One short letter's huge impact on the opioid epidemic

[IronLionZion]

(CNN)Every day, 91 Americans die from an opioid overdose. Drug overdoses overall -- most of them from opioid painkillers and heroin -- are the leading cause of accidental death in the US, killing more people than guns or car accidents. In fact, while Americans represent only about 5% of the global population, they consume about 80% of the world's opioid painkillers. But how did we get to this point?

Many public health experts point to a simple five-sentence letter to the editor published in a 1980 edition of the New England Journal of Medicine. The 101-word letter, titled "Addiction Rare in Patients Treated with Narcotics," was signed by Jane Porter and Dr. Hershel Jick of Boston University, who said that of their 11,000-plus patients treated with narcotics, there were only four cases of addiction.

And although this letter provided no further evidence and was not a peer-reviewed study, it has often been cited as proof of the safety of prescribing long-term narcotics for chronic pain.

This week, the journal published yet another letter to the editor, this one an analysis from researchers at the Institute for Clinical Evaluative Sciences of how frequently Porter and Jick's letter has been cited by other researchers and physicians in studies and journals since its publication. The analysis found 608 citations of the initial letter as of May 30, 72% of them pointing to it as proof that addiction was rare among long-term narcotic users.

Dr. David Juurlink, one of the researchers involved in the analysis, wrote in an email that the "5-sentence letter to the editor in medicine's most prestigious journal was leveraged as proof that opioids could be used safely over the long term, even though it offered no evidence to support that claim. It's clear that many of the authors who cited it hadn't actually read it."

http://www.cnn.com/2017/06/01/health/opioid-epidemic-1980-letter-origins-study/index.html

Some assholes need alternative facts to sell drugs. Hook em while they're young and find new ones to replace the dead.

Ohio is suing 5 drug companies. Kentucky and other states have done so in recent years. Rush Limbaugh and other prominent conservative blowhards have been high on drugs. Someone should test our president.

No matter how many small rural towns across red states have heroin addictions and overdoses and people catching HIV from sharing dirty needles in rural parts of Indiana while Mike Pence was governor, too many still believe it is an "urban" problem.

Trump country is heavily medicated.

[Kittycow]

1. Where do legit severe chronic pain patients fit in?

There's only so much that cortisone shots, PT and other non-opiote treatments can do.

[IronLionZion]

3. The recommended dosages were known to be too high

The lawsuits claim the pharma companies knew it was unsafe and addictive from clinical studies, but chose profit over people.

Doctors follow recommended dosages from the pharma companies, who sell it very aggressively. Addiction to these drugs also leads to drug seeking behavior where patients will seek out multiple doctors until someone writes them a prescription, or go on the street for the illegal stuff.

Chronic severe pain is the hardest thing to diagnose. It's not like a doctor can see pain or do a lab test to measure it. They have to take the patients' word for it. It's often a guessing game as it can be pointless arguing with a patient over their level of pain.

Like with many things in this world, moderation is key. Too much can ruin your life.

And there are specific reasons why this opioid addiction is highly concentrated in Appalachia.

[Kittycow]

4. Well in my case. ..

The cause of my severe debilitating chronic pain is easily seen on MRIs of my spine but I get your point about how the pain cause could be vague and also subjective. But people like me are getting lumped in with drug seekers.

I have to go to the pain management clinic once a month and am subject to random pee tests and pill counts. They also routinely cut my opioid dosage down to see what will happen to my pain level and I have to go through a month of true suffering before they restore it back. There's no surgical solution.

I'm also under the impression that there's a state wide data base that tracks my prescriptions but maybe I'm wrong about that. It seems that states with "loose" rules should tighten up their regulatory systems to cut down on doctor shopping and drug seeking then, but in a way that makes sense to not harm legit patients.

This is a serious concern on both sides of the fence, so to speak.

[JesterCS]

5. You're right about the database

I goto pain management as well. My dr prints a report every month from an Ohio database showing exactly where and how many pills I get from anywhere. Er, dr, etc. Only narcotics however. It's mostly him making sure I'm not Dr/Hospital shopping

[IronLionZion]

10. Is it national? Does it track if you go out of state?

[Chuuku Davis]

25. Not national

But most states do it
And a doctor or pharmacist can check any state

[JesterCS]

35. Ya not national. State by state

And not every state participates

[IronLionZion]

6. Sorry to hear that

abusers tend to ruin things for everyone. A lot of meds have become more tightly controlled due to abuse. For example, cold medicines like sudafed used to be over the counter, but people used it for meth so now one has to ask the pharmacist and sales are tracked in a database.

The doctor shopping I was thinking of is if doctors won't write a script, the drug seeker would ask other doctors until they got one who would do it.

There was even a doctor in the news recently who got busted giving prescriptions in exchange for sex. He was encouraging addiction.

[Kittycow]

7. I would have to agree with coming down hard on bad doctors.

Besides coming down on all kinds of patients. That would at least cut down on some of the illegal and abusive practices. I wonder if bad doctors are shielded somehow by the AMA or privacy laws. I never thought about it.

I think the government made the manufacturers of hydrocodone cut down the amount that they made by a third this year but I forget the details off-hand.

ETA: also the feds won't let me try medical marijuana even though it's legal in my state. The pain clinic would kick me out since I would be breaking federal law and it would reflect on my doctor's tightly regulated practice.

[hunter]

32. Yep. Addiction is a medical problem and ought to be treated as such.

And this being the U.S.A., we rarely hear about secular treatments as it seems everything has to be about religion, or has to be a pathway to religion.

Even our money says "In God We Trust."

[Mariana]

39. We've accepted that some percentage of the population are alcoholics.

I don't know why people think there's some huge difference between an alcoholic and an opioid addict. The only real difference is that one of those addicts can go buy his drug of choice off the shelf, as much as he wants, with no questions asked.

[anneboleyn]

13. Oh bullshit. "Chronic severe pain" can be seen on an MRI when a patient has bone cancer or spinal

damage or endometriosis or one of the many conditions in which opioid treatment is the best option because it WORKS. Yes, there are some conditions that are not visible on imaging. But arguing that it's all subjective inevitably undermines the patient. There are many chronic pain patients who have a visible condition (via imaging). The problem is that doctors are terrified of the FBI and DEA now because the gov has terrorized doctors, and they constantly fight with legitimate patients to give them the lowest doses possible so the patient can barely manage. It is a living hell for these people.

[IronLionZion]

27. Why the opioid addiction and abuse problem?

it exists, obviously. So why?

[thecrow]

34. I'll say that I would rather have the meds and not need them

than need them and not have them.
I have degenerative disc disease in my neck and lumbar spine, with stenosis in my spine.
I had this doctor who was sending me through the hoops trying to find out why I was having so much pain... in the middle of all this, he cut off my pain meds. He made me go to a "pain clinic" where we were taught to think the pain away through meditating. As if I hadn't already tried many variations of that. Plus prayer! The leader of the group was the regional pain management big cheese and so we had this discussion with her.

Where my doctor had described me as a drug seeker, she checked my pain med prescriptions and use for the last two years and said I was incredibly modest in my use. I told her how I would only take half a pill then wait about 45 minutes and if it didn't relieve the pain, I'd take the other half. She said I should have been on Oxycontin! I said no no no I wasn't ready for that and besides, my pain was chronic, not constant. She called my doctor and gave him a piece of her mind about how he was treating me! This was at a time when opioids were bad and doctors were having their licenses taken away from over prescribing. He said he didn't want me to get addicted... so he'd rather I suffered??? Geez.

Long story short, I changed doctors and talked about the pain quite openly and said that I really would like it if I NEVER had to take another pain pill again. The side effects of opioids are really not that pleasant, after all. Nausea, drowsiness, constipation... who needs that when you're in pain? Now I have been taking cortisone shots to help with the back pain, but I have come to the cutoff point where I have to wait six months to get another series. I asked my doctor (who looks SO young to me) what I'm supposed to do in the meantime.
He said "Take your pain meds".

I think the thing is to find a doctor who has been on terrible personal physical pain. I know my doctor has had a lot of pain himself, so he is fine with my prescriptions so far. I'm just praying that remains the case.

Medical schools don't teach people to deal with chronic pain. Even when they can see the cause on an MRI or CAT scan, they seem to think it should go away in a week or so. All of us who need ongoing prescriptions know that isn't the case. They are not going to heal us and make us "new" again. Chronic pain is pain that keeps coming back. Very few doctors know how to deal with it or medicate it.

There are some weeks or when the weather's bad (I have a lot of arthritis) when I rely on those meds to make life ok but then there are times when everything's pretty good and I can do without the big guns. Then maybe some ibuprofen will work or best of all, there are days (or a week or more!) that I need nothing. But I would like to be able to make that choice, and I guarantee you I am not addicted.

I get so mad at the pill mill docs and the irresponsible people who abuse *my* prescription meds !!! What to do?

[IronLionZion]

36. Abusers ruin it for everyone

There has to be some sort of solution where the people who need meds can get it, and the addicts get treatment and abusers are identified.

[Mariana]

40. Abusers don't ruin it for anyone.

Do alcoholics ruin drinking for everyone else? No, because their drug of choice is legal to buy off the shelf. NO ONE CARES if an alcoholic has enough booze in his house to fill a swimming pool. Therefore, the guy who likes to drink a cold beer after cutting the grass, or the people who have a glass of wine with supper have no problems getting it.

[IronLionZion]

49. We've passed and repealed prohibition in this country

and there are many dry counties throughout America. There are literally entire professions called law makers and regulators who look at studies an popular opinion and lobbying efforts to see what to ruin for everyone.

Trump doesn't drink and won't allow Melania to keep any in the house. He's ruined it for her.

When I organize social events, I have to look at locations that are not alcohol focused like bars because of the one guy on my team who is on the AA program. So that means lunches and sporting events, not happy hours.

When abusers are killing themselves and others, it causes society to do something about it as policy or law to restrict it. It's happened with many things throughout history. On the liberal side we have people who want more gun control. On the conservative side, they want to ban travel from certain countries and pretend there's only one type of American.

[anneboleyn]

11. I can't stand the anti-opioid hysteria as we have seen the suffering of REAL patients in our own

family. People are so goddamned flippant about this issue -- is their goal to outlaw these drugs for everyone including the cancer patients or patients with severe spinal damage who simply cannot live without powerful pain medication?! Do they ANY IDEA WHAT THESE PEOPLE GO THROUGH TO GET A PRESCRIPTION EVEN WHEN THEIR CONDITION IS VISIBLE ON AN MRI?!! It makes me furious as we have had to deal with it and the ignorance from the right and left on this issue is just appalling to me as well as the "oh well, I guess your relative will just have to suffer until she dies" attitude. This country has a seriously fucked up attitude about treating patients with chronic pain. "Give her some Advil when she starts crying and moaning from bone pain." There will be mass suicides like people have never seen if legitimate pain patients are denied the drugs that WORK and are instead told to "think away the pain" and are doped out of their minds on drugs like Xanax and Lyrica (designed to treat epilepsy but now often prescribed for chronic pain since doctors are terrified about being raided by the FBI and the DEA and being shut down for prescribing opioids). Lyrica did nothing for our relative except make her legs swell severely (and the medication was stopped). Lyrica has nasty side effects and is also addictive, yet very few of these other drugs, which have become very popular in the wake of opioid hysteria, are ever even mentioned.

Even people who think other drugs should be legalized will pile on the opioid hysteria bandwagon. I hate the denial of mortality and the refusal to understand what living with chronic, severe pain is like -- 99% have no idea what that hell is like. And they also in their ignorance comment that Tylenol worked for them when "x" happened so it should work for a guy with permanent spinal damage -- to me that is as asinine and irrelevant and offensive as saying "it's god's plan" to someone whose child dies. Yeah, it won't work when bone cancer is eating your bones. I see an anti-opioids post on DU almost every day now, and/or on one of the MSM shows every night.

I can't believe that people are so indifferent to the suffering of cancer patients, children with bone cancer or other hideous disease that cause lifelong suffering, vets with hideous spinal damage, women with extremely severe endometriosis -- that they'd rather see them languish in pain so terrible they can't even scream because we need to focus entirely on abusers. Abusers can be dealt with as they deal with them in Europe. Of course it's a lot easier for the DEA and the failed war on drugs to claim a win by closing down LEGITIMATE doctors, and forcing an elderly woman dying a slow, terrible death from bone cancer to pee in a cup every single fucking month, see her doctor every month as refills are not allowed on these drugs, and still get dirty looks from pharmacy techs who think everyone on opioids is some "reefer madness" abuser.

[Crunchy Frog]

14. +1000.

[Leghorn21]

18. Right. Fucking. ON, anneboleyn. Your fury and frustration towards every aspect of this

criminal lack of respect and care are magnificently expressed here. Many thanks for this post.

[IronLionZion]

29. I sense your frustration

What you are talking about is very important and needs to be shared but really not anything to do with my post about overdoses/addiction and deliberate lies from big pharma who put profit over people.

I'm so sorry that your loved ones are suffering but my post is not about them or stopping them from getting their meds.

[Coventina]

47. Except that it DOES stop them from getting their meds.

All this opioid "reefer madness" means that suffering people do NOT get the pain relief they used to get.

Last summer I was cut open from sternum to groin to remove 4.5 lbs. of tumors from my abdomen. I had to BEG and PLEAD to get any pain relief, both in the hospital and after I got home.

I was told, "It shouldn't hurt that much" even though gut wounds are some of the WORST pain recorded, and, with chronic back issues, laying still on my back as I recovered was EXCRUCIATING!

To anyone who thinks opioids are not needed for those who are suffering, I say a hearty FUCK YOU! You don't know what you're talking about, and you don't know what is going on in the world of pain management.

[Coventina]

44. Don't forget meditation! Oh! And also "counseling" to make you accept pain will be your life.

[dalton99a]

2. Kick.

[kcr]

8. One letter. A convenient scapegoat that lets us ignore lots of other impacts.

Just how is it that all those other countries manage without all those opioids? Can we spot the differences?

Let's see. They have health care systems vastly better than ours. People who don't have to worry about how they're going to pay medical bills can see their doctor. They're less likely to develop painful chronic health conditions that require long term pain medication. They aren't worked to the bone with no time off, either. Not to mention all the chronic stress, untreated mental health issues, etc.

But now we're going to be shamed and called addicts and told we're lying about the pain and suffering caused by basically being a citizen of this wonderful country. And no one is going to fix any of those systemic problems any time soon. That's too hard. Pretending that's not the issue is so much easier. Better to treat pain and addiction like a crime and punish that, instead.

[IronLionZion]

9. Drug companies are exploiting people

and deliberately lying and encouraging addiction. That's why they are being sued.

[anneboleyn]

12. This isn't tobacco. Real people, with real diseases, are suffering hideously, and if these drugs

are ever outlawed because people want to punish abusers and/or companies (there are many other addictive drugs that we never hear about yet are widely prescribed -- see drugs like Lyrica -- blaming the companies for the behavior of every abuser seems very misguided to me) I can't even imagine what pain patients would do.

Many of them of course would choose to die when their lives are already a living hell fighting for the prescription they get each month as it is. I do not understand the indifference to pain patients in this opioid hysteria. You almost never hear about who actually takes these medications every month!!! It is a horrible fate, and yes in many states marijuana is illegal and a monthly pee test shows marijuana use and will get a pain patient booted out of a doctor's office in two seconds.

[Kittycow]

15. Agree with you about indifference to pain patients.

A pain forum I read really has some desperate people at times that will threaten to turn to heroin or suicide, not in the moment, but if they can't get their pain relieving drugs. It's frightening when the government threatens more sanctions.

Now the practitioner is pushing me to get a spinal cord stimulator. I don't want to because of the risks.I think it's becoming a medical device industry.

What's so simple in my case is that they forced me to go off Elavil so I haven't had a good nights sleep in a year now. Sleep is so restorative!

Sorry to go on and on but I feel like legit pain patients are invisible in this country overall.

[kcr]

17. Pharmaceutical companies are being sued? It must be Tuesday.

It's no reason to ramp up the drug war and add even more targets. It's never solved anything before. It will only cause more suffering.

[IronLionZion]

30. It's Friday and who's ramping up the drug war?

[kcr]

48. Sorry. I thought that was old enough for DU. Apparently not.

Here: http://www.urbandictionary.com/define.php?term=must%20be%20tuesday

As for who? That would be anyone who jumps on board the latest media drug panic and is fine with punishing addicts instead of treating them, as always. This is nothing new. Only now everyone gets to suffer as doctors will be afraid to treat pain as a result.

[hatrack]

16. The medical version of the 1975 "Global Cooling" article in Newsweek

The miracle article/letter, that gets rid of that pesky reality!

I just wonder if there's a vindictive, Protestant-specific, self-righteous streak in this society that demands someone to belittle, to hurt, to look down on.

If you can't berate on basis of race (at least openly/often), berate on basis of "you're just a junkie/bum/fat fuck/lazy/poor/moocher/failure/sponge/slut.

People are just fucking disgusting.

[kcr]

19. That's exactly what it is.

The war on drugs is all about self-righteousness. This battle in particular. Pain isn't real. It doesn't show up in tests. People are just lying to get a fix. Giving in to pain is a weakness. You've got to be tough. Mind over matter. If you ask for pain relief, you're weak and must be an addict. This movement also puts them in the savior role. They're the righteous ones because they're saving lives. They find a grieving mother for a spokesperson and who can speak against that?

[Warren DeMontague]

22. I'm sure if we make it harder for people in crippling pain to get relief, good things will happen

http://www.opb.org/news/article/oregon-heroin-opioid-prescription-addiction-treatment/


everyone will go to 12 step meetings and find jesus, and even cut their hair and go into finance.

Drug wars always work!

[IronLionZion]

28. I want to do something about drug overdoses and deaths

and treatment of addiction. It's increased in recent years and is a widespread problem in areas people won't admit. And I would like to remind people that the problem of drug addiction is more rural and white than the Trump humpers would have us believe.

I have heroin users in the park across the street from me. The syringes are on the sidewalk for people and pets to step on. It's pretty shitty.

If judging me as the bad guy makes you feel better, go for it.

[Warpy]

26. The problem isn't oipiates given for chronic pain

the problem is the type of opiate that was marketed for both acute and chronic pain, the long acting drugs like Oxy Contin. With those, dependence occurs quickly along with tolerance, meaning a person on them for more than a few days is going to require an increased dose for the same relief.

The letter refers to a study in Boston in the early 80s and the numbers are correct. However, it refers to people with acute pain who were given short acting opiates in the hospital. Very few looked for more drugs after the pain decreased and they healed completely. Dependency is higher in people with chronic pain but not addiction. They are separate.

The devastation from OxyContin overprescription and diversion into criminal gangs is worst in rural areas and in states like FL, KY, WV, and IN with fairly lax drug laws that allowed the operation of pill mills. Once the person was totally dependent on the drugs, organized crime took over.

I'm glad they're suing the drug companies that overhyped this shit and encouraged doctors to overprescribe it.

[IronLionZion]

38. Thanks for sharing that

It makes sense when there are different types of pain and dosages. The drug companies are definitely guilty and organized crime has taken advantage of people in desperate situations.

There have been several news pieces and interviews of addicts and most of them started off with legit medical conditions requiring painkillers.

[Warpy]

42. They might not have been addicts. They might have been dependent

on the drugs, almost a given if they were on the long acting pain killers for more than a few days.

The press and the drug warriors have both been guilty of conflating dependence and addiction for too long. They really are different phenomena that need to be treated differently.

[Mariana]

43. Would you explain the difference between addiction and dependency, please?

You say they are not the same. I've always tended to think in terms of physical addiction, i.e. if you have physical withdrawal sickness when you stop taking the drug, you're addicted. I understand it's more complicated than that, but I really don't understand the difference between addiction and dependency.

I was on hydrocodone daily for a couple of years and didn't have any problems reducing the dose and then stopping altogether when the condition causing my pain improved. However, I did have some withdrawal symptoms. Was I addicted, then? I thought so. I'm glad it happened when it did and not today. My doc wasn't afraid to prescribe what I needed.

[Warpy]

45. I answered someone else about that last night

so here you go: https://www.democraticunderground.com/?com=view_post&forum=1002&pid=9152453

[Coventina]

46. Dependency means you need the drug to live a decent life.

Kind of like diabetics are dependent on insulin.

Some chronic pain sufferers, like me, depend on drugs to get through the day.
In my case its a cocktail of ibuprofen, methocarbomal, tramadol, and tizanidine.

My dosage has been stable for the last several years, but as my bones continue to deteriorate, I will need to change things up, except, now, I will no longer be able to get a stronger opioid, due to the current drug hysteria.

I guess I have decades of pain ahead of me...

Unless I decide to just blow my brains out.

Some days, that does seem like the better option.

[seaglass]

37. I don't know the answer to this. I used oxycontin for weeks when I broke my shoulder 5 or so years

ago, I've also had percocet prescribed after dental surgery. Honestly though the oxycontin did get me high and I did like the feeling but I knew at that time about its addictive properties and stopped taking it after I didn't need it any more. So I am a firm believer in pain relief and cannot imagine what it is like to experience the level of pain as I did with my broken shoulder every day of my life with no suitable relief.

On the other hand - someone is making lots of money selling this stuff to young kids who easily get addicted. My son got addicted when he was 19 yo over a very short period of time. Fortunately our insurance covered rehab for him and I was able to find a doctor who had an opening for prescribing suboxone. My son was on suboxone for a year and also received MH treatment.

I can never describe what his addiction did to him and our family financially and emotionally. A lot of trust was broken and I still live in fear for him 7 years later. My son was not unique, a number of his peers became addicted and a few have since died. This is a real problem and there are unscrupulous greedy people including doctors and people getting prescriptions under false pretenses who are contributing to this issue.

I wish people on both sides could acknowledge what people are telling them - that real people suffer with pain and need pain relief and that the street availability of these drugs is causing a lot of pain in our communities.

[AngryAmish]

41. Very soon a simple genetic test will identify people highly likely to be an addict.

We could treat them differently then.