Can somebody give some context on the root cause of the problem - the chronic pain epidemic in US. What caused it, why it is more than in other parts of the world and why so many painkillers?
>What caused it, why it is more than in other parts of the world and why so many painkillers?
>Is it cultural?
That's actually a really common misconception on HN. The United States ranks 27th among countries which abuse opiates, [1] behind many first-world countries like the UK, Italy, Spain, Switzerland, Ireland, and Russia, to name a few.
What's the cause? A lot of HNers like to pin it on unemployment and low-wage, low-skill jobs. I think that's narrowing the field in the right direction, but it isn't quite right; I know many very happy people who just make ends meet. There's something more that no one has been able to pinpoint quite yet.
I think part of it is how the social safety net is done in the US. Americans have to "deserve" help, so when the lumber mill closes down for good, the 50 year old manual laborer has to become "disabled" due to his back pain in order to access the money he needs to survive. I've heard anecdotes of doctors asking whether patients have college degrees when they come in complaining of back pain. And the ranks of the disabled have swelled tremendously in recent years.
Those data for opiate use, not abuse. I suspect the percentage of the population who have used any opiates at least once in the past year tells you very little about about opiate-related problems - using cocodamol once a year is obviously very different to the habitual use of oxycodone.
I further suspect that the availability of opiate-containing drugs over the counter in some countries accounts for some of the differences in those statistics (e.g. cocodamol in the UK).
People take painkillers because they can't afford surgery.
Say you have a messed up disk in your spine. Surgery is tens of thousands of dollars. Getting a prescription for opioids from a primary care physician is a bit cheaper.
You don't see doctors in europe routinely prescribing hard pain killers because they try to fix the problem instead.
Healthcare in america is set up in such a way that hospitals just bill whatever and then have the lawyers argue over whats reasonable. That kinda works when youre part of the medicare system and their lawyers represent your side, but when youre on your own, you're suddenly in hospital recovering from major surgery, facing bankruptcy and have to hire a lawyer to tell the hospital to suck it.
So you just take the painkillers and hope for the best.
I'm not saying that everything has to be surgically repaired. Whatever the surgeons decide to do I'm cool with 99.9% of the time.
Its just that there are people who "should" have surgery who "can't" have it because money.
Another issue is that just because a doctor advises you to take opioids doesn't mean that you're not abusing them. Doctors tell you to do all kinds of things that are bad for you because they are the lesser evil. The prime example being chemotherapy.
The primary use-case of morphine-like substances is to treat acute pain. Taking any kind of opioid for prolonged periods of time leads to systemic adaptation and you end up an "addict".
Is there data on this? Probably. Depends on what you want data for. The fact that america is under-insured when it comes to healthcare is well-established fact.
I don't buy "people take opioids because their lives are lame" - because its bullshit. There are drugs that are way easier to acquire that provide a lot more "fun". You don't start on heroin and then switch to vicodin, either. A heroin addiction is treated with methadone.
If you want a really clean "feel awesome" high, you want a benzodiazepine like Lorazepam. I had a prescription for that once. Popping one of those pills, you smile from ear to ear within seconds and experience pure bliss. If you intentionally try to have negative thoughts, you just laugh harder because it feels so ridiculous. If you wanted to "trick" a doctor into prescribing those, faking the necessary symptoms is really simple.
The drug industry has a pretty good grasp on how to engineer drugs to do one specific thing really well without causing a bunch of secondary effects. Modern painkillers are good at dealing with pain, without turning people into loonies. But opioids are opioids and if you take them indefinitely, you mess with brain chemistry.
People also take painkillers to recover from surgery...That is how many folks get hooked, and in some cases, eventually switch to heroin (because they can't afford the pills off-script at black market prices)
You mean there's a non-trivial number of patients who are prescribed opioids to essentially self-medicate at home because keeping them in the hospital until they're recovered is "too expensive" - who are then told to deal with their addiction themselves because no doctor felt the need to actually guide them through responsibly using their drugs?
Who are THEN told that they just can't get drugs anymore because now they're just filthy addicts. That's actually impressive. For a glorious nation like the united states of america. Borderline malice.
There's no "chronic pain epidemic". As is often the case, the pharma market created (or rather, in this case, reshaped) a problem for a particular kind of product to solve.
Obviously, ceteris paribus, less pain is much better than more pain, and there will probably always be acute and chronic pain for therapeutic innovation to tackle. There's no virtue in the experience of chronic pain. But the evidence strongly suggests that patients are worse off with casual access to powerful opiates, and that these products are packaged and sold irresponsibly.
No legitimate underlying medical phenomenon spurred the uptake in opiates.
What does that actually mean? If I stop and think about it, I'm experiencing a variety of chronic pains right now. Most of them don't warrant an aspirin, but they're pain nonetheless. Your response here is really a quibble over definitions: in context, I'm clearly talking about "chronic pain whose severity warrants powerful opiate analgesia" ("powerful" because maybe we should have T2 or something like it available in the US).
I tried to avoid this pointless debate with a second paragraph to immunize my argument from the trope that arguments against opiates are arguments in favor of pain.
My point --- I think obviously --- is that no underlying medical pathology occurred to spur the uptake in consumer opiate products.
> no underlying medical pathology occurred to spur the uptake in consumer opiate products.
The uptake of opiates wasn't driven by any change in pathology, but it was partially driven by a change in how we think about pathology. The IOM report I linked to helped to popularize the idea of treating pain itself as a disease that should be treated, rather than as a symptom which shouldn't be treated until the underlying cause is known:
"Because pain often produces psychological and cognitive effects—anxiety, depression, and anger among them—interdisciplinary, biopsychosocial approaches are the most promising for treating patients with persistent pain. But for most patients (and clinicians), such care is a difficult-to-attain ideal, impeded by numerous structural barriers—institutional, educational, organizational, and reimbursement-related. [...] In addition, adequate pain treatment and follow-up may be thwarted by a mix of uncertain diagnosis and societal stigma consciously or unconsciously applied to people reporting pain, particularly when they do not respond readily to treatment. [...] Understanding chronic pain as a disease means that it requires direct treatment, rather than being sidelined while clinicians attempt to identify some underlying condition that may have caused it."
I'm definitely not arguing that opioids should be first line treatments for chronic pain, but I also agree with the IOM that they should be more accessible when needed.
The article you just linked to literally says it's over 50%. The 11% statistic is the percentage of Americans who are currently in pain. Whereas chronic pain is basically pain that's intermittent.
The root cause is Purdue Pharma, who successfully marketed the drug to primary care physicians by lying about the risk of addiction:
Perhaps knowing that doctors would be vigilant against prescribing drugs with the potential for abuse, Purdue set out to distinguish OxyContin from rivals as soon as it dropped. The cornerstone of its marketing campaign was the drug's incredibly low risk of addiction, an enviable characteristic made possible by its patented time-release formula. Through an array of promotional materials, including literature, brochures, videotapes, and Web content, Purdue proudly asserted that the potential for addiction was very small, at one point stating it to be "less than 1 percent."
(http://theweek.com/articles/541564/how-american-opiate-epide...)
Overeagerness to prescribe. Other countries have similar problems too.
Conversely, the country I live has a benzo problem. Hell, go into any doctor complaining you haven't been sleeping properly and he'll happily prescribe you clonazepam to help you with that. You have just been prescribed an addictive and strong psychoactive drug, just like that. He won't care if you have been working too much, or not eating or sleeping well, he will not care at all about possible factors that may be causing your current insomnia.
"take this and come back to reassess in 2 months", the doctor will say, and ofc, in 2 months you will come back saying this helped immensely, and from that there's a whole slew of problems that everyone knows: try to wane off it, insomnia comes back, sometimes worse. or maybe some new anxiety gets thrown in....
They want money, because if they wanted you to get well they you'd be treating the cause of your symptoms and not your symptoms :D
That's the whole point - doctors have more work, so they can ask for more money and pharmaceutical companies make a killing. Doctors are not interested in curing their patients nowadays, they are interested in making money for pharma.
totally anecdotal, yes, but reading several local news articles about the 'benzo epidemic' here I think doctors just don't care. It's easier for them to just walk you out after 3 minutes of consultation instead of trying to solve the puzzle in front of them. It's also more profitable to them as well so you can see how dangerous this can turn for us... doctors aren't exempt from corruption.
I certainly know people here (Denmark) who are hooked on prescribed opiates for no real good reasons at all. They are, in all but their own perception, addicts.
Seems to me it comes down to competence and ethics of individual doctors, as well as to preferences and susceptability of individual patients, of course.
We are not experiencing quite the epidemic proportions of the US, presumably owing to a different structure of health services, and probably a higher general level of scepticism towards medical authority, but the mechanisms and the potential are clearly in place.
Hospitals are funded based on patient satisfaction and pain was added to patient satisfaction scores. To boost their ratings and funding hospitals and their doctors started heavily prescribing pain killers - in a way that pushes the problem from their hospital.
Something I've noticed: in the US people generally have an aversion to being even mildly uncomfortable.
And, it's culturally acceptable to be on medication so people take it for basically any inconvenience.
Sweating a little? Crank the AC. Small headache? take a pill. Bad day? Have a drink. Workout left muscles sore? Another pill. Sprained ankle? Obviously you need pain medication!
It's easy to see how there is a low threshold to abusing pain medication.
This! Living in the UK for the last few years, the difference is remarkable. Yes, the UK has its hypochondriacs, but the comfort culture in the US takes it to a whole other level. Great for business, I imagine.
We found enormous unmet need for pain treatment. Fourteen countries reported no
consumption of opioid pain medicines between 2006 and 2008, meaning that there are no
medicines to treat moderate to severe pain available through legitimate medical channels in
those countries.
These countries are concentrated in Sub-Saharan Africa, but are also found in Asia, the
Middle East and North Africa, and Central America
My takeaway was that opiates were incorrectly classified as a non-addictive way to treat pain, so doctors started dolling them out far too liberally. Hospitals also started employing pain specialists who's sole job was to treat pain in patients. It's pretty easy to find people in any sort of "pain" if that's all you're looking for.
Read the article. It's economic - the makers of these opiate drugs have large marketing budgets they employ to encourage physicians to prescribe these addictive drugs and there has been essentially no governmental oversight on these marketing efforts because these marketing budgets also fund lobbying activities.
There have been a few prosecutions of individual sales/marketing people for knowingly supplying pill mills, but it's just a cost of business expense for large pharma companies.
Yeah but the problem goes deeper. Not sure how to properly describe it. The initial sentence people waking up to take painkillers is unbelievably weird. If you manage to fell asleep - then the pain itself is unlikely to wake you up.
What the farma company did was exploit already existing predisposition of people to take painkillers. They were working on fertile ground.
I don't know - having large population of people that need constant painkillers in their day to day life is just strange. Abusing the people is despicable. But why did this population existed in the first place?
Article argues that patent evergreening necessitated dishonest marketing and resulted in a "created market" type of strategy.
The patent for OxyContin was predicated on the claim that each dose lasted longer than older poducts. When that didn't work they raised the dose instead of shortening dosing intervals, which caused a reward/withdrawal cycle in patients.
>Money/greed on the supply side. Lack of happiness on the demand side.
You have nothing to back that up. In fact, all the evidence I've seen points towards the opposite: the places with the least opiate abuse are (1) not happy countries (2) with very strict laws. See Qatar, Saudi Arabia, Singapore, etc.
If money and greed on the supply side, and lack of happiness on the demand side is the true cause of this, surely those countries would be ravaged with an opiate epidemic. But they are not. The problem is much more nuanced than you make it out to be.
It's hard to be scientific about this. For example, you wrote of Singapore being unhappy, but in my experience in Singapore people seem really happy. A lot more than in the States, as far as I can tell (and especially far, far less anger).
>Is it cultural?
That's actually a really common misconception on HN. The United States ranks 27th among countries which abuse opiates, [1] behind many first-world countries like the UK, Italy, Spain, Switzerland, Ireland, and Russia, to name a few.
What's the cause? A lot of HNers like to pin it on unemployment and low-wage, low-skill jobs. I think that's narrowing the field in the right direction, but it isn't quite right; I know many very happy people who just make ends meet. There's something more that no one has been able to pinpoint quite yet.
1. https://en.wikipedia.org/wiki/List_of_countries_by_prevalenc...