ALTO....sounds like a muppet character

[Groove]

---

Members don't see this ad.

Contary to the current opioid crisis political talking points, physician't aren't the problem. Addicts will be addicts. People who want to get high will use precription drugs if they have it, and street drugs when they don't.

I'm not saying that more stringent standards for prescribing and/or utilizing them shouldn't be used by physicians, but let's get real... if you want to curb addiction, you've got to do something about the $100+ billion/yr illegal drug trade.

I don't know about you guys, but I don't get many Rx overdoses on lortabs these days. I get heroin and fentanyl OD and I had one die on me a week ago and one barely make it. Physicians aren't anywhere near the primary problem. I'm disgusted that we're the ones getting singled out as the reason people are addicted to drugs in this country.

This whole opioid "crisis" hysteria is going to swing completely backwards in the other direction as soon as we get more chronic pain martyrs committing suicide because they were cut off from their narcs. I'm already starting to see the articles. You watch...I give it 5 or 6 years, tops.

 

[Groove]

Watch, you'll start seeing more of these:

As doctors taper or end opioid prescriptions, many patients driven to despair, suicide

Doctors and medical establishments are sharply reducing doses of – or altogether no long prescribing -- pain medications, leaving many among the estimated 20 million Americans who suffer from daily debilitating chronic pain to consider ending their lives, and many others to kill themselves.

www.foxnews.com

 

[GeneralVeers]

Contary to the current opioid crisis political talking points, physician't aren't the problem. Addicts will be addicts. People who want to get high will use precription drugs if they have it, and street drugs when they don't.

I'm not saying that more stringent standards for prescribing and/or utilizing them shouldn't be used by physicians, but let's get real... if you want to curb addiction, you've got to do something about the $100+ billion/yr illegal drug trade.

I don't know about you guys, but I don't get many Rx overdoses on lortabs these days. I get heroin and fentanyl OD and I had one die on me a week ago and one barely make it. Physicians aren't anywhere near the primary problem. I'm disgusted that we're the ones getting singled out as the reason people are addicted to drugs in this country.

This whole opioid "crisis" hysteria is going to swing completely backwards in the other direction as soon as we get more chronic pain martyrs committing suicide because they were cut off from their narcs. I'm already starting to see the articles. You watch...I give it 5 or 6 years, tops.

The whole reason we have a problem (that the rest of the world doesn't) is that we are starting opioid-naive patients on narcotics for relatively minor complaints, like sprains, back pain, headaches, and other issues which could be handled with NSAIDS. The numbers suggest that 1 in 50 opioid-naive people will develop dependence or addiction. The best practice would be to not start people on these to begin with. People are killing themselves because doctors have been their legal drug dealers for 30 years, and now they are cut off.

 

[deleted109597]

No, the reason why people get addicted to heroin is it’s the most addictive substance commonly used by man. No ER docs use heroin for migraines.

Swing and a miss

Also, most people don't start with heroin in the streets. They start with normal pharmaceuticals. They end up on heroin. Read Dreamland.

 

[DrDrummer]

They're not the same drug. Replacing the hydroxyl groups via acetylation makes it less polar and makes it more fat-soluble, therefore heroin crosses the blood-brain barrier more readily and is thus much more potent / euphorogenic than morphine. Hydromorphone has similar properties which, probably among other reasons, is why people get so fixated on getting Dilaudid. That's one reason among others I avoid using hydromorphone.

 

[gro2001]

Contary to the current opioid crisis political talking points, physician't aren't the problem. Addicts will be addicts. People who want to get high will use precription drugs if they have it, and street drugs when they don't.

I'm not saying that more stringent standards for prescribing and/or utilizing them shouldn't be used by physicians, but let's get real... if you want to curb addiction, you've got to do something about the $100+ billion/yr illegal drug trade.

I don't know about you guys, but I don't get many Rx overdoses on lortabs these days. I get heroin and fentanyl OD and I had one die on me a week ago and one barely make it. Physicians aren't anywhere near the primary problem. I'm disgusted that we're the ones getting singled out as the reason people are addicted to drugs in this country.

This whole opioid "crisis" hysteria is going to swing completely backwards in the other direction as soon as we get more chronic pain martyrs committing suicide because they were cut off from their narcs. I'm already starting to see the articles. You watch...I give it 5 or 6 years, tops.

Check out this graph. I use this one in a talk I give about substance abuse. It's data from the International Narcotics Control Board, which tallies up all the opiates prescribed in just about every country, converts it to a morphine equivalent, and divides per capita. Includes what's administered in hospitals and prescribed. Does not include street drugs.

I think it's interesting for a number of reasons, but one of them is that it puts in context just how much more opioids are used in the US compared to the world average (admittedly dragged down by lots of places with no functional healthcare delivery) or a random prosperous country (Sweden).

Also the downtrend starting around 2010-2011 has led to a lot of people who are now addicted to prescription opioids without a legal source of opioids. A lot have switched to buying pills on the street, and eventually to heroin once the increasing tolerance makes Percocet unaffordable in quantities that they would need.

 

[d2305]

I've seen DHE 45 work well. Bet no one remembers Sansert.

 

[thegenius]

Swing and a miss

Also, most people don't start with heroin in the streets. They start with normal pharmaceuticals. They end up on heroin. Read Dreamland.

Wow...you so easily show how changing two acetyl groups for two hydroxy groups turns a Schedule 1 extremely addictive drug with no accepted medical use to one that is legal to use in our health care system. Amazing that a small change in moieties can produce different physiologic results!!

You had your eyes closed with your pitch. Swing and a home run!

I'm winning, 5-2. Your being yanked for a reliever. You give up too many big hits (but you do have an effective slider though.)

 

[Groove]

Check out this graph. I use this one in a talk I give about substance abuse. It's data from the International Narcotics Control Board, which tallies up all the opiates prescribed in just about every country, converts it to a morphine equivalent, and divides per capita. Includes what's administered in hospitals and prescribed. Does not include street drugs.

View attachment 277332

I think it's interesting for a number of reasons, but one of them is that it puts in context just how much more opioids are used in the US compared to the world average (admittedly dragged down by lots of places with no functional healthcare delivery) or a random prosperous country (Sweden).

Also the downtrend starting around 2010-2011 has led to a lot of people who are now addicted to prescription opioids without a legal source of opioids. A lot have switched to buying pills on the street, and eventually to heroin once the increasing tolerance makes Percocet unaffordable in quantities that they would need.

And who's fault is that?

The Opioid Epidemic: It’s Time to Place Blame Where It Belongs - PMC

www.ncbi.nlm.nih.gov

The other part of my criticism has to do with the overall victim culture that we live in. Everyone is looking to blame someone else for their poor decisions. We can blame Purdue, Joint Commission, Press Ganey, CMS, physicians for overprescribing, but at the end of the day...human beings have been abusing the opium poppy since 3500 BC. Way before any of these institutions existed. Addicts will be addicts! Yes, hydrocodone has addiction potential. So does alcohol, so does nicotine, so do McDonald's french fries and Doritos for that matter. In the end, people will choose to abuse things...because they can and because they make poor decisions. That's just human nature. Sooner or later people have to own up to their bad decisions and take responsibility for them instead of blaming everyone else.

Have you ever had a narcotic? I have and it sure as hell didn't create a craving for street heroin or make me want to steal morphine from the hospital Pyxis. The dilaudid IV upon waking after my cervical spine surgery was instant relief for what felt like a molten hot rod running down my spine. It was miraculous pain relief. I thanked the nurse over and over before I drifted back to sleep. I've never had it since and hope I never need it again. What about all those hydrocodone tabs that my ENT Rx when I underwent an adult tonsillectomy. Any idea how much those hurt? You can't even take a nap on day 3-4 because it feels like razor wire coated with Carolina Reaper sauce in the back of your throat. Those little pills were miraculous on days 3-4 and helped me sleep and get some much needed relief. Did I gobble them down and start buying some off the street? Of course not. I've still got 3/4 of the prescription in a bottle 2 years later.

It's as if human beings are becoming so helpless that we as physicians can't prescribe ANYTHING with addiction potential. I find it laughably ironic that states and the gov want to spend so much time wiping narcotics off the face of the continent, while politicians continue spearheading efforts to legalize marijuana. All while completely ignoring the $100 Billion dollar illegal drug market in this country. I sincerely doubt most of my fentanyl/heroin overdoses in the ED became addicted through valid narcotic prescriptions in the past.

Heroin....2000kg seized at our SW border a decade ago. 8000kg seized today. But hey, I'm sure it has nothing to do with our current problem and everything to do with those pesky lortab prescribing doctors.

Here's a few facts some might find interesting:

What should that show you? That we're a rich nation with a massive market for illegal drugs making us the number one destination for crime syndicate drug operations. I don't disagree that narcotic use has gotten out of hand in the U.S. nor do I disagree that physician's have been prescribing too many of them over the years. I just don't think that people are helpless little lambs being led to the slaughter nor do I think physicians should be solely to blame for overprescribing (see my first article). All the prescribing policy change in the world won't get carfentanyl and all the other maximum potency synthetics off the street and out of people's hands. I don't know about you guys, but I didn't used to get half the number of critical condition overdoses until all this fentanyl hit the streets. I've seen a rapid increase in my practice that correlates EXACTLY with the fentanyl rise in popularity. I wish as much energy was being spent to get this stuff off the streets compared to how much is being spent to influence physician prescribing patterns.

 

[VA Hopeful Dr]

So couple things:

First, different people respond to opioids differently. I have patients who actively hate the way it makes them feel. I have some that love the way it makes them feel outside of just the pain control part. Some current theory is that your rapid metabolizers are like that - after all, its not the hydrocodone that gets you high, its the hydromorphone its metabolized to that does.

Second, lots of people do whatever the doctor tells them. After my vasectomy I took 2 norco and then nothing but motrin from there on. But there are people who will dutifully take 1 tab q4h for the 7 days the prescription is good for. Combine that with point 1 and you have the makings of a problem.

Third, I don't think many people are saying patients are completely blameless. But neither are we.

 

[Groove]

Yes, thank God for the genetic variance argument that allows morbidly obese people to continue to eat 6 Big Macs a day and blame it on a "slow metabolism". The alcoholic who just can't quit because he's "predisposed". The cigarette smoker who's "tried everything" and just "can't" quit. Human beings are predisposed to all sorts of vices but in the end we choose or choose not to indulge them. I'm sure my philosophy probably rubs a lot of addiction psychologists the wrong way, but it's just how I feel and how I view the world. Nobody is helpless.

 

[BoardingDoc]

Wow...you so easily show how changing two acetyl groups for two hydroxy groups turns a Schedule 1 extremely addictive drug with no accepted medical use to one that is legal to use in our health care system. Amazing that a small change in moieties can produce different physiologic results!!

You had your eyes closed with your pitch. Swing and a home run!

I'm winning, 5-2. Your being yanked for a reliever. You give up too many big hits (but you do have an effective slider though.)

Umm, that's the breakdown pathway of heroin. E.g. heroin turns into morphine in your body. Heroin itself has a relatively low affinity for mu-receptors. It's the conversion to morphine that is getting people high.

As for the "single dose in the ED for a headache" post from earlier: vehemently disagree. All the data out there suggests that opioids should not be used in headache treatment. Whether it's one and done vs an Rx, it's still bad medicine.

 

[deleted109597]

Came back in to say the same thing. That's literally how it is metabolized in the body.

And yes, there is genetic variability. Not in the "slow metabolism 6 Big Mac" way, but the actual neurochemistry that leads to addiction. Sometimes it only takes a single dose.


And I can't even fathom how you can both blame all of it on the patients, and then continue to give opioids for headaches.

 

[Groove]

And I can't even fathom how you can both blame all of it on the patients, and then continue to give opioids for headaches.

What did I say? I said that most respond to toradol,reglan,benadryl combo and for the "select few" I add in 4mg morphine. Hey, it works. To my knowledge, nobody has designed a study to see if low dose morphine has any synergy with non opioid abortive therapies. That being said, most don't ever require it. That's a far cry from opioid first line therapy for migraines.

 

[VA Hopeful Dr]

Yes, thank God for the genetic variance argument that allows morbidly obese people to continue to eat 6 Big Macs a day and blame it on a "slow metabolism". The alcoholic who just can't quit because he's "predisposed". The cigarette smoker who's "tried everything" and just "can't" quit. Human beings are predisposed to all sorts of vices but in the end we choose or choose not to indulge them. I'm sure my philosophy probably rubs a lot of addiction psychologists the wrong way, but it's just how I feel and how I view the world. Nobody is helpless.

I must have missed where I mentioned anything about obesity, want to go point out where I said that?

 

[carbonizedeyesockets]

What did I say? I said that most respond to toradol,reglan,benadryl combo and for the "select few" I add in 4mg morphine. Hey, it works. To my knowledge, nobody has designed a study to see if low dose morphine has any synergy with non opioid abortive therapies. That being said, most don't ever require it. That's a far cry from opioid first line therapy for migraines.

There are SO MANY other options than morphine for 2nd and 3rd line. I use valproate with good results. Have used magnesium. Never ever have considered morphine. I rarely tell anyone to consider changing their practice, but this is a situation where I think it is a great idea to try other options.

 

[thegenius]

As for the "single dose in the ED for a headache" post from earlier: vehemently disagree. All the data out there suggests that opioids should not be used in headache treatment. Whether it's one and done vs an Rx, it's still bad medicine.

I agree, I never argued that narcotics should be used for migraines.

 

[WilcoWorld]

FYI for doctors who want to call things by their correct names:
narcotics =/= opioids

 

[BoardingDoc]

FYI for doctors who want to call things by their correct names:
narcotics =/= opioids

Just to further complicate matters though, while narcotics != opioids, opioids do == narcotics.

Brief definition list for people who don't know the difference:
Narcotics = Any sleep inducing substance. Typically has a connotation of being illegal though that isn't required. Examples include heroin, oxycodone, valium. Caveat: the DEA specifically defines narcotics as opioids which as noted below, would not include benzos.
Opioids = Any substance that binds to an opioid receptor in the brain. Examples include morphine, fentanyl, dilaudid.
Opiates = Any drug derived from the poppy plant. Examples include codeine, heroin, morphine.

 

[d2305]

Many opioid addicts never want to stop and will stay on methadone or suboxone forever. Alcoholics just stop.

 

[thegenius]

And who's fault is that?

The Opioid Epidemic: It’s Time to Place Blame Where It Belongs - PMC

www.ncbi.nlm.nih.gov

The other part of my criticism has to do with the overall victim culture that we live in. Everyone is looking to blame someone else for their poor decisions. We can blame Purdue, Joint Commission, Press Ganey, CMS, physicians for overprescribing, but at the end of the day...human beings have been abusing the opium poppy since 3500 BC. Way before any of these institutions existed. Addicts will be addicts! Yes, hydrocodone has addiction potential. So does alcohol, so does nicotine, so do McDonald's french fries and Doritos for that matter. In the end, people will choose to abuse things...because they can and because they make poor decisions. That's just human nature. Sooner or later people have to own up to their bad decisions and take responsibility for them instead of blaming everyone else.

Have you ever had a narcotic? I have and it sure as hell didn't create a craving for street heroin or make me want to steal morphine from the hospital Pyxis. The dilaudid IV upon waking after my cervical spine surgery was instant relief for what felt like a molten hot rod running down my spine. It was miraculous pain relief. I thanked the nurse over and over before I drifted back to sleep. I've never had it since and hope I never need it again. What about all those hydrocodone tabs that my ENT Rx when I underwent an adult tonsillectomy. Any idea how much those hurt? You can't even take a nap on day 3-4 because it feels like razor wire coated with Carolina Reaper sauce in the back of your throat. Those little pills were miraculous on days 3-4 and helped me sleep and get some much needed relief. Did I gobble them down and start buying some off the street? Of course not. I've still got 3/4 of the prescription in a bottle 2 years later.

It's as if human beings are becoming so helpless that we as physicians can't prescribe ANYTHING with addiction potential. I find it laughably ironic that states and the gov want to spend so much time wiping narcotics off the face of the continent, while politicians continue spearheading efforts to legalize marijuana. All while completely ignoring the $100 Billion dollar illegal drug market in this country. I sincerely doubt most of my fentanyl/heroin overdoses in the ED became addicted through valid narcotic prescriptions in the past.

Heroin....2000kg seized at our SW border a decade ago. 8000kg seized today. But hey, I'm sure it has nothing to do with our current problem and everything to do with those pesky lortab prescribing doctors.

Here's a few facts some might find interesting:

View attachment 277347
View attachment 277348
View attachment 277350View attachment 277349

View attachment 277351

What should that show you? That we're a rich nation with a massive market for illegal drugs making us the number one destination for crime syndicate drug operations. I don't disagree that narcotic use has gotten out of hand in the U.S. nor do I disagree that physician's have been prescribing too many of them over the years. I just don't think that people are helpless little lambs being led to the slaughter nor do I think physicians should be solely to blame for overprescribing (see my first article). All the prescribing policy change in the world won't get carfentanyl and all the other maximum potency synthetics off the street and out of people's hands. I don't know about you guys, but I didn't used to get half the number of critical condition overdoses until all this fentanyl hit the streets. I've seen a rapid increase in my practice that correlates EXACTLY with the fentanyl rise in popularity. I wish as much energy was being spent to get this stuff off the streets compared to how much is being spent to influence physician prescribing patterns.

What's up with Spain and cocaine use? Seems a bit random. Maybe they like to party. I like how there is no data for Great Britain.

 

[gutonc]

What's up with Spain and cocaine use? Seems a bit random. Maybe they like to party. I like how there is no data for Great Britain.

That's because they're all going to Ibiza to do coke...hence Spain's bright red nature on the coke map.

 

[Groove]

Speaking of cocaine...If you guys haven't watched "American Made" with Tom Cruise playing Barry Seal (true story), you should totally watch it. Incredible story.

 

[deleted109597]

For the record, we are red on the opioid map because we prescribe close to 80% of the world's opioids, and 99% of the world's hydrocodone. With 4.4% of the population.

https://www.health.state.mn.us/communities/opioids/prevention/painperception.html

The things we give narcotics for, other countries give tylenol, or a warm glass of suck it up. But here's the thing. Doctors are prescribing them (well, and NPs/PAs). I've never seen a single person say "well, I just went and started using heroin". They use it because they're addicted to opioids and it's all they have left.

Nobody has ever died of pain. More people die from pain medicine than guns, MVCs, or the flu every year.

Again, I implore everyone to read Dreamland
Amazon product ASIN B00U19DTS0

 

[Groove]

They use it because they're addicted to opioids and it's all they have left.

Not true.

Heroin use is rare in prescription drug users | National Institute on Drug Abuse

While prescription opioid abuse is a growing risk factor for starting heroin use, only a small fraction of people who abuse pain relievers switch to heroin use.

www.drugabuse.gov

While prescription opioid abuse is a growing risk factor for starting heroin use, only a small fraction of people who abuse pain relievers switch to heroin use. According to general population data from the National Survey on Drug Use and Health, less than 4 percent of people who had abused prescription opioids started using heroin within 5 years (Muhuri et al., 2013). This suggests that prescription opioid abuse is just one factor in the pathway to heroin. Furthermore, analyses suggest that those who transition to heroin use tend to be frequent users of multiple substances (polydrug users) (Jones, et al., 2015)

If you haven't met any heroin users in your ED that were not addicted to prescription pills first before using/absuing heroin, you either aren't looking or aren't asking the right questions. I just logged into work following up on one of my pt's who got an addiction consult and they talk about how he got addicted to IV heroin as a teenager.

I lived in a foster home as a teen with a guy who unbeknownst to me was a closet IV heroin user and I didn't find out until years later. He didn't abuse any prescription pills.

Open your eyes. Most of these addicts did not get addicted through physician prescriptions and then switch to hardcore drugs. An increased supply of 6000kg of heroin over 10 years to our country being smuggled through our borders. You think that's for all the prescription users? Illegal drugs are killing this country and killing our youth.

 

[Groove]

Here's some date from San Francisco:

Opioid Overdose Deaths in the City and County of San Francisco: Prevalence, Distribution, and Disparities - PubMed

Drug overdose is now the leading cause of unintentional death nationwide, driven by increased prescription opioid overdoses. To better understand urban opioid overdose deaths, this paper examines geographic, demographic, and clinical differences between heroin-related decedents and prescription...

www.ncbi.nlm.nih.gov

Most deaths also involved other substances (74.9%), most commonly cocaine (35.3%), benzodiazepines (27.5%), antidepressants (22.7%), and alcohol (19.6%). Deaths were concentrated in a small, high-poverty, central area of San Francisco and disproportionately affected African-American individuals. Decedents in high-poverty areas were significantly more likely to die from methadone and cocaine, whereas individuals from more affluent areas were more likely die from oxycodone and benzodiazepines. Heroin decedents were more likely to be within a younger age demographic, die in public spaces, and have illicit substances rather than other prescription opioids.

 

[GeneralVeers]

Not sure why we even need to have these discussions. We know opioids/opiates/narcotics are bad, and have devastating consequences. Can we please stop prescribing them for: back pain, headache, lacerations, sprains, strains, chest pain, abdominal pain, and abscesses?

Now I pretty much give them only for fractures with the occasional shingles patient.

 

[Groove]

Increased use of heroin as an initiating opioid of abuse: Further considerations and policy implications - PubMed

Given that opioid novices have limited tolerance, the risk of fatal overdose for heroin initiates is elevated compared to prescription opioids, particularly given non-oral administration and often unknown purity/adulterants (i.e., fentanyl). Imprecision of titrating dose among opioid novices may...

www.ncbi.nlm.nih.gov

the use of heroin as an initiating opioid increased from 8.7% in 2005 to 31.6% in 2015

CONCLUSIONS:
Given that opioid novices have limited tolerance, the risk of fatal overdose for heroin initiates is elevated compared to prescription opioids, particularly given non-oral administration and often unknown purity/adulterants (i.e., fentanyl). Imprecision of titrating dose among opioid novices may explain observed increases opioid overdoses. Future policy decisions should note that prescription opioid-specific interventions may have little impact on a growing heroin epidemic.

I'm certainly not exonerating physicians or minimizing their culpability in the prevalence of prescription drugs, but it's much bigger than that. We've got to get this stuff off the streets and out of the hands of our youth. I'm tired of seeing young heroin/fentanyl addicts show up half dead with permanent anoxic brain injury d/t illicit drug overdoses. In my personal observations over the past few years, it seems to be directly tied to the synthetic fentanyl prevalence. I get these guys almost every shift now whereas a few years ago it was much less common. Also, I have many more "dead on arrivals" versus in the years past. I hate this stuff with a passion.

 

[Apollyon]

Not true.

Heroin use is rare in prescription drug users | National Institute on Drug Abuse

While prescription opioid abuse is a growing risk factor for starting heroin use, only a small fraction of people who abuse pain relievers switch to heroin use.

www.drugabuse.gov

While prescription opioid abuse is a growing risk factor for starting heroin use, only a small fraction of people who abuse pain relievers switch to heroin use. According to general population data from the National Survey on Drug Use and Health, less than 4 percent of people who had abused prescription opioids started using heroin within 5 years (Muhuri et al., 2013). This suggests that prescription opioid abuse is just one factor in the pathway to heroin. Furthermore, analyses suggest that those who transition to heroin use tend to be frequent users of multiple substances (polydrug users) (Jones, et al., 2015)

If you haven't met any heroin/fentanyl users in your ED that didn't get hooked on pills first, you either aren't looking or aren't asking the right questions. I just logged into work following up on one of my pt's who got an addiction consult and they talk about how he got addicted to IV heroin as a teenager.

I lived in a foster home as a teen with a guy who unbeknownst to me was a closet IV heroin user and I didn't find out until years later. He didn't abuse any prescription pills.

Open your eyes. Most of these addicts did not get addicted through physician prescriptions and then switch to hardcore drugs. An increased supply of 6000kg of heroin over 10 years to our country being smuggled through our borders. You think that's for all the prescription users? Illegal drugs are killing this country and killing our youth.

The bolded doesn't go with the rest of your post, unless I am reading it wrong.

 

[Groove]

Not sure why we even need to have these discussions. We know opioids/opiates/narcotics are bad, and have devastating consequences. Can we please stop prescribing them for: back pain, headache, lacerations, sprains, strains, chest pain, abdominal pain, and abscesses?

Now I pretty much give them only for fractures with the occasional shingles patient.

Generally, I don't prescribe hydrocodone/oxycodone. I don't know what state regulations you have in place but we can't prescribe more than 3 days of scheduled drugs in my state without the pharmacy calling and asking for ICD codes, etc.. for state reporting purposes. I will prescribe tylenol #3's on occasion but it's usually for kidney stones along with my usual kidney stone prescriptions. i.e. toradol/flomax, etc. Sometimes, I'll give Tylenol #3 for really bad flu's with cough.

Bad fractures...sure, I might prescribe a few lortabs or some tramadol. Reasonable stuff. Like I said, they are very good at pain relief when legitimately used.

 

[Groove]

The bolded doesn't go with the rest of your post, unless I am reading it wrong.

I edited it to make it less confusing.

 

[Groove]

That's because they're all going to Ibiza to do coke...hence Spain's bright red nature on the coke map.

That's hilarious, I just noticed Ibiza lighting up as a red dot right beside Spain. LOL, that totally make sense.

 

[Apollyon]

If you haven't met any heroin users in your ED that were not addicted to prescription pills first before using/absuing heroin, you either aren't looking or aren't asking the right questions. I just logged into work following up on one of my pt's who got an addiction consult and they talk about how he got addicted to IV heroin as a teenager.

He didn't abuse any prescription pills.

Most of these addicts did not get addicted through physician prescriptions and then switch to hardcore drugs. An increased supply of 6000kg of heroin over 10 years to our country being smuggled through our borders. You think that's for all the prescription users? Illegal drugs are killing this country and killing our youth.

I guess I'm still not getting it. Are you saying that people did, or did not start with prescribed pills? I can't even tell what you edited.

The bolded statements are in contradiction, at least to me. Dumb it down for me.

 

[Groove]

I guess I'm still not getting it. Are you saying that people did, or did not start with prescribed pills? I can't even tell what you edited.

The bolded statements are in contradiction, at least to me. Dumb it down for me.

I'm saying they DID NOT start with prescription pills.

If you haven't met any heroin users in your ED that were not addicted to prescription pills first before using/abusing heroin, you either aren't looking or aren't asking the right questions.

Take out the "not" between were and addicted and read it again. Then put the "not" back in...maybe I'm butchering the english language but it sounds right...at least to my ears.

 

[deleted109597]

Not true.

Hmm.

The changing face of heroin use in the United States: a retrospective analysis of the past 50 years - PubMed

Our data show that the demographic composition of heroin users entering treatment has shifted over the last 50 years such that heroin use has changed from an inner-city, minority-centered problem to one that has a more widespread geographical distribution, involving primarily white men and women...

www.ncbi.nlm.nih.gov

However, more recent users were older (mean age, 22.9 years) men and women living in less urban areas (75.2%) who were introduced to opioids through prescription drugs (75.0%).

Also, it's weird how heroin deaths went up once they started cracking down on the pill mills.

I wonder why that was...

There is evidence that, in the current epidemic of opioid overdose deaths, some individuals addicted to prescription opioids transition to heroin.

Opioid Overdose Deaths and Florida’s Crackdown on Pill Mills - PMC

Objectives. We examined the effect on opioid overdose mortality of Florida state laws and law enforcement operations targeting “pill mills.” Methods. We collected 2003 to 2012 mortality data from the Florida Department of Health and the North ...

www.ncbi.nlm.nih.gov

I'm still at a loss for why, if you don't actually prescribe much of them or care, why you wouldn't be for removing all of them from the supply? You seem to be defending a drug that, for the most part, the rest of the world gets by without.

 

[deleted109597]

Also, this.

However, in our exploratory qualitative online survey of a subgroup of 267 patients, among the 129 respondents who reported abusing prescription opioids prior to heroin use, 73.0% (92 of 126 respondents) primarily cited practical factors, such as accessibility and cost, when explaining their transition to heroin.

https://www.nejm.org/doi/full/10.1056/NEJMc1505541#ref1

And some regions are better/worse.

https://www.nejm.org/doi/suppl/10.1056/NEJMc1505541/suppl_file/nejmc1505541_appendix.pdf

 

[thegenius]

Not sure why we even need to have these discussions. We know opioids/opiates/narcotics are bad, and have devastating consequences. Can we please stop prescribing them for: back pain, headache, lacerations, sprains, strains, chest pain, abdominal pain, and abscesses?

Now I pretty much give them only for fractures with the occasional shingles patient.

Fine with me. There is a lot of hoopla and sparkles in this thread over perceived large differences of opinion, yet my guess is we have much more narrow difference of beliefs on the topic of narcs, tx of headaches, and the social aspects of drugs.

Yea orthopedic injuries...I can see giving a 2-3 day supply depending on how bad it is. Burns suck big time and I’ll give it to them. If I can see the injury....either visibly or on an imaging study...I will consider 2 to 3 days worth.

 

[VA Hopeful Dr]

Not true.

Heroin use is rare in prescription drug users | National Institute on Drug Abuse

While prescription opioid abuse is a growing risk factor for starting heroin use, only a small fraction of people who abuse pain relievers switch to heroin use.

www.drugabuse.gov

While prescription opioid abuse is a growing risk factor for starting heroin use, only a small fraction of people who abuse pain relievers switch to heroin use. According to general population data from the National Survey on Drug Use and Health, less than 4 percent of people who had abused prescription opioids started using heroin within 5 years (Muhuri et al., 2013). This suggests that prescription opioid abuse is just one factor in the pathway to heroin. Furthermore, analyses suggest that those who transition to heroin use tend to be frequent users of multiple substances (polydrug users) (Jones, et al., 2015)

If you haven't met any heroin users in your ED that were not addicted to prescription pills first before using/absuing heroin, you either aren't looking or aren't asking the right questions. I just logged into work following up on one of my pt's who got an addiction consult and they talk about how he got addicted to IV heroin as a teenager.

I lived in a foster home as a teen with a guy who unbeknownst to me was a closet IV heroin user and I didn't find out until years later. He didn't abuse any prescription pills.

Open your eyes. Most of these addicts did not get addicted through physician prescriptions and then switch to hardcore drugs. An increased supply of 6000kg of heroin over 10 years to our country being smuggled through our borders. You think that's for all the prescription users? Illegal drugs are killing this country and killing our youth.

The question isn't how many prescription drug users go to heroin it's how many heroin users started on prescription drugs.

 

[thegenius]

I'm still at a loss for why, if you don't actually prescribe much of them or care, why you wouldn't be for removing all of them from the supply? You seem to be defending a drug that, for the most part, the rest of the world gets by without.

Fine with me. Or have the pharmacies charge a $3/pill surcharge. Or maybe government can tax $3/pill. Insurers could stop covering the drug. Pharmacies could stop stocking them.

I’ve asked this before...with no response...what do people do in other countries for chronic debilitatingly painful disease? Does fibromyalgia not hurt as much in other countries? Maybe myofascial low back pain isn’t as terrible as it is here.

A real L5 radiculopathy from a herniated nucleus pulposis can be terribly painful.

 

[Groove]

I'm still at a loss for why, if you don't actually prescribe much of them or care, why you wouldn't be for removing all of them from the supply? You seem to be defending a drug that, for the most part, the rest of the world gets by without.

Because they can ameliorate certain types of pain much more effectively than many other drugs. Would you deny a cancer patient or hospice patient narcotics? What if it was your child with end stage lymphoma, in excruciating pain, begging you for relief? If you admit that hospice and cancer patients can and should use narcotics for pain control, then ask yourself...what about that class of patients makes them worthy of narcotics vs some of the other patients that you might see on a daily or weekly basis? Fractures, sickle cell crisis, amputations, third degree burns, testicular torsion, I can think of many patients where IV narcotics are much more likely to relieve their pain versus IV toradol, or haldol for that matter.

As for prescribing them...sure, I'll admit that physicians should be prescribing less of them (a lot less), but that's a far cry from removing them entirely from western medicine simply because certain people can't use them responsibly. If that were the litmus test for allowing human beings to have access to certain substances, then we should still be exercising prohibition as humanity has demonstrated ad nauseam that we can't use alcohol responsibly.

Personally, I blame all of the organizations mentioned above that have pressured physicians to treat pain as the fifth vital sign and encouraged us to prescribe narcotics over the years. However, I don't think they should be removed entirely nor do I think physicians should be demonized when prescribing them responsibly nor blamed when patients abuse them (when given a justified prescription).

In the end, we probably don't disagree as much as you think we do.

 

[deleted109597]

Except you said you've never used haldol for pain. It's incredibly effective. Remarkably. I promise. And it's not habit forming as it doesn't act on mu receptors.
Low dose ketamine works as well. Doesn't make people high. Sure, at high doses it can, so don't do that.

On the flip side, the data for T3 and Ultram show that they're actually not very good for pain. Either they work too well, or not enough. The pharmacokinetics are ridiculous. That being said, because writing for any C-II in Texas is a pain, that's all most people get. It turns out, we are a really good state when it comes to opioid abuse, and it's because we weren't ever able to give it out like candy (Percs, Oxys, you name it).

 

[Zebra Hunter]

There is nothing like getting a hand off from a colleague for a patient with chronic back pain who he decided to order an MRI on despite the patient already having 2 in the last year and had no current neuro deficits and normal vitals. Then they proceeded to give 2 doses of 1mg IM dilaudid spaced an hour apart, 10mg of percocet given right after the second dose of dilaudid, also gave 10mg of flexeril, this on top of the opioids the patient took prior to arrival. The patient is 5'4", 300 lbs, has COPD and OSA. He had the patient sitting in the ER for 8 hours at hand off time, on no oxygen. The patient was lucky that the nurse caught the patient becoming bradypneic and hypoxic relatively quickly; however, the patient had also vomited and aspirated, as well and ended up requiring intubation. I of course was then yelled at by the family for "letting this happen".

I disagree with the notion that doctors are not part of the issue. Are most doctors part of the problem? No, probably not, but there are some that have significant culpability for our current opioid crisis. All you have to do is perform a prescription monitoring review of your frequent flyers to see the absurd stuff that some docs are rx'ing. I had one doc rx'ing 180 oxy 10s, 120 tylenol #3s, 180 xanax 2mg, 90 klonopin 1 mg MONTHLY to a single patient, and somehow there was a pharmacy filling these rx's for over 2 years. This patient had presented 4 times in a single year for opioid/benzo overdose requiring intubation, pressors, and an ICU stay. I made a formal complaint to the medical board about that guy. Essentially the only accidental overdoses I see are patients taking too much of their oxys and xanax. I actually haven't seen a heroin overdose in over a year. Also, I foresee benzos being the next drug of abuse supplied by MDs to be cracked down on.

 

[d2305]

Just give them tylenol or motrin Combined acetaminophen, ibuprofen produces similar amount of pain relief as opioids in ED patients

 

[GeneralVeers]

Just give them tylenol or motrin Combined acetaminophen, ibuprofen produces similar amount of pain relief as opioids in ED patients

"But doctor those don't work for me only Dilaudid, and I'm allergic to Tylenol cuz of stuff but I can't remember!"

 

[thegenius]

Just give them tylenol or motrin Combined acetaminophen, ibuprofen produces similar amount of pain relief as opioids in ED patients

I work in two different ERs with vastly different patient populations. One is a relatively low socioeconomic patient population with lots of chronic medical problems and routine injuries and pain “seemingly” don’t respond to Tylenol and Motrin. It’s a daily fight and gets quite tiresome.

The other ER is relatively high socioeconomic patient population and it’s interesting how 7/10 to 10/10 pain of all sorts does quite well with Tylenol and Motrin. Sometimes I’m surprised when people are in 8/10 pain...I give them toradol and it goes to 6/10 pain, and i offer a dose of morphine and they say “Huh?? My pain isn’t that bad! That sounds strong. I’ll just be here in pain that’s Ok.”

 

[Groove]

"But doctor those don't work for me only Dilaudid, and I'm allergic to Tylenol cuz of stuff but I can't remember!"

Almost all of my drug seeker patients that use that one fall into my "poisoned percocet" routine.

Me: "Oh Snap! You're allergic to tylenol?! That's terrible, here I'll get you a percocet then. You can take those, right?"

<Vehement nodding...spittle of drool coming out of the corner of their mouth>

I even turn completely around and will start to walk out the door and then grab the doorframe....pause....turn around with a confused, befuddled look on my face...like it's the first time the thought has ever dawned on me....and go "But wait....percocets have tylenol in them so.....you can't possibly be allergic to tylenol. What a relief! I'll order you some Tylenol right away." Notice, I waited until I was at the doorframe to tell them this so that gives me a split second to whip around and out the door before they can put up any fight about the tylenol.

It almost always works. I actually enjoy that one. Almost as much as I enjoy the CSMD pill shoppers that assure me they haven't filled any prescriptions in months. I slowly pull out a folded piece of paper...unfold it ever so slowly and peer down my nose while squinting, with an annoyed look on my face like I forgot my reading glasses (I have 20/10 vision) and go "Hrmmmm.....well it says here....if I'm reading this right, that you filled 100 percocets a week ago and then 50 more 3 days later from another doctor....Hrmmmmm" I'll make a small gasp, look up at them suddenly and go "Oh my....you haven't had your identity stolen have you?!"

I seem to have mastered hidden sarcasm to the point where my patients rarely pick up on it anymore.