harder, but some drug warrior somewhere will figure something out.

  31. 31
    sparrow says:

    @RSA: Thank you on mentioning “not understanding women’s pain”.

    Before the miracle called the IUD, my monthly(-ish) periods were a nightmare. I had cramps so bad that I would just curl into a ball and want to die for about 24-48 hours. I would be crying, couldn’t sleep, miserable.

    The doctors just told me to take advil. Yeah, that didn’t do anything. Tylenol, alieve, every single over-the-counter drug was useless.

    Fortunately, my family has bad dental health and we had a small stockpile of vicodin from root canals that had never been taken. Those pills were a lifesaver for my highschool years. Yes, they made me groggy, but I could actually make it through a school day (and sleep at night) whereas before I was missing days regularly.

    I could never get a doctor to understand that yes, my pain was real and excruciating, and no, advil did not work. Thank god for the IUD, because otherwise I could see myself going to dealers if I had to.

  32. 32
    Tommy says:

    I want to be careful here, cause reading through the comments it is clear there are some folks that need these drugs. I want them to have them. But I do think they are given out too freely. I was handed a golf club and tennis racket when I was in the crib. Played most of my life. Does things to your back that isn’t right. As an adult I’d bend over, just a few things a year, and pick up a penny or my keys and fall into a fetal position. Unable to move.

    I was given drugs.

    Good drugs.

    But it kept happening.

    Then I started to do yoga. Not had a single problem with my back.

    I don’t mean to sound like some hippie liberal that is against drugs or science. I am a hippie liberal, but all in with science. I just feel like these drugs are given out, people make a lot of money, and nobody questions it.

  33. 33
    Joel says:

    I cannot post on this subject. I’ve removed all mentions of drugs and trade names, yet still end up seeing my comments eaten. Why the hell is this happening. It’s endlessly irritating.

  34. 34
    jibeaux says:

    50 vicodin is an absurd prescription. You’re begging someone to get addicted. I got about a dozen for childbirth too, didn’t take them all but like aimai hung onto them in case. Probably long expired though, guess it’s time to send the hubby to get snipped.

  35. 35
    Joel says:

    But let’s just say that the problem is something that is added to virtually everything. Its IUPAC name is N-(4-hydroxyphenyl)ethanamide. It was added to “deter abuse”, courtesy of our wonderful war on drugs. I want to empasize that people should avoid taking any multisymptom medication for this purpose, and only take this drug when they intend to, or if its unavoidable, as in the case of prescription opioids.

    There are non-addictive (in mice) formulations in the works, using a mix of mu (morphine-type) and kappa (salvia-type) opioids. The idea is to get the painkilling without the euphoria. Who knows if it will work, but it’s a good idea. Hopefully then (or perhaps by ending the war on drugs) we will finally drop the stupid additive.

  36. 36
    Redshift says:

    @Gex: It’s definitely due to a fear of the DEA. Ms. Redshift once got a prescription that had an error, so she went back and got a replacement from the doctor. This earned the doctor a rather unpleasant visit from the DEA, and made her much more reluctant to prescribe what she knew was the appropriate dosage.

    Since I live with someone with two conditions that cause chronic pain, this whole thing is an issue near and dear to my heart, and while I’m sympathetic to the aim of reducing overdoses, when I read these proposed solutions, they all sound like they’d make our lives more miserable. Both in this post and in the all-too-frequent news stories about the DEA pushing the FDA for further restrictions on opiates, I feel like ensuring that those who need these drugs can get them is never on an equal footing with preventing abuse.

  37. 37
    japa21 says:

    Couple points:

    In general, ERs, if they provide medication at all, will generally provide only enough to get someone through until they can get to a pharmacy. With all the 24 hour pharmacies out there, this tends to reduce the amount they provide even more. Not saying this is appropriate, but it is the way it is. Additionally, they generally prefer that a patient’s own doctor do any follow up prescribing.

    A major controversy right now in the Workers’ Compensation field is the amount of opiods that are being prescribed. Although it is cheaper to prescribe opiods than do physical therapy or other appropriate interventions, due to long range issues, it ultimately becomes more costly. Courts have generally ruled that a person who gets addicted to pain killers given to treat a WC injury are entitled to have any treatemnt for addiction also covered under the WC treatment plan.

    Additionally, particularly in WC case and specially in certain states (FL is a big problem state) a lot of doctors not only prescribe the drugs but also dispense them charging outlandish rates which the payors must, by state law, pay.

    And as a side note, patients on pain killers are not always very nice to the staff in a doctor’s office. My wife is an office RN and more than once patients have started getting out of hand demanding refills on prescriptions are a week when the prescription should have lasted a month. Twive, the authorities had to be called in to avoid physical attacks by the patient.

  38. 38
    Joel says:

    @PhoenixRising: You should be able to get pseudoephedrine by handing your drivers license over to the pharmacists (total pain, I know). I agree that phenylepherine (the PE that replaced it) is worthless. Its only value is elevating blood pressure, which I don’t think most people would find very valuable.

  39. 39
    maximiliano furtive, formerly known as dr. bloor says:

    @Gex: As Richard’s experience suggests, the DEA really shouldn’t be much of a concern for most docs–everybody uses that same watermarked/triplicate scrip system for Schedule 2 medications, and you pretty much have to go nuts in terms of prescribing practices to trigger the WTF alarm with the G-men. Sounds like her docs either weren’t very bright or had already had their hands slapped at one time or another.

  40. 40
    Wag says:

    could someone release my post. I used a bunch of wrong words like X@N@X and Ativ@n, and am now in limbo

  41. 41
    Wag says:

    could someone release my post. I used a bunch of wrong words like X@N@X and Ativ@n, and am now in limbo

  42. 42
    askew says:

    @cmorenc:

    There’s also the case of folks like me whose bodies are very poorly tolerant of most opoids, and if we’re given them for post-op pain, might take one pill before we’re reminded of that fact by the intense nausea and vivid opium nightmares that we’d rather take the pain than this. The last Vicodan prescription for 12 I had, 11 pills sat in thir bottle for several years before I finally tossed them.

    I get kidney stones and they are unbelievably painful yet I can’t tolerate opioids very well so it is always a tradeoff on whether I’d rather be writhing in pain or throw up while itching like crazy but be pain-free.

    I wish there was another alternative besides marijuana which never did a damn thing for me besides make me want to eat my entire fridge.

  43. 43
    RSA says:

    @sparrow: I’m glad you got through that time in your life okay. I hear similar stories from friends who suffer from under-treated migraines. On the lighter side, I have to say that this made me laugh:

    Fortunately, my family has bad dental health…

  44. 44
    Redshift says:

    @Tommy:

    I don’t mean to sound like some hippie liberal that is against drugs or science. I am a hippie liberal, but all in with science. I just feel like these drugs are given out, people make a lot of money, and nobody questions it.

    If you think nobody questions it, you’ve never known someone with a chronic pain condition. They may be given out too freely and too randomly for acute conditions, but if you have an ongoing need for pain medication, it’s constantly questioned.

  45. 45
    askew says:

    @Gex:

    Have we learned nothing from Portugal? Has my need to fill out a form and show my ID for cold meds stopped the use of meth?

    It has made a huge impact in the reduction of meth actually. I hate being treated like a criminal every time I need some advil cold and sinus but I’ve talked with pharmacists about it and it really has made a difference. It’s still annoying that you can’t use a drive-thru pharmacy to get cold medicine though.

  46. 46
    Redshift says:

    @maximiliano furtive, formerly known as dr. bloor:

    you pretty much have to go nuts in terms of prescribing practices to trigger the WTF alarm with the G-men

    That may be how it’s supposed to work, but it has not been my experience.

  47. 47
    elmo says:

    Goddammit. We have a horrible pain management problem in this country, with untreated and undertreated pain literally crippling people, and then we imprison them for resorting to self-help. Overdoses are terrible, no doubt, and 16,000 deaths is a tragedy, but there are far, far more people who are left hopeless, crippled and miserable because of our Puritanical approach to pain management and the purifying beauty of suffering.

    Addiction is another issue entirely, and it’s another result of our failure – frankly, our refusal – to treat people as whole human beings.

    Sorry, but the idea of further limiting pain management options just reduces me to sputtering incoherent rage.

  48. 48
    maximiliano furtive, formerly known as dr. bloor says:

    @Redshift: Yeah, I saw your post after I responded to Gex. Never heard of anything like your doc’s experience before.

  49. 49
    Cassidy says:

    @JVader: I’ll take your paycheck then. Death by Tylenol toxicity is a shitty way to go and stands out dramatically against overdose. That being said, tylenol is harmful when directions aren’t followed. There are dosage instructions for a reason.

    The flip side to this issue is we’re creating a medical culture where everyone is a drug seeker. I’ve seen it in ER’s and on EMS calls; heaven forbid you ask for pain relief or the Paramedics will immediately assume you’re using and will pass that to the nurse and doc. Some people are just in pain.

  50. 50
    Mnemosyne says:

    @pontiac:

    It would be a great start to ensure that every ‘new’ prescription to opiates comes with a short (like 5 minutes with a nurse) counseling session on pain management. People need to be told how to use NSAIDs and other techniques for maintenance to avoid breakthroughs, and opiates to tamp back breakthroughs.

    This is a great idea and, I agree, it would probably prevent a lot of pain and grief later on for people to know how to use these powerful drugs properly and when they should call the doctor because they’re having problems.

    Being on a Schedule II drug is kind of a pain — I get Concerta (aka speed) for my ADHD and I have to see my doctor every 3 months for a new prescription (no refills permitted by law), which she has to write on her special DEA pad, etc. I’m ablebodied, but I can see how that regimen would be a giant pain in the butt for someone who is in constant pain but has to get themselves to the doctor’s office every 90 days for a new prescription.

  51. 51
    Lizzy L says:

    Generally speaking, I agree that dr-prescribed painkillers present a huge problem. However, I want to remind everyone that some of us — ME — are allergic to aspirin, ibuprofen, and Alleve, and for minor pain I can only take Tylenol. For major pain — I can’t take V****din, I’m not allergic but I react badly to it. I’ve been fortunate, I haven’t needed much major pain medication, but life has a way of throwing curve balls…

    Also, I agree with all the commenters who’ve pointed out that for years the medical profession refused to take pain, especially women’s pain, seriously, and they under-medicated like crazy. The pendulum has swung the other way, maybe, but I would hate to go back to a time when you couldn’t get medication for serious pain. When you’re hurting, you don’t care that there’s an opiod-dependent epidemic all around you, you just Want. Your. Drugs.

  52. 52
    elmo says:

    @Redshift:

    If you think nobody questions it, you’ve never known someone with a chronic pain condition. They may be given out too freely and too randomly for acute conditions, but if you have an ongoing need for pain medication, it’s constantly questioned.

    Goddamn right.

  53. 53
    Mnemosyne says:

    @cmorenc:

    I got to find out after my knee surgery that Vicodin makes me vomit uncontrollably within about 24 hours. That was … fun. Luckily, ibuprofen usually works for me, so I was able to switch to that pretty quickly.

  54. 54
    Tommy says:

    @Redshift: I saw what you wrote about your wife. I wish that on nobody. Why I said why I wanted to be careful with my words.

    My experience is I put on my Brooks Brother suit. Nice health care plan. They just write me a script. I think what is happening to folks with pain management issues is wrong, but so is it I feel like I can get a script for anything when I don’t really need it.

    I guess it is a chicken or an egg thing. That I might be able to get a script when I don’t need it means your wife is questioned. Honestly no clue how we deal with this.

  55. 55
    Wag says:

    please release my post from moderation

  56. 56
    jenn says:

    @Redshift: Maybe I’m wrong, but I read that as a societal ‘no one questions it’, not as individuals.

  57. 57
    Dead Ernest (Thought Wrangler) says:

    This is smack dab in the middle of my wheel house.
    My practice is precisely focused upon treating chronic pain.
    The intensity of the conflict between the mis-use & abuse of all the ‘scheduled’ or controlled medications (mostly, but not only medications for treating pain) – and the use of these risky medications for providing benefit to people who suffer chronic pain, the intensity of the conflict is truly profound.

    There is surely no simple solution, there isn’t even a complex one on the horizon.

    It is a dilemma with many dimensions; very strong emotions are front and center:

    –“what about my suffering parent?!” – “What about my dead 14 yr old?!”.

    –How tempting it is to presume the solution can’t be all that complicated – because most everyone is under the impression that they have a reasonable grasp on the Big Picture …”All they gotta do is…” among the general, educated public (see all prior comments) AND the overwhelming degree which health care providers are wrong, and wrong, and wrong…

    It is a ‘sore’ point for me every single day.

    An immediate example; Yutsano’s physicians thinking (his post above) is entirely incorrect. Certainly nice that Yut’s felt well, but it wasn’t because of the strategy he described.

    (additionally, nearly every post I read here before starting this comment had an error of fact or indicated that behind a conclusion there was some misinformation or an assumption that lead to, let’s say ‘a less coherent path chosen’ to a less than accurate point from which to view the issue)

    I *could* stand on my soap-box and carry on for, well, a painful amount of time. Fortunately for everyone, I need to return to the universe of chronic pain problems.

    My day will start to wind down around 11pm CST, I’ll try to check back and see if there are any specific questions anyone wishes to ask.

    Just this last comment; as I said, my practice is treating people with chronic pain. Other than seeing them (and contending with ins co’s, pharmacies, and far too many other players), the rest of the time I’m engaged with the the literature, the books and articles, the academics of pain and its treatment – and I can tell you with absolute conviction – that I barely know anything at all. I most certainly do not have a reasonably easy solution to the dilemma.
    Cheers.

  58. 58
    Mnemosyne says:

    Also, too, I will once again put out to the universe my plea that there be some kind of screening test to figure out which people are more prone to addiction so they can be warned and monitored as necessary and everyone doesn’t need to be treated like a frickin’ criminal from day one.

  59. 59
    Violet says:

    Right now, opiod prescription culture is extraordinarily varied. When my wife gave birth to Kid #2, she was sent home from the hospital with a bottle of 800mg Motrin and a prescription for twelve Vicodins. When I had my vasectomy, I came home with a bottle of 800mg Motrin and a prescription for fifty Vicodins.

    Yeah, you’re male, she’s female. That’s how it goes in the medical world. Men get better treatment and more medication. I have first hand experience of this and these days take a male person with me to a new doctor’s appointment until I know how the doctor is going to treat me. Your experience doesn’t surprise me in the least.

  60. 60
    gvg says:

    Most docs underprescribe not over per my sister the doctor, but definately some do the overprescribe. My sister decided not to open a practice in a nearby small town because the last several docs that town had were arrested or lost their license for pretty much writing prescription for anything wanted. She felt that she’d get to many patients who expected the same and would be angry when they didn’t get it plus she’d get a reputation in the medical community associated with the past bad practices.
    However she always has had to spend hours on the phone making pharmacies change prescriptions back to what she ordered not what the insurance prefers. Like she doesn’t have enough to do already. I was astounded that its so common, Insurance companies and pharmacies routinely change the prescriptions to something they think is the same. Mostly it doesn’t matter but sometimes it does. Sometimes the formulations are just simular in effect so are substituted but it may matter with that particular patient due to multiple underlying medical issues or drug interactions and sometimes individual known intolerances or allergies. Sometimes the dyes in the coatings of different company versions of a pill are different and you can have an allergic reaction or sometimes a version of the pill does a better job of slow release…different reasons. If a doc says no substitution on the prescription then she shouldn’t have to spend an hour on the phone arguing with anyone (pharmacist nor insurance company)
    Watch out for regulations that are big on inconvience and short on results.

  61. 61
    Mnemosyne says:

    @Dead Ernest (Thought Wrangler):

    When you come back, can you address Pontiac’s idea of having a short appointment with a nurse to explain how to manage a pain regimen? Weird as it sounds, I do think that some people are more willing to listen to a nurse with stuff like that than they are to the doctor.

  62. 62
    Dead Ernest (Thought Wrangler) says:

    @Mnemosyne:

    Glad to.

  63. 63
    elmo says:

    @Dead Ernest (Thought Wrangler):

    My wife suffers from chronic pain. The current working diagnosis is cervical dyskinesia, but we are still working on getting something definitive. Before we could get her on my health insurance, she was a Medicaid patient, and I still burn with fury at what she had to endure in order to avoid the accusation of “drug-seeking” and “doctor-shopping.”

    Why shouldn’t she “doctor-shop?” In what other field is the consumer prohibited by law from changing service providers? If she is so unfortunate as to land with a service provider who “doesn’t believe” in her condition, or “doesn’t believe” in providing pain management services – both of which happened – she should be forced to rely on that provider to treat her condition?

    I’m sorry, I’m ranting at you because this is your field, not because this is your fault. But goddammit, there is a reason people “seek drugs.” It’s because they are in pain. It might not even be physical pain as medicine describes it, but people don’t go to such lengths for no reason. And it is evil and inhuman to consign them to their pain just because we can’t yet figure out what causes it, or how to make it go away.

  64. 64
    aimai says:

    @Mnemosyne: Also, frankly, you hardly see your doctor and they routinely don’t spend any time explaining things to you. (I should add that I love my doctor but being dismissed from a hospital is an entirely different thing. By the time you’ve had a hospital stay and they have decided to send you home there is an incredibly rush, after hours of waiting, that doesn’t include a serious exit interview or any chance to reflect on the overall treatment course.)

  65. 65
    aimai says:

    @elmo:

    I want to agree with this wholeheartedly. I think we would be better served, as a society, if addicts were free to purchase their damned pills from a government organization and left the rest of us, who just want to be treated humanely w/r/t chronic pain or end of life issues, being treated for actual medical conditions.

    Its ridiculous that hospitals and their staff, who are ill equipped to do so, end up having to triage patients into thieves/drug seekers and “real” patients.

    I don’t care at all if people want to get addicted and OD. I’m sorry for them but I don’t see that everyone needs to be treated as a criminal in order to prevent people from pleasure seeking in ultimately self destructive ways.

  66. 66
    WereBear says:

    Also, there was some work done on LSD which showed it was very effective with certain kinds of pain, especially terminal conditions, but Drug Hysteria closed that door on us.

    Speaking of which, I was always astonished that doctors were told to worry about addiction with people who had excruciating terminal conditions. Really, you think they are going to get better and their lives will be ruined because now they are addicted? Really?

  67. 67
    dr. luba says:

    @sparrow: That was my experience, too, and my mom’s before me. Horrible periods. Rolling around on the bed with gut pain horrible. Midol, which was the OTC treatment of the day, was useless. My mom’s doc prescribed val ium for her–didn’t help. (There were some in the medical community who actually thought that menstrual pain was all in a woman’s head. Really. Something to do with penis envy.)

    The thing that changed my life was OCPs. A godsend. My friends with less severe dysmenorrhea were saved by Anaprox, which was then a brand new and very expensive prescription medication. I kept one of them supplied throughout graduate school thanks to a helpful drug rep.

    Do you have a medicated IUD? My experience back in the day was that patients got worse periods on the IUD. I am now menopausal and thankful for that, and practicing obstetrics only.

    (Reposted because I sued the dreaded v word.)

  68. 68
    MathInPA says:

    As with several others here with chronic conditions, I would highly, highly be skeptical of any further attempt to regulate or limit pain medication; to be blunt, there’s already too much and it’s made my life hell. If you want to prevent overdoses, then work on education for ERs, docs, etc. and get better psychiatric care with more regularity and less expense so that we have less intentional overdoses. Then after that, loosen the damn laws on the painkillers and especially loosen the damn DEA grip.

    Which leads, of course, to the contempt I have for anyone who thinks we’re overmedicated. Leaving aside the lethal consequences that sort of attitude has, especially for psychiatric care as I know from familial experience, the idea that ‘pain management techniques’ and someone’s favorite hobby horse can deal with chronic physical pain is utterly ridiculous. In my case, I use the pain management and prevention techniques from years of physical therapy, two 400mg pills of gabapentin four times daily, two 10-325 mg pills of hydrocodone four times daily and one alleve four times daily, and I still spend half the time in agony and the other half hypersensitive and achey. It’s not even a case of acquired resistance; I was ratcheted up to this level almost immediately after my doctors started taking my pain and multiple ER visits from being in screaming pain standing, sitting, or lying down.

    That degenerated fast due to the slipped disc, and while cortizone stopped the ‘knife of fire in one of my feet’ problem, it didn’t stop — or even blunt– the acceleration of hypersensitivity to touch, constant muscle aches on all of my limbs and my trunk, cyclical joint pain, headaches, etc. I have fibromyalgia; I’m overweight; I’m an insomniac with sleep apnea; I’m asthmatic and allergic so I’m chronically dried out, tense physically and mentally, I have a heart condition, and more. And I’m not alone, nor are my pain symptoms an outlier so much as an upper quartile.

    I have cycles, basically, of medication. For the first 2 or so hours after taking my pain meds, I remain in agony. The pain is intense, but thank God, not nearly as devastating as when I’m not on my meds, either because I forgot a prescription (thank you, ADD and anxiety…) or because I forgot to take them with me and a trip extended past a deadline. There’s a brief, jittery period where the pain starts to slowly unkink, and then I have about two hours or so of aches and pain and soreness but at least at levels where I can do things without becoming absorbed– hypnotized, I call it– by the pain. Then that starts to jitter out and I start to feel another two hours of massive pain where I stare at the clock and wonder if I can’t take my meds just a little bit early, just this once, I mean, I’m going to be asleep for some of the time, right, that means I can take them a bit early, and then a brief bit of slight placebo mitigation when I take the meds and then start again.

    As for off the meds… best not described. I haven’t gotten into the position where I screamed myself hoarse since being on the meds, at least, nor where the sheer agony consumes second to second, but I lose my ability to concentrate on virtually anything else. Even on the meds, car rides longer than about 30 minutes start to hurt and longer than an hour and I’m screwed for a whole day or more. I have no idea what an airplane trip would be like at this point but I don’t really want to think about it much.

    And there’s nothing more that can be medically done. Neither my regular doc nor my pain doc nor anyone else has any more answers for me. No one around here wants DEA attention for anything prescribed long term. My physical therapist, her boss, her consultations, all the rest just shrug, grimace, and look sympathetic. It’s already hard enough for me to keep in the pain meds I have thanks to other limitations, and you want to make things harder?

    Fuck that. My pain is not a political point to be made, and neither is anyone else’s. ODs need to be dealt with as social ills, not legal mechanics.

  69. 69
    Redshift says:

    @Tommy: Social class plays a role, but I think it’s even more an acute/chronic distinction, and, as others have pointed out, a male/female distinction. (I have had excellent employer-paid insurance through all of this.)

  70. 70
    Wag says:

    @WereBear:

    No physicain that I practice with who treats hospice and terminal patients worries about “addiction’ in that patient population.

    can someone please release my long post from moderation.

    Third request..

  71. 71
    Redshift says:

    @gvg: Let me strongly agree with all of this. We’ve experienced it as well. Having insurance companies messing with your prescriptions based on their costs is like going to a doctor who’s deciding treatments based on kickbacks. In some cases, they may really be equivalent, but there’s no way to know, because their incentives do not put effective treatment for you anywhere near the top of the list.

  72. 72
    Violet says:

    I’d also like to point out that some pain can be treated with non-medication solutions. Like Tommy above used yoga for his golf-related pain issues. John Cole has changed his diet and his aching joints are much improved and he hadn’t needed an ibuprofen when he used to pop them all day. Obviously these are people who weren’t dealing with pain issues that need stronger medication, but it does point to the concept that there are other paths that might work for pain management or even elimination of the pain altogether. How much of that is being suggested or studied, even?

  73. 73
    Sister Rail Gun of Warm Humanitarianism says:

    @WereBear:

    Speaking of which, I was always astonished that doctors were told to worry about addiction with people who had excruciating terminal conditions. Really, you think they are going to get better and their lives will be ruined because now they are addicted? Really?

    I made that exact argument to the nursing home doctors during my father’s last months. There had been a law passed within the previous year that exempted end-of-life care from the restrictions on opiate dosages. I ended up flying to TN with a hardcopy of that law in my hand, but I got him his palliative drugs.

    @Wag:

    No physicain that I practice with who treats hospice and terminal patients worries about “addiction’ in that patient population.

    Pretty sure that’s changed in the fifteen+ years since I had to fight with my dad’s doctors, but it was a long fight to get it changed.

  74. 74
    elmo says:

    @MathInPA:

    ::standing ovation::
    Bravo. Thank you for that. I tried to express some of that – not for myself, but for my wife – and just devolved into sputtering, because it really is just horrific and inhuman how we treat people who are in pain.
    I wish I could hug you.

  75. 75
    Joel says:

    @Cassidy: formulations of pills like percoset and vicodin have 100mg of tylenol for every mg of opioid. The difference is lethal dose between the two (measured in rats) is about 5-fold. You can do the math to figure out what lethal dose you’re gonna hit first.

  76. 76
    Mnemosyne says:

    @aimai:

    I don’t care at all if people want to get addicted and OD. I’m sorry for them but I don’t see that everyone needs to be treated as a criminal in order to prevent people from pleasure seeking in ultimately self destructive ways.

    Uh, it’s not exactly a choice to get addicted. Are there any other mental illnesses you think should be left untreated because you don’t really care if, say, someone with bipolar disorder jumps off a bridge when they’re in a manic phase?

  77. 77
    Mnemosyne says:

    @Violet:

    There is a fair amount of evidence that fibromyalgia is a form of arthritis and sometimes changes in diet to eliminate gluten or other allergens can help alleviate some of the symptoms. Not a magic cure-all, but it can help.

  78. 78
    PST says:

    @Dead Ernest (Thought Wrangler): I would appreciate your comments on something I believe several people talked about in this thread, because it made good sense, but I can’t remember being told this by a doctor or nurse before. For something like post-surgical pain, start taking an NSAID on a regular schedule as directed without waiting for pain, then take the opiate as needed for breakthrough pain, and do so promptly without waiting to see if you can tough it out.

    I had back surgery recently and was given a whopping big prescription for a standard opiate/acetaminophen combination and another one for a medication for muscle spasm that is often prescribed for anxiety. The results of the surgery were great and I ended up having little pain and taking very few pills, but the volume of medication I was handed on a “use as needed” basis bothers me, and if there is an effective technique for using these in the best way possible, I wish I’d been instructed more effectively.

  79. 79
    Violet says:

    @Mnemosyne: Yeah, I don’t think diet is a cure-all for every ailment, but it’s certainly known to be helpful for enough people that it seems like it should be in the repertoire of pain doctors as something to try in appropriate circumstances. Same with yoga or similar types of things. Sometimes those can work amazingly well. Other times not at all. Everyone is different.

    Doctors, in my experience, do not seem to be very well informed about diet as an option to help people. People who struggle with chronic pain would probably most likely prefer to be pain-free and not have to take medication to get there. Pain management is just that–managing pain, not eliminating it.

  80. 80
    Fair Economist says:

    Chronic pain is awful but so is dying. IMO take-home opiates, beyond once-off prescriptions of a small number for post-op pain and similar conditions, should be reserved for patients for whom it would be acceptable for them to die due to overdose. So, metastatic cancer, certain degenerative diseases, and various terminal conditions. The DEA paranoia is overdone but there are some doctors who ignore their Hippocratic oath and prescribe too much. The last 15 years have shown us that take-home opiates are a very lethal set of drugs.

  81. 81
    MathInPA says:

    @elmo: Thank you. I’ve gotten used to expressing it out of necessity, and in a kind of bitter ‘the worst is done’ sort of way– I’ll probably never teach again given my experiences during the worst of the years prior to surgery for the slipped disc and more importantly the way the administration treated me, and my job prospects are limited, so why do I care about more public expression of private issues? I hate being treated like I, and those like me, are just edges on the bars to be shifted around, to be put into tolerance ranges and carefully “balanced” against other concerns. Addicts shouldn’t be either, of course, but again, the best way to deal with that is preparation and treatment, not proscription of prescription.

    I can’t believe that I’m somehow so special that there aren’t others in as bad pain as I am, or near it, or worse, and as much as I hate the BS I have to deal with and the unrelenting pain that merely ebbs and flows, I can’t stand that it’s done to other people. You and especially your wife have my sympathy. Yoga, stretching, various physical and meditative exercises.. all of that can be nice augments for long term treatment, but it does so very little for me at this point, especially with the exhaustion. I think anything like that, especially given how idiosyncratic it is in terms of amount of effort and effect, needs to be treated as something to do once a good baseline is established through medication, not as an “oh, well, sorry you can’t actually get to where you need to be, here, try these various things that deplete your limited effort and time availability pools and just hope…”

    In summation, I suppose, is this: pain is incredibly toxic to quality of life both for one’s self and for those who care about you. It is radioactive, spreading out through your work, your pursuits, your relationships, your love. Why is it treated as something that can be leveraged against other concerns?

  82. 82
    MathInPA says:

    @Fair Economist: No. Absolutely not. Chronic pain isn’t just bad. It is actively, suicidal-thoughts inducing terrifying. It is not something you can just ‘live with’ because it devours and destroys your life. The lethality of take home opiates– which they share with any number of other things including sleep medication and heart medication– has to be dealt with through treatment and education, not restriction of options that can relieve the problem.

  83. 83
    aimai says:

    @Mnemosyne:

    I’m not going to get into an argument with you about this. There is a societal cost to everything –to trying to prevent people from becoming addicts to trying to prevent people from driving while drunk. Some of the harms people cause when they have an illness or an addiction are primarily to themselves and some to other people. I think society has a duty to try to mitigate both kinds of harms but I don’t see that it makes sense to mitigate all harms, to all kinds of people, while causing harms to others.

    In particular I do not see that it makes sense to criminalize all drug use, and turn all drug and health providers into an arm of hte DEA, to protect drug abusers from the consequences of their addiction. A certain number of people, for whatever reason (biological or social) are going to drink or drug themselves to death. Criminalizing everyone in advance to prevent those people from getting their hands on their drug of choice is not a good solution.

    I have friends and family members who have mental illness issues. I don’t see what that has to do with anything.

  84. 84
    aimai says:

    @Fair Economist: I don’t think the evidence is in that people who were prescribed opiates by their doctors in the course of an actual treatment plan are OD’ing on those meds. The problem (as I understand it) is that some doctors are overproscribing to people who either dont’ need the drugs at all (are drug seeking) or who allow the drugs to be sold on after they aren’t needed anymore to other users. Sometimes the doctors are part of the scam, and sometimes they aren’t.

    People are living longer with horrific illness and cancers, often at home. Why should pain management stop at the hospital doors when most people can’t afford and don’t want to die in a hospital? In addition you have the problem of people with chronic pain who can and should be permitted to manage their own care. I have been told by doctors that the latest thinking about severe pain is that if you are in severe pain you don’t suddenly become addicted to the opiates you are taking because they just basically keep you level with a normal person’s situation. They don’t produce the addictive high or feeling that people then start seeking.

    Overproscribing and failing to alert patients to the issues surrounding pain management is a huge problem of physician communication with patients. And at the same time the individual patient is at the mercy of their doctor’s most proximate experience with other patients and doctors and assumptions about pain. Richard got 50 vicodin for an outpatient snip? His wife gets twelve for a child birth + episiotomy? That’s a theory about pain that is simply absurd. But its not a violation of the hippocratic oath.

  85. 85
    Fair Economist says:

    @MathInPA:

    The lethality of take home opiates– which they share with any number of other things including sleep medication and heart medication– has to be dealt with through treatment and education, not restriction of options that can relieve the problem.

    No, the opiates are vastly worse than all the others. They’re now causing the majority of prescription drug deaths. They have two particular, killer (literally) problems. First, in chronic users, the effective dose gets close to the lethal dose. Second, they directly affect the mind’s motivational systems.

    The mortality rate of regular opiate users from overdose is 2% per year- meaning, roughly, that if you prescribe a young person regular opiates, they are more the 50% likely to die eventually of overdose. Take-home opiates are acceptable only when death is acceptable because, if the person isn’t going to die of something else quickly, that’s probably what’s going to happen.

  86. 86
    Mnemosyne says:

    @aimai:

    I have friends and family members who have mental illness issues. I don’t see what that has to do with anything.

    Addiction is a mental illness. I know people don’t like to think of it that way, because they want to blame the addict for their condition, but it is. So saying that we should just let addicts overdose if they want to is IMO just like advocating we should let schizophrenics go untreated because it’s their free choice.

  87. 87
    Fair Economist says:

    @aimai:

    People are living longer with horrific illness and cancers, often at home. Why should pain management stop at the hospital doors when most people can’t afford and don’t want to die in a hospital? In addition you have the problem of people with chronic pain who can and should be permitted to manage their own care. I have been told by doctors that the latest thinking about severe pain is that if you are in severe pain you don’t suddenly become addicted to the opiates you are taking because they just basically keep you level with a normal person’s situation. They don’t produce the addictive high or feeling that people then start seeking.

    Overproscribing and failing to alert patients to the issues surrounding pain management is a huge problem of physician communication with patients. And at the same time the individual patient is at the mercy of their doctor’s most proximate experience with other patients and doctors and assumptions about pain. Richard got 50 vicodin for an outpatient snip? His wife gets twelve for a child birth + episiotomy? That’s a theory about pain that is simply absurd. But its not a violation of the hippocratic oath.

    Well, as I said, if you’ve got a terminal condition, the death risk from opiates is acceptable.

    Yes, the thinking is that people using, as needed, for serious pain are far less likely to become addicted but that’s actually based, AFAICT, on short-term treatment. 12 Vicodin for take-home post-op probably isn’t that addictive. But long-term regular use, for whatever reason, is certainly addictive.

    *50* Vicodin for take-home is creating a huge addiction risk. And especially for a vasectomy! Addicting a patient to a dangerous drug most definitely counts as “doing harm”.

  88. 88
    Another Holocene Human says:

    @cmorenc: I messed up my stomach with ibuprofen and aspirin, while it stops my migraines, is very rough on my stomach as well. Mild does of acetaminophen are perfectly safe.

    Most of the acetaminophen problems come from high doses to dried out alcoholics, which body slams the liver. That’s why you can drink and pop Vicodins–the alcohol creates some metabolite that actually protects the liver against acetaminophen. But if you take an alcoholic and dry them out… say, in the hospital… their body is adapted to that alcohol drip so they become vulnerable to Tylenol. Tylenol is preferred in hospitals so if the workers aren’t thinking–“Hey, this dude came in here stinking drunk”–they can really hurt somebody. You can also OD at home if you take a bunch of extra strength pills in a short amount of time… OR… here’s where the druggies come into it… you take one of those tylenol+opiate drugs, the two drugs are supposed to enhance the analgesia, certainly does for me, and allegedly makes the pill less appealing to abuse. Well, that was a failure, and addicts just snort the pills, putting way, way more acetaminophen in their systems than any human should.

    As a result, the government has been pushing to eliminate Vicodin and other combo pills. There are still legit reasons to take them together, but all the deaths at home by addicts have proven that their theory about preventing abuse was dead wrong.

  89. 89
    Richard Mayhew says:

    @Dead Ernest (Thought Wrangler): Yeah, there is a lot of good evidence that people will talk through complicated scenarios and their confusion with nurses but not with docs because of the societal pressure to “not be a bother” to the very important doc.

  90. 90
    Another Holocene Human says:

    You can kill yourself with water, too, and I don’t mean by drowning. The poison is in the dose with things like that.

  91. 91
    WereBear says:

    @Fair Economist: *50* Vicodin for take-home is creating a huge addiction risk. And especially for a vasectomy! Addicting a patient to a dangerous drug most definitely counts as “doing harm”.

    Drugs don’t addict people. People get addicted.

    I’ve done peer counseling, and every single one got into drugs… or alcohol… or shopping… or gambling… or hoarding… because doing that thing made their brain light up. And they’d never felt their brain light up before.

    Call it untreated mental illness (I do) but drugs are not the problem. Or everyone with a root canal would be mugging old ladies to get their “fix.”

  92. 92
    Mnemosyne says:

    Though I don’t agree with the policy advice, this policy brief from the CDC is interesting to see the maps of overdoses vs. prescriptions.

    We all knew this, but Florida is pretty fucked up.

    Also, reading through that, it sounds like a huge part of the problem is intra-family theft or just giving away of drugs. We were dealing with this in my husband’s family for a while, where his sister was “borrowing” Vicodin from their father. After their dad died, she was pissed that her younger brother got to their dad’s apartment first and flushed all of the Vicodin before she could get to it.

  93. 93
    Another Holocene Human says:

    @PhoenixRising: Phoenix, ask your ENT about Singulair. It really works, and it doesn’t raise your blood pressure like those damn little red pills.

    My father took those for years with detrimental effects on his health. I got heart palpitations taking them. They only address a symptom, not the overall problem. Singulair calms down your overactive immune system so you can breathe. I highly recommend at least giving it a try.

    In a few years they might be promoting parasite therapy, as that also seems to stop a lot of autoimmune problems. :)

  94. 94
    MathInPA says:

    @Fair Economist: I thought before you were just being repulsively ignorant. Now I know you’re either insane or willfully blind. They affect the mind’s motivational systems because pain– torture, basically, by your own body– is an incredible motivator. You are talking about torture by law. There’s no high on these things unless you count _returning to a state near to human normal from below_ and the relief at that sensation as being high.

    The dosing problem is one that is shared by a lot of other drugs– believe me, since I have a heart condition and others, I know the dangers of lethal doses pretty intimately– but pain is far more universal and it hits at such a higher level. Opiates and similar drugs are treated as being such severe dangers that it severely limits to outright prevents their prescription in cases where nothing else is working and the result is just “Well… that’s too bad, live with agony.” Not to mention the chilling effect on getting better medication researched in the first place, let alone researched ethically and safely with the proper regulations for the testing.

    That’s madness. Sadism. It might be the cold sadism of simplified statistics, but it’s still sadistic; deciding what level of someone else’s pain is acceptable to one’s cause. If opiate patients can be separated from opiate users and a real statistical study shown then let that information be given to patients and their doctors and let THEM MAKE THE CHOICES about what constitutes an acceptable risk. Deal with the users, the addicts, through treatment programs and preventive education.

    But more restriction? More barriers between people and being able to live like humans rather than wounded animals? Evil. I don’t care what your motivation is; I don’t care what the reason you think this is a good idea or your place or the government’s place to intervene and decide what a manageable level of socially _required_ torture is, but the outcome is the same: evil. Not to mention the fact that even the CURRENT levels of restriction create sufficient barriers to ongoing anti-pain use that they increase the likelihood of overdose because it puts people in situations where their pain spikes and as a result they get tempted to take more– something that removing restrictions and allowing people to more easily establish and maintain a baseline would prevent.

    I’ve been taking my current level of pain medication, sans the cymbalta I’ve just started in addition to the rest, and substituting lyrica for gabapentin earlier, for eight years. I’m told that where I am is the maximum safe dose of the gabapentin, and the maximum dose of the hydrocodone that I can get without attracting DEA attention around here that no doctor can deal with.

    The only time I’ve had danger to my life is when I’ve had problems keeping up with my SVT meds due to my insurance company dicking around. But because there’s no solution that will leave me consistently free of pain, my economic prospects and those of my family have been severely damaged and my quality of life has been degraded. I spend hours sometimes being unable to engage in even pleasurable leisure activities like reading favorite books, playing computer games, or even -eating-, which would at least get me the food-rush because of the sheer level of agony.

    And I’m not alone. Not by far. And I severely doubt I’m so special as to be an outlier.

  95. 95
    Another Holocene Human says:

    @Tommy: I’ve met enough people who ruined their lives and livelihoods with opiate pills to be very, very skeptical.

    I’d be the first advocate for the medical profession to tell people with back pain and cancer pain and stuff to take vaporized marijuana first before trying opiates. I’ve known a lot of potheads, too, and aside from the idiot teenagers who never should have been touching that stuff, adults can smoke a little or even “shitloads” of pot and still hold down a job, be a decent human being, etc. Pillheads lie. Most of all, they lie to themselves.

    Opiates lie to you. They cause pain in your body that wasn’t there before. They make you progressively disabled. They make your life be about the opiates. They probably cause depression by the way they impact life activities which also causes more phantom pain and misery.

    I say this as someone who had codeine after tooth surgery and hey, it was what I needed at the time. But that codeine lied to me, too. It was singing a sweet sweet song about a place with no pain, no troubles, no needs, no problems. Oh yeah. Codeine had a silvered tongue. (It also made me shit a brick, despite taking laxatives on recommendation of friends, dental surgeon didn’t even mention it.)

    One problem in the US is that doctors have very little pharm background. They should be collaborating with pharmD’s. This only happens in big institutional practices. Otherwise it’s like outsourced or something. And the result is disaster. Also know some people who were made disabled by their multiple doctors prescribing drugs that interacted and sent them to the hospital. One lost a foot and the other needed a heart transplant when all was said and done. Horrifying.

    People abuse benzos too, it’s not just opiates. But opiates are pretty fucking bad.

    There has to be a better way. An evidence and science based way. Because right now we have the worst of all worlds, people with terrible pain being denied by doctors who are insensitive or afraid of the DEA and also people whose lives are being ruined by these drugs.

    And again, marijuana for adults has such less worse consequences, why isn’t that the one to try first (unless we’re talking about these acute, short duration post surgery kind of uses)?

  96. 96
    Cassidy says:

    @Joel: That means nothing. You will not reach the lethal dose for tylenol before you hit the lethal dose for opioids. Now, tylenol can do lasting and permanent damage at much lower levels than the lethal dose and is toxic at about half the lethal dose, but we’re still talking grams of tylenol. So, what I’m getting at, while you may have too much tylenol in your system when ODing on a narcotic pain pill, the effects of the narcotic is what’s killing you, not the extra gram or so of tylenol.

    ETA: Not saying you, but in general, part of the problem is people not understanding that acetaminophen is not this horrible, monstrous drug. The effects of abusing it is horrendous, but you really have to work hard. If you follow the dosage instructions, you’ll be fine. If you take Nyquil that has 325mg and another medication, you’re still good for a single dose up to 650mg. You can take 1000mg every 6-8 hours. It is in and out pretty quickly. People here stories about “TO MUCH TYLENOLZ!!!!” and don’t bother to actually read up on the drug itself. It’s dumb.

  97. 97
    Another Holocene Human says:

    @RSA: You know what rarely gets discussed with migraines?

    Magnesium levels.

    The gov’t doesn’t care, but Mg levels vary all over the country and where your food is grown makes a difference. It also varies in water.

    Mg is important for keeping Ca in your bones and teeth, helping your muscles relax (Ca and Na make them contract) and seems to play a role in … headaches.

    I soak in epsom salts when I can. It seems to help. I also eat a lot of dark chocolate, very high per gram in Mg. Ocean fish are pretty good too but I can’t get those much where I live now. Vegetables vary based on soil. When they fertilize to increase yield they usually don’t put down Mg because it doesn’t effect yield or color of vegetable crops, so Mg levels in carrots and such are lower than a century ago.

    Just some things to think about. Though it is too bad you have to go through some weird hoops to get a non NSAID migraine-stopping drug prescription. Almost if it were more about money for pharma companies than safety. Excedrin does work for me but that aspirin tears my insides up. When will we get a topical formulation?!

  98. 98
    Cassidy says:

    @Another Holocene Human:

    They should be collaborating with pharmD’s

    Don’t get me started on these folk. I have never met a group of people who so singularly thought they were medical practitioners by osmosis. Just being around Doctor’s doesn’t give you the ability to diagnose shit. If that was the case, the receptionist would be writing scrips.

  99. 99
    Another Holocene Human says:

    @elmo: A lot of it is mental illness/community issues and throwing a pill at it is the easy way out for a society that has already thrown these people away.

    Not that you can’t end up with real disease after years of abuse, neglect, isolation. I’m not saying you can just love on an addict and they’re cured. But I think there’s a reason that in Canada a pharmacist can give you certain opiates if you have a cold and yet the big abuse problems are in places like Ohio and Florida.

  100. 100
    Another Holocene Human says:

    @Tommy: You are right on, Tommy. There is and has been for years a subculture among the wealthy of being able to get any drug, legally, from their doctors, and it’s socially acceptable. Piles of pills they really shouldn’t have. Look at all the people abusing that little blue ‘heart’ pill or anti-anxiety meds. Speed, in a previous era, which was given for weight loss, and crazy downers for insomnia.

    But if a poor person needs pain management, the Calvinism comes out in a heartbeat! Poor people should never enjoy themselves! They’d get too accustomed to being poor!

  101. 101
    MathInPA says:

    @Another Holocene Human: I’d forgotten how paternalistic and smug people get about pain and pain mitigation. To be blunt, pain in the same places, patterns, and motions, and degenerating in the ways (and at a reduced rate, thank God) as before you ever touch an opiate aren’t being ‘created’ or worsened by the opiates. The fact that they spike off the meds has more to do with the pain than the opiate.

  102. 102
    Another Holocene Human says:

    @Cassidy: I said collaborating, not supplanting, of course PharmD’s aren’t MD’s, but the reverse is true as well–!!

  103. 103
    Wag says:

    @Richard Mayhew:

    Can you release my comment around #40 from moderation?

  104. 104
    Another Holocene Human says:

    @MathInPA: It’s not just pain that you take you to the edge. I got crazy unstable over albuterol because after months of underfunctioning lungs I could finally breathe and the LNP was going to take that away. I started crying. I was completely unhinged.

    But I would really caution against the harsh language you’ve directed against others because your subjective experience is subjective. Others can’t feel the pain that you experience (or the misery I was enduring mentally because of lack of sleep because of not breathing). And under the influence of a body desperate to heal itself you aren’t exactly objective or able to apply a critical faculty to your thoughts and actions.

    Pain is much more complicated than stimulus + reaction. I don’t think our science has really scratched the surface.

  105. 105
    Another Holocene Human says:

    @MathInPA: You’re just plain wrong about opiates and the scientific literature, and it isn’t smugness or paternalism to say so. Why does talking about the facts about these drugs cause you to squeal as if somebody hit you?

    All pharmacologically active substances have their benefits and drawbacks.

  106. 106
    Fair Economist says:

    @MathInPA:
    I’m aware there are medical conditions bad enough that you’d be better off dead. But that’s what you need to reserve permanent take-home opiates for because, if you prescribe them for a young person with a normal life expectancy, they mostly likely *will* end up dead from the opiates. Sending somebody home on maintenance opiate therapy is close to a death sentence. Facing intense pain without the opiates doesn’t change the fact that the prescribed opiate will probably kill the patient, and that likely death has to be considered when making the prescription.

    Take-home maintenence opiates are basically euthanasia-lite, and should have a similar level of scrutiny.

  107. 107
    Another Holocene Human says:

    @Violet: Whites get prescribed opiate pain pills more than Blacks, also, too.

  108. 108
    Another Holocene Human says:

    @elmo: People who yearn for single payer should be careful what they wish for. In the NHS if you get branded as a confabulator, good luck every getting that statement overruled. Heard some horror stories from people in the UK with Asperger’s Syndrome who got put in the system as NPD. Also people with poorly understood auto-immune digestive disorders. Those can really “mess” up your day.

  109. 109
    Another Holocene Human says:

    @Violet: And don’t forget the reduction in pain that can come from treating major depression.

  110. 110
    elmo says:

    @MathInPA:

    limited effort and time availability pools

    Oh god exactly. My wife refers to this as “spoons,” as a proxy for quantifying the amount of effort and energy she has available. Some days she has quite a few. Many days almost none at all. So “Do yoga!” “Stretch!” “Walk!” “Exercise!” “Explore new foods!” “Cook!” “Take your mind off it!” is just such incredibly high-handed arrogant ignorant smug rubbish.

  111. 111
    maximiliano furtive, formerly known as dr. bloor says:

    @Fair Economist:

    if you prescribe them for a young person with a normal life expectancy, they mostly likely *will* end up dead from the opiates. Sending somebody home on maintenance opiate therapy is close to a death sentence.

    No matter how many times you restate your argument in overwrought terms like this, it still doesn’t make withholding opiate medications from the vast number of patients who use them responsibly and benefit from them either (a) good medicine or (b) good social policy. Fortunately for us, the people who actually set these policies approach this very difficult issue with a somewhat less simple-minded approach.

  112. 112
    elmo says:

    @Fair Economist:

    Take-home maintenence opiates are basically euthanasia-lite

    Then there should certainly be more than 16,000 OD deaths a year, no?

  113. 113
    Another Holocene Human says:

    @Mnemosyne: I dunno about fibro but I found out through my gluten travails that some people–certainly not me–get arthritis-like symptoms after eating large quantities of solanaceous crops such as:

    potatoes (esp: skins), eggplant, hot chili peppers, bell peppers, tomatoes, tomatillos, pepino

    It’s not clear why; could be a reaction to well-known toxins these foods share such as solenin. (Solenin is fatal in high enough doses, of course, but we’re talking about people who get severe pain eating stuff with super low levels that are considered safe by the FDA. There are other plant chemicals that appear with solenin, of course. And it could be some wacky allergy-like thing based on a solanaceous plant protein.)

    Tobacco is also in this family. Also Belladonna, nightshade.

  114. 114
    Stiv says:

    Mathinpa,
    Thanks for that post.
    Nobody realizes what constant chronic pain means.
    I didn’t until a tumor started growing on my spinal cord. After spending the first 7 years of this century in pain and diminished physical acuity in my legs, I finally had an MRI done higher up in my spine thoracic area. A “benign” tumor was choking off my cord, surgery by a neuro was done within the week. He had to cut a root nerve and there was damage to the nerve sheaths in that area.
    Since 2007, instead of getting better, I am in a similar situation as you.
    30 minutes siting in a car and I can’t move. 30 minutes doing anything and I feel like I’ve been in a car wreck. Nothing helped, and as time went on we switched from gab opening to lyrica to anti depressants to try and slow down all the misfiring electrical currents.
    Cannabis is and was a great help, but the unending waves of pain made life unbearable.
    All this time I and my doc avoided the opiates. But since going all in with the vikingdin
    last year I am sleeping through the night, and in the morning I still feel like I was hit by a truck, but the V kicks in and I can actually feel like a real person again.
    My situation as far as chronic pain and doctors seeing it for what it is, is obvious by looking at my mri’s, surgery, and my withered right leg, but I still had to go through a lot of steps before my doc would prescribe. I had to go to a pain center, get another docs blessing, and here I am looking at the rest of my life taking pain meds.
    It’s a hassle, but the alternative is hell.
    I totally get it When I read of someone ending their time on earth because of pain, because I am the king of pain.

  115. 115
    Cassidy says:

    @Fair Economist: This is where tylenol toxicity kicks in actually. As they develop a tolerance for the opiate, they take increased amounts and then reach a point where they are taking toxic levels of acetaminophen daily and permanently damaging themselves.

  116. 116
    Fair Economist says:

    @Another Holocene Human:

    You know what rarely gets discussed with migraines?

    Magnesium levels.

    I soak in epsom salts when I can. It seems to help. I also eat a lot of dark chocolate, very high per gram in Mg. Ocean fish are pretty good too but I can’t get those much where I live now. Vegetables vary based on soil. When they fertilize to increase yield they usually don’t put down Mg because it doesn’t effect yield or color of vegetable crops, so Mg levels in carrots and such are lower than a century ago.

    If you cook, a really easy source is the magnesium citrate in the drinkable saline laxatives. A few tablespoons in a soup or casserole is easy, cheap, and unnoticeable. Not too much, of course – you get a laxative effect. Pills are almost always Magnesium Oxide, which is basically insoluble and thus not absorbable at all. Magnesium hydroxide (milk of magnesia) is absorbable, but kind of gross and messy. And yeah, getting enough magnesium really helps with my migraines.

    But – what has really helped with my migraines is cutting out artificial sweeteners. I was already avoiding aspartame, because there’s some research showing headaches from that in particular, but when I cut out all of them (mainly sucralose) I went from 2 a week to 2 a month. Plus, not as bad – not the ones that make you want to bang your head on the wall (and sometimes actually do it, in my case).

  117. 117
    karen says:

    I’ve had kidney stones and root canals and I have Rheumatoid Arthritis. I only use pain pills when I need them (one of the perks of being a control freak and hating to not be in control) and all they do for me is dull pain. Because the addicts ruin it for people who actually need the pills, when I’ve had them prescribed for me, I have to save up the left over pills. The fact that I have left over pills says everything. I know it’s selfish of me but I really think that the addicts or the fear of creating addicts have created a problem for people like me who would like the drugs to be around when they need them, NOT to get high.

  118. 118
    Another Holocene Human says:

    @elmo: I’ve read this has something to do with the NO (nitrous oxide) cycle in the body, of course knowing this still doesn’t provide avenues to fix it. BTDT.

  119. 119
    Another Holocene Human says:

    @Fair Economist: Yeah, they oughtn’t sell Magnesium Oxide because it is a waste of money. Not absorbed at all.

  120. 120
    Fair Economist says:

    @elmo:

    >>Take-home maintenence opiates are basically euthanasia-lite

    Then there should certainly be more than 16,000 OD deaths a year, no?

    Not really. 2% deaths per year probably won’t kill you this year or this decade, but, eventually, it most likely will. That’s why I used the -lite terminology.

    Really, 16,000/year is a shocking, horrifying number. It’s up there with car accidents, and *exceeding* gun homicides. Or 3 Iraqs per year, in terms of what it did to the US. Very, very, bad.

  121. 121
    Fuzzy says:

    @Dead Ernest (Thought Wrangler): Have you ever had constant 8 to 10 pain level and not been able to get help reducing it?. Well I have, as a burn victim and amputee my pain was mismanaged both in the hospital after ICU and after discharge and the results are devastating to the patient and family. That was 15 years ago and a more recent problem was dealt with promptly so maybe the science of pain is making progress.

  122. 122
    karen says:

    @Mnemosyne:

    I also have fibro with my RA, I wouldn’t say it’s like arthritis, but it’s definitely autoimmune.

  123. 123
    Mayken says:

    @Patternmaker: Yes, and folks who have actual chronic pain conditions, who get treated like drug-seeking addicts when they really are just in that much pain. (Not from personal experience but my bestie who was a paramedic till some idiot diddling with his cell phone hit her and caused her severe spinal injuries.

  124. 124
    sparrow says:

    @dr. luba: Yeah, I have one that releases hormones. In fact, I had a hard time getting even an IUD at first! Because they want you to have had kids first for some kind of nebulous reason (I suspect because there’s an off-chance of things going really bad and making you infertile, but they never would say).

    I was saved by joining a clinical trial for the new low-dose mirena IUD. It worked great for 3 years. Unfortunately at the end of the trial I couldn’t get another one (not out yet), but my study doc got me hooked up with someone who would put in the regular mirena. I know some people don’t like them but it has seriously changed my life. I am so happy to have this thing which just turns my periods off. It’s amazing.

  125. 125
    sparrow says:

    @sparrow: Just wanted to add that the new IUD is called “Skyla” and it is being marketed for nuliparous women.

  126. 126
    Stivkit says:

    Mathinpa,
    Thanks for that post.
    Nobody realizes what constant chronic pain means.
    I didn’t until a tumor started growing on my spinal cord. After spending the first 7 years of this century in pain and diminished physical acuity in my legs, I finally had an MRI done higher up in my spine thoracic area. A “benign” tumor was choking off my cord, surgery by a neuro was done within the week. He had to cut a root nerve and there was damage to the nerve sheaths in that area.
    Since 2007, instead of getting better, I am in a similar situation as you.
    30 minutes siting in a car and I can’t move. 30 minutes doing anything and I feel like I’ve been in a car wreck. Nothing helped, and as time went on we switched from gab opening to lyrica to anti depressants to try and slow down all the misfiring electrical currents.
    Cannabis is and was a great help, but the unending waves of pain made life unbearable.
    All this time I and my doc avoided the opiates. But since going all in with the vikingdin
    last year I am sleeping through the night, and in the morning I still feel like I was hit by a truck, but the V kicks in and I can actually feel like a real person again.
    My situation as far as chronic pain and doctors seeing it for what it is, is obvious by looking at my mri’s, surgery, and my withered right leg, but I still had to go through a lot of steps before my doc would prescribe. I had to go to a pain center, get another docs blessing, and here I am looking at the rest of my life taking pain meds.
    It’s a hassle, but the alternative is hell.
    I totally get it When I read of someone ending their time on earth because of pain, because I am the king of pain.

  127. 127
    karen says:

    @sparrow:

    Sorry to sound ignorant but what is nuliparous?

  128. 128
    Glocksman says:

    My personal experience is that small quantities of vicodin or lortabs are fairly easy to get.
    Easy for me because of my medical history of life-threatening bleeding ulcers that resulted as a complication from gastric bypass surgery.

    As a consequence, I cannot take NSAID’s of any kind.
    When I do experience severe pain my doc prescribes a small amount of painkillers to deal with the short term pain.
    Luckily for me, the time I needed painkillers was during a gout attack over a year ago.
    The doc prescribed a prednisone dosepack and a 12 lortabs.

    The gout receded within 2 days and I threw the rest of the lortabs away.

  129. 129
    Fred Fnord says:

    See, what we have here is a difficult problem.

    Because every study tells us that opiates are seriously UNDERprescribed. There are literally millions of people who are in needless pain because doctors are afraid of being sued and/or are judgmental about addiction in the face of horrible pain, and because politicians would rather judge addicts than find out what people actually need.

    So, the more we fight the ‘overprescription’ problem, the more people suffer, and the more people literally commit suicide to get away from overwhelming pain.

    Sadly, that seems to be the country that the vast majority of people who aren’t CURRENTLY in pain want to live in.

  130. 130
    Fair Economist says:

    @karen:

    Sorry to sound ignorant but what is nuliparous?

    A very fancy word for “hasn’t had children”.

  131. 131
    Joel says:

    @Cassidy: What means nothing, that there are two orders of magnitude (100-fold) more tylenol in prescription opioid compared to the actual active compound? You understand the concept of lethal dose, right?

    Here’s the acute oral toxicity (LD50) for Tylenol provided by the manufacturer itself:

    2680-3100 mg/kg in rats
    630-770 mg/kg in hamsters
    2640-2800 mg/kg in rabbits
    1180-1450 mg/kg in dogs

    Here’s the acute oral toxicity for hydrocodone (the opioid in vicodin) provided by the NIH:

    375 mg/kg in rats

    Yes, it’s true that there are long term effects of steady consumption, and that these are not reflected in toxicology studies (at least not in these particular ones) but my point is pretty simple: The relative toxicities of tylenol and opioids are very close — less than an order of magnitude apart — so when you add 100-fold the amount of tylenol, you’re going to hit the toxicity threshold for that drug a lot sooner than you will for opioids in most cases.

    The FDA has recently begun to recognize the problem with tylenol toxicity in opioid scripts, which is why they lowered the maximum allowable dose of tylenol in those formulations.

  132. 132
    Joel says:

    @Cassidy: My response got eaten in moderation, but you’re wrong.

    Acetaminophen is fine when used as directed, but supplementing so many drugs with acetaminophen is problematic for a number of reasons, including accidental overdose.

    The animal-model acute toxicity threshold of the drug is not much higher than it is for hydro- or oxy-codone but formulations of opioids contain roughly 100 fold more acetaminophen than it does opioid. These drugs are ostensibly mixed to provide extra analgesia, but that’s bullshit. They’re really added to “deter abuse” by making high levels of pills acutely toxic to users.

    Don’t take my word, take it from the FDA:

    The public health burden of acetaminophen-associated overdoses has been estimated using data from a variety of national databases and other resources. (3) A summary of data from four different surveillance systems indicates that there were an estimated 56,000 emergency room visits, 26,000 hospitalizations, and 458 deaths per year related to acetaminophen-associated overdoses during the 1990s (Ref. 10). Within these estimates, unintentional acetaminophen overdose accounted for nearly 25 percent of the emergency department visits, 10 percent of the hospitalizations, and 25 percent of the deaths (Ref. 10).
    Prescription products contribute significantly to the toll of liver damage from both unintentional and intentional acetaminophen overdoses. For example, in the study of ALF patients by Larson et al., 63 percent of the unintentionally overdosed subjects and 18 percent of intentionally overdosed subjects had taken prescription acetaminophen combination products prior to injury (Ref. 4). According to data from the Toxic Exposure Surveillance System (now named the National Poison Data System (NPDS)), 30 percent of all acetaminophen-associated calls to poison centers in 2005 involved prescription acetaminophen combination products (41,999 of 138,602 calls). Prescription acetaminophen combination products were involved in approximately 44 percent of acetaminophen-associated calls that resulted in serious injury (1,470 of 3,310 calls) and 48 percent (161 of 333 calls) of acetaminophen-associated calls that resulted in fatalities (Ref. 11). (4)

  133. 133
    Cassidy says:

    @Joel: I’m thinking that maybe you don’t understand the difference between a toxic level and a lethal level.

  134. 134
    Joel says:

    @Cassidy: I’m thinking you’re being an asshole. No offense.

    “Acute toxicity” in my post above refers to LD50, which I’m sure you know.

  135. 135
    Joel says:

    @Cassidy: Please, edify me.

  136. 136
    Mnemosyne says:

    @Joel:

    I think — but I’m not sure — that the distinction Cassidy is trying to draw is between a lethal level that causes you to OD and die on the spot, and a toxic level that will poison your liver and cause you to die in a few days or weeks without treatment.

    It’s not that acetaminophen won’t kill you, it’s that it won’t drop you dead on the spot and leave your family to find you with the Tylenol bottle still in your hand like they found Philip Seymour Hoffman with the needle still in his arm.

  137. 137

    @Mnemosyne:

    saying that we should just let addicts overdose if they want to is IMO just like advocating we should let schizophrenics go untreated because it’s their free choice.

    The reason we force medication on schizophrenics is not that we all want them to be their best selves and their sick selves can’t see that meds help with that; it is because people having psychotic and paranoid symptoms create problems for those of us who are oriented to time & space.

    In exactly the same way, if addicts OD quietly at home after they self-medicate poorly, they’re not setting the rest of us up for disaster we had nothing to do with.

    Addiction is like every other mental illness: We don’t know jack about how to treat it, and health policy and law are aligned to make the sufferer the family’s problem, if that.

  138. 138
    Joel says:

    @Mnemosyne: Sure, you won’t get acute respiratory failure, but in effect a dead person is dead, even if it takes a few hours (or even days) to get there.

  139. 139
    Mnemosyne says:

    @PhoenixRising:

    Addiction is like every other mental illness: We don’t know jack about how to treat it, and health policy and law are aligned to make the sufferer the family’s problem, if that.

    We have no idea how to treat bipolar disorder? No idea how to treat depression or schizophrenia?

    As far as I can tell, we know a lot about how to successfully treat those disorders in most people (combination of ongoing, usually weekly, psychotherapy and medication) but the treatment is expensive and insurance companies don’t want to pay for it. If the person is poor and the treatment is supposed to be paid for by the government, they don’t want to pay for it, either. It’s not a matter of not knowing how to treat it, it’s a matter of paying for it. Those are two completely different problems.

  140. 140

    @Mnemosyne: No, we really don’t know how to provide all patients with major depression, bipolar and schizoid episodes with solutions that work for them. Addiction is right in the middle of that pack, in that we have drugs that work wonders on some addicts and do bupkus for others.

    It’s nice that we have pills that help some sufferers with some symptoms as long as they keep taking them; this is a better time to have an elderly relative with schizophrenia than 30 years ago, by far, and I appreciate the incremental improvement.

    But compared to how we can treat most physical aliments…we don’t know shit. Sounds like you happen to be a patient who is helped by one of those drugs. That’s nice for you and your family. It’s just not universal. We are a long way from having underfunded but effective treatments for a sprained or broken mind to rival all the ways we have to set a broken ankle.

  141. 141
    Don K says:

    @Joel:

    Well, to be fair, in me it causes nausea as well. Too bad, I used to enjoy a shot of that night time cold reliever at bedtime when I had a cold. Now I just down a pseudoephedrine with a whiskey chaser.

  142. 142
    Mnemosyne says:

    @PhoenixRising:

    Sounds like you happen to be a patient who is helped by one of those drugs.

    Yes, I was helped by drugs (Wellbutrin, specifically). But I was also a patient who was able to afford long-term therapy out of pocket rather than having it doled out at 20 sessions a year like most insurance companies do. I was in psychotherapy a minimum of once a week (at one point, it was twice a week) for seven years before I was able to have a reasonably normal life. The drugs helped move that process along, but it was that ongoing therapy that helped me fix my problems. And I “only” had dysthymia, which is a mild but persistent depression.

    Medication is great, and helpful, but as the saying goes, Pills don’t teach skills. Handing a schizophrenic a pill once a week will do jack shit to help them without intensive, ongoing, supportive psychotherapy.

    We are a long way from having underfunded but effective treatments for a sprained or broken mind to rival all the ways we have to set a broken ankle.

    Actually, there’s a bit of a resemblance there, too — surgically, we know how to set a broken ankle, but without physical therapy, the person will end up almost as crippled after the surgery as they were before it. And it’s a giant pain in the ass to get the insurance company to pay for enough physical therapy to restore normal motion. But most orthopedists know how important physical therapy is and will fight for their patients to get it. How many general practitioners handing out Prozac are equally insistent on their patient getting ongoing psychotherapy?

  143. 143
    Violet says:

    @Mnemosyne: There are the studies that show that placebos are just as effective, sometimes more effective, than antidepressants. And then there’s the newer research into gut bacteria and mental health issues. Like this:

    The digestive tract and the brain are crucially linked, according to mounting evidence showing that diet and gut bacteria are able to influence our behavior, thoughts and mood. Now researchers have found evidence of bacterial translocation, or “leaky gut,” among people with depression.

    or this one about successfully treating a teenage girl with OCD and ADHD with probiotics.

    There’s still a lot about treatment mental illness that we don’t know.

  144. 144
    dr. luba says:

    @sparrow: It’s because of the Dalkon shield. Look it up some time–a poorly designed IUD with a string that wicked bacterial into the uterus. A horrible, horrible device. Even though all the other IUDs out there were safe, they got a bad rap because of this one bad device.

    For a long time we were very strict about who could get an IUD, and nullips didn’t qualify. It was more of a medicolegal thing–since the Dalkon shield had caused infertility, and someone who’s never conceived has unknown fertility, it was risky to place one and then be blamed for any subsequent infertility.

    I’m glad you have relief. There are so many more options now than there were in the 70s and before.

  145. 145
    phoebesmother says:

    @Fair Economist: I know this will show up WAY LATE but you are abusing math and statistics and obviously have some sort of personal ax to grind. Simply taking a prescription opioid a few times will not make you an addict, even if you take them home with you. No matter how young you are. Many people, especially those with serious chronic pain, never experience a “high” from an opioid if taken as directed. There just isn’t that much hydrocodone in most prescriptions. This isn’t crack or heroin with a rapid onset o fphysical and psychoactive effects, unknown potency, and short metabolism. If you have followed the NYT stories on Vermont’s heroin problem, you can see that those who’ve become addicted often have baseline problems of low incomes, few expectations, poor education leading to boredom, and a host of similar family and life disorders; those who become addicted to prescription painkillers most likely share those characteristics. Keeping the average Joe and Jane from effective pain management won’t address the addict’s real problems. It’ll just make the rest of us suffer when we needn’t.

  146. 146
    Greg says:

    //Hello, interesting exchange of comments and some great points. One thing I do have to comment on is that the 50 Vic’s may be extreme for a new script from post surgery with no tolerance, but is actually a low number for those on long term pain management. For me, pain medicine has been a life saver! I have been on 110mg of opiates daily since 2007. Never abused but of course, regardless of my pain level, I must take the same amount of milligrams daily or the effects of withdrawn is shown. Yes, that is something I don’t like, but to flip the coin,,, my daily pain level is always around a ONE with continued pain management. Retired Air Force with Purple Heart from Iraq (Tallil Air Base, 2005) //

  147. 147
    TriassicSands says:

    A quick look at the statistics in the article reveals that doctors are not the “top source of prescription drugs for chronic abusers.”

    The numbers are:
    Doctors 27.3%
    Given by friend or relative 26.4%
    Bought from friend or relative 23.2%

    The way I read that, friends and relatives are the source of almost 50% of these drugs. Is it really a meaningful distinction to separate friends and relatives who give and those who sell the drugs when one is talking about the source?

  148. 148
    StringOnAStick says:

    @phoebesmother: As someone who has occasionally been given a bottle of 30 vico’s (knee surgeries, severely broken or damaged bones, etc) I can easily say (1) I did not become an addict, and (2) when you are in chronic pain, what these drugs do is get you back to a functioning baseline – they are not a party if you are in pain when you take them. NeoCalvinists, please take note. It sounds like too many people are remembering the 1980’s club culture and ‘Ludes. People like MathinPA can either be on serious pain reduction meds, or they can commit suicide because the pain is unbearable. The latter is NOT preferable because some suburbanite finds they have a taste for codeine and starts organizing their life around it – that’s a choice for them, MathinPA has no choice about having their pain stop. Further restricting MathinPA’s access so we can feel like we’ve done something about drug abuse is pretty rich coming from a crowd that generally slags the War on (some) Drugs as being ineffective and stupid.

    No matter what mind-altering drug we are talking about, there will always be people who have addiction problems. If it didn’t then making all recreational drugs illegal would have completely stopped by now, right? I’d much rather have pain drugs available to those who need them than force those people to suffer because we as a society don’t want to spend the money to help those who do become addicted.

    The anti-drug craziness hits at too many levels. In my state, having something as low level as a 20 year old minor pot conviction means you will never be allowed to obtain a license for any kind of medical or dental profession, all the way down to being a CNA. Of course, if you already have an MD or DDS license and you get popped, you’ll get therapy and license review, but God help you if you are an RN or below – that license is gone, gone, gone. And I’m in Colorado, you know, the legal pot place?

    I’ve read that the reason we are seeing an increase in heroin use is because people have pain (mental or physical) and docs cut off their prescription meds, plus street heroin is cheaper anyway. Does that seem like a system designed for success, or for ruining lives and sending people to jail?

  149. 149
    karen says:

    @StringOnAStick:

    Does that seem like a system designed for success, or for ruining lives and sending people to jail?

    It sounds like a system that’s designed to punish people. They’re thrilled when people OD because that kills two birds with one stone: punishing and consequences.

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