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The Opioid Epidemic.

19 March 2018

I never abused opioids, and I almost never took any. Not even when I had a legal and appropriate prescription for them in my 30s, during my drinking period. I took a couple of pills of tylenol+codeine when I had my wisdom teeth out and I didn’t like it. I was given IM and then IV demoral when I broke my arm, and I did like it. I liked it a lot. But other than those times, opioids have not been a part of my story.

So I may be unqualified to talk about them.

But I am qualified to talk about addiction. I am an alcoholic, and and a former smoker. I remain addicted to both alcohol and nicotine. That means there is no safe amount I can use. Because of the addictions I have, I also abstain from any other addictive and mind-altering substances. I don’t use any drugs, and I will refuse narcotics or opioids for pain unless I am under the direct, immediate care of a physician.

The opioid epidemic is tragic and vexing. Most of us feel like we understand how it started now: as new classes of pain medicines became available, initially optimistic ideas about their addictive properties gradually faded into venal calculations about profitability. Patients love being pain-free. Humans love being altered. And the drugs themselves turned out to be incredibly addictive.

The question is what to do now. The instant anyone proposes restrictions to prescribing, the outrage brigades arrive shrieking that “people deserve pain management”. How dare anyone suggest that someone doesn’t need oxycontin to address their chronic back pain. How would YOU like to live in constant, soul-shredding agony!? It’s tiresome and disingenuous.

I usually wonder if these people are outraged on behalf of others (righteous indignation!) or if they are personally defensive about their use (or abuse) of painkillers. I suspect its the latter as much as the former. We react with fury against any threat to our own comfort and access to the “medicines” we “need” to “control” our “pain”. Usually that kind of defensiveness is reserved for protecting access to a drug we want to support our addiction.

The sad truth is, there’s not a lot of hope, at the population level, for the current (or any) generation of addicts. Addiction is common. Recovery is rare. Most of us die. Medicalized addiction treatment is generally ineffective, and in my experience simply trades the hell of addiction for a fresh one of withdrawal and relapse. Beyond primary detox, there’s little or no role for physicians and scientists in treating addiction. They make it worse, not better.

Only pain changes us. We need to come to the place where our pain in addiction is less tolerable that the pain we imagine the drugs are treating (but which often departed long ago). Most people never come to that point.

The solution to the opioid epidemic is not to save the addicts. That, largely, can’t be done. The solution is to stop making new ones. Stop prescribing opioids for outpatients. Stop giving people these medicines for all but the most severe pain. Never chronically. Stop making new addicts. The ones we’ve made already will either find their way to recovery, or die.

7 Comments leave one →
  1. Aimee permalink
    19 March 2018 12:19

    It’s very dificult. I never abused narcotics either, although I have taken them more than you did – for example after my tonsillectomy I took them for about ten days. And I needed them, too. I wouldn’t wish that kind of pain on anyone. Now they are talking about making post-surgical prescriptions longer than three days illegal. I think that’s insane. Can you imagine three days of pain control after bowel surgery? After a gunshot wound? The risks of addiction from a one or two week prescription of moderate painkillers like Vicodin for a person without addictive history is extremely small. According to latest CDC numbers it’s still under two percent of people who will abuse them in that time frame. I think people ought to be allowed to make their own informed decisions about pain control, absent contraindications. Chronic pain is a whole
    Other ball of wax, but I am wary of people who have never experienced severe chronic pain making decisions for people who live in pain they have no understanding of.

    • 19 March 2018 12:22

      I’m wary of that too. But that wariness has to include not only policy makers and pundits (ahem), but also the prescribing physicians, most of whom do not have personal experience with the kind of pain they treat.

      • Aimee permalink
        19 March 2018 13:13

        I had to stop before I was done….. there is a lot of good evidence that long term opioid use actually makes people more sensitive to pain, and that when people are weaned off of opioids, most of them have less pain than they did while taking the meds. We need to do a lot more research on pain, we know very little about pain in general, and not much about alternative pain control methods. Clearly the need for opioid pain control has not gone up commensurate with the increase in usage over the last fifteen years. Chronic pain is – by definition! – an intractable problem. It will take a major paradigm change to address it in new ways.

  2. Jennifer Mindlin permalink
    19 March 2018 17:09

    The current opioid epidemic is actually not very related to rx drugs….except in that when all the new formulations came out drug companies (and then doctors, innocently misinformed) changed the general perception of opioids as “safe” which led people who likely would have been extremely careful with their prescriptions to think that there wasn’t much harm in using more than prescribed…..
    But the real problem here is the same as it ever was, illegally smuggled street drugs, not people with prescriptions. Fentanyl is the major culprit here, it has been found in approx 60% of autopsies ruled as opioid OD nationally…..but fentanyl is only very rarely prescribed to outpatients….its coming almost exclusively from China, illegally, and going straight to the exact same folks that were dealing heroin (or meth or crack) before the massive influx of fentanyl….. But fentanyl is WAY WAY more potent than heroin….and way cheaper….so people used to taking x amount of heroin, take the same amount of fentanyl and die….its also starting to be sold as other drugs on the street….anything sold as a powder these days likely has fentanyl cut into it to bulk it up cheaply… friend’s oldest son just died last month of fentanyl when he thought (was told) he was taking ecstasy….
    The actual rates of addiction among chronic pain patients using narcotics under the supervision of a doctor have stayed pretty constant. It’s very frustrating as a chronic pain patient to see the prescribing restrictions getting tighter and tighter in an effort to curb a problem that has very little to do with narctoics prescribed by doctors. Its also frustrating to be lumped into a category with people who abuse street drugs when the vast majority of us use our medications as prescribed and never become addicts. You are perpetuating an inaccurate and hurtful narrative of the problem…..

  3. 19 March 2018 17:52

    You are correct. You are not qualified for this conversation. So many people discussing this epidemic and their opinions about solutions are not in fact qualified. However it is not that difficult to find people who are, particularly as an academic.

    • 19 March 2018 18:27

      The idea that academics are more qualified to discuss addiction and recovery than addicts is risible. That arrogant attitude is why academics and physicians kill so many of us.

      If you want to learn, as an academic, about recovery, shut the fuck up and listen to people in recovery.

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