Opioid addiction - Time for a fresh approach or new front in War on Drugs?!

[karaddin]

So a discussion on the opioid addiction crisis in the US came up for a few pages in the last iteration of the US Politics thread that I missed, and I'd like to contribute. I know there has been a prior thread on this broad subject, but from my recollection it took far too much of a knee jerk moral panic response.

Personally I'd like certain things to be accepted as reasonable starting points in the thread:

• Addiction is the psychological condition of being addicted to a stimulus, this is distinct from dependence.
• Dependence is the physiological condition of being dependent on a drug, this is distinct from addiction.
• The level of depdence on, and to a lesser extent addiction to, opioids by people in the US is a significant problem.
• Dependence on opioids stemming from a legitimate prescription for acute or chronic pain, that may or may not be ongoing, is a separate issue to addiction to opioids (primarily heroin) that started directly as a drug taking habit rather than a medical one. The use of heroin as a psychological painkiller is a complicated one, and I view its use as primarily this but it is still separate from the chronic physical pain flavour of dependence.
• Ensuring that people with chronic and acute pain are able to access the pain relief they require should be a cornerstone of any drug policy.
• Protecting individuals from, and preparing them to deal with, dependence is an important component of this same drug policy.
• Following on from the point above, compassionately assisting individuals in dealing with dependence should be part of the same policy, as dependence will occur.
• Treatment for addiction regardless of where it originates represents an additional challenge. Someone who is dependent but not addicted will want to stop drug use when its no longer needed, but will experience a lot of difficulty with the physical process. Someone who is addicted will not necessarily, and generally speaking will need to want to stop and will require support to work through the psychological process.

Posts I wanted to respond to from the locked thread:

@Fez

Quote

Not sure I'd go that far. The opioid epidemic has gotten rather strange in the past few years, in a way that almost no one talks about. If you look at stuff like the NSDUH data, the total number of people misusing prescription opioids is way, way down from its peak in 2010. The total number of people using heroin is up a lot percentage-wise, but in raw numbers doesn't even come close to the reduction in Rx opioids. There's still millions of people misusing opioids, but its a lot fewer than it had been.

However, when you look at data on overdoses (fatal and non-), those numbers have been skyrocketing; for both Rx opioids and heroin. So the problem is being contained to a smaller number of people; but the problem for those remaining people keeps getting worse and worse.

I've also looked at the stats relating to falling usage vs increasing overdoses. The cause of death in the majority of cases from the statistics I saw was not impurities in the drugs, or too large a dose as such - it was drug interactions. Alcohol x Opioid and Benzo x Opioid interactions are both very dangerous as the different sedative effects of these drugs can act as multipliers leading a person to simply stop breathing and die. Both of those have been around for a long time though, so you wouldn't expect them to explain the surging fatalities. The big change is...

@Maithanet

Quote

I did not know that.  Fentanyl must be practically off the charts.

Fentanyl. Fentanyl is absurdly potent, but also synthetic and cheap as fuck to synthesise (compared to the other drugs being discussed here). Blackmarket pills are using a tiny amount of fentanyl to increase the potency and using less of the drug they're actually selling, however fentanyl is so potent that even a tiny amount added can be far too strong which leads to overdoses. This is a huge problem without an obvious solution.

Fez - I suspect there may be some confirmation bias going on with the people you talk to thinking that the problem is just that doctors won't comply. A lot of these people are invested in enforcement being the solution to the problem and will struggle to see the problem from other angles. From what I've read there have been significant numbers of chronic pain sufferers that have had their treatment pulled out from under them and left to deal not just with their ongoing chronic pain, but with dependence and no support. I don't care how large the problem is, that's a fucked approach that is only going to cause more problems. Past patients should have at least been grandfathered or something like that.

Personally I've needed pain management for acute pain following surgery in the past. I was lucky and had a doctor who was able to provide me with the relief I needed, and that relief was very very high dosage. He trusted me, and I rewarded that trust. I weaned off the oxy as soon as the pain subsided and I've had zero ongoing problems with it. A girl I knew who had the same surgery with very similar difficulties afterwards was not so lucky. She worked at Bioware in Texas, did not get any pain relief help and killed herself to stop the pain. This is a very very personal thing for me, so I'd ask people to really refrain from knee jerk panic or callous judgements of "if some legitimate patients get screwed over then so be it". Know that you are killing people when you make that decision.

I also access pain medication for migraine, although I'm lucky that triptans are the heavy hitters for most of mine. @Simon Steele what are the prophylactics you've tried/what has helped? What was the reason triptans aren't allowed anymore, and does it also rule out ergotamine? Codeine has been available over the counter here, but that is changing next year and I'm a little concerned with how I'll go after that, although my neurologist will likely keep me OK.

I'd also ask people to consider the amount of work that was detailed in the prior thread to get the prescriptions in certain places. Visit the doctor in person once a month, get a handwritten prescription, take it in person to the same chemist you always use. It may not seem like a lot, but its a significant expense. More importantly if you are suffering severe chronic pain, its an incredible amount of effort to have to go through, especially if you are currently unmedicated and getting to the doctor causes agony. Then if anything causes your routine to change, you can run afoul of the state tracking and get cut off.

I've run out of time for now, I'm sure I had some other points I wanted to make though.

[Centrist Simon Steele]

6 hours ago, karaddin said:

So a discussion on the opioid addiction crisis in the US came up for a few pages in the last iteration of the US Politics thread that I missed, and I'd like to contribute. I know there has been a prior thread on this broad subject, but from my recollection it took far too much of a knee jerk moral panic response.

Personally I'd like certain things to be accepted as reasonable starting points in the thread:

• Addiction is the psychological condition of being addicted to a stimulus, this is distinct from dependence.
• Dependence is the physiological condition of being dependent on a drug, this is distinct from addiction.
• The level of depdence on, and to a lesser extent addiction to, opioids by people in the US is a significant problem.
• Dependence on opioids stemming from a legitimate prescription for acute or chronic pain, that may or may not be ongoing, is a separate issue to addiction to opioids (primarily heroin) that started directly as a drug taking habit rather than a medical one. The use of heroin as a psychological painkiller is a complicated one, and I view its use as primarily this but it is still separate from the chronic physical pain flavour of dependence.
• Ensuring that people with chronic and acute pain are able to access the pain relief they require should be a cornerstone of any drug policy.
• Protecting individuals from, and preparing them to deal with, dependence is an important component of this same drug policy.
• Following on from the point above, compassionately assisting individuals in dealing with dependence should be part of the same policy, as dependence will occur.
• Treatment for addiction regardless of where it originates represents an additional challenge. Someone who is dependent but not addicted will want to stop drug use when its no longer needed, but will experience a lot of difficulty with the physical process. Someone who is addicted will not necessarily, and generally speaking will need to want to stop and will require support to work through the psychological process.

 

I also access pain medication for migraine, although I'm lucky that triptans are the heavy hitters for most of mine. @Simon Steele what are the prophylactics you've tried/what has helped? What was the reason triptans aren't allowed anymore, and does it also rule out ergotamine? Codeine has been available over the counter here, but that is changing next year and I'm a little concerned with how I'll go after that, although my neurologist will likely keep me OK.

I'd also ask people to consider the amount of work that was detailed in the prior thread to get the prescriptions in certain places. Visit the doctor in person once a month, get a handwritten prescription, take it in person to the same chemist you always use. It may not seem like a lot, but its a significant expense. More importantly if you are suffering severe chronic pain, its an incredible amount of effort to have to go through, especially if you are currently unmedicated and getting to the doctor causes agony. Then if anything causes your routine to change, you can run afoul of the state tracking and get cut off.

I've run out of time for now, I'm sure I had some other points I wanted to make though.

18

I worry, too, about the moral panic that tends to come with this topic. Many countries have effectively treated and managed this issue for people who are addicted without criminalizing nor moralizing, and those methods are often shockingly effectively. Switzerland being most shocking and compelling to me. I think criminalization of drugs, in general, in America is a worthy subject--and I'll be honest Karradin, where that thread went when I brought it up was a bit shocking. I didn't expect people to still hold onto such negative ideas about the rising heroin epidemic--but I'll come back to this later today when I have more time.

As for me, the triptan class of medicine began giving me the severe reactions listed on the box and paperwork--essentially mimicking severe issues with my heart. I had to leave work, one day, it got so bad, and the doctors were concerned enough to give an EKG. Either way, the triptans were leading me to significant heart issues, they feared. I take Topomax and that's helped manage the migraines quite efficiently for years now (took some time to find it), but while settling on a preventative medicine, the hydrocodone was about it.

About the same time stricter laws came back, so did the medicine Midrin which is a weird combo of some type of muscle relaxer and tylenol, so I did that for awhile, and now I use butalbital. As for Ergots--I tried the nosespray, but the biggest issue for me was that when I tried them, I was getting migraines almost every day, and a box of 8 doses cost me 60 dollars through my awful, teacher insurance. I just couldn't afford it. And the treatment was really hit or miss.

I've really learned to read the signs and head them off, I suppose.

[Fez]

Quote

Dependence on opioids stemming from a legitimate prescription for acute or chronic pain, that may or may not be ongoing, is a separate issue to addiction to opioids (primarily heroin) that started directly as a drug taking habit rather than a medical one. The use of heroin as a psychological painkiller is a complicated one, and I view its use as primarily this but it is still separate from the chronic physical pain flavour of dependence.

Not sure I fully agree on this one. It is not uncommon for opioid dependence to lead to opioid addiction. And there's a fair amount of evidence that quite a few people with opioid addictions view heroin and Rx opioids as substitutes for each other; for instance after Oxycontin changed its formula, rates of heroin use went up.

Quote

 

I've also looked at the stats relating to falling usage vs increasing overdoses. The cause of death in the majority of cases from the statistics I saw was not impurities in the drugs, or too large a dose as such - it was drug interactions. Alcohol x Opioid and Benzo x Opioid interactions are both very dangerous as the different sedative effects of these drugs can act as multipliers leading a person to simply stop breathing and die. Both of those have been around for a long time though, so you wouldn't expect them to explain the surging fatalities. The big change is..

Fentanyl. Fentanyl is absurdly potent, but also synthetic and cheap as fuck to synthesise (compared to the other drugs being discussed here). Blackmarket pills are using a tiny amount of fentanyl to increase the potency and using less of the drug they're actually selling, however fentanyl is so potent that even a tiny amount added can be far too strong which leads to overdoses. This is a huge problem without an obvious solution.

 

Oh I agree. Drug interactions are serious problem here; as is the potency of Fentanyl (and the facts that many people doesn't realize just how potent it is, and that people often aren't told when its in what they're taking). There are other causes as well (e.g people resuming use after a loss of tolerance caused by being incarcerated or in abstience-based treatment; people upping their use too excessively; etc.), but those two are probably the biggest growing issues. At least, that's what it seems. Its so difficult to get comprehensive medical examiner reports in a widespread fashion (when they even exist).

Quote

Fez - I suspect there may be some confirmation bias going on with the people you talk to thinking that the problem is just that doctors won't comply. A lot of these people are invested in enforcement being the solution to the problem and will struggle to see the problem from other angles. From what I've read there have been significant numbers of chronic pain sufferers that have had their treatment pulled out from under them and left to deal not just with their ongoing chronic pain, but with dependence and no support. I don't care how large the problem is, that's a fucked approach that is only going to cause more problems. Past patients should have at least been grandfathered or something like that.

I didn't say the people thought the problem was "just" doctors not complying; but rather that doctors not complying was part of the issue. And not all doctors, its some doctors. All prescription opioids originally came from somewhere legal, and the number that were stolen is relatively small. Doctors, and by "doctors" I really mean all prescribers, are supposed to be the gatekeepers. And some of them issued a lot of illegitimate prescriptions over the years; either from not doing due diligence or because they were seeking a profit (though fortunately most out-and-out pill mills have been shut down).

I absolutely agree that maintaining legitimate access to Rx opioids is incredibly important. But the various categories of opioid misuse are responsible for one of the larger public health crises in recent memory. The US death rate from opioids is closing in on the US death rate from AIDS at its peak.

[Lily Valley]

I understand the moral panic issue.  I have personally had to turn to the black market for pain relief due to the inability to fill a very short term prescription for a much needed painkiller.  It was especially infuriating to me because I live in Louisiana, where we have more opioid prescriptions than people.

http://www.wwltv.com/news/health/louisiana-has-more-opiod-prescriptions-than-residents/328637722

That said, there is ZERO support or responsibility from the same medical professionals who prescribe this medication to their patients.

As always when this type of thread comes up, if you are dealing with a loved one who is either dependent or addicted, here's some resources:

The Addict's Mom

This group has a closed and private facebook support network.  There are chapters in every state.

Nar-Anon Family Groups

The Nar-Anon forum is very well moderated and offers wonderful support.

Al-Anon

The Al-Anon program should be required of all humans.  The 12 step program and meeting style are a 101 course on personal responsibility and empathetic listening.  Their blue book is a lifeline to anyone who has ever dealt with co-dependency and other interpersonal relationship issues.

There are face to face and online meetings worldwide.  Much love to all of you.

[zelticgar]

A lot of this discussion had tied opioid addiction to pain management and i agree that is a huge component but the way we treat mental health needs to be looked at. 

I believe a significant contributing factor to the growth in additiction is due to the very early conditioning we are giving people with pre-existing mental health issues. The message they received is that the answer to all their problems are tied to medication and drugs. This correlation naturally leads to expansion to illegal drugs. I have no good answers on how to solve this but I can guarantee you there is a large population of young people being over prescribed a variety of medication related to behavioral issues that could likely be dealt with outside of using medication. Those young people are now conditioned to look at pills and medication for solutions to problems that they would otherwise would have been taught to deal with more inwardly. The next natural progression is illegal drugs. 

[Mlle. Zabzie]

@Lily Valley Thank you so much for posting these resources.

I think these are really hard questions.  And I don't think we know why some people can use opiods for short periods of time without issue and others simply cannot.  Nor do I think that we have good answers regarding pain management strategies in general for people with chronic pain - what works for one patient may fail utterly for another, for completely inexplicable reasons.  Making resources like the ones you posted above widely available and without stigma would be a great first start.  But I'm not in charge of the universe.  *sad face*.

[Iskaral Pust]

Really interesting and socially significant topic.  I'm not knowledgeable enough to make a contribution.  I like Karradin's axioms though. 

It worries me that most of us already have some level of external psychological dependence or addiction -- exercise, religion, relationships, food, career, tribe, entertainment devices, adrenaline stimulation, porn, etc -- of various degrees that can be replaced by more compelling chemical dependence or addiction if circumstances create the opportunity.  Our behavior and lifestyles are already hostage to our neurotransmitters and can be hijacked by synthetic neurotransmitters offering a bigger effect.  And there is huge individual variation in our ability to manage this.

The various prohibition movements and social stigmas have tried to reduce the circumstances that create those opportunities because there is an anxiety that it's hard to resist or recover from the hijacking.  But we all know that approach has a lot of collateral damage, whether people in pain being denied relief or unsympathetic treatment for those who do succumb.  I doubt we'll ever cease to be hostages of our neurotransmitters, so we'll always be managing some trade-off on healthy/acceptable/endorsed/supported pandering versus prohibited/controlled/stigmatized protectionism.

[Lily Valley]

5 hours ago, Mlle. Zabzie said:

@Lily Valley Thank you so much for posting these resources.

I think these are really hard questions.  And I don't think we know why some people can use opiods for short periods of time without issue and others simply cannot.  Nor do I think that we have good answers regarding pain management strategies in general for people with chronic pain - what works for one patient may fail utterly for another, for completely inexplicable reasons.  Making resources like the ones you posted above widely available and without stigma would be a great first start.  But I'm not in charge of the universe.  *sad face*.

There are very specific symptoms for people who are prone to addiction.  Opioids will act as an upper instead of a downer.  Much like ADD meds based on meth calm people with ADD and allow them to focus.  This is "anecdotal evidence" that intake professionals and addiction counselors have known for a very long time.  In addition, opioids have a LOT of unpleasant side effects.  People with a predisposition do not experience / report those symptoms.  They feel SUPER.  These are two easy things a doctor could talk to a patient about and offer a warning and reliable assistance in case they have patients who experience these symptoms.  About 5-10% of people experience the "upper" phenomenon.  100% of opiate addicts report it.

The mortality rate for addicts is appalling.  Most US healthcare will not pay for detox, rehab won't take you without detoxing first.  Private detox costs somewhere around $5000 for a week.  It's considered "not life threatening".  They still pay for alcohol detox.  This shit is breaking people and killing them.

In New Orleans REPORTED overdoses just replaced our murder rate.  I have spoken to NOPD homicide who say they get called to 2 or 3 deaths PER WEEK that are drug/overdose related.  My son is still young and he has buried 3 friends every year for the last five years.  Fifteen children.  FIFTEEN.  It's not right.  I am a YOUNG woman (thankyouverymuch) and should NOT be at funerals for my son's friends.  

There is new evidence that behavioral testing for impulsivity can find youth at risk for addiction.  I'll find that and post it when I can.  It received ZERO attention from the larger med industry.

I could go on (and have).  I won't here, but if anyone has questions, I'll do my best to help.  I am in the US, so YMMV on my experiences.

[Iskaral Pust]

There were some good articles last year in the NYTimes, The Atlantic (I think) and elsewhere that lamented the lack of data on or scrutiny of the efficacy of detox & rehab programs, and showed that the 12-step program of AA (and extended to other addictions) had no discernible advantage, despite being widely endorsed as the official approach to addiction treatment, e.g. through court-ordered treatment following crime associated with addiction.  Not to mention the slightly creepy faux-religion at the core of the 12-step program.  Some of the rehab centers were basically run like luxury spa vacations for the rich & famous, and priced accordingly.  It seems like there is a lot of room for a clinical approach to improve detox and rehab.

I know some countries have seen a lot of success by sponsoring "shooting galleries" to minimize the secondary social problems from drug addiction, while basically punting on the root problem of addiction until the addict is ready to seek treatment.  That is a moral grey area because it may enable addicts for longer and possibly make it easier for some to migrate from use to addiction, but I really don't know what the best answer would be.  We cannot (and I would say should not) compel an addict to treat their addiction, nor do we currently have any particularly effective treatment for those seeking help other than a lifelong behavioral toil with a high rate of regression.

[Lily Valley]

9 minutes ago, Iskaral Pust said:

We cannot (and I would say should not) compel an addict to treat their addiction, nor do we currently have any particularly effective treatment for those seeking help other than a lifelong behavioral toil with a high rate of regression.

Watching an addict recover from close quarters is the most heroic thing I have ever seen.  Watching an addict do addict stuff from close quarters is the most hellish thing I have ever seen.  Nobody would pick that.  Nobody.  It is absolutely disgraceful that addiction is stigmatized the way it is.  I understand why, it's easier to hate something than to look at it.  It's still inexcuseable.

I want to say that it's not necessarily lifelong toil.  I know a lot of people who recovered and a decade later they are more self-aware than most non-recovered peers.  They KNOW when they need to get some help.  They KNOW what type of thing pushes their buttons, etc.  They are some of the most vibrant and self-aware people I know.  I was frankly shocked to find out that many of them ever had a substance abuse problem.  It hits across everything.

 

[Xray the Enforcer]

33 minutes ago, Lily Valley said:

The mortality rate for addicts is appalling.  Most US healthcare will not pay for detox, rehab won't take you without detoxing first.  Private detox costs somewhere around $5000 for a week.  It's considered "not life threatening".  They still pay for alcohol detox.  This shit is breaking people and killing them.

This is what shits me more than anything. Most of the addicts I've known ended up caught in this particular trap, and it led to most of them dying of overdoses because they simply could not afford treatment and the consequent despair led them right back into using. 

[karaddin]

I have to admit I have a hard time having a reasonable response to when people say that doctors have been a large part of the problem. That has not been true here, but because so much of our discourse migrates over from the US we still have the strict, war on drugs style, advocates that talk up this problem. It makes me push back on it on an emotional level even though I know the situation (and the problem) in the US is different. I also have reservations about criticism of big pharma from the left sounding too close to anti Vax shit, so again it's the same kind of thing with me. Pharmaceuticals aren't inherently evil but the corporation's are certainly capable of being that way.

10 hours ago, Fez said:

Not sure I fully agree on this one. It is not uncommon for opioid dependence to lead to opioid addiction. And there's a fair amount of evidence that quite a few people with opioid addictions view heroin and Rx opioids as substitutes for each other; for instance after Oxycontin changed its formula, rates of heroin use went up.

I didn't mean there's no cross over, just that the cause of the addiction is generally different. With a different motivation for the addiction they need to be approached differently.

6 hours ago, Mlle. Zabzie said:

@Lily Valley 

I think these are really hard questions.  And I don't think we know why some people can use opiods for short periods of time without issue and others simply cannot.  

While there isn't anything concrete and proven, there is a theory of drug use that explains at least part of this (watch Lily go all hard scientist on my ass for bringing in something softer :p).

Zinberg's theory of drug use posits that three different things control what a drug will do to a person:

Drug - Relatively obvious. The pharmacological properties of the drug will of course have a significant impact in both the immediate effect of the drug and how a person feels about the experience.

Set - The mindset of the person towards the drug they are taking. This includes whether they're in a good or bad place, their expectations about what the drug can do, their hopes for what it will do, their fears about what side effects may be, etc. It also includes the purpose for the use - medicinal, recreational etc.

Setting - The environment that the drug is being consumed in. A hospital is very different to a home, which is very different to a derelict house.

The mindset of a person is obviously hugely influenced by the views of society at large towards drugs and towards that particular drug. This is one of the reasons I'm so negative on moral panic, because that can feed back into the drug itself becoming more harmful to the people living in that society. 

Things that have been found to reduce negative impacts of drugs include being very clear in your purpose for taking it. Studies of historical ritualistic use of hallucinogens in Central American cultures have found much lower negative reactions to the drug. Associated with this is that having a very clear medical purpose in mind when taking it, and even just having a regular routine in which you take it can also function as a kind of ritual limiting the negative outcomes. 

When someone is going to need the drug for treatment of acute pain we should prepare them for this. They have a legitimate need for the drug, it will help with their pain. They are likely to become physically dependent on the drug and that's just another medical detail, getting off the drug afterwards is just another step in their recovery. It's just routine and manageable, not at all alarming.

Chronic pain is different in that there is notnecessarily going to be an end point. And if there's not, we should really stop seeing dependence as a problem in the way we currently do. The problem there is the build up of tolerance, the risk of overdose associated with tolerance, the risk of overdose if resuming after a break to lower tolerance etc. These are all things which we can manage differently, and better, if we take the panic out of it and just wish list approach them as medical details that are part of the treatment plan. Yes, the drugs aren't ideal but they're better than life in pain, why are we trying to tell people in pain they should be clean and suffering rather than trying to have a decent quality of life?

The other problem here is that the other pharmaceuticals which have been pushed as alternatives are generally speaking crap. There are certain people and certain conditions that they work well for, but outside these narrow bands they provide much less relief and come with much more major quality of life side effects. A lot of the time it really looks like a moral judgement of "they're better because you can't get high" as though the possibility of incidental pleasure is a sin.

Of course throughout all this fixing the pain is better than smothering it, this is why triptans are far superior to opioids for migraine when they're effective and safe. But even in that example you may need pain relief while the triptans take hours to work.

I've continued to avoid the more complex issue of heroin addiction and so on because it's not the scenario that's changing. Injecting rooms are a big thing you can do to improve health outcomes for addicts, but aren't going to take away the problem all by themselves. There needs to be a huge cultural shift across multiple things for that to really change, but the war on drugs approach needs to end and we need to treat addicts as people in need not people to condemn. I agree with Isk that you shouldn't force people to stop, and if compassionate arguments don't cut through on this then the fact it doesn't work should. You need to convince people to want to stop first or they'll just find a way eventually. Society needs to look after them until they can be convinced. And fuck health insurance that doesn't cover actual health problems.

I know I'm forgetting stuff again but this is already massive.

[Lily Valley]

1 hour ago, Xray the Enforcer said:

This is what shits me more than anything. Most of the addicts I've known ended up caught in this particular trap, and it led to most of them dying of overdoses because they simply could not afford treatment and the consequent despair led them right back into using. 

Yes, and the shame cycle.  The incredibly opaque nature of the courts AND hospitals to deal with this shit is infuriating.  People who are already fragile spending hours and hours on the phone dealing with bad information and obstinate bureaucrats is fucking infuriating.  In addition, the stigma makes them so much less likely to ask for help.  So they die.  They die and die and die and it is fucking shameful.

This is a derail from the OP and I apologize.  The moral policing isn't working.  At either end of that argument leaves an enormous burden of the irresponsibility on the shoulders of the medical profession.  IMO, they fucking deserve it.  They haven't listened to their peers on addiction and know less about pain management.  It's not that fucking hard.  Especially since this is such a big deal right now and LAWS are changing to govern their practices as a result.  A few fucking hours of professional development for ONE Doctor in each large practice could make a difference.  The fact that this isn't happening is just fucking sickening.

Edit:  X-Ray, I am so sorry for your losses.  I miss my mine too.

[Xray the Enforcer]

24 minutes ago, Lily Valley said:

Edit:  X-Ray, I am so sorry for your losses.  I miss my mine too.

And I'm very sorry for yours. Love you.  

[Manhole Eunuchsbane]

25 minutes ago, karaddin said:

I have to admit I have a hard time having a reasonable response to when people say that doctors have been a large part of the problem. That has not been true here, but because so much of our discourse migrates over from the US we still have the strict, war on drugs style, advocates that talk up this problem. It makes me push back on it on an emotional level even though I know the situation (and the problem) in the US is different. I also have reservations about criticism of big pharma from the left sounding too close to anti Vax shit, so again it's the same kind of thing with me. Pharmaceuticals aren't inherently evil but the corporation's are certainly capable of being that way.

Oh man, don't even get me started of the responsibility and complicity between Big Pharma and the AMA when it comes to the opioid mess. I don't have the slightest clue as to how this all played out in Australia, but here in the States, it was pretty clear cut. Especially when it comes to OXY's.

  http://www.newyorker.com/business/currency/who-is-responsible-for-the-pain-pill-epidemic

http://thefreethoughtproject.com/big-pharma-exposed-knowingly-causing-opioid-epidemic-ushering-heroin-catastrophe/

http://articles.mercola.com/sites/articles/archive/2016/10/05/us-opioid-addiction.aspx

 

This is not in anyway analogous to the Anti-Vaxxer bullshit. This was about money. Big money for both Big Pharma and for HMO's and other health organizations who sold their patients down the river with no substantive research on hand regarding the addictive properties of Oxycontin. 

From the first week I started working at the HMO that employs me, I got a bad taste in my mouth regarding Pharma reps. You'd have these sales reps from various Big Pharma companies coming into the clinic weekly talking to doctors. Leaving them with large amounts of sample sized packs of medications to give to their patients. They often brought gift bags, usually stocked with small electronic devices like Ipods or fitbits, t-shirts, and gift certificates to local businesses and the like. When I saw this, I was left scratching my head. The Medical Assistants,Pharmacy Techs and Nurses at my facility have annual compliance testing every year. It's basically a series of videos you watch on your computer followed by multiple choice questions to show that you've picked up the main points of the videos. One of the largest portions of the test involves what is considered to be acceptable interaction with outside vendors. Accepting a gift from an outside vendor is a serious no-no, which can result in instant termination. "So what is this shit?" I asked myself.

 On top of this, these reps were all (without exception) very physically attractive people. And there were always two of them, one male, and one female. Dressed to the nines in expensive, tailored suits. The women often made up to a tee, looking like they were about to go out to the club, only dressed in business casual. It was really blatant and more than a bit disgusting. 

The rules have since changed. Maybe five years ago or so, my HMO stopped allowing Pharma Sales people into the clinic, and doctors were no longer allowed to accept gifts or samples.

[Lily Valley]

30 minutes ago, karaddin said:

I have to admit I have a hard time having a reasonable response to when people say that doctors have been a large part of the problem. That has not been true here, but because so much of our discourse migrates over from the US we still have the strict, war on drugs style, advocates that talk up this problem. It makes me push back on it on an emotional level even though I know the situation (and the problem) in the US is different. I also have reservations about criticism of big pharma from the left sounding too close to anti Vax shit, so again it's the same kind of thing with me. Pharmaceuticals aren't inherently evil but the corporation's are certainly capable of being that way.

I didn't mean there's no cross over, just that the cause of the addiction is generally different. With a different motivation for the addiction they need to be approached differently.

While there isn't anything concrete and proven, there is a theory of drug use that explains at least part of this (watch Lily go all hard scientist on my ass for bringing in something softer :p).

Zinberg's theory of drug use posits that three different things control what a drug will do to a person:

Drug - Relatively obvious. The pharmacological properties of the drug will of course have a significant impact in both the immediate effect of the drug and how a person feels about the experience.

Set - The mindset of the person towards the drug they are taking. This includes whether they're in a good or bad place, their expectations about what the drug can do, their hopes for what it will do, their fears about what side effects may be, etc. It also includes the purpose for the use - medicinal, recreational etc.

Setting - The environment that the drug is being consumed in. A hospital is very different to a home, which is very different to a derelict house.

The mindset of a person is obviously hugely influenced by the views of society at large towards drugs and towards that particular drug. This is one of the reasons I'm so negative on moral panic, because that can feed back into the drug itself becoming more harmful to the people living in that society. 

Things that have been found to reduce negative impacts of drugs include being very clear in your purpose for taking it. Studies of historical ritualistic use of hallucinogens in Central American cultures have found much lower negative reactions to the drug. Associated with this is that having a very clear medical purpose in mind when taking it, and even just having a regular routine in which you take it can also function as a kind of ritual limiting the negative outcomes. 

When someone is going to need the drug for treatment of acute pain we should prepare them for this. They have a legitimate need for the drug, it will help with their pain. They are likely to become physically dependent on the drug and that's just another medical detail, getting off the drug afterwards is just another step in their recovery. It's just routine and manageable, not at all alarming.

Chronic pain is different in that there is notnecessarily going to be an end point. And if there's not, we should really stop seeing dependence as a problem in the way we currently do. The problem there is the build up of tolerance, the risk of overdose associated with tolerance, the risk of overdose if resuming after a break to lower tolerance etc. These are all things which we can manage differently, and better, if we take the panic out of it and just wish list approach them as medical details that are part of the treatment plan. Yes, the drugs aren't ideal but they're better than life in pain, why are we trying to tell people in pain they should be clean and suffering rather than trying to have a decent quality of life?

The other problem here is that the other pharmaceuticals which have been pushed as alternatives are generally speaking crap. There are certain people and certain conditions that they work well for, but outside these narrow bands they provide much less relief and come with much more major quality of life side effects. A lot of the time it really looks like a moral judgement of "they're better because you can't get high" as though the possibility of incidental pleasure is a sin.

Of course throughout all this fixing the pain is better than smothering it, this is why triptans are far superior to opioids for migraine when they're effective and safe. But even in that example you may need pain relief while the triptans take hours to work.

I've continued to avoid the more complex issue of heroin addiction and so on because it's not the scenario that's changing. Injecting rooms are a big thing you can do to improve health outcomes for addicts, but aren't going to take away the problem all by themselves. There needs to be a huge cultural shift across multiple things for that to really change, but the war on drugs approach needs to end and we need to treat addicts as people in need not people to condemn. I agree with Isk that you shouldn't force people to stop, and if compassionate arguments don't cut through on this then the fact it doesn't work should. You need to convince people to want to stop first or they'll just find a way eventually. Society needs to look after them until they can be convinced. And fuck health insurance that doesn't cover actual health problems.

I know I'm forgetting stuff again but this is already massive.

You know I am going to fisk the SHIT out of this, right??  Unfortunately, my internet connection in Third World USA is shit (high traffic on Friday, how could a cable company ever predict that?)

We are in agreement about the "moral panic" part of this argument.  What I will say in response to your defense of MP is that WE HAVE MORE PRESCRIPTIONS FOR OPIATES THAN PEOPLE in Louisiana.  We have something called "pain clinics" where people just show up to get their prescriptions filled.  MORE PRESCRIPTIONS than every man woman and child.  The system (as it was) would pay out of medicare / medicaid to fill the prescriptions, but not much for the chronic health issues that caused it.  Also, a simple TEN MINUTE conversation with a health care provider could prevent a dependent person from becoming an addict in the first place.

I really want to get into this some more as I think you have some great points.  I think (and what little science on the subject that is available backs me up) that there is a pre-disposition in a fairly large group of us.  In other words, there's a chance that anyone can "turn on" under the right set of circumstances. Medical practitioners have an obligation to warn people and have resources for their patients available.

[karaddin]

Lily - not a derail at all. It's all a big tangled mess. My view of things needing to dealt with as matter of fact medical details still needs the doctors to be educated and responsible. The drug used needs to be appropriate for the pain being experienced. The patient needs to be primed by the doctor to approach it the right way. That's shit that falls on them.

One of the other details that gets lost when talking across the Pacific is that there's basically no drug advertising here at all. Over the counter drugs get advertised because they're in the consumers power, but nothing that's prescribed by a doctor is. Even advertising from pharmaceutical companies to doctors is heavily restricted, so this idea of big pharma pushing the drugs heavily is kinda weird to me.

The professional development you talk about is definitely one of the issues though. Doctors need to be made aware of changes in the pharmaceutical landscape, whether it's "use x drug less" or "triptans are a relatively new drug that are amazing for most migraine sufferers" and if an overburdened health system leaves doctors without sufficient time for ongoing education then it's going to fall to the pharmaceutical companies to educate them. That's not where it should be happening.

[karaddin]

Lily and MEB - I think my disclaimer came across the wrong way. I wasn't trying to defend medical practitioners or big pharma and their role in all of it. I'm saying I have a knee jerk tendency to do so due to different circumstances that I recognise is not just unhelpful but flat out wrong in this instance. Sorry for the miscommunication.

Lily - That 10 minute conversation is absolutely part of what I think needs to be happening as part of responsible prescribing. Everyone should be getting that regardless of why they're receiving the drugs. Just handing them over without setting expectations or knowing how to look after yourself is indeed exactly how you end up in that mess. I'm trying to envisage how it should look, not defend how it is now.

You're also right on the predisposition being a factor. I don't think that was known at the time that theory of drug use was devised, but I think that still fits neatly under the "drug" category - that just varies person to person based on their physiology. The point of the other two categories is that the drug will do certain things as a baseline based on the physical properties of the drug and the person, these things are then modified by the other two categories to get the end result.

Someone who is predisposed to be vulnerable to opiate addiction will get much more pleasure out of experience, but they won't necessarily get addicted just because of that. It will tilt the equation to make taking the drug/addiction much more attractive, but if they have the right mindset, the right support, a healthy circumstance in life they can decide that pleasure isn't worth the downsides. Getting them all those other things is the challenge there.

[Larry of the Lawn]

1 hour ago, Triskan said:

Yes.  12 step is a big time joke.  It's a total emperor's new clothes thing where all of the adults are incapable of acknowledging the reality.  It is perceived to be a solution because a huge portion of people struggling with addition are funneled into it with only some small percentage having success at  any given time...the same as if people are not treated at all.  But 12 step claims success for the success and claims no responsibility for the myriad failures.  

Now I believe in free speech and freedom of assembly, and if someone wants to attend a 12 step cult that's their right.  But there should be no policies funneling people towards it, and people that push it should be called out.  The flip side of free speech.  

There's actually been quite a bit of anti-12 step stuff that's finally seen the light of day in the last few years, thankfully.  But even these criticisms tend to miss a crucial point:  it's not just that 12 step doesn't really work for most people.  It's that people exposed to it tend to do even worse than if they'd never been.  This is quite predictable and understandable if you know what 12 step preaches.  It says that it's the only way and that "jails, institutions, and death" are the only alternatives to those that have "the disease," and if you're there you're to understand that you certainly have the disease.  And since it's never actually been a successful treatment program it doesn't help most people so they leave believing that they must be the most hopeless of all addicts.  This increases despair which is often one of the driving forces of addiction in the first place. 

It would not even shock me if there's eventually a class action lawsuit where everyone who was pushed into 12 step has some kind of legal recourse.  

 

Couldn't have said it any better.  I have a very good friend who is alive today and doing fine because of AA, he'd been a strident atheist his entire life but struggled with addiction until joining the program.

However, he's the exception.  

About a dozen other friends are in jail or dead because it was the only legal option and it's just, in my opinion, a sick, sad, joke.  The first guy I mentioned who is doing well, I'm thankful it was able to help him, or that he was able to get clean despite it.  However it worked.  But the idea of 12 step as the only way is garbage and it's totally incompatible with a secular treatment.  And the data backs that up.

[Lily Valley]

I've got nothing bad to say about AA / NA.  I have friends who are alive today because of the program.  Al-Anon has gotten me through some really hellish life experiences.  It's program also helped me be a better listener and have a hell of a lot more empathy.  No really, you guys should have met me before.

The most remarkable thing about AA is the human network it creates.  People in the program, at least here, take their responsibilities to their sponsees very seriously.  I've seen people in that program drop EVERYTHING to help a member in crisis.  For one of my friends, who is an atheist, the Higher Power is a type of awe at how generous those in recovery are to the newbies they sponsor.  I imagine that what he sees is some global rug woven of compassion that is standing by to help.  

I also know that my friends who have been through AA or are currently involved have a lot more maturity than the ones that haven't as a general rule.  They are very good at saying, "no."  They are very self-aware.  They're good at minding their own business.  They have an emotional maturity that most people, frankly, lack.

Personally, I've never seen more kindness anywhere than I have at Al-Anon.  When I've needed it, just walking into a room knowing that everyone I am looking at understands why I'm there feels like shedding a huge load.  There is something comforting about being around people who GET IT.  Sometimes I don't say anything at all.  Sometimes I just sit there and cry and it's fine.  The Al-Anon program is much different than AA, the motto is, "Take what you need and leave the rest."  Sometimes it's the damndest little thing that someone says that will help get through a tough situation.  There's always someone available for a coffee after in case one needs to vent.  There's also a phone list.  People on it don't mind taking calls.  They just don't answer if they can't. 

Anyway, I'm getting long-winded.  Trisk, I can see your point.  It hasn't been my experience, but New Orleans is unique in a lot of ways.  Addiction is a huge fucking problem here.  Everyone I know has been hurt by it in some form or another.  There are so many different groups in town that it's pretty easy to find a meeting that works for each individual.  I went to several that were really unhelpful before I found a couple of good ones that are extremely well run.  I'm now wondering if our Catholic tradition doesn't make it a little more helpful here.  Taking time every week and every Lent for self-reflection and conscience searching is part of the culture.  Maybe it makes the groups here a little better.  I don't know about the overall success rates.  I do know that the first year is critical.