[johnisgood]

> We all know about opiates

No, I do not think we do, because it causes none of the side-effects associated with NSAIDs, and it is even safer than acetaminophen, i.e. there is no risk of hepatotoxicity whatsoever. The only side-effect is euphoria. Please do not mention respiratory depression here, that is a non-issue, it matters as so much as liver failure matters with acetaminophen overdoses. Opiates are safer than any painkillers currently in existence, the problem is with impure products (i.e. not from the pharmacy), and people misusing / abusing them. They might as well abuse NSAIDs and acetaminophen, and the result is the same: harm. Taken therapeutically though, it is way safer than any other painkillers.

So I am not sure what your intention was with that sentence, because sadly no, people do not realize the therapeutic safety profile.

Tramadol is a nasty atypical opioid though, you could have singled that one out. It affects almost all receptors (serotonin, dopamine, etc.) there is, and it is one of the nastiest opioids out there, but that is why it is called an "atypical" opioid.

Edit: I missed constipation as a side-effect, see my other comment.

[water-data-dude]

"...the problem is with impure products and people misusing / abusing them."

That second part "people misusing/abusing them" is a lot bigger than you're letting on. People can get hooked on opiates easily - a quick trip to Wikipedia turns up: "Long-term opioid use occurs in about 4% of people following their use for trauma or surgery-related pain" [1]. That's a pretty big knock-on effect! If you're prescribed opiates you're rolling the dice, and if you have the right mix of brain chemistry and genetics, you might be screwed.

[1] https://pubmed.ncbi.nlm.nih.gov/30063596/

[johnisgood]

I do not disagree with that.

> if you have the right mix of brain chemistry and genetics, you might be screwed.

Right. I experience no euphoria whatsoever from any opiates (in any dose)[1]. Blessing or a curse? I personally call it a blessing because I have an addictive personality so I would get hooked up on it too. It works for my pain and my depression & anxiety, and for that I am grateful, all while not causing euphoria, all it seems to do is just mood stabilization, i.e. I am less likely to be emotionally volatile.

The constipation side-effect can really be frustrating though, but thankfully I can manage it through diet and skipping doses.

[1] It possibly has to do with my neuro{biology,chemistry} and my brain lesions but who knows. Psychiatric medications never affected me the way they typically affect others and I have gone through _a lot_. It might be genetic, metabolic (as well), I have no clue.

[plooooooop]

I had an opiate after surgery once and the constipation was so bad, it was worse than the pain it was supposed to be treating. I switched to Aleve instead, which was both better at pain management and had fewer side effects.

[johnisgood]

"an opiate"? You do not get constipation from one pill that is "so bad".

Plus it depends on the opioid. Hydrocodone and oxycodone for example leaves the system pretty quickly (ER, too), and once it does, you can defecate without issues. Morphine on the other hand causes awful constipation but can be treated with proper diet. Hydrate, plum jam, magnesium citrate, or laxatives if serious. You can skip a dose or two so you can defecate.

[mindslight]

When I had my wisdom teeth out, they gave me percocet (oxycodone + tylenol). "Take one every 4-6 hours." I split the pills in half and took one just as the pain was starting to come back, generally right after 2 hours. It worked great. Then after several days the pain started coming back in my knees and other joints. Wait... I don't generally have joint pain. I guess that's withdrawal from developing a tolerance, aka addiction. I quickly ramped down and stopped using them shortly thereafter.

Of course it would be tempting to wax poetic about how I just needed to use my willpower to stop, and so can anyone else - just-world-fallacy while singing my own praises. But it's more honest to admit that while things worked out fine that time, control can be quite illusory. I wouldn't hesitate to use opiates again for extreme pain, but I sure would set up some social accountability systems beforehand.

[jrflowers]

> The only side-effect is euphoria. Please do not mention respiratory depression here, that is a non-issue

I like this point because it is complete gibberish. If you simply do not mention the side effect that makes a drug lethal, it sounds a lot like the drug does not have lethal side effects. Obviously we cannot do that with acetaminophen though, we must talk about hepatoxicity when it comes to that drug.

On the one hand we have a drug that can cause both mental and physiological dependence and addiction (so what), has an admitted side effect that encourages some users to escalate their dosage beyond medical guidance (who cares), and can cause you to either stop breathing or aspirate and choke on your own vomit if you take too much (that part is a little tricky so we just proceed as if that is not the case)

On the other hand you have a drug that is hepatoxic at several multiples of its recommended dosage. Obviously the second one is more dangerous becau

[johnisgood]

You misunderstood me, then.

Therapeutic doses of opiates do not cause respiratory depression, overdoses do, similarly to how acetaminophen overdoses cause hepatotoxicity, except this is not true, because regular consumption of acetaminophen causes hepatotoxicity, too, whereas opiates, when taken as prescribed, do not cause respiratory depression, in case of opiates, ONLY overdoses do, and therein lies the huge difference.

And then we did not even mention NSAIDs which cause from ulcers to cardiovascular events, even if taken as prescribed.

As for addiction, I would not like to get into the topic of addiction because a lot of people have an obsolete view on it and people already have their mind made up with regarding to it. Similarly to how my parents' generation think mental illnesses do not exist or that you can just "think away" depression.

[jrflowers]

Oh I know that you’re correct, your phrasing was just hilarious.

Under the caveats of a competent physician and a completely med-compliant patient, opiates are perfectly safe. Those are enormous caveats though, given the history and prevalence of incompetent physicians and noncompliant patients (at least in the US).

Generally if you see someone complaining about opiates being dangerous, they’re likely factoring in opiates as things that exist in the context of society rather than a strictly clinical context. You can’t really use the reasoning of one context to dispute the other, it looks silly because you have to say stuff like “ignore all the deaths and the mechanism of those deaths”

[johnisgood]

> Oh I know that you’re correct, your phrasing was just hilarious.

My bad. :P

But yeah, I agree. Eastern Europe is on the other spectrum with regarding to opiates. They do not even get prescribed codeine, regardless of severity of pain. You will get naproxen instead along with a possible stroke. :D

> context of society

I would hope so. According to my experiences here on HN, they (some people) just decided opiates are bad (because of "junkies") and that was it.

But yeah, people made opiates look terrible and it is a bummer, it is another case of "this is why we can't have nice things". Kratom is legal here (for now) and people with pain use it, but probably will be taken away from them sooner or later.

In any case, thanks for the reply, pleasantly surprising!

[vel0city]

Acetaminophen related deaths are a few hundred a year in the US.

Opiate related deaths in the US have been around 50,000+/yr.

I don't personally know anyone who has died from acetaminophen usage or even particularly injured. I personally know several people who had their lives nearly destroyed by opiate abuse, and a few others who have died. And it's not like I'm hanging out with junkies all the time.

[hrfvbgcc]

Yup. As someone in the US the idea that opiates are “actually really great and safe drugs, just misunderstood!” is insane.

[albedoa]

I appreciate your sensible and articulate responses here.

[kelnos]

I think you're missing the point, though. Patients are much more likely to abuse/misuse an opiate, leading to much more than the "therapeutic" dose being taken. But most people aren't going to overdose on ibuprofen or acetaminophen. If they do, it's because they've made a foolish decision ("the pain didn't go away with one pill, so if I take five maybe it will"). When it comes to opiates, taking too much will generally be because of a chemical dependence, not a conscious choice. Even if the ibuprofen overdose is a stupid choice, it's still a conscious one.

> regular consumption of acetaminophen causes hepatotoxicity, too

That would be misuse/abuse, though. The bottle label tells you to seek a doctor's advice if you need to take it longer than a certain period of time. Sure, people can fail to read that and not know about it, or just choose that the risk of complications is acceptable given their pain situation, but that's still not as bad as chemical dependence driving the decision-making.

Don't get me wrong, I'm not saying we should ban opiates or never prescribe them, and I imagine the result of the backlash toward decades of over-prescribing has been a foolish swing to the other extreme. But I still don't think we should prefer opiates over ibuprofen/acetaminophen when the latter will do the job. Maybe that's not what you were arguing, but I do take issue with your suggestion that opiates are safer.

[johnisgood]

> taking too much will generally be because of a chemical dependence, not a conscious choice.

This is an oversimplification and not universally true, but I do not wish to get into the details of it and addiction in general. We could brush away every decisions based on "chemical imbalances", too, if we so want. :)

> we should prefer opiates over ibuprofen/acetaminophen when the latter will do the job

Yes, after a careful risk assessment. If you are likely to get ulcers, or a stroke, or any cardiovascular events from NSAIDs, then you might want to consider something safer. Tylenol would be safer in this case, but what if that does not help with the pain at all? In any case, I do not necessarily disagree, and I was not advocating for blind consumption of opioids. If Tylenol works, take it with milk thistle (with high silybilin content) and you will be fine, even if you take it on the daily.

[kelnos]

Abuse and misuse of opiates is the key problem though. "Just don't abuse them" isn't a solution. As far as I understand, ibuprofen and acetaminophen are not addictive, while opiates are.

Opiates are only the best option if we ignore addiction, but we can't seriously do that.

AFAICT, I don't tend toward addiction, but I would much prefer ibuprofen or acetaminophen over opiates; I know that I can use those responsibly and not overdose and damage my gut or my liver, but I don't have the same confidence toward opiates. Not to mention I can't get opiates without a prescription, while the others are available OTC. I'm not going to go to the doctor to get an opiates script just for a headache or minor-injury pain.

I've been prescribed codeine before after minor surgery, and I was fine from the not-getting-addicted perspective, but wow does that drug mess with your brain. Sure, I'm not going to deprive myself of an effective painkiller when I really need it, but I'd rather not be in a fuzzy mental state if the pain is manageable with something else.

[johnisgood]

I am sorry it made you feel fuzzy. I did not say it works for everyone. My grandma gets delirious from Tramadol, for example. Many people are just simply pain-free on it without getting "high", let alone delirious. I personally do not experience these mental symptoms of opiates so I have no first-hand experiences. I know what euphoria is like, I have taken MDMA, but opiates works more peripherally for me, even the ones that are supposed to pass the CNS greatly.

Of course, I think, ultimately it is for you to decide whether it is worth the risk (feeling fuzzy) or not. It is not for me to decide what works for you. :)

[nkrisc]

> The only side-effect is euphoria.

> …

> the problem is with […] people misusing / abusing them.

I think these two facts are inextricably linked, and is what makes them indirectly dangerous for some people.

[johnisgood]

I do not disagree.

Ultimately, it is "pick your poison[1]".

[1] Or others will pick it for you (control, regulation, whatever). You said "some people", which is true. I do not experience euphoria from opiates and I am sure I am not alone with this. In my case it is a blessing because I do have an addictive personality. Some other people do not get psychologically addicted to opiates despite euphoria. There is a great study, I think if you search for "rat park study", you can find it. The whole topic is complicated anyways, so I will just say that yeah, you are right, generally speaking.

[Spivak]

I think the stronger point of what you're saying is if you can set yourself to avoid addiction—you have a time limited dose, you have no means of acquiring more—then opiate painkillers are the safest option in terms of potential damage to your body.

There's no avoiding it when it comes to some people's chronic pain but it's a tragedy we've ruined the reputation for opiate painkillers because they were prescribed for long periods which all but guarantees addiction. Folks in US hospitals have to unnecessarily suffer short term acute pain because squeamishness around prescribing effective painkillers in a situation where there's virtually no risk.

[johnisgood]

Thank you. This is what I essentially meant. See, this is what I meant by someone being able to express my thoughts better than I could ever hope for, so again, thank you!

[zeven7]

If the safest drug is also the one most prone to misuse, and misuse makes it unsafe, then it is no longer the safest drug. The reason society should be wary is precisely because people misuse it on a scale that vastly eclipses garden variety drugs like acetaminophen.

[polishdude20]

Yeah, "misuse" IS a side effect.

[xeromal]

They do cause constipation

[johnisgood]

You are right. It varies a lot though by different opioids and dosage plays a major role, too.

Morphine causes more constipation than oxycodone does, for example (not to mention IR vs ER formulations), and in some people morphine causes more sedation and oxycodone might be more stimulant-ish, so they may be opioids / opiates, but they can be significantly different.

That said, constipation can indeed be a major issue, especially in the elderly, but they are most likely are already taking or being given laxatives.

For adults without any GI problems, they can safely be on a better diet and take magnesium citrate before they want to defecate (if they have no kidney issues either). It takes 4-12 hours for magnesium citrate to work. There is an even better form of magnesium, but magnesium citrate should be fine, along with prunes or prune jam, lots of hydration and so forth.

I take opiates for pain, and the way I manage constipation (which is indeed frustrating) is through diet (fibre, prune jam, and so forth) and skipping two days (of the ER formulation) if I have no stool for a few days, along with taking magnesium citrate. I would not recommend taking opiates AND laxatives all the time (or rather, I do not recommend treating OIC with regular consumption of laxatives). Constipation would not be a problem with lower doses and IR formulations though, or much less so.

Just FWIW, if you can pass gass, your bowels are not obstructed, and it is a good sign, so if you take opiates, pay attention to that. If you cannot pass gas and you have abdominal pain, then it can easily become a medical emergency. You should not get to this point though, either by taking less, switching to a different formulation (ER -> IR), or switching to a different opioid, along with a better diet.

Additionally, if you do not take opioids (especially ER ones) on a regular basis (similarly to how some people only take NSAIDs once in a while), then constipation is not going to be an issue at all.

I hope this answers your concerns regarding opioid-induced constipation.

[davidw]

And nausea. Yuck.

[johnisgood]

Some people have it. Some do not. I have taken very large amounts of opiates before and I have never ever experienced nausea from them. I think you are not likely to experience it at lower doses from say, codeine or hydrocodone either, but honestly, it varies by individuals.

It would suck if I experienced nausea, and it would equally suck if I experienced euphoria from opiates, because I have an addictive personality. Thankfully I do not experience euphoria at all from opiates.

BTW I remember having ulcers from NSAIDs before, that is yuck, too. I ended up vomiting blood and I had to be admitted to the hospital. I think I would choose constipation (which can be managed) over this. But yeah, if opiates caused nausea for me, I would not take them for sure.

Ultimately, people should figure out what works for them and stick to it. Unfortunately it might work until it does not, i.e. causes harm. Some people get no ulcers from taking NSAIDs on the daily, and I did just from a few days of taking it (and it was not even naproxen!). :| I am also allergic to metamizole which is the most common painkiller around here (Algopyrin, Optalgin). For my grandma, it seems to work best for her, although she may want to try pregabalin, as her pain is neuropathic (too). She was given tramadol not that long ago and she got somewhat delirious. They probably gave it to her deliberately because she was making a scene at the hospital.

[jalapenos]

> I have taken very large amounts of opiates before

> I have an addictive personality

I take it this means: "I was a heroin junkie"?

[AndyPa32]

The risk of NSAID ulcers can be vastly reduced by Pantoprazole (Protonix®)

[catlikesshrimp]

You can see blood that you vomit, But NSAIDs also cause kidney damage, which you don't realize until it is extensive. Lost nephrons don't come back.

[johnisgood]

I know, and there is something called Venter (sucrate). Combining both works best.

[wilkystyle]

The silent killer

[johnisgood]

I would say it is not so silent, bowel obstruction is very painful which you feel even if you are on opiates. In any case, I hope my other comment proves to be helpful to those taking opiates if they do not already know what to do or pay attention to.

[jalapenos]

Possible that this is an elaborate defence of an addict - addiction being the known major problem with them?

[slenk]

Tylenol isn't addictive. Every opiate is. Even as an alcoholic having to get surgery terrifies me because of how addictive opiates is and that is all doctors push now-a-days.

eta this is nothing to do with purity of the product. I never heard of someone selling themselves for Tylenol/acetaminophen

[johnisgood]

That is an oversimplification, and there are many studies out there proving that people receiving opiates at the hospital do not get psychologically addicted to it, if you are talking about that.

And surely I am not alone with not experiencing euphoria from opiates. It is probably a low % of people though, I do not deny that.

> purity of the product

Overdoses and negative public perception does have to do with that though.

[hrfvbgcc]

Are you sure you are not addicted to opiates?

[johnisgood]

Physically I am (although not at the moment). Psychologically, I am not. I just have an aversion to pain, depression, anxiety, and incontinence. If you love any of these things, you do you.

If you are asking because I mentioned lack of euphoria, then no. I NEVER experienced euphoria from opiates, ever. Not even the first time I have taken it, and I did take enough of a dose that should have given me euphoria or the feeling of warmth and bliss which I have never experienced.

Why? There could be many reasons, but I suspect it has to do a lot with how psychiatric medications have messed with my brain AND I have brain lesions due to MS.