Opioid settlements against pharmacies

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#28

You are leaving out one vital piece of information. Persistent opioid use is defined as a second prescription at least one month after the surgery. The assumption is that the pain for a relatively minor surgery should have subsided by then. As for the small numbers, that actually supports my position. The surgery is sufficiently minor that only a small number require opioid pain killers. Of that small number, 12% are still using opioids at least one month after the surgery.

This led an author of the linked paper to conclude:

“Even a small number of oxycodones can start the addiction process,” said senior author David S. Frankel, MD, an associate professor of Cardiovascular Medicine and director of the Cardiac Electrophysiology Fellowship Program at Penn. “The significance of this study is to make other electrophysiologists aware that even a low-risk procedure like a pacemaker or a defibrillator can lead to chronic opioid use and that physicians may want to be more conservative in prescribing opioids after surgery.”

In another study of persistent opioid use (now given the more stringent standard of use at least 90 days after the surgery) similar results were obtained. The conclusion of the authors:

“In a cohort of previously opioid-naive patients, approximately 6% continued to use opioids more than 3 months after their surgery, and as such, prolonged opioid use can be deemed the most common postsurgical complication. New persistent opioid use is not different among patients who underwent minor and major surgical procedures, thereby suggesting that prolonged opioid use is not entirely due to surgical pain.”

I guess you could continue to argue that persistent opioid use has nothing to do with addiction but I think that is basically sticking your head in the sand.

#29

During my bilateral mastectomy in 2015 for double-sided breast cancer, I had expanders implanted under my pectoral muscles to stretch them to accept silicone breast implants. The expanders were rock-hard and painful. The process went on for months before the expanders were swapped for the soft silicone implants.

I took opioid painkillers for two months since my pain was very bad. This wasn’t due to addiction. My experience is that opioids aren’t addictive as long as they don’t make you feel good but only take the edge off severe pain (together with NSAIDs and acetaminophen at the same time).

Don’t say that this is “sticking your head in the sand” until you, personally, have severe, intractable pain. Which you probably can’t imagine until it happens to you.
Wendy

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#30

WORD!

The thing that opioid naive people don’t understand is that, pain relief aside, opioids aren’t pleasant drugs to take. They make you feel a bit “dopey”, nauseous and they cork you up like nobody’s business. Back when I had the practice, when double checking a new patient’s medical history I noticed quite frequently that second only to an allergic response to penicillin was codeine/Vicodin/the percs. etc. Now, given that it’s important to double check a claimed allergy (even to the Usual Suspects like antibiotics) I’d always ask how this “allergy” manifest itself. Disorientation, nausea and constipation were the responses. When I’d point out that these were normal side effects of the drugs, I swear they’d look at me as if I was crazy…because, how do people get addicted to anything that does that???

P.S…mind you, both our outcomes might’ve been different if we’d been tobacco users, suffered from alcohol and other substance abuse disorder, mood disorder or any of the other risk factors itemised on the posted link.

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#31

You certainly have my sympathy and respect for your experience but I would gently suggest that what you went through was probably not the norm for the 240M opioid prescriptions fulfilled in 2015. Opioid pain killers are obviously a necessary component in the treatment of pain. It certainly was for you. But that is a separate issue from whether it was overprescribed and if that overprescription is the cause for the current opioid addiction epidemic.

To be clear, are you and VeeEnn arguing that the high levels of opioid prescriptions beginning in about 2000, and in particular the marketing and availability of Oxycontin/oxycondone were not major contributors to the rise in opioid addiction levels that occurred during that same time period?

The CDC has a graph depicting the rise of opioid overdose deaths in America. The increase began in 2000 with opioid prescription overdoses. This was followed by the uptick in heroin in 2010 and synthetics in 2013. The likely foundational role of overprescription of opioids to the current opioid addiction epidemic seems pretty obvious.

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#32

Wendy,

I agree the hammer of regs is hitting more than the nail on the head. People with major pain problems need the care.

The inactions concerning the abusive use of opioids had or has to be stopped. The major companies profiting off of it would kill my family member, your family member or anyone’s for a buck. That is very wrong.

The law swang to far the other way. Patients do need painkillers. That is no reason to side step the addiction problem. Doctors are overachievers it is getting straightened out. The drag is the bureaucracy.

#33

I won’t answer for Wendy but what I have been saying is that a legitimate prescription for an opioid painkiller is not likely to pitch a person who doesn’t already have substance abuse issues into an addiction spiral

For sure, more opioids in circulation makes it much easier for folk who wish to use them for recreational purposes to get a hold of them so, manifestly here’s a potential for more opioid abuse. Availability offers more temptation to the existing or potential addict.

OxyContin presented its own unique issues when it hit the market. For anyone not totally familiar with this formulation, it was a specially coated time release form of oxycodone. Intended to even out the highs and lows of the more readily metabolised form as an attempt to reduce the potential for dependence and addiction with long term users (not opioid naive, for obvious reasons). A plausible mechanism of action, it seems, if taken orally as prescribed. Thing is, addicts getting a hold of the stuff didn’t take it as Intended but either chewed, crushed and snorted, injected or even shoved it up their bum!!! In the process, getting a super high the likes of which were apparently not available with abusing regular oxy. Not something any manufacturer should be held accountable for, in my opinion. Problem was, it transpired that even the proper formulation still had the same addiction potential and Perdue had hidden the data, misleading an inadequately diligent FDA as well as the doctors it was marketed to.

#34

Another issue muddying the waters is the unintended consequences of the rehab/recovery industry. Something I’d never thought about until a former user wised me up.

After a stint in rehab and getting “clean” a good many folk go back to using (I’m sure the intention was there to stay clean but sometimes the underlying problems don’t disappear) …oftentimes at the same amount of drug as before and not realising that the tolerance they’d built up over the months/years of abuse had diminished. A former “just right” dose is suddenly an overdose.

You can learn a lot from drug addicts…and find out that they are generally not like you.

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#35

ah but that is so untrue. There were a lot of high school student athletes who needed a painkiller and became an addict as the doctors were misinformed early on about opioids. Today most of those kids would have been sent home with Tylenol. Many of them either have shattered lives or lie dead.

There were also a lot of high school students that were not addicts but young and trying drugs experimentally. I know of one who was drinking on graduation night and popped one Oxy. His mother came down stairs the next morning and found him dead. He was not an addict just young.

#36

Meanwhile, we have luminaries like a Councilman in Middletown, Ohio, and the Sheriff in Butler County, Ohio who advocate refusing to administer Narcan to addicts, and letting them die, as the Puritanical punishment culture raises it’s head again.

Steve

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#37

OMG how did one oxy pill kill him??? That’s terrible!!!

#38

The rise of opioid addiction and other “deaths of despair” (alcoholism and suicide) are clearly related to macroeconomic factors – the loss of well-paid factory jobs in middle America that began in the 1980s and accelerated in the 2000s. The chart of manufacturing employment correlates closely with the rise in opioid overdose deaths (negative correlation).

It’s no coincidence that lower back pain, which has no objective measure for diagnosis, is the largest source of disability in the U.S. It’s no coincidence that laid-off workers can go to a doctor and get on Social Security Disability but ONLY if their back pain is disabling enough that they cannot work at any job – so severe that they need opioids to treat it. It’s no coincidence that these despairing laid-off workers, with no hope of regaining the American dream that was snatched away by outsourcing, are dying from overdoses.

A book has been written about this: " Deaths of Despair and the Future of Capitalism," by Anne Case and Angus Deaton.

The medical pendulum swung from ignoring pain* to treating pain as a vital sign which needs to be aggressively treated to withdrawing painkillers even from surgical and cancer patients in dire agony to (hopefully) a balanced approach to pain control.

The agony caused by macroeconomic despair is real but it should not be treated by opioids. Doctors need to treat actual physical pain adequately while withholding addictive opioids from those whose pain is more existential than physical.

Wendy

  • I can personally attest to doctors’ ignoring pain since I was subjected to two (2) bone marrow taps without anesthesia at age 16 in one day. (1970) Each bone marrow tap consisted of a doctor hammering a large-diameter hypodermic needle into the top of my hip bone with a mallet. This was pure torture. They failed to get an adequate sample the first time and returned a couple of hours later to repeat the biopsy on the other side. The pain lasted for hours after the test but I received no medication for it. Fortunately, this test is now done with anesthesia.
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#39

A fair number of opioid overdoses involve other drugs…alcohol being at or near top of the list. Opioids, among their other properties, are respiratory depressants so add ethanol… As to whether just one could do it, well, theoretically possible. If you’ve drunk enough that you’re so close to the edge, one could do it and kick in sometime later and render a person unresponsive to, say vomiting from the volume of alcohol drunk.

I guess that’s how binge drinking at frat parties happens…just that one extra measure of alcohol on top of everything else can be the difference between a drunk with a hangover or a corpse. Would you blame the last drink (or one oxycodone)…or the sum total of ethanol?

#40

If you are getting drunk that is a depressant. Having an oxy on top of that I think, it has been a while since I heard this, slows the heart till it stops. I believe Oxy is another depressant. He came in after all the partying turned on the TV and sat down. His heart stopped. His mother found him in front of the TV the next morning.

#41

It’s hard to see how this is an indictment of opioids, their manufacture etc…especially since it’s hearsay and personal recall after the fact. A tragic story, for sure and one that’s probably repeated many times …whether that one extra thing is a 5mg tablet of oxycodone, an extra shot of whatever, or deciding to get behind the wheel of a car. A parent should never have to bury a child under such circumstances but I’d say that there’s more underlying stories such as this than popping one oxy

#42

I fancy that folk who haven’t experienced severe, debilitating pain…acute or long term…don’t appreciate that it actually is a bit more than discomfort that can be dealt with.

Thinking back to whe dh had his bio-Bentall procedure (a bone saw to his sternum, rib cage jacked open for 6+ hours needed more than a couple of Tylenol and that’s for sure) The incongruity of reading the hospital’s attempt at patient education…“ask your doctor if opioids are necessary” sort of thing…on the inside of every elevator that went up to cardio thoracic ICU didn’t escape me. Especially since dh, apparently, isn’t a slow metaboliser of opioids (as was my good fortune) If I didn’t get that oxy inside him on schedule because he was fast asleep, say, sure enough the pain would start to kick in before he woke, his breathing got shallower from the pain…reducing an already low O2 sat…and, wallop Afib and alarms chirruping and bringing staff in on the double.

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#43

This is also true of convicts who are released from prison. Some law enforcement people suggest that released convicts be immediately started on Medically Assisted Treatment (MAT) for opioid addiction, which quells cravings before said ex-addicts have a chance to hook up with a potentially-fatal opioid dose. But this sensible suggestion has not been widely adopted.

Wendy

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#44

Most recent studies indicate that this “deaths of despair” model may only be significant for the more recent phase of opioid overdoses that stem from illicit drugs like heroin and fentanyl.

Mortality data indicate that the earlier “prescription opioid phase,” from about 2000 to 2011, most affected adults in the age range of 25-54, Native American/Alaskan Natives and Whites, and rural more than urban populations. In this phase, the epidemic was most severe in areas of high physical disability rates, which, following epidemiological research, we use as an indicator of physical pain. We found little evidence that local economic misfortune accounted for the substantial geographic differences in the severity of this phase across State rural areas or counties. https://www.ers.usda.gov/webdocs/publications/100833/err-287.pdf?v=1708

In short, from 2000-2011 large numbers of patients were prescribed opioids for pain relief and this led to an increase in opioid deaths that did not correlate with local economic conditions.

The problem is that opioids are problematic for long-term pain because of physiological tolerance (larger doses required over time) and its addictive potential. This is what drove the initial rise of addiction from prescription drugs. From the linked paper:

“We found the geography of the prescription painkiller phase of the opioid epidemic during the 2000s to be largely shaped by State rural area and county differences in physical disability rates, which we took to be a measure of the prevalence of chronic pain. Whatever difficulties physical disability entails, the prescription phase brought more difficulties, as addiction grew and prescriptions proved eventually unable to quell the pain, resulting in rising opioid deaths.”

Heroin and synthetics like fentanyl are impacting a different demographic than the prescription drugs, and there is some evidence to suggest the impact of economic difficulties. However, the most recent and detailed studies indicate that the primary driver of opioid addiction is drug availability rather than despair. Or as the linked paper concludes:

> "There is no doubt that the economic trends over the past 20 years have placed tremendous stress on the prime-working-age population whose schooling did not extend beyond high school. But the rises in drug overdose mortality that have characterized, first, the prescription opioid phase of the epidemic and, more recently, the illicit opioid phase, seem to have reflected more the increasing availability of more dangerous opioids than growing stress or despair"

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#45

A side-effect of the opioid epidemic is that doctors/emergency rooms won’t dispense pain medication in a timely manner anymore. When I had my kidney stone a few years ago, I arrived at the emergency room and was writhing on the floor, but they wouldn’t give anything for the pain until a scan showed a stone. Finally a few hours later, after the scan, they gave me dilaudid via my IV. After 2 days in the hospital they sent me home with a prescription for [I think} percocet. I filled it, and I took HALF a pill (and then a few weeks later had to discard the rest of them). Unfortunately, half a day after being released I ended up in a different hospital with severe abdominal pain, so I spent nearly a week in the hospital due to that darn kidney stone. I didn’t take any strong pain medication in the second hospital, maybe they gave me something like tylenol.

I generally don’t take ANY medication at all, not aspirin, not tylenol, not advil, etc. Nothing. The only medication I will take is antibiotics if prescribed by the doctor for infections or to forestall possible infections (before certain dental work or surgery). I am quite afraid of narcotics and avoid them as much as possible.

#46

The industry pumped out pills in massive quantities and evaded the legal controls meant for opioids. Not sure why you are not following that? Are you just wanting to see addicts as guilty people? So the guilty of the powerful can be totally ignored?

It seems personal to you that this is all about addicts having problems.

The reality is the corporations did not follow the law and thousands of people died. Those people some of whom were addicts and some of them were incarcerated were still loved family members. Life is not that cheap that the big box stores have special rights.

Because the manufacturers were pumping out so many pills they were on the street. Not just sold as prescriptions. High school students were dying from street drugs. Not sure how you ignore that by seeming your labeling addicts as the culprit.

#47

Not a bad idea…along with excess alcohol etc. I certainly try to do that and I’m sure others do too…certainly anyone who’s been prescribed opioids appropriately in the past. Best way to accomplish it is to avoid anything that might provoke a need for such industrial strength pain medication. However, as you’ve read upstream and experienced yourself, that isn’t always something you can accomplish voluntarily.