[stef25]

The doctors. Anyone who spends the better part of a decade studying medicine can't be ignorant about opioids and addiction, regardless of what the slimy Purdue representative tells them.

The only excuse they have for the blatant over prescribing of opioids (2 months worth of oxy for getting wisdom teeth pulled kind of thing) is that if they don't do it, the patient will just go to another doctor.

But how can you justify setting someone up with fistfuls of oxy (knowing full that heroin / fentanyl and a world of misery for them and their loved ones is just around the corner) just "to make money" ?

> Or is it the responsibility of patients to not seek strong opiates for the smallest aches?

What the patient seeks is irrelevant. The only one who decides what prescriptions a patient should take is a doctor.

Personally I suffered from lower back pain for about 10 years and went from one useless quack to the next. Eventually I found a physio who taught me how to strengthen my core, now I'm at the gym 2x a week and loving it, did couch25K (and beyond) and am pain free for 3 years.

All I sought was pain relief but pills is not what I needed. If I was in W-Virginia instead of the EU I guess I'd be shooting heroin by now.

The US health care system is broken in more ways than one, no doubt this is made worse by various societal factors like joblessness.

[umvi]

> What the patient seeks is irrelevant. The only one who decides what prescriptions a patient should take is a doctor.

That kind of rubs me the wrong way, but I'm not sure why. I like having the option of overriding the doctor if I disagree.

[toomanybeersies]

I understand where you're coming from.

I have a little stack of benzos (valium, xanax, some others) that I use on the odd occasion, despite not being prescribed. Obviously possessing them is illegal. I know that I'm sound enough to know when to use them and when not to, and they've saved me a lot of avoidable pain. I wouldn't go so far as to say they've saved my life, but they've come damn close.

I also use my fair share of recreational drugs, as I've mentioned in previous comments. I know I'm good for them, I practice harm reduction strategies and rave safe. However, I am aware that not everybody is me. There are people who have amphetamine habits, or benzo habits, or {{drug_of_choice}} habits. It's by luck,good planning, and good friends that I don't have a habit and manage to use drugs without causing excessive harm.

That's something that a lot of readers here seem to forget. The average HN reader is very intelligent and usually very capable of looking after themselves (although I am aware there is a fair share of HN readers who've had struggles with addiction). Not everyone is as switched on as the average HN reader though.

[amaccuish]

In the NHS, that isn't possible. You either take the doctor's treatment, or you get no treatment at all. You can go around, asking different doctors, or having a discussion with your doctor, but you will not be prescribed something you don't need. The incentive being, that with a tax payer funded system, money should go to those who actually need it. It is understood here I guess that the doctor is the expert, not you.

[toomuchtodo]

I can totally appreciate this. As an American though, I have gone around my doctor and ordered prescription medications online when they would not prescribe them (ivermectin, anti-parisital, non-controlled substances, almost zero risk to myself if my diagnosis was inaccurate).

[umvi]

Slightly related, sometimes I just want a new pair of glasses without the hassle of going to/paying the eye doctor. I can still see 20/20 with my current prescription, but since it's "expired", physical retailers won't sell me glasses nor will they use their refractometer to read off the prescription of my current pair. So I instead go online and order a pair from Zenni using my expired prescription that I wrote down.

[toomanybeersies]

That's an interestingly unique problem to the USA I think.

Here in Australia, I haven't been to an optometrist in 5 or 6 years. I just keep ordering new glasses for $60 a pair online, my vision hasn't changed enough that I feel that I need to go to an optometrist again. The optometrist is legally required to give me my prescription, which I can then use as I want.

I haven't bought glasses in a brick and mortar store for 5 or 6 years (last time I got an eye test), but I'm fairly sure they won't/can't refuse to make me a pair to my specifications. Actually, I did get a pair made in the shop in Vietnam 2 years ago, and they were more than happy to make them (overnight too, I might add), although they did laugh at how blind I was.

[cm2012]

Could you email me (in profile) which sites you've used? Would love to pick up non controlled stuff online but the sites are all shady.

[toomuchtodo]

Unfortunately, this was almost 6 years ago, and I don't recall the site I used. My apologies!

[skookumchuck]

> The incentive being, that with a tax payer funded system, money should go to those who actually need it.

The idea that people, absent the profit motive, will work solely to the benefit of society is not correct. They're always selfishly motivated - career advancement, risk aversion, corruption, etc.

For example, if the doctor gets punished for prescribing to junkies, he's going to reduce his risk by avoiding prescribing to legitimate pain patients, just to be on the safe side.

Pray you don't get into a situation where you've got painful, terminal cancer and the doctor won't prescribe opiates because you might get addicted.

[roenxi]

Maybe one of the following? These are a couple of takes of that attitude from a few slightly different viewpoints.

* Removal of agency from the patient in relation to how their body is treated; anti-individualism.

* Decision making power assigned to an agent who does not have skin in the game; anti-system-thinking.

* Attitude runs counter to having a strong sense of personal responsibility; anti-some-morality-systems.

* Imposition of doctors value system overrides patient values; not-sure.

[sangnoir]

> That kind of rubs me the wrong way, but I'm not sure why. I like having the option of overriding the doctor if I disagree.

If you're American - my guess is it is cultural: you don't want someone else making decisions for you, rather, they should be making suggestions and you have the final say. American culture extolls autonomy/individualism.

I think this is explains some of the differences between the US and other developed countries when it comes to drug abuse and over-prescription. In the US, the doctors tend to defer to the patient on what's good for them more than elsewhere, especially around pain management.

[stef25]

It would be fair to make choices in the sense of picking a longer treatment that doesn't force you to stay home from work, vs a shorter treatment that would. And of course "another round of chemo" or "I can't be f*cked anymore" are valid choices.

But really, when things like opiates are involved patient input is rarely useful.

[skookumchuck]

> But really, when things like opiates are involved patient input is rarely useful.

Since there is no method for determining the level of a patient's pain, and opiates are for pain management, how can you conclude that?

[stef25]

Yeah, I didn't phrase that properly. Of course patients should communicate how much pain they are in, but they shouldn't communicate the type of painkillers that are to be prescribed.

[ams6110]

> 2 months worth of oxy for getting wisdom teeth pulled kind of thing

Surely this is not the norm? My son had his wisdom teeth out a few years ago, they gave him about a day's worth of hydrocodone and told him to take Tylenol after that. And all the doctors my family has seen for the past couple of decades have been pretty conservative about prescribing anything narcotic for pain.

[akuji1993]

Here in the EU, the doctor didn't give me any strong opiod. They just pulled the tooth and sent me home. When the pain reached a score of 8 / 10 on my personal score card, I took one Tylenol and another 1/2 before bed that day and didn't take anything else the next day.

[maccard]

> When the pain reached a score of 8 / 10 on my personal score card, I took one Tylenol

What's a 10/10 on your personal score card, out of interest? I hope you understand that your 8/10 may be akin to a 2/10 for someone else.

[akuji1993]

It might also have been a 7/10. When I had surgery on my back, right above my buttocks, they dug a hole deep right onto my bone and then it had to heal on its own, took 4 months to close. The first two days were a solid 9.5/10.

[freeflight]

Yup same here in Germany, you can ask for something against the pain, but that will usually only get you a prescription for Ibuprofen 600/800 mg.

Took those way to long over jaw issues until I got stomach problems, asked the dentist for something else and he prescribed metamizole drops.

Didn't use many of those as they sometimes give me kidney pains.

[mrguyorama]

Both my sister and I received A few days worth of Hydros despite being particularly gentle wisdom teeth removals, in her case eating solid food hours later. I took one and probably didn't even need that. This was a very drug prone and poor area.

If they wanted to, they could have gotten away with "take extra strength Ibuprofen", but what is their incentive to do that? They don't want patients telling the next guy "It hurt a lot" after.

[toomanybeersies]

I'm from New Zealand. I had two molars pulled out when I was 15 to fix an overbite problem. It was a serious enough procedure that they gave me an IV anesthetic.

All they prescribed me afterwards was ibuprofen. The general rule around here seems to be that if they're not using a knife, they don't give you opioids. I had to get 6 stitches in my head a few years ago, and they refused to give me anything stronger than ibuprofen again.

[solean]

I had all 4 wisdom teeth pulled 8 years ago (USA). Was given 60 Lortab pills for pain. I only took 1 the day after the operation, the pain really was not bad at all. Insanity.

[LeifCarrotson]

Look for the root cause,not the proximal one.

You can certainly blame one bad doctor. You could probably blame a group of associated doctors, if the problem was associated with a certain hospital or medical school.

But when the problem is something that thousands and thousands of individual doctors mess up, it's hard to blame them all.

Personally, I blame the slimy Purdue salesmen and the idiot bureaucrats who let prescription drug companies advertise prescription drugs on TV, or give kickbacks to doctors who prescribe their medicine. Without these awful incentives, you wouldn't have this widespread failure.

[stef25]

This is like saying web developers aren't responsible for thousands of websites getting hacked through some plugin, because the authors of a plugin simply said it was cool, and they advertised it as such and the devs got some affiliate kickback every time they implemented it on a site.

The analogy doesn't work 100% but pretty close :)

[mercer]

To alter the analogy, perhaps these web developers might be implementing said plugin because their manager told them to, and once said plugin took off clients started demanding it.

Most web developers that I know who have this problem fit this description. they don't like doing any of this, but it's what they're told to do. Or alternatively they're barely 'developers' and care about other things instead (many designer-developers, for example).

[js2]

> The doctors.

Certainly training them to prescribe less is a place to start: Doctors trained at lower-ranked American medical schools prescribe more opioids

https://www.economist.com/graphic-detail/2017/08/23/doctors-...

[mtw]

> found a physio who taught me how to strengthen my core, now I'm at the gym 2x a week and loving it

Most other patients demand quick and effective pain relief. When most doctors operate within a system that promotes total customer satisfaction and when they know an opioid is going to make the pain go away right now, the opioid prescription is easier. Plus this will make extra dollars for the system.

Changing this would require mindset change for patients (I need to endure the pain and follow a clean diet/exercise), and having doctors look to 360 treatments, including diet, sleep and exercise recommendations, instead of opioids

[ce4]

Here's a discussion from 7 months ago about exactly that. US patient came to another country and was faced with a mindset change and subsequently wrote an article about it in the nyt titled "After Surgery in Germany, I Wanted Vicodin, Not Herbal Tea" [0].

[0]: https://news.ycombinator.com/item?id=16252372

[nonbel]

I have a friend who had brain surgeries as a child and then again a few years ago. He said even though he weighed 2-4x more for the recent surgery they gave him half the morphine dose he got when younger. Apparently that dose was only enough make his feet itchy without sufficient pain relief, but they said they couldn't give him any more for whatever reason (legal, hospital policy, etc).

If that story generalizes it may be that somehow outpatients are getting too much painkillers while inpatients are not getting enough. The latter group is, of course, much less likely to get addicted.

[village-idiot]

American doctors are persistently and openly reluctant to prescribe lifestyle changes for fear of patient anger and noncompliance. Even in cases where the medical advice is something along the lines of “get some exercise or start planning your own funeral”.

Obviously doctors continuing to hand out pills (opioids, statins, etc.) to patients who really need therapy, exercise, or dietary changes is helping to reinforce the problem.

[dominotw]

> 2 months worth of oxy for getting wisdom teeth pulled kind of thing

I saved mine after wisdom tooth/root canal combo and used them as mood enhancer later.

I am not sure I am addicted to them though. I find this theory hard to believe that opioid overdose is an end result of series of missteps starting from wisdom tooth oxy prescription.

[toomanybeersies]

Most of the population drinks alcohol. Most of the population are not alcoholics.

I haven't abused opioids for recreational purposes, but I know people who have saved their prescribed codeine and gotten fucked up on it. They aren't addicted. I also walk to the supermarket every day, past the safe injection centre filled with smackheads. I've seen dead heroin addicts wheeled into the ambulance.

Not everyone is as susceptible to addiction as others, but the more opioids/alcohol/other drugs you take, the more likely you are to get addicted.

[mercer]

that's a very important point. I've had a number of friends who struggle with addiction (whether alcohol, cigarettes, or other things), and a smaller number of friends who seemed almost entirely impervious to addiction. It's been quite frustrating to find that the latter would simply not understand the former. Some of them would suspend judgment, but others just concluded that those who were addicted simply "didn't try hard enough".

To some extent, I can understand this rather uncharitable conclusion. It's like explaining being in love to someone who hasn't been. Addiction is difficult to explain without having experienced it.

Nonetheless, what makes me side with the addicts, so to speak, and their helplessness, is that when I look at the 'whole' of their person, many of them clearly don't lack willpower or discipline in other areas of their lives. I've either seen the addiction infect the rest of their lives, or seen them being functional, even successful, in other areas despite the addiction. The only conclusion I can draw is that some (most?) people are just unusually susceptible to certain vices.

[nioesd]

Keep in mind that some people are at much higher risk for becoming addicted to opiates. You may have been able to take them recreationally without major issue, but the same behavior could have a much more severe consequence for someone in that at-risk group.

[dominotw]

> some people are at much higher risk

Why is that? Something in their genetic makeup? Wonder if its possible to identify these ppl preemptively.

[freeflight]

Genetics play a huge role [0], but so do social and environmental factors.

[0] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2442454/

[dwaltrip]

Possibly that, but life experiences and environmental factors (stress at work, etc) play a huge role.

[free652]

For wisdom teeth I got 25 tablets - that's like around a week worth. So other "patients" ask upfront for more tablets?

[zolthrowaway]

Yes, many people will take the largest script the doctor will prescribe. Insurance generally helps cover the cost of the prescription, so reselling them can be really lucrative. Even in your scenario, 25 pills seems like a lot. Many people will be totally pain free in 2-3 days. No one needs 8 pills a day for wisdom teeth. Let's say they take 4 a day for 3 days, that's still 13 pills leftover.

Go to any manual labor job (construction for example) in the Midwest. You will find people wanting to buy leftover prescriptions and people selling them. It's a pretty large black market. The vast, vast majority of people I know doing construction, laying asphalt, etc are all daily drinkers, potheads, or addicted to opiates. It's honestly super depressing.

[ensignavenger]

Since the insurance charges the same for a large prescription versus a small one, even if you aren't planning on selling them, it makes sense from a financial perspective to get the extra pills, just in case you do need them. (If there are complications, or if something else happens, etc.)

[matwood]

Wow. I had my ACL done and got 3 days worth of Oxycontin (6 tablets, 1 every 12 hours). I didn't want to finish taking them because they made me hallucinate. Looking back, I probably could have gotten by after the first day with only ibuprofen. The doctor was very concerned about staying ahead of any pain though.