I recommend people here watch PBS Frontline's documentary on the opiate epidemic called "Chasing Heroin". Excellent watch.

http://www.pbs.org/wgbh/frontline/film/chasing-heroin/

This obv.

"We're taking a well known addictive drug and making it extended release. That will make it not addictive."

To be fair, it's tough to expect the physicians to not rely on what the published research studies tell them. I don't think we normally want them second-guessing the science.

Not sure how old you are Howard but here's how it worked in my town. Kid gets his wisdom teeth out, doctor prescribes him a giant bottle of pain killers. Kid sells extras to his friends. Those friends get a dependency, eventually switch to actual heroin.

That's a heck of a thing. I had my wisdom teeth removed when I was a young teen. Somehow I can't imagine a young teen being given a giant bottle of opioids which is then sold to friends many of whom eventually switch to heroin.

Oh, I'm 67, but a young 67. Heh.

In the early nineteen hundreds Bayer came out with a miracle drug that had all the same pain reducing effects as morphine except without the addictiveness problems that you get with using morphine. It was synthetic derivative of a different compound of the poppy plant. They called this miracle Heroin. In German Heroin means "strong and heroic".

What Purdue did is repackage a new heroin that they knew was just as addictive as heroin. And the way they did it is wine and dine doctors, and did a massive promotion of their new miracle cure for pain with none of dangers of morphine or heroin. They managed to get their message through in medical journals and even had it medical books that were used to teach new doctors.

They made billions. The doctors were just as greedy and stupid as Purdue. The misery and death is going to be happening for the foreseeable future.

30-60 Vicodin is like the standard "hey thanks for letting us extract your wisdom teeth" prescription.

This starts in Nevada Jan 1 2018 by statute

Before writing an initial prescription for a CS, each practitioner must:
 Have a bona fide relationship with the pt;
 Establish a preliminary diagnosis and a treatment plan;
 Perform a Patient Risk Assessment (see below);
 Obtain and personally review the pt’s PMP report;
 Discuss non-opioid treatment options with the pt;
 If the practitioner decides to write an initial prescription:
o It must be for ≤ 14-day supply if treating acute pain;
o It must not be for > 90 MME daily for an opiate naïve pt; AND
o An Informed Consent (see below) must be completed by the pt.
Patient Risk Assessment
 Obtain and review the pt’s medical history/records; and
 Conduct a physical examination of the patient and assess their mental health, their risk of abuse, dependence, and addiction.
Informed Consent
The practitioner must obtain informed written consent after discussing the following with the pt:
 The potential risks and benefits of using the CS;
 The proper use, storage, disposal of the CS;
 The treatment plan and possible alternative treatment options;
 Risk of CS exposure to a fetus of a childbearing age woman;
 If the CS is an opioid, the availability of an opioid antagonist; AND
 If the pt is an unemancipated minor, the risks that the minor will abuse, misuse, or divert the CS and ways to detect those issues.

My reaction to this is:

1) It's going to be a ginormous pain in the nuts for my specialty in terms of jumping thru all those hoops multiple times a shift. Hopefully we're going to be able to streamline the process with a lot of template type stuff prepared ahead of time. I'm especially concerned about the requirement to "assess their mental health, their risk of abuse, dependence, and addiction." - that seems a tall order for an ER doc to do on someone with a sprained ankle, and I've never had anything in the way of training/education as to how to determine that sort of thing.
2) I'm skeptical as to how much it's all going to help.
3) Patients are going to have a lot harder time getting pain meds, legitimate and otherwise.
3) I think it's worth a try. I really hope that somewhere in the background someone/some agency is going to collect data and tell if this is helpful, or even better, what parts of this are and what aren't - so it doesn't end up being one of those things people do to check a box and move on feeling better about themselves without actually improving a problem.

MM MD

1. Before prescribing Tramadol for my mother's severe arthritis the Dr. gave her a mini-lecture and made her sign some kind of form. She's hardly used any.
2. I have suddenly developed a very painful toothache.

My sister, a surgeon, explained how some years back, the medical field was taught to treat pain as an additional vital sign. Hence the question you get in ER, "rate your pain one to ten." Pharma was all over this development.

I saw a sports doctor about a foot pain. He gave me a cortisone shot in the sole of my foot which hurt more than it was worth, and then a scrip for 30 hydros. I took just one and didn't really need it.

My sister says people should not expect to lead pain free lives.

After my 19-year-old's death two years ago, found in his text messages that he didn't think oxy was a "hard drug," just smack. Oxy was of course what killed him.

Pain used to be way under treated, a reaction to the whole-scale addiction beginning late 1800s. Now pharma and boredom have flipped things back to a previous century.

Pharma is why pill heroin spread so widely that it became casual.

Yo. Surprising number of people cruise medicine cabinets for just such opportunities.

It's a complicated topic. For one thing, we really (AFAIK) don't have any good idea about who is at risk for developing addiction at any particular dosage of narcotics. I'm old enough to have accumulated 7 or 8 (I'd guess) courses of pain meds in my life. Never had a thought about taking the pills once I wasn't really hurting. But some people seem to get hooked quickly, and we don't know why.

I have a HIDEOUS family history of alcohol issues, too. Up to living under a bridge in a cardboard box type of stuff. So I'm careful with the booze.....but narcs don't do much for me.

MM MD

I have only needed pain pills twice in my life. Once when I broke my finger and it swelled up and hurt like a mofo for a few days. some vicodin was helpful but I didnt need anything stronger. this was recently and they asked me a bunch of questions and were very reticent to give me any. ended up getting 10 pills.

needed surgery on the finger but that was fairly pain free.

played sports and had tons of injuries. bad ankle sprains. broken ankle. bone chips in the ankle. broken elbow. pulled muscles. foot pain. never took any pills for it.

only other time I was prescribed pain pills was after acl surgery. this was over 10 years ago. the injury itself wasnt too bad. but post surgery was a ton of pain. the drs were pretty surprised when I woke up in a lot of pain bc they had a nerve block.

they gave me a script for 50 vics. they were useless. and when the nerve block wore off some hrs later it was pure hell. they upped me to percocet. still pretty useless. I did realize if I took a ton of pills I would sleep which was better than being awake and in pain.

I ended up going thru 50 vics and 40 percs that first week. I think I did 40 more percs the next week.

after 2 weeks I was fine. doc asked if I need more pain pills and I declined. but every time I saw him he straight up asked me if I wanted pain pills. even a year later, after declining pills every single previous time, he still asked. there is no doubt that I would have been hopelessly addicted to vic or perc and had easy access without even trying.

but what really makes me mad is that when I was in true pain, they were not willing to give me the good stuff. instead I was forced to pile on tons of the weaker drugs in hopes of minor relief. and after that there were no qualms about providing opiates to me for months on end.

my friends were incredulous that I wasnt taking him up on the scripts. "you can sell it if you dont want it." "hey just give it to me." the truth is, after those first 2 weeks, I was quite scared to continue taking opiates and saying no to the doc was very hard. ultimately, I didnt trust myself. the first week was no doubt for pain relief but sometime after 10-12 days it had bled into seeking the euphoria.

so I can totally see how ppl go in for surgery and come out as junkies a few months later. now this was over 10 yrs ago. and I think this doc was just a kinda clueless older guy who just wasnt aware of the dangers and not some nefarious part of the big pharma plot. I mean, it was just low dose vic, but that has proved to be quite dangerous in and of itself or as a gateway.

and I think there were a ton of docs just like this guy. combine that with those complicit with Purdue and for many years a ton of addicts were created. pretty sad.

I never felt the need to take more pills but I was scared ****less by how well Oxy worked. I literally felt a tingling sensation coming up from my toes. It's was like smoking extremely good weed and having the entire joint hit you in like 30 seconds... without having to even inhale.

From a shrink's perspective, I'm assuming just sticking something in such as "pt denies hx illicit substance use" or "pt counseled on possible increased risk of dependence given past hx" is going to meet the threshold of that law. Seems that portion is there to prevent folks from giving Oxy to a recovering heroin addict b/c they didn't ask about any addiction hx.

I'm hoping you're right. But it's pretty clear that the people who wrote the law had essentially no medical knowledge. The way it reads at present, I'm supposed to magically be able to determine if someone is at risk for developing a drug habit, and I suppose not write for narcs for them.

Which seems bad. I mean, suppose someone comes up with some sort of screening questionnaire that actually predicts a higher than average risk of developing dependence in a patient, and that patient comes in with an open femur fracture. Tylenol and sympathy?

MM MD

And that's a bad example, as an open femur would be admitted. But say shingles, or a kidney stone. Both hurt like hell. If I was a paient, dunno how happy I'd be if someone told me that there was a hypothetical problem with potential addiction, so you're gonna get tylenol for your excruciating pain. Believe me, I understand the problem. But as I said, we're doing something to make ourselves feel better about ourselves - not something that's best for the individual patient.

MM MD

The worst thing Purdue did was to advise Docs to up people's doses when they weren't getting the duration of relief which was claimed. A percocet has at most 10 mg of oxycodone. Oxycontins come in doses as high as 80 mg which is an absurd amount.

Combine that with the existence of unscrupulous doctors who churn out the scripts for anyone who walks through the doors and now you've got a serious problem. I've seen news reports from WaPo that both Tennessee and Ohio had more opiate scripts written than people living in the state. There's no way that the company wasn't aware they were shipping drugs in which were not being used for a legitimate medical purpose.

this comes up again and again in these arguments. ppl like to make a distinction between deserving the opiate for the pain, or seeking it bc one is a junkie.

I dont think its as clear. withdrawing from opiates is awful. the junky absolutely does need it to function. so I would argue that he does have a legitimate medical purpose in the usage of opiates. and I would further argue that a chronic bad back does not indicate as great of a need as withdrawal.

but if an addict with a bad back comes in, sure, he may be seeking the opiate for his bad back to some degree, but his desire is driven much more by withdrawal. ppl like to think that this particular guy with a history of pain and a bad back is somehow a legitimate pain pill user and somehow deserves it more than someone who is seeking it to function without withdrawal. I think that is bs. the guy with a history of pain is almost certainly just as much of a junky as the other.

and really, I dont think either should be denied the substance that allows them to function.

In 2011, I dislocated my hip in a one-car accident (bad roads I slipped off of and went into a tree). Aside from some morphine at the hospital ER (which didn't help at all), I received no opiates.

I guess I'd have a year's worth of oxy if I did that today.

These meds weren't prescribed often in Spain. I broke my collarbone and suffered a grade 3 shoulder separation in a fall last year and received no prescriptions for pain meds after surgery. One would think that an international company would work to spread their miracle drug to other countries but thankfully they didn't.

Well, if I dislocate my hip I sure as hell want some pain meds. I'm even OK with some for home for a few days.

But, I'm about certain I'm not going to get dependent on them. Problem is, I'm certain because I've taken them in the past post surgery and not had issues. For someone else, it could be a (BIG) issue. And AFAIK, no one has a even plausible way to sort the sheep from the goats. Which is how we got here, I suppose.

MM MD

Canada is suffering from an opiate crisis also.

An example of the ridiculousness. I had a wisdom tooth out in the late 90's as well. Was given a script for 20 vicodin. My gums were sore for like a few hours, not even enough to justify taking tylenol.

I wonder how many forum regs are addicts. I bet there are at least a couple Politard junkies. Gotta be dozens site-wide.

It's a pretty big site and largely populated by gamblers, some of them compulsive. There are likely quite a few. Maybe not hard lining junkies but cocaine and downers for sure.