Make America Green Again: Opioids for Chronic Pain

Unless you have been living under a rock for the past few years, you are aware that there is an opioid epidemic.  Your 25-year-old cousin is now more likely to die from a drug overdose than from a car accident.  Much of this column is my opinion that has been derived from facts and 16 years’ experience as a physician working in primary care, the emergency department, and more recently in addiction medicine.

After my training in Columbus, Ohio, I began working in Redding.  Where I trained, opioids were infrequently prescribed for chronic pain.  In Redding, I was perplexed by the number of relatively young people who were receiving opioids regularly for chronic pain.  I would see people in their 40s who required 6 Norco (hydrocodone/acetaminophen) per day for their back pain.  At the same time, I would get x-rays of elderly patients in the emergency room whose spines looked like someone took a jackhammer to them and they would take a couple aspirin per day for their pain.

This never made sense to me.  Curious about this phenomenon, I have asked many older physicians over the past decade the same question, “Thirty years ago when we weren’t prescribing all of these opioids, were people’s quality of life worse?”  Nobody who has been in the medical field for decades has been able to honestly answer that we have made people better by the widespread use of opioids for chronic pain.

Part of the problem is the way that opioids work.  In the short term, they block the signals that your brain receives about pain.  If you break your arm and take some oxycodone, you will feel better.  However, if you take that same oxycodone several times per day every day, your brain changes.  It then takes more opioid to have the same effect.  Even worse, you go through withdrawal before each dose of medication.  A person’s brain then perceives this as an increase in pain and decrease in well-being.  Most people interpret this as a need to take opioids to control their pain and conclude that without these medications their pain would be severe and they would not feel well nor function in their daily lives.  In fact, for many people, it’s the opioid itself that is causing that pain and dysphoria (unease or dissatisfaction with life).  Opioids are known to cause a hyperalgesia, making normal stimuli turn into painful ones.  If you have ever seen someone in opioid withdrawal, they usually hurt all over.  In fact, I have seen many patients who have either taken themselves off the medication or were forced to stop.  Most were either no worse or much better than when they took the medication.  It is for this reason that people with chronic pain often find themselves taking escalating doses of medication and running out early.

There are many people who take opioids on a regular basis and don’t die.  So how do people who are not abusing the medications die from them?  One way is that our bodies develop tolerance to opioids and people increase their doses, sometimes to a level that is dangerous.  Many times, it is the addition of another sedating medication, like anti-anxiety drugs, or alcohol that worsens the sedation and respiratory depression.  In older people, these medications increase the risk of falls, which can lead to fractures and complications that result in death or disability.  Often, people drive while taking prescribed medication, not realizing that they are impaired (and that they can get a DUI), increasing their chances of crash.  This is something that I see commonly in the emergency department when patients are clearly quite impaired but they insist that the medication is not affecting them.  One risk that people who are on these medications often fail to appreciate is that they may do fine on medications for quite a while.  Then they get sick from a virus or pneumonia and that pushes them over the edge to over-sedation or not breathing, resulting in death or brain damage.  Their death may never get attributed to the medication that made them susceptible to this happening.

When the makers of OxyContin were marketing their new wonder drug for pain, they fed doctors the same bullshit study that only 4 in 10,000 taking opioids for chronic pain would get addicted.  This was from a letter to the editor that was published and was not based on good scientific data.  Nevertheless, physicians were encouraged to prescribe OxyContin, fentanyl patch, long acting morphine, and others for chronic pain while the drug companies emphasized how safe and effective the medications were.

To underscore the importance of treating all pain, all physicians in California were required by a law passed in 2001 to take a 12-hour course on pain management.  Thank you, lawmakers.  These courses emphasized the potential legal risks of undertreating pain as well as encouraging the use of opioids to treat subjective complaints of pain.  This is while the Joint Commission required the assessment of pain as the “fifth vital sign” and required the assessment of pain and evidence that the pain level was addressed.  As it turns out, a lot of people get addicted to opioids.  Addiction doesn’t just mean you have withdrawal if you stop taking it.  It is a psychological pattern of loss of control of use despite adverse consequences in your life, often despite a desire to stop using.  It’s difficult to get an exact number, but about 40 percent who take opioids for longer than 4 weeks are still taking them a year later, possibly a sign of addiction.  At least one out of six people who take opioids in the longer term meet criteria for addiction.

Here is how I think the discussion about prescribing opioids for chronic pain should go:  “I have a medication that will make you feel better when you take it for pain.  Although I am prescribing it as needed, you are always in pain, so you will probably take it regularly.  This medication helps in short term but probably makes your pain worse in the long term.  Since you will be relying this medication, you probably won’t focus as much on exercise and better ways to manage the pain.  This medication will impair your ability to drive and, although you tell me you won’t drive after you take it, you probably will, and it may cause you to get into an accident.  This medication may just kill you even if you take it as directed.  Although the chances that this helps you in the long term are relatively low, you may also become addicted.  This addiction may destroy all of your relationships, your career, and turn your life into a living hell.   You will then spend much of your time figuring out how to get more of the drug and doing things that you never would have imagined to obtain them.  Even though you say it will never happen to you, your addiction may take such a hold over your life that you turn to heroin.  At some point, you may find yourself unemployed, your family having given up on you, your children wanting nothing to do with you, your health failing, and you injecting heroin wondering how you could have possibly gotten there.  Do you want 30 or 60 pills?”

I believe it is a fallacy that any given patient can know if opioids will be safe for them and that any physician can predict who will benefit and who will have problems.  Certainly, we can detect those at higher risk (mood disorder, adverse childhood experiences, family history of addiction, personal history of addiction, etc.) but the no-risk population is a myth.  Time has proven that we harm more patients with opioids for chronic pain than benefit.  This is not the same for acute pain from conditions such as surgery, broken bones, etc.  This also doesn’t apply to end of life care where opioids are the mainstay of palliation of pain and suffering.  I am well aware that there are people who benefit from opioids for chronic pain and use the medications appropriately.  From a population standpoint, however, we have to look at the vast harm that they have caused and limit their use.

Much of the medical community has accepted that starting patients on opioids for chronic — not end-of-life pain — is probably not a good idea.  The hard part is what to do with those who are currently on the medications.  Two years ago, my answer would have been to leave people on the medication regimen that they are stable with and avoid opioids with benzodiazepines (sedative, anti-anxiety medications).  Now, I think that most people taking opioids for chronic pain should try to wean off of the medications over a period of several months.  The reason that I say that is more practical than medical.  At the beginning of this year, Attorney General and All Around Creepy Guy Sessions announced that he is stepping up the prosecution of physicians and pharmacies related to opioids.  There are indications that medical and pharmacy licenses will be revoked, and physicians will be prosecuted.  If your physician’s livelihood and possibly freedom is at stake for trying to treat your medical condition, they will change their practices.  Most providers will not take transfers of patients using chronic opioids for pain, so you have to hope that your doctor is in good health.

On April 2, the DEA sent out a press release that they had a surge in enforcement and administrative resources.  During this 45-day surge there were 28 arrests, 54 other enforcement actions, and 283 administrative actions (including revocation of DEA license).  This is just the beginning.  The message is clear that something has to change.

Although individual experiences vary, opioids for chronic pain cause more harm than benefit.  This is a problem that has been caused or at least worsened by the pharmaceutical companies.  Nevertheless, the medical community is changing its practices.  The government, through legislature and enforcement, is responding to the opioid epidemic through further regulation and enforcement.

If you have chronic pain, opioids are unlikely the answer for your long-term pain control.  Soon enough your provider’s hands will be tied because we have allowed the pharmaceutical companies to set this runaway train down the tracks that we haven’t been able to stop ourselves.

If you can, consider weaning off of the medications while the choice is still yours.  If you find yourself unable to control your use, there are resources in the community.  You can email me at gregagreenberg@icloud.com for resources or suggestions for opioid addiction.

Greg Greenberg
Greg Greenberg grew up in Santa Monica, California. After undergraduate training at UCLA he attended medical school at Ohio State University and completed a residency in family medicine in Columbus, Ohio. He moved to Redding after residency in 2004 and has served the Redding community as a family physician, hospitalist, emergency physician, and, most recently, in addiction medicine. When he’s not enjoying the calm atmosphere of the emergency department he enjoys the chaos of being a full-time parent as well.
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44 Responses

  1. Avatar conservative says:

    There is wide variation in death rate by county for drug induced death.
    https://www.cdph.ca.gov/Programs/CHSI/CDPH%20Document%20Library/CHSP-County%20Profiles%202018.pdf
    See page 40.
    Humboldt and the other emerald triangle counties have some of the highest death rates for drug overdose and cirrhosis due to hepatitis C from injected drug use.

    209 Days until the election. This could be another blowout as Shasta County voters go to the polls to elect another BOS and Redding City council opposed to commercial pot growing.

    • Avatar conservative says:

      Then Chief Paoletti many times said that methamphetamine and heroin are cheap and abundant in Shasta County. Shasta county has less obvious gang activity (drive by shootings, graffitti, people wearing gang colors) than county seats like Oroville, Eureka, Marysville, Stockton, Yuba City etc.

      The cartels flood injectable drugs into the commercial pot growing regions. Cartels buy pot and pay for it in part with injectable drugs. The best evidence is the frequent seizures of cars transporting injectable drugs, pot, cash and illegal firearms.

      • Greg Greenberg Greg Greenberg says:

        Norco 10/325 costs about $7-10 in Redding per pill. My average patient who uses heroin spends about $20-40 per day for heroin. It’s cheap and easy to get.

  2. Avatar conservative says:

    https://www.cdc.gov/drugoverdose/maps/rxcounty2016.html
    Map of opioid prescription rate by county. The good news is the rate has fallen.

  3. Avatar Beverly Stafford says:

    Thanks for another informative column. Years ago, I asked my pharmacist husband what withdrawal is like. He said it’s pretty much like having the flu. It seems as though many people don’t want to experience any sort of pain if a pill will blunt it. It’s a bit like thinking we should always be happy. So much for reality.

  4. Avatar Jamie Watts says:

    Thank you Sir for the eye opening message. I hope people will wake up before it is too late. Loved working with you.

  5. Avatar Virginia says:

    Your article with information on opioid was well written, but unfortunately, even some smart enough to knowing they are addicted, don’t believe they are hurting worse from the opioid than they are from the regular pain they were trying to help. I know two women that are addicted and well educated, with one being an RN. So the only way to stop them from wanting, and sometimes getting more from doctors will be to take the drugs off the market.

    Sadly, the individuals and their doctors don’t seem to understand, 30 days with these meds and they become addicted.

    But one thing I feel you wrote in your article which is informative info is not political, but by inserting into the article your comment that was totally unnecessary, “Attorney General and All Around Creepy Guy Sessions” is disrespectful of the man, and your political views shouldn’t be brought into something so important to the public as the terrible opioid problem here in this Country. Needless to say, the article was very important, but please keep further columns without political rhetoric please. What you write it too important to make it political………… Thank you…..

    • Greg Greenberg Greg Greenberg says:

      Virginia, I agree that mocking Sessions was unnecessary but irreverence is my sense of humor and does creep into my writing. When the democrats gain any power, I will gladly mock them as well. Although I don’t think that Sessions’ extreme approach to the law is a good idea, my mockery is toward his creepiness and that’s based on his previous approach to racial issues as well as issues related to people’s sexuality when he was the Alabama attorney general.

      • Avatar Virginia says:

        May be your sense of humor, Greg, but please don’t bring that into subject matter that is so important.

        Catch more flies with honey, than vinegar. ;o)

        • Greg Greenberg Greg Greenberg says:

          You have a valid point. It’s a good thing you didn’t see the first draft of my article after some people talked some sense into me. 🙂

          • Avatar Beverly Stafford says:

            Golly, I found your Sessions comment appropriate.

          • Avatar Virginia says:

            It wasn’t appropriate at all, but you do recognize that fact. Good for you, even if other don’t. ! That is good thinking Doctor to understand. Not everything is political. ;o))

          • Avatar Common Sense says:

            A persons Opinion is just that….His or Her Opinion! My Opinion is Sessions is a Racist Baffoon. So whether you are a Doctor or not a doctor we are All Entitled to our Opinions! The reason people get so uptight and upset is when others Opinions go against their Beliefs! That creates Discord within. Get over it.

    • Avatar Mary Scarpete says:

      I totally agree with you Virgina, the doctor’s comment gave me a sour taste in my mouth.

      • Greg Greenberg Greg Greenberg says:

        Mary, I think this is part of the problem in our country. We have become so sensitive about any criticism of anyone who is part of our political party. Twenty years ago, nobody would bat an eye if someone took a jab at Janet Reno. Over the past twenty years, we continue to be more polarized and defensive. Now both conservatives and liberals have become snowflakes who are offended at the tiniest slight against their views.

        I understand where it’s coming from but I think your negative reaction to my comment may be a sign that you need to open yourself up to other view points. I’m to the left of center and I watch Fox News and listen to Bill O’Reilly’s podcast without being constantly triggered.

        • Avatar Virginia says:

          I don’t mind political discourse in it’s place. Yet, I feel it doesn’t belong in your article the way you wrote it. At least the swipe at the A.G., to me, seem inappropriate for the article. When you lose the value of what you write, then writing is worthless, Greg.

          And I for one, reading what you write about, which is medical, I find informative. Thanks for that……..;o)

  6. Avatar conservative says:

    Opioid prescription rate at VA hospitals has fallen by about 40%.
    https://www.data.va.gov/story/department-veterans-affairs-opioid-prescribing-data

  7. Greg, while we have never met I must say that I appreciate your Honesty and Candor and you having no problem calling it the way it is! I would think at this present time it must be very difficult for a Dr. especially with the pain/opioid topic. To not prescribe, you are labeled barbaric, to prescribe even what you believe to be an adequate amount and the person dies and you may be sued as a result. It sounds almost like a no-win situation now days for Doctors!

    With your column heading I thought for a moment you had become a 215 recommending Doc.

    There appears to be some medical benefits from other more natural sources but I am guessing in Medical school there is no education or training on any alternatives to the RX Drugs?

    As a respected Doctor in our Community, I am curious what your thoughts are on more natural pain relief options? This is obviously a very hot topic.

    • Greg Greenberg Greg Greenberg says:

      Richard, I think that the distinction between natural and artificial sources is an emotional distinction and says little about the benefits and harms of a given substance. That being said, the reference is clearly to marijuana!

      I wish we had good research on marijuana but the government’s limitations on research on a schedule I drug has stifled it. Although it’s not covered much in medical school and residency, it’s a common discussion at my addiction medicine conferences. Tomorrow I’m driving down to San Diego for the annual American Society for Addiction Medicine conference so I may have some updates.

      I think that marijuana clearly has some benefits for pain for some people. Over the years, I’ve seen many patients refuse opiates in lieu of marijuana for chronic pain. There seems to be little doubt that it has some benefits for chronic pain. Just like any other drug, you have to weight the risks versus benefits. Marijuana use disorder (addiction) is on the rise and that is clearly a risk of regular use. Marijuana has known harms in teenagers including psychological issues and many studies associate marijuana use in teenagers with lower IQ in adulthood. In other words, I’m ambivalent and the data is lacking. I’ve seen people helped and I’ve seen people harmed by marijuana. As a physician, I have recommended it to patients, but not many. For chronic pain, there is not a pill, an herb, or a bud that works well without a lot of side effects. Exercise, physical therapy, yoga, mindfulness, etc. have more proven benefits without a lot of side effects.

  8. Avatar conservative says:

    Before I retired, I went through several Joint Commission inspections as department chair and chair of other medical staff committees. One medical staff president used to say, “I never heard of a resident who wanted to be a Joint Commission doctor”. Joint Commission docs, by reputation, are burn outs who could not make it in practice. Many are from Talbott Marsh in Atlanta, the famous drug and alcohol rehab for doctors. They could not find any other employment because of their record before rehab.

    Amazing how the least regarded docs came to have so much influence in clinical practice. For a hospital to pass Joint Commission inspection, it had to implement aggressive pain control practices. In practice, that meant nurses calling docs at all hours of the day telling them patients requested more narcotics. Docs got in the habit of prescribing narcotics for longer periods to avoid the phone calls. Patients who only needed a day or two of narcotics after a fracture or wisdom tooth extraction got prescriptions for 30 pills.

    • Greg Greenberg Greg Greenberg says:

      None of us went into medicine because we like to argue with patients, nurses, and administrators. More often than not, I see people give in to avoid the fight. It’s understandable but we see where that has led. The drug companies hold a lot of responsibility for our current opioid epidemic. However the same politicians who point fingers at Purdue forget their own contribution when creating these regulations that require us to address pain and send incompetent administrators to cite hard working clinicians (forgive the hyperbole). The pharmaceutical industry has spent well over $2 billion in the last decade for lobbying our politicians.

      Unfortunately, the culture change in medicine is going to require a fear of prosecution or at least loss of a medical license along with regulations imposed on clinicians. I’m sure that our politicians will go too far in the other direction in order to garner votes and sound bites.

      • Good points! When some people start blaming the Doctors for the Opioid problems I am the first one to point a finger at the RX companies. With the Record profits made + their Lobbying efforts etc, its clear to me that money comes well before patients. My Mother was an R.N for 28 years and Doctors and Nurses are exceptional in my opinion!

      • Avatar Jane Babin says:

        Perhaps Redding has been insulated, but the pendulum has swung far to the other side already in many parts of the country. Chronic pain patients are the sacrificial lambs offered up by the likes of Andrew Kolodny, Jayne Ballantine and others who have a stake in the expansion of lucrative addiction treatment practices and centers. I certainly hope that you, or someone you love, Dr. Greenberg, have the opportunity to empirically determine whether and to what extent someone (you, perhaps, or you mother, father spouse, child…) is more able to live with adhesive arachnoiditis, trigeminal neuralgia, chronic pacreatitis, failed back surgery or a litany of other conditions with opioid medications or without. More importantly, whether such person’s care should unilaterally determined by the DEA, CDC, Congress, CMS, the VA or yourself. Thankfully we live in a state that protects patient’s right to adequate pain relief, despite your own views. – you many need to exercise that right one day.

  9. Avatar conservative says:

    Shasta county voters should read the Eureka Times Standard, like this recent story. What the drug culture is doing to Humboldt county should motivate voters on election day.
    http://www.times-standard.com/general-news/20180406/humboldt-county-law-enforcement-seizing-more-heroin

    Residencies have journal clubs and regular lecture series. Residents know a lot about marijuana and alternative healthcare. I suspect most residents saw pot users when they were undergrads and saw students with the grades and SAT scores to be engineers flunk out. In my day they went to Vietnam.

  10. Avatar Rebecca says:

    You failed to address us terminal cancer patients who are adversely affected by this Opiod Crisis. I am literally dying and have increasingly terribly pain. It is not from the opioids, it is from Cancer.
    The fact that we are not able to get the meds we need, are treated terribly by pharmacies, and have to be drug tested to ensure we are taking the drugs is not something we should endure.
    It is a real problem for those of us supposedly exempt.

    • Greg Greenberg Greg Greenberg says:

      Rebecca, I’m sorry for what you are going through. I think I mentioned that end of life care is an exception to what I referred to. It is truly a different category where the goals and risks are different.

      • Avatar Jane Babin says:

        How does terminal, end of life pain differ qualitatively from chronic non-terminal pain, exactly? Far too often and at an increasingly alarming rate, untreated chronic non-terminal pain is becoming terminal when it ends with suicide.

  11. Avatar Cassandra Estep says:

    Dr Greenberg,
    I tried to send you an email at the above address (gregagreenberg.icloud.com ) I keep getting an error that it’s an invalid email, do you have any other way of contacting you(private ) ?

  12. Avatar Crystal says:

    How dare you disrespect this fine man. Sessions is a gentleman among the average repressive racist!

  13. Avatar Patricia Bay says:

    Great article. Thank you.

  14. Avatar Joanne Lobeski Snyder says:

    Greg Greenberg, this article is brilliant. It is about all of us, even if we think we’re better than those “drug addicts”, because any of us can become addicted if we don’t understand the sorts of risks you described with taking what-have-become-common medications for pain. I have two thoughts.
    The first is that friends who became addicted just followed doctor’s orders without paying attention to health changes due to long term use of the drugs. Their health was in the doctor’s hands. They weren’t actively participation in their recovery. I’m convinced that the pain med “discussion” you wrote about would have made a difference. In a couple of cases, people I knew started having a succession of surgeries…one man had 12 surgeries on the same shoulder.
    My second thought is that we all have to take a good look at the pain we experience and explore other ways to deal with the pain than with medication. I’ve resorted to opioids for excruciating pain, but tried other methods successfully for a broken bone and rotator cuff tear. Yoga and exercise has helped myself and others for neck and back pain. I want the opioids be be there when I really need them.

  15. Avatar conservative says:

    The good news: the rate of opioid prescriptions has already fallen and the trend will continue.
    The bad news: synthetic opioids like fentanyl and derivatives are more potent, more lethal, and are cheaper and easier for organized crime to produce than heroin from opium poppy. Fentanyl derivatives are made in China and North Korea. Manufacturing is spreading rapidly to Mexico and other Latin American countries. A small amount is made in the U.S. Organized crime is distributing pills made to look like prescription drugs, but made with fentanyl.

    There are two pathways to opiod addiction: one is via prescription drugs. The other is like the path to methamphetamine which does not involve medicalization. Many opioid users in their teens and 20s are people seeking to get high and the cartels are very good at flooding the market with cheap options.

  16. Avatar Ann says:

    It’s all well and good to say “wean off” but I wish you had given better instruction on where to get help to wean off. For instance, acupuncture can help with the withdrawals AND the pain management.
    Counseling, hypnosis, exercise, accountability partners, and, of course, drug rehabilitation could all be mentioned. Even if a user KNOWS and WANTS to stop, doesn’t mean they CAN by themselves. Optiod withdrawl is a bear–a little direction on how to kill this beast is needed. Thank you.

  17. Avatar Suzanne Nelson says:

    I am not a pill popper and gave birth to 3 kids at home with no meds. But for a year (2016) i needed vicodin round the clock typically to cope with increasing pain from stage 4 terminal triple negative breast cancer. I got in to a clinical trial and no longer need pain meds right now.but want access if i need them again.

    Here’s a thought…let’s focus on the diseases that lead people to opiod use. Such a stage 4 breast cancer. A terminal condition. About the same number of people die from this annually as opiod overdoses. Add other cancer types and the numbers go up dramatically.

    In CA it is more than sadly ironic that a physician can give you an RX to kill yourself (death with dignity or whatever other pretty name you want to call it) but now they may face negative repercussions for giving regular opiod RX to people who choose to live with pain instead of death and want relief? So wrong. And for people who want to comment that it excludes terminal cancer I know of too many people already who are problems with getting their pain RX filled here and there this year.

    Before cancer I preferred OTC ibuprofen first if i needed pain meds…but now am on blood thinners so i can’t take that anymore. Vicodin is most effective RX for me.

  18. Avatar Linda Cooper says:

    I have had an illness for eighteen years. There is no known cure, and it’s listed on the Medicare site as a justified disability. Fortunately, with appropriate pain management, I was able to work until retirement, and not “take” disability. My pain management was fairly simple. 3 hydrocodone-acetamin a day as needed. This has been reduced by fifty percent, with a “promise” of more reductions to come. There has been a suggestion of taking Tramadol, which I understand from my web searching, is even more difficult to “come off of” than my present prescription.

    I’m in pain. I now have trouble walking, which is contributing to other problems. I missed Grandparent Day at my grandchildren’s school this year, which is five hours away. I’m having trouble standing, and cooking my typical healthy meals.

    And yes, I have tried all kinds of therapies. Including being so desperate, I once spent $5,000 on some questionable alternative therapy.

    I really don’t like to disclose on social media. However, when I read some of the comments from those with cancer, I felt a need to contribute and to lend my support. My reservations about articles such as this, is that there is no delineation between those who have responsibly not doctor shopped, and who have one pharmacy, verses the epidemic of those who acquire the drugs illegally. Pain advocacy groups define an addict as one with a reduced quality of life, and one with appropriate pain management as an increased quality of life.

    There is an answer. I read “Chasing the Scream: The First and Last Days of the War on Drugs,” by Johann Hari for my book group. In the final chapter, he describes how Portugal decided to eliminate the enforcement of drugs, and direct the money saved into rehab centers. Beautiful ones! With tea and massage and comfort. And it’s working! That will never happen in America. The culture seems to be such that one is expected to “fight” their disease, instead of being given comfort. And what about those veterans, who are committing suicide because their meds have been denied, and they can’t live with the pain? Unconscionable in my mind.

    There is a political reason for all this, that I haven’t figured out yet. Especially when alcohol and tobacco are so readily condoned. Additionally, marijuana is now legal! (I grew up watching anti-Jane films in 8th grade where pot heads cracked glass soda bottles and drank out them because someone was high.) I’m not against any of the listed items, just curious why these venues are legal, and pain relief between a doctor and patient isn’t as readily available. It’s like political kabuki, with pain patients not being protected.

    I do feel for the compassionate doctor who is fearful of prescribing, for fear of losing their profession. Somehow, on a federal level, there has got to be a means to reduce the liability for the doctors. Because people are suffering.

    • Avatar Common Sense says:

      The One thing that can help you and others from Pain is the one thing Jeff Sessions fights tooth and nail. When one can “Open up their minds” and get over the Refer Madness programming, their pain will vanish upon using Cannabis. My Father, bless him, was brainwashed by the Propaganda of the 40’s and still continues today to lesser extent.He had so much pain in his late 70’s he could Hardly get out of bed. After sharing good info with him for YEARS, and the fact his pain was So great….he finally tried it! He can now sleep at night ( first time in 30+ years after his back surgeries…sometimes up to 8 hours now!…before he got 3-4 hours on a good night. Even after all the relief he felt and the improvement he is still not an advocate and still won’t 100% admit that it works the best (stubborn old cush at times)…..its the best pain med to help people with the least amount of side effects!

      As I have learned, Peoples Cognitive Dissonance is just too deep on the topic! Just ask Jeff Sessions!!

  19. Avatar Tim says:

    Yes, drug companies overhyped their drugs, but that is nothing new and certainly not unique to opiods. So I think doctors & the US medical culture bear a lot of the blame for simply accepting biased parties’ say so as the truth.

    Over the past few decades, the medical industry has been emphasizing speed more and more. 5 minute office visits. Snap judgements.

    Other professions have moved away from this because of the perils of “system 1” thinking. Pilots are forced to slow down and go over a preflight checklist before taking off — a condescending procedure for smart men, but one that dramatically cut down on accident rates. After disasters like the Tacoma Narrows Bridge and St. Francis Dam, the engineering profession began to force students to slow down and use a methodical framework for problem solving & design (e.g. identify the problem, list constraints, list assumptions, work through a solution, check the results, and re-enter the design loop if necessary). There is no reward for getting the answer first and few professors give “partial credit” for wrong answers — so students are forced to really slow down and use System 2.

    After numerous studies showed predictably irrational sentencing (e.g. judges hand down longer sentences right before lunch), there is even a push now in the legal profession to make a judge’s sentencing methods more rational.

    Yet for all its basis in science, “accepted medicine” is surprisingly not very methodical. Even Dentists fall victim (e.g. there is no scientific basis for flossing). Drug companies & lobbyists employ super-attractive people and employ every psychological trick in the book to slowly influence the industry into unsound positions. Just look at the differences between what is considered the “normal range” on various blood tests internationally vs in America. For instance, globally the normal range for the TSH test is 0.5 to 5.0, with treatment not recommended unless the TSH exceeds 10. In America, the drug industry has lobbied for 0.3 to 2.5 to be considered “normal” with treatment not recommended unless the TSH exceeds 3.0. 4 times as many people *need* a prescription for hypothyroidism in the US as a result!

    That’s one of the most dramatic differences on a blood panel, but there are others. Taken together, its not hard to see why the number of Americans with a prescription has jumped from 40% in the 80s and 90s to 50% in the oughts to 70% today. Canada, with its free healthcare, has just 40% of its population taking a prescription.

    But it isn’t just drug companies. Doctors have been too quick to suggest dramatic (and untasty) changes in diets. Remember saturated fats? A bunch of foods were reformulated to be healthier. And then we found out that the replacement trans fats were even worse for us! Then they suggested replacing animal fats with vegetable oils and pointed to lower cholesterol numbers as proof this was healthier. But the most rigorous studies showed people substiting vegetable oils did not actually live longer despite lower cholesterol. In fact, the study strongly suggested slightly shortened lifespans! Turns out that aldehydes are worse for you than lard…

    So yeah, drug companies are greedy. But the US medical industry tends to be overconfident and intellectually lazy when it comes to the next new thing.

  20. Avatar conservative says:

    In my specialty, I seldom prescribed after internship. There are plenty of excellent sources available to a doc, like The Medical Letter (subscription), journal articles, Handbook of Medical Therapeutics (also peds and surgery), continuing education courses which are required to maintain a license. Most docs totally ignore drug company advertising like you ignore the pitches we are exposed to every day. Many docs don’t allow drug reps to call on their offices, even though they bring coffee mugs, pens, sweatshirts, hats and bags of bagels with creamed cheese which the overweight staff don’t need. A doc has an ethical duty to inform himself about the best therapeutics. Drug reps are pretty much regarded as bottom feeders. The worst nightmare is to make some malpractice mistake, lose the license and wind up a drug rep.

    The joint commision should never have had such influence on standard of care. The Joint commission does not determine the standard of care for anything else I know of. The standard of care should be set by academic hospitals and the medical literature.It was a crazy over-reach by regulators. Hospitals, nursing administrators will do whatever it takes to pass the inspection, even though 99% do. Failing the inspection means the hospital cannot bill Medicare. The Joint commission job is to make sure hospitals follow the standard of care. Instead the joint commision took it on itself to set the standard of care by requiring nurses to ask patients about their pain and document. In my day, a patient rang the call button or asked the nurse when he needed pain medicine.
    The joint commision crusade to create documentation led to nurses making phone calls to docs when the patient, in response to questioning, said he was uncomfortable. The root cause of American overprescribing opioids was botched regulation by the joint commision with their crusade called “pain is the fifth vital sign.”

    Doctors really do know a lot about the drugs they use and have plenty of resources. Docs frequently discuss issues at monthly department meetings. In a group, there is active peer review. If a doc in making mistakes, it can effect the livelihood of the rest of the practice. Hospitals are required to have a pharmacy and therapeutics committee which studies problem prone drugs like antibiotics. A doc whose prescribing practices are out of line with his peers is likely to be called by one of the docs on the p&t committee or a hospital pharmacist.

    In our group we used to say, “if you screw up, the group will get you long before the medical staff or state medical board”.

  21. Avatar Fred W. says:

    The is very much Opinon” There is a huge difference between someone living in chronic, debilitating pain and a backache. You struggle totally disregarded those that suffer from severe chronic pain and rely on these medications to have any semblance of a real life. We don’t need high, we don’t abuse medications, but we are being treated as and our medications cut..at times with deadly consequences. Age has nothing to do with it, so your reference to young adults vs seniors is irresponsible. You obviously are not a specialist that deals with patients suffering from true chronic pain. I have been on these medications and others for years, no increase in dosage but they are used with other medications, and living a reasonably normal life, where before I was bedridden of and on since I was 13, I am now 56. Addiction is a disease of its own, I also know that the CDC itself has admitted grossly inflating the numbers of deaths related to prescription drugs by gripping ALL forms of opiate derived drugs, including illicit drugs and one does not equal the other. When you have real pain, all there is, is relief from the constant pain. I hope that noon one you love our care about is stricken by this type of debilitating pain, but if you did, maybe you wouldn’t be so cavalier and mocking of those who are.

  22. Avatar Tim says:

    A new report indicates that cutting off opiod prescriptions has caused an increase in overdoses due to people turning to unsupervised illicit opiods: http://reason.com/blog/2018/04/19/as-opioid-prescriptions-fall-opioid-deat