Senate investigation into prescription opioids

It’s unfortunate that it has taken this long for the issue to be addressed in any actual way. Investigative reporting shows have done stories on the prolific dispensing of opioids for years, but no one seemed to be paying much attention.

Just a couple of articles about the terrible situation in WV that is years old. The numbers are astounding.

http://www.wvgazettemail.com/news-cops-and-courts/20161107/unsealed-court-filing-details-drug-firms-pain-pill-shipments-to-wv

http://www.post-gazette.com/local/region/2015/12/23/W-Va-doctor-pleads-guilty-to-dispensing-narcotic-painkillers-illegally/stories/201512230173?pgpageversion=pgevoke

http://www.cbsnews.com/news/drug-distributors-under-fire-in-west-virginia-painkiller-epidemic/

http://www.huffingtonpost.com/chris-hedges/west-virginia-oxycontin-abuse_b_1820493.html

This is an ongoing situation that has been addressed and re-addressed for years.40 years. It’s not new. Just not many great solutions. It just gets harder.
I do know that many good people are working on it from many fronts.

It’s a complex issue. I know it turns political on a regular basis and I really hate that. I hate it because some law will be made to some politician’s stupid credit applauded by good people who don’t know better and the poor person who actually needs pain management most will be the loser. Fine if it’s not you or your family member.

In a perfect world we would do the addiction research needed, provide help for that and at the same time do much more research on pain management (for both men and women–we aren’t the same).

Patient satisfaction surveys in a hospital don’t push narcotic use.

Managing pain successfully will make any patient more satisfied. It is part of an overall experience. If your doc cuts you open in surgery, don’t you want pain relief? Proper pain management doesn’t turn people into addicts.
And addicts aren’t signing up to be admitted for surgery and tests to get drugs.
Where do addicts show up? The emergency room.

From an article referenced for patient surveys – ‘We want to make sure that everybody in the emergency department is happy and their pain is relieved and so you need to do that,’” Barlow said."

Well, actually you don’t “need to do that”. The trick is knowing who is actually in pain and who your addicts are.
Problem–sometimes that’s very difficult to do.

I know someone who sat for HOURS with kidney stone pain–50 years old in the local ER at 2am with no one else around–he found out later they thought he was a drug addict. Want to be in his shoes?

For those who have lost loved ones to drugs and addiction–I’m extremely sorry and sad. I see that as all the more reason to study pain management and addiction to the fullest.

My fear is that making blanket laws about drug use leads to a ban on research about those very drugs as it has on marijuana use for decades.

I don’t think people need to suffer needlessly from pain or live in addiction if research is encouraged.

My daughter had rib removal surgery in December. The pain was excruciating, and she needed her painkillers for almost a week. She will need a similar operation on the other side, and I’m already dreading the medication. It is all too easy to get hooked on those things.

^^^I don’t believe it’s as easy to get hooked as people believe. For an operation that has an expected recovery time, it there should be no reason for addiction as long as the surgeon is responsible in his practice. Recovery of short duration pain should be easy-treat the pain but don’t prescribe refills that go beyond the normal time span of recovery without very careful consideration.

Like many other medical treatments, this is region dependent. In some areas, the medical culture was to offer opiods at the drop of a hat. In other areas, it wasn’t.

This is far, far beyond what that area could possibly need for pain relief.

There was another thread about 6 months ago where we discussed the over prescription of these drugs, especially to teenagers. Both of my children were prescribed oxycontin within the last 18 months. My S for a hockey injury that required him being taken to the ER and my D when she had her tonsils removed.

After taking 2 doses my S said it made his brain feel “weird.” He switched over voluntarily to Motrin which worked fine for him as far as pain relief was concerned. D said the Oxycontin made her body feel “polluted” and just refused to take it anymore. So my conclusion was that neither really needed that level of pain medication and I did wonder why something of that level was prescribed.

I have no idea why some people can take it and get addicted while others just want to get off it, but seems to me there should be guidelines as clearly it is poses a problem for a good portion of the population.

@“Cardinal Fang” Yes, that was one of the links I posted above. The numbers are astounding.

I used to do pain management in the hospital where I worked. At the time it was very new. But I keep up with the research.

We were one of the first hospitals in our area to introduce “pain pumps” where patients could control their own pain relief after surgery. It was basically an IV drip with pain medication and a “button” you can push to dose yourself.

The research showed that a patient in control of their own pain relief after surgery (its main use for us at the time) used FAR less pain medication than having a nurse doing the dispensing.
And I mean FAR less.

Why?
Pain medication could be given in MUCH smaller doses on a more frequent basis on patient demand.
This is how pain meds actually work. One milligram of morphine given timely through a pump to MAINTAIN pain relief was worth much more than the 4 mg given later by a nurse. Over several days that could add up big time.

Factor in that people are AFRAID to be in pain–they’ll ask for pain meds without being in pain on the basis that in a few hours they MAY be in pain and not have someone respond timely. The pump put that back in their hands.

Our actual problem was making sure patients pushed the IV button to STAY out of pain (you have to stay on top of the pain). The fact they had control was very empowering.

The fact they had control made patients “stoic” . They could wait too long and then it would be harder to get out of pain (requiring a bigger dose to reach ground zero again).

There was very much a placebo effect–some patients never needed any pain meds-- knowing they could get relief without waiting was comfort enough.

People need narcotics for a very legitimate uses.

As for illegal use–there are pharmacies that are stationed in semi-trucks doing a whopping mail-order business–it’s a too unfortunate market.

I think that a big part of the problem is that most insurance plans do not cover alternative treatments - e.g. yoga, massage - that could greatly help those with certain forms of chronic pain. Yes, my insurance plan website encourages yoga…Sure, at $18 a class on my own nickel. Most insurance plans cover a limited amount of PT per year, so folks in pain gladly have a couple of months of PT at the beginning of each year, then turn to painkillers to get them through the rest of the year.

The other problem with Oxycontin in particular was that the pharma company that sells it lied about how it worked. They said a dose lasted 12 hours; that was the big selling point of Oxycontin over earlier pain meds. For many people, Oxycontin’s pain relief does not last 12 hours, but 10 hours, or 8 hours, or 6 hours, and then the pain rebounds and it’s worse.

When doctors came to the pharma company saying patients were saying the pain relief doesn’t last 12 hours, the pharma company, Purdue, said to prescribe bigger doses. They emphatically denied that the solution would be to give smaller doses more frequently, although that would have been the correct answer. They worked very hard to stop doctors from prescribing smaller doses more frequently. The bigger doses still didn’t control the pain for 12 hours. This is the way to get people addicted to drugs-- to have them suffering for a couple of hours in withdrawal, then getting a big hit of a euphoric, over and over and over again.

http://www.latimes.com/projects/oxycontin-part1/

“In Minnesota there have been overdoses due to a drug that an opioid can be cut with. It is an elephant tranquilizer! One grain of it the size of a poppy seed is terribly dangerous.”

I believe that is a synthetic version of fentanyl, and there was an article in the NY Times that the Chinese government has now banned it,significant quantities were coming from dubious sources in China (where it was legal, but not abused apparently) The article pointed out something stupid about US mail, apparently they don’t screen regular mail for these kind of things and on the dark net apparently standard advice with shipping drugs is 'use the US regular mail" and a lot of this was being shipped from suppliers in China to US based drug dealers (or to Mexico where the Cartels then distributed it).

I think there is a real problem around this issue, and what scares me is the simplistic “throw addicts in jail” kind of mentality or ‘fight the drug gangs’, when it is complex. Some of it is that these drugs are being overprescribed and there are many reasons for that. I have had surgery, not necessarily major, but enough that it could be painful and was getting prescriptions for oxycontin and percoset, both pretty powerful (I never filled them, did fine with advil and then when no threat of bleeding, aspirin). Why start with the heavy duty ones, why not try less addicting ones first before bringing in the big guns? If someone is in pain and the lower dose /strenght one doesn’t work, give them one for the bigger ones. Obviously, if the doctor has a patient who they know has serious pain and regular pain relievers don’t work, something like oxycontin could be the only way to keep them comfortable, and that should not change, but we should be looking at the routine use of these kinds of things. There are also some shady doctors who thanks to lax oversight with the prescriptions they write, were writing prescriptions to feed the illegal drug trade. One thing that should be banned are paper prescriptions, when doctors write prescriptions for controlled, addictive drugs like these they should be sent to monitoring agencies and if they see patterns of questionable prescription writing, they should be audited (and no, this is not a lot of doctors, but one doctor doing this could wreak havoc).

@gouf78 mentioned something I have heard, that with pain management they tend to assume someone need more,rather than less, and i remember reading a study on the pain pumps that people who used them tended to use less than they would be given by a provider. The problem is everyone’s pain levels are different, and in trying to be proactive they may use more than necessary or may use a stronger one than necessary to start out with.

Other problems are people leave this crap laying around when they are done with it and the kids grab it, and so forth.Not to mention this addiction problem is similar to what we have seen in the past, it is tied to issues of economics and cycles of issues, just a different cast of characters is being affected. I have been reading articles where farmers, for example, are wondering who they will leave their farms to, they are often faced with kids who either have od’ed or have drug problems, read another article where employers have job openings and are desperate because so many of those applying are turning up positive for drug use, the people running the show at one company they were leery about bringing in refugees from places like Syria, but were finding them a blessing because they were ready to work and didn’t have drug problems and the like.

The basic answer to me is there are no simple answers, and that is what I fear, we saw with the last ‘war on drugs’ that the emphasis was placed on putting people in jail, and look where that left us, rather than on treatment and figuring out why people are using them in the first place.

@gouf78 mentioned something I have heard, that with pain management they tend to assume someone need more,rather than less, and i remember reading a study on the pain pumps that people who used them tended to use less than they would be given by a provider. The problem is everyone’s pain levels are different, and in trying to be proactive they may use more than necessary or may use a stronger one than necessary to start out with.

Just to be clear(er)–It takes more medication to get OUT of pain than maintain a comfortable level (not necessarily totally pain free).
The pain pump works only when a patient has received an adequate dose for pain relief PRIOR starting the pump. Since it is in the patient’s control it avoids the “you have to wait 12 hours before your next dose” which would require a much higher dose to AGAIN get a patient out of pain. With short wait times and small doses a patient can easily use smaller incremental doses to maintain pain relief.

Yes, I think the cases of someone getting addicted after a one time 5-day supply are mostly the stuff of urban legends. I agree some of the other posters are assuming these drugs are more addictive than they are.

To start with, I’ve always found OTC pain pills to be almost useless for relieving even minor pain.

https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm

The CDC estimates that 20% of people who come into a doctor’s office with pain symptoms or a pain-related diagnosis, and who don’t have cancer, leave with an opiod prescription.

“Rates of opioid prescribing vary greatly across states in ways that cannot be explained by the underlying health status of the population”

“The CDC estimates that 20% of people who come into a doctor’s office with pain symptoms or a pain-related diagnosis, and who don’t have cancer, leave with an opiod prescription.”

Which means 80% do not. And there are lots of legitimate reasons to need pain relief beyond cancer to justify 20%.
Fact is that the most popular pain med used for years that needed a prescription is now over the counter–Motrin.
A couple were removed from the market for lack of efficacy (much to some patient’s dismay).

I have a young relative that I am pretty sure became addicted. He had had significant pain but was still on the opiods a couple of years later.

I think some of his issue was word choice and connotation. Towards the beginning when asked if his pain was controlled he would answer no because he was not pain free. It may not be a realistic goal to be completely pain free 3 weeks after major surgery. One may be “uncomfortable” without “pain”

I have learned over the years to be super particular with how the doctor and I define words. If told “your ankle should feel better in a week, if not come back” does that mean improved or back to normal? I walked around on torn ligaments because it was “improved/better” not “normal/better”.

@gouf78:
That kind of comparison , saying Motrin was once prescription and is now OTC, is a bad comparison. There are different levels of prescription medicine that have differing levels of controls on them. Motrin is not addictive and the reason it was a prescription med originally was for safety reasons because access is controlled, once they have it out in the field and can see the safety of the product, it can go OTC with FDA approval, either at the prescription strength or a lower one. Sudofed was once prescription, and eventually became OTC at a lower dosage than the original prescription strength, hydrocortizone creams otc are a lot less strong than prescription strength to this day.

When you are talking strongly addictive drugs like the opiods, the controls are very tight (as they should be), even things with relatively small doses of opiods, like codeine cough syrup or tylenol 3, are controlled tightly. Given how addictive these drugs are, I think it is legitimate to question how much of these are being prescribed, given the strength of these drugs, what percentage of people need that kind of strength? Freely prescribing motrin when it was prescription only is not the same thing, you would expect a relatively mild painkiller to be prescribed a lot.

I can’t believe we’re even discussing Motrin and opiods in the same paragraph. One of them killed over 30,000 people in 2015 and is ravaging communities all over the country, and the other one helps athletes with mild strains and women with menstrual pain. These are not remotely comparable.

In the hospital I was given an opioid every day after having open-heart surgery. One morning my nurse gave me 19 pills before lunch, and then 5 more after lunch.Plus my opioid. I stayed for only a week.

When I finally got home, the first thing I did was throw the bottle of opioids in the trash. Why? It was the same drug that led to my daughter’s drug addiction five years ago after her foot injury. I wasn’t taking any chances.

If anybody knows how I can help my daughter get monthly Vivitrol shots I would appreciate it.