FDA on opioids

[epidural man]

http://www.medscape.com/viewarticle...227_mscpedit&uac=130366SN&impID=1262676&faf=1

"
* Support better pain-management options, including alternative treatments."

So you think the FDA will push for funding for functional restoration programs or more spinal fusion?

I suspect it depends on who gives them more money under the table - so it looks like fusions will win! Yeah pedicle screw companies.

---

Members don't see this ad.

 

[DrCommonSense]

http://www.medscape.com/viewarticle...227_mscpedit&uac=130366SN&impID=1262676&faf=1

"
* Support better pain-management options, including alternative treatments."

So you think the FDA will push for funding for functional restoration programs or more spinal fusion?

I suspect it depends on who gives them more money under the table - so it looks like fusions will win! Yeah pedicle screw companies.

NEJM just had an article a few months ago comparing fusion surgery vs laminectomy alone. They came to the conclusion that fusion was essentially more costly with more complications with zero added value for disability or pain scores.

Of course this is the NEJM where nothing actually works in procedural medicine including stents for stable CAD, kypho, meniscus surgery, etc.


Interestingly, the CDC just came out with a "study" where they found that prescription opioids has fallen off as the "biggest killer" from 2010-2014 with heroin and cocaine being larger killer when stratifying the data.

Also, they find benzos and alcohol to be prevalent in these "deaths" as well, confounding the situation further. Are the benzos the real culprit for the deaths? Xanax was up there in terms of death rates as well.

Ergo, the "opioid" problem appears far more complex than appears. Also, decreasing numbers of prescription opioids are NOT decreasing death rates overall in the last few years.

 

[epidural man]

Yes, the decrease in opioids from doctors has totally increased the number of opioids from the street (heroine).

 

[bedrock]

Yes, the decrease in opioids from doctors has totally increased the number of opioids from the street (heroine).

true,

but if someones dies from a heroin overdose, doctors aren't being sued as they would if the overdose was from prescribed medications.

 

[Disciple]

For what is under the FDAs jurisdiction, I think they'll push for MAT for treatment of Addiction, new non-opioid pain medications or abuse deterrent formulations and naloxone products.

Aside from their stated goals, the 21st century CURES Act will compel them to do this, and they will be working under a climate of deregulation.

Hopefully, they will lighten up on medical devices that have promise as well.

 

[Ducttape]

Do we have evidence at that prescription opioid use is decreasing??

I'd rather not be presumptuous, but I can't find this data except in certain small locales...


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[Disciple]

Do we have evidence at that prescription opioid use is decreasing??

I'd rather not be presumptuous, but I can't find this data except in certain small locales...


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Can't remember the source right at the moment, but # of prescriptions filled has decreased over the past 2 years.

 

[DrCommonSense]

Do we have evidence at that prescription opioid use is decreasing??

I'd rather not be presumptuous, but I can't find this data except in certain small locales...


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http://www.pressherald.com/2016/10/06/dea-will-cut-amount-of-opioids-produced/

Here the DEA is cutting prescription quotas for opioids by over 25% but the death rate in Maine (highly regulated) has GONE UP since the implementation.


Here is Ohio that cut prescription opioids by 11.5% since 2012 while overdose rates INCREASED during that same period of time:

http://www.cleveland.com/healthfit/...s_to_kill_at_alarming_rates_photos_video.html


Even the newest CDC "study" on the subject, quietly released, confirms that heroin and cocaine are BIGGER killers than prescription opioids that continues to decline. This is the first time they actually attempted to separate the causes of death.

Furthermore, most of the "opioid" prescription deaths were mixed with benzos, alcohol and other drugs, further confusing the situation. Benzos kill almost as much as prescription opioids as well.

https://www.painnewsnetwork.org/stories/2016/12/26/new-cdc-overdose-study-reduces-role-of-pain-meds

 

[DrCommonSense]

Do we have evidence at that prescription opioid use is decreasing??

I'd rather not be presumptuous, but I can't find this data except in certain small locales...


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Here's an interesting opinion piece by the AAPM head:

https://www.painnewsnetwork.org/stories/2016/4/25/will-cdc-opioid-guidelines-help-reduce-overdoses

Im not a big fan of Webster but he makes a good argument here.


Here is another GREAT article discussing the how the vast majority of people who got "hooked" to opioids either obtained them illegally or already had a drug problem before being prescribed them.

Ergo, very few became "addicted" to prescription opioids WITHOUT ALREADY having a prescription problem.

https://www.theguardian.com/comment...ion-drug-abuse-addiction-treatment-painkiller

 

[Ducttape]

http://www.pressherald.com/2016/10/06/dea-will-cut-amount-of-opioids-produced/

Here the DEA is cutting prescription quotas for opioids by over 25% but the death rate in Maine (highly regulated) has GONE UP since the implementation.


Here is Ohio that cut prescription opioids by 11.5% since 2012 while overdose rates INCREASED during that same period of time:

http://www.cleveland.com/healthfit/...s_to_kill_at_alarming_rates_photos_video.html


Even the newest CDC "study" on the subject, quietly released, confirms that heroin and cocaine are BIGGER killers than prescription opioids that continues to decline. This is the first time they actually attempted to separate the causes of death.

Furthermore, most of the "opioid" prescription deaths were mixed with benzos, alcohol and other drugs, further confusing the situation. Benzos kill almost as much as prescription opioids as well.

https://www.painnewsnetwork.org/stories/2016/12/26/new-cdc-overdose-study-reduces-role-of-pain-meds

First article - the cuts begin in 2017. its the quotas AFTER 2017. has nothing to do with death rates of Maine going up now. incorrect conclusion there.


the second article is slightly more disingenuous. Ohio decides to cut opioid production in 2012... but these "New initiatives were developed, then launched in 2013 or later, and it will take some time for their full impact to be reflected in reducing the number of drug overdose deaths." ( http://mha.ohio.gov/Portals/0/assets/Initiatives/GCOAT/Combatting-the-Opiate-Crisis.pdf ).
and the article includes illicit fentanyl deaths and U-47700 overdose deaths and attributes them as part of the prescription opioid problem. thus an inappropriate conclusion. yes the overdose rate did go up, but in large part due to illicit opioid use...

agree with most of your last point, the CDC, with the exception that the original article states that 52% of the death certificates state 1 drug. there were more certificates listing a single drug as opposed to "more than 1" (by default, 48%).

also noted in the study is that, in 95% of the time that a benzo was listed, another drug was listed - benzos by itself was listed only 5%.

In contrast, among deaths involving alprazolam and diazepam, more than 95% involved other drugs.
The average number of concomitant drugs involved (excluding the referent drug) also varied among the top 10 drugs involved in drug overdose deaths. For example, drug overdose deaths involving diazepam or alprazolam had on average more than
two additional drugs involved in death.

or to put it another way - it is very difficult to come to the conclusion that benzos by themselves are as dangerous as opioids, since they do not often kill by themselves.

 

[Aether2000]

Nah....the CDC has intermittently but not consistently separated the cause of death for several years. The public data is limited to the X42 code (accidental death from hallucinogens and narcotics), the unspecified code of accidental death X49 (when there are multiple drug causes and the coroner does not know what to code), 2 similar suicide code, 2 similar homicide codes, codes for hospital related opioid deaths, and 2 unknown intent codes. These are lower level codes that do not distinguish which opioid or hallucinogen was responsible for death. The CDC does have access to T codes, high level codes that lend more specificity to the drug(s) involved, and this is how the CDC has been able to calculate the percentage of drug deaths were due to prescription opioids, and again, they have done this for several years but not consistently. I will discuss these issues in another thread.

The DEA has announced to cut SOME of the opioid allotment that can be produced by manufacturers, but that is because the DEMAND of hydrocodone in particular has fallen due to hydrocodone finally being appropriately rescheduled as a Schedule II drug to keep the PCPs from writing 6 months of drug or calling in infinite refills, perpetuating addiction and chemical dependence. Individual states do not have the authority to cut opioid production.

Webster is completely wrong on this one. 80% of addiction to opioids started with prescription opioids given via a valid prescription. It is usually an exposure at an early age or whenever the first exposure occurs due to a surgical procedure, dental procedure, or injury, with subsequent euphoria from use of the drug (imprinting), and then later use (continued prescriptions) eventually accelerates into substance abuse and diversion of prescription opioids, then buying them on the street, then conversion to heroin occurs later. Now the conversion is occurring earlier due to tightening of the supply of prescription opioids by physicians.

 

[101N]

"Webster is completely wrong on this one." Webster is just a crass, unrepentant, opioid pimp.

http://real-psychiatry.blogspot.com/2016/04/ama-versus-cdc-patient-education-on.html

 

[DrCommonSense]

Nah....the CDC has intermittently but not consistently separated the cause of death for several years. The public data is limited to the X42 code (accidental death from hallucinogens and narcotics), the unspecified code of accidental death X49 (when there are multiple drug causes and the coroner does not know what to code), 2 similar suicide code, 2 similar homicide codes, codes for hospital related opioid deaths, and 2 unknown intent codes. These are lower level codes that do not distinguish which opioid or hallucinogen was responsible for death. The CDC does have access to T codes, high level codes that lend more specificity to the drug(s) involved, and this is how the CDC has been able to calculate the percentage of drug deaths were due to prescription opioids, and again, they have done this for several years but not consistently. I will discuss these issues in another thread.

The DEA has announced to cut SOME of the opioid allotment that can be produced by manufacturers, but that is because the DEMAND of hydrocodone in particular has fallen due to hydrocodone finally being appropriately rescheduled as a Schedule II drug to keep the PCPs from writing 6 months of drug or calling in infinite refills, perpetuating addiction and chemical dependence. Individual states do not have the authority to cut opioid production.

Webster is completely wrong on this one. 80% of addiction to opioids started with prescription opioids given via a valid prescription. It is usually an exposure at an early age or whenever the first exposure occurs due to a surgical procedure, dental procedure, or injury, with subsequent euphoria from use of the drug (imprinting), and then later use (continued prescriptions) eventually accelerates into substance abuse and diversion of prescription opioids, then buying them on the street, then conversion to heroin occurs later. Now the conversion is occurring earlier due to tightening of the supply of prescription opioids by physicians.

I just posted two articles that showed the vast majority of addicted patients were NOT started with a legal prescription.

Where did you get this 80% of addiction was started with a valid prescription? Do you have some source to back that claim up?

 

[Aether2000]

https://www.drugabuse.gov/publicati...rescription-opioid-use-risk-factor-heroin-use I took this data and did in depth interviews on patients being treated with suboxone. We went back to the original use of the medications, spending an hour in interview, documenting the earliest use and progression of opioid use. Eighty percent of those that subsequently moved to heroin had started with prescription opioids with a valid prescription, usually prescribed between age 12 and 16, frequently for dental work, injury, or surgery. The progression was not immediate in most cases, but this is the hit that switched on the gene. Usually in less than a year they were seeking opioids from friends or stealing them from family. The average age kids begin non-medical use of opioids is 14. But kids don't just suddenly wake up and decide they want to use drugs. They have prior exposure.

 

[DrCommonSense]

https://www.drugabuse.gov/publicati...rescription-opioid-use-risk-factor-heroin-use I took this data and did in depth interviews on patients being treated with suboxone. We went back to the original use of the medications, spending an hour in interview, documenting the earliest use and progression of opioid use. Eighty percent of those that subsequently moved to heroin had started with prescription opioids with a valid prescription, usually prescribed between age 12 and 16, frequently for dental work, injury, or surgery. The progression was not immediate in most cases, but this is the hit that switched on the gene. Usually in less than a year they were seeking opioids from friends or stealing them from family. The average age kids begin non-medical use of opioids is 14. But kids don't just suddenly wake up and decide they want to use drugs. They have prior exposure.

The article you linked states "Pooling data from 2002 to 2012, the incidence of heroin initiation was 19 times higher among those who reported prior nonmedical pain reliever use than among those who did not (0.39 vs. 0.02 percent) (Muhuri et al., 2013). A study of young, urban injection drug users interviewed in 2008 and 2009 found that 86 percent had used opioid pain relievers nonmedically prior to using heroin, and their initiation into nonmedical use was characterized by three main sources of opioids: family, friends, or personal prescriptions (Lankenau et al., 2012)."

Clearly is says NONMEDICAL opioids that are largely STOLEN from others. Your article clearly shows that most of these people basically just stole meds off friends or family and then just got it off the street. Addicts largely just attempt to steal prescriptions off family/friends before just buying it off the street rather than just previously buying it right off the street. Either way, these types would buy the drugs illegally one way or the other.

Where is the evidence that 80% of heroin addicts STARTED by taking LEGALLY prescribed narcotic prescriptions with NO PRIOR HISTORY of drug abuse?

 

[Aether2000]

Nonmedical does not necessarily mean stolen, but it can mean stolen. This article states that the incidence of moving from non-medical use of prescription opioids to heroin is much higher than using prescription opioids legally then jumping straight to heroin. I agree with this. But what the article does not state is that those that were using the prescription opioids non-medically did not usually start out using opioids non-medically. There was a progression that began with legal use of opioids first. This is precisely what I found in my population. I found if I dig hard enough and ask enough questions, this is the answer I receive.

 

[DrCommonSense]

Nonmedical does not necessarily mean stolen, but it can mean stolen. This article states that the incidence of moving from non-medical use of prescription opioids to heroin is much higher than using prescription opioids legally then jumping straight to heroin. I agree with this. But what the article does not state is that those that were using the prescription opioids non-medically did not usually start out using opioids non-medically. There was a progression that began with legal use of opioids first. This is precisely what I found in my population. I found if I dig hard enough and ask enough questions, this is the answer I receive.

Do you have any stats supporting the fact that opioid naive patients with ZERO history of substance abuse are becoming addicted to legally prescribed narcotic medications in a large percentage of patients?

That is the CRITICAL information needed.

Patients with a history of substance abuse/stealing meds from family/friends that obtain a legal precription for Norco by fooling a physician can't honestly be blamed on "prescription opioid use" as the cause of their addiction.

 

[Aether2000]

I see this as a continuum of overlapping venn diagrams reflecting a progression of exposure, genetic switch activation, non-medical use, chemical dependency, opioid abuse, then progression to significant tolerance and significant withdrawal cycles, finally engaging in the use of heroin due to finances and unavailability of prescription opioids in order to avoid withdrawal rather than to obtain euphoria. I don't have stats nor believe most people using opioids appropriately ultimately engage in later overt addiction, because depending on the published studies, the addiction rates range from 0.02% to 25% largely because of the lack of a generally agreed upon definition of addiction. We have a 1959 randomized controlled trial demonstrating chemical dependency occurs in as few as 2 weeks of continuous use of opioids. We do have several studies showing the rate of substance abuse is 25-50% in chronic pain populations being prescribed continuous opioids.

 

[DrCommonSense]

I see this as a continuum of overlapping venn diagrams reflecting a progression of exposure, genetic switch activation, non-medical use, chemical dependency, opioid abuse, then progression to significant tolerance and significant withdrawal cycles, finally engaging in the use of heroin due to finances and unavailability of prescription opioids in order to avoid withdrawal rather than to obtain euphoria. I don't have stats nor believe most people using opioids appropriately ultimately engage in later overt addiction, because depending on the published studies, the addiction rates range from 0.02% to 25% largely because of the lack of a generally agreed upon definition of addiction. We have a 1959 randomized controlled trial demonstrating chemical dependency occurs in as few as 2 weeks of continuous use of opioids. We do have several studies showing the rate of substance abuse is 25-50% in chronic pain populations being prescribed continuous opioids.

The real question that occurs with all the gibberish is such:

Are we creating addicts in substantial numbers that DIDN'T exist before?

The narcotic abuser that was taking cocaine, THC, etc during partying that happens to steal a few Norcos/T3s from friends/family to "party" was NOT created by the "prescription drug epidemic" and would exist regardless.

Ergo, those people will continue to overdose with extreme restrictions of legal narcotic prescriptions.

The group of patients that were OPIOID NAIVE who were LEGALLY prescribed narcotic medications without any history of narcotic abuse/substance abuse are the real question mark cohort. These would be the ones that WOULD BECOME addicts due to LEGAL PRESCRIPTION DRUG use because they had no history of misuse in the past (weren't already addicts).

It seems from the data, that group of opioid naive patients have a VERY low chance of becoming addicted. The newest Ortho study out of MGH using postop patients showing that 99.9% of older opioid naive patients being off narcotics after 1 year from surgery despite obtaining Norco/Oxy for pain control postoperatively supports this notion.


Restriction of prescription narcotics will ONLY work to decrease overdose deaths if the opioid naive/non abuser group is becoming addicted in large numbers NOT the former. The former group who are already addicts will just get Heroin/Fentanyl off the street rather than steal it off friends (or take cocaine as a substitute).

That is why i suspect a reduction in narcotic prescriptions say by 25% won't see anywhere near the level of decrease in overdose rates of 25% due to opioids because the already addict group will just go to the street.

Until our resident "experts" like 101N can actually prove the assertion that opioid naive/non addicted patients are becoming addicted to legally obtained prescription narcotics in large numbers, all of his rhetoric will continue to be hollow.

If it turns out that the vast majority of addicts were already addicts before prescription opioids (what I suspect), then the real question for the physician is to be able to see the signs of people who are ALREADY ADDICTS coming into the physician office. This isn't that hard to determine using UDS, prescription drug monitoring programs, medication diversion, excess demand of narcotic meds compared to pathology, age of patient, insurance of patient, etc.

 

[Aether2000]

The problem is in the definition of addiction....

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[DrCommonSense]

The problem is in the definition of addiction....

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Ok lets define it as patients that become so dependent on narcotic medications that when tapered off/down they have to go out on the street to obtain fentanyl/heroin.

How many opioid naive patients do you see having this problem after taking a few Norcos/Percs per day?

Are these people dropping like flies by either overdosing on these meds by themselves or becoming so "addicted" they have to go onto the streets to get higher and higher dosages?

Surely, that should be easy to show considering the claims of 101N.

101N and PROP have far from proven their cases that opioid naive patients under these circumstances are overdosing in large numbers or becoming so "addicted" to these meds they have to go onto the streets to get heroin/fentanyl.

If we don't accurately diagnose the problem, any solution will never solve the problem.

 

[Aether2000]

PROP made recommendations on speculative data but now with more data available some of their premises for restriction are valid. Addiction to street drugs transitioning from prescription opioids being prescribed by doctors presupposes that the supply is dwindling rapidly. If this were the case then why would they continue to be opioid overdoses due to prescription narcotics in increasing amounts?

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[DrCommonSense]

PROP made recommendations on speculative data but now with more data available some of their premises for restriction are valid. Addiction to street drugs transitioning from prescription opioids being prescribed by doctors presupposes that the supply is dwindling rapidly. If this were the case then why would they continue to be opioid overdoses due to prescription narcotics in increasing amounts?

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First off, PROP is the Phoenix House that makes good money pushing Suboxone clinics (good racket that pays well), so they have financial reasons to hype up the issue.

Granted, Lynn Webster has financial reasons to downplay the issue.

Ergo, neither side is "impartial" from a financial standpoint.

Once again, PROP has never proven opioid naive patients are becoming street addicts in great numbers through legal prescription narcotics.

As a result, their "solution" will never solve the problem if the vast majority of addicts would be addicts regardless.

 

[Aether2000]

That assumes there is no way out and addiction is a constant forever..

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[DrCommonSense]

That assumes there is no way out and addiction is a constant forever..

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So these "addicts" are just magically going cold turkey and doing fine? Damn, kind've weird "addicts" to me.

 

[Aether2000]

Some have done exactly that. Others require a graded approach.

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[DrCommonSense]

Some have done exactly that. Others require a graded approach.

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Do we have any evidence that opioid naive patients with no substance abuse/mental health issues being prescribed Norcs/Percocets/Oxy are becoming hardcore addicts that are ODing in large numbers from legal prescriptions or going onto the streets to get heroin/fentanyl when the high becomes insufficient?

I personally have NEVER seen this even once.

However, I am open minded if there is any data to support this assertion.

 

[Aether2000]

It is not about euphoria or the "high" for long term opioid addicts. Most are simply trying to avoid withdrawal. The progression of venn diagrams overlapping become smaller and smaller in size. We do have evidence that the number dying of overdose compared to those using non medically is small.

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[DrCommonSense]

It is not about euphoria or the "high" for long term opioid addicts. Most are simply trying to avoid withdrawal. The progression of venn diagrams overlapping become smaller and smaller in size. We do have evidence that the number dying of overdose compared to those using non medically is small.

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I still don't see how you have answered the fundamental question of opioid naive/no mental disease patients taking Norco/Percs becoming "addicts" in good numbers such that they are ODing in large numbers or going onto the street to get heroin/fentanyl.

Any data to back that up?

 

[Aether2000]

I never said that. What I said is 80% of patients on heroin started with a valid prescription for opioids from a physican or dentist. It is a stretch to draw conclusions otherwise. We do not have psychological evaluations nor SOAPP-R on most people before they start prescription opioids.

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[lobelsteve]

I never said that. What I said is 80% of patients on heroin started with a valid prescription for opioids from a physican or dentist. It is a stretch to draw conclusions otherwise. We do not have psychological evaluations nor SOAPP-R on most people before they start prescription opioids.

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I believe the population you are talking about is highly skewed and in no way represents the general population in America.

 

[Aether2000]

I agree. It represents the heroin addicted population from in depth interviews conducted in two states with identical results.

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[Ducttape]

GoogleJamie Lee Curtis & opioids. Now you know one opioid naive patient who became addicted to opioids after surgery.
And:

https://med.stanford.edu/news/all-n...d-to-increase-risk-of-chronic-opioid-use.html

http://www.bmj.com/content/348/bmj.g1251 - 3% of opioid naive postoperative patients used > 90 days of opioids.

This article I take with a grain or two of salt - https://globenewswire.com/news-rele...gnificantly-Higher-than-Previously-Known.html . It is drug company sponsored, and unlike others, I try to link only original studies, but since you asked... it sites a 1 in 10 risk of addiction or dependence.


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[lobelsteve]

2012. 259 million rxs for opiates written, 2 million opiate rx addicts. And 591000 heroin addicts.

That much exposure would have me believe there 10x more addicts than there actually are.

 

[Aether2000]

The past month non-medical use of prescription painkillers in the 2014 NSDUH demonstrated a rate of 3% of the 18-25 population and 2% of everyone else over age 12 giving a last month non-medical use for a total of just over 6.2 million over the age 12 in the US that are engaging in non-medical use of prescription opioids. The same survey found 435,000 current heroin users in the US, and 914,000 who used heroin in the past year.

 

[DrCommonSense]

I never said that. What I said is 80% of patients on heroin started with a valid prescription for opioids from a physican or dentist. It is a stretch to draw conclusions otherwise. We do not have psychological evaluations nor SOAPP-R on most people before they start prescription opioids.

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80% of heroin STARTED with prescription drugs legally prescribed implying they weren't addicts before obtaining a prescription?

Wow I have literally NEVER heard that statistic quoted anywhere.

Got a source?

 

[DrCommonSense]

GoogleJamie Lee Curtis & opioids. Now you know one opioid naive patient who became addicted to opioids after surgery.
And:

https://med.stanford.edu/news/all-n...d-to-increase-risk-of-chronic-opioid-use.html

http://www.bmj.com/content/348/bmj.g1251 - 3% of opioid naive postoperative patients used > 90 days of opioids.

This article I take with a grain or two of salt - https://globenewswire.com/news-rele...gnificantly-Higher-than-Previously-Known.html . It is drug company sponsored, and unlike others, I try to link only original studies, but since you asked... it sites a 1 in 10 risk of addiction or dependence.


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1) Standford Study study of 11 common surgeries compared people who hadn't gotten prescribed opioids for over 1 year compared to controls that weren't prescribed for over 1 year. The study showed that there is a 0.5% chance increased possibility of using opioids at 7 months after surgery ( 4 months + 3 month window after surgery as per study) compared to control. That is a 1/200 chance of using opioids at the 7 month mark. That isn't particularly impressive.

The MGH study showed it being less than .1% at 1 year.

2) 3 months after at 3% is meaningless and not impressive. We need to look at a 1 year and above. Those studies at 1 year from MGH after Ortho procedure showed opioid naive patients using at .1% or so. Far from an "epidemic".

 

[DrCommonSense]

GoogleJamie Lee Curtis & opioids. Now you know one opioid naive patient who became addicted to opioids after surgery.
And:

https://med.stanford.edu/news/all-n...d-to-increase-risk-of-chronic-opioid-use.html

http://www.bmj.com/content/348/bmj.g1251 - 3% of opioid naive postoperative patients used > 90 days of opioids.

This article I take with a grain or two of salt - https://globenewswire.com/news-rele...gnificantly-Higher-than-Previously-Known.html . It is drug company sponsored, and unlike others, I try to link only original studies, but since you asked... it sites a 1 in 10 risk of addiction or dependence.


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http://www.dailymail.co.uk/tvshowbi...cription-painkillers-wake-Prince-s-death.html

Jamie Lee Curtis CONFIRMS my previous arguments about PREVIOUSLY addicted patients.

Notice in the article, she had a history of abusing alcohol and cocaine as well.

Ergo, she confirms my argument that I have never seen someone who wasn't already an ADDICT personality with mental problems.

Was she also addicted to cocaine and alcohol due to prescriptions from physicians?

 

[101N]

Source> https://www.ncbi.nlm.nih.gov/pubmed/25005636

 

[DrCommonSense]

The past month non-medical use of prescription painkillers in the 2014 NSDUH demonstrated a rate of 3% of the 18-25 population and 2% of everyone else over age 12 giving a last month non-medical use for a total of just over 6.2 million over the age 12 in the US that are engaging in non-medical use of prescription opioids. The same survey found 435,000 current heroin users in the US, and 914,000 who used heroin in the past year.

Ok so they are stealing prescriptions from other people?

Don't see how that relates to the argument that non narcotic addicted/mentally ill people/non addict people are becoming addicts through legal prescriptions.

 

[DrCommonSense]

Source> https://www.ncbi.nlm.nih.gov/pubmed/25005636

Once again, your article doesn't address the fundamental question:

How many non addicts who are opioid naive are becoming addicted to prescription narcotics that are LEGALLY prescribed?

You keep skirting around that question with hyperbole.

All it says are addicts are largely trying to steal prescription narcotics and the type of people who are addicts have changed to middle aged white people.

 

[Aether2000]

This is the bubble...the 7 million that need treatment who are chemically dependent/addicted. The train has left the station with these people and the way out is not to continue prescribing.

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[DrCommonSense]

This is the bubble...the 7 million that need treatment who are chemically dependent/addicted. The train has left the station with these people and the way out is not to continue prescribing.

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Making policy changes won't change the overdose rate unless addicts were created by legal opioid prescriptions for people who were not previously addicts.

This really isn't that complicated.

Time will tell.

 

[Aether2000]

Lets spin it in reverse. What data do have that shows those with a thorough psychiatric workup, SOAPP-R negative, ORT negative DAST negative DSM-V addiction negative before receiving prescription opioids DO NOT develop chemical dependency or addiction or substance abuse when given opioids?

 

[DrCommonSense]

Lets spin it in reverse. What data do have that shows those with a thorough psychiatric workup, SOAPP-R negative, ORT negative DAST negative DSM-V addiction negative before receiving prescription opioids DO NOT develop chemical dependency or addiction or substance abuse when given opioids?

The only data we have are the recent ortho study out of MGH that showed opioid naive patients who took pain killers after surgery only were on the medication at less than a .1% rate over a year later.

The other data at 7 months from surgery (study you cited out of Standford) confirmed only .5% remained on narcotics after these surgeries.

If these stats are accurate, far less than 1% of legal prescription narcotic users that had zero addiction beforehand seem to be on these medications after 1 year.

Ergo, the "epidemic" levels of heroin/fentanyl overdose seem well in excess of those numbers presented above.

So it can be assumed that most of the "epidemic" is fueled by people who are ALREADY addicts for whatever reason beforehand.

When we restrict narcotic prescriptions by 30% (or so) over the next years, I suspect there will be negligible decreases in mortality rates overall.


P.S. This reminds me of BLM complaints where the murder rate in Chicago was being blamed on the "police" presence causing disrespect in these communities. The argument was once police pulled out of these neighborhoods, the murder rate would decline.

Clearly, the opposite has happened this year.

Sometimes you have to blame people for their own behavior rather than others.

 

[Aether2000]

This study shows a 13% incidence of 3 month use of opioids s/p hand surgery. It requires only 2 weeks to become chemically dependent. This was in opioid naive patients.

J Hand Surg Am. 2016 Sep 7. pii: S0363-5023(16)30427-0. doi: 10.1016/j.jhsa.2016.07.113. [Epub ahead of print]
Risk of Prolonged Opioid Use Among Opioid-Naïve Patients Following Common Hand Surgery Procedures.
Johnson SP1, Chung KC2, Zhong L2, Shauver MJ2, Engelsbe MJ3, Brummett C4, Waljee JF5.
Author information

Abstract
PURPOSE:
To evaluate prolonged opioid use in opioid-naïve patients after common hand surgery procedures in the United States.

METHODS:
We studied insurance claims from the Truven MarketScan databases to identify opioid-naïve adult patients (no opioid exposure 11 months before the perioperative period) who underwent an elective (carpal tunnel release, carpometacarpal arthroplasty/arthrodesis, cubital tunnel release, or trigger finger release) or trauma-related (closed distal radius fracture fixation, flexor tendon repair, metacarpal fracture fixation, or phalangeal fracture fixation) hand surgery procedure between 2010 and 2012 (N = 77,573 patients). Patients were observed for 6 months to determine the number, timing, duration, and oral morphine equivalent dosage of postoperative opioid prescriptions. We assessed prolonged postoperative opioid use, defined as patients who filled a perioperative opioid prescription followed by a prescription between 90 and 180 days after surgery, and evaluated associated risk factors using multivariable logistic regression.

RESULTS:
In this cohort, 59,725 opioid-naïve patients (77%) filled a perioperative opioid prescription. Of these, 13% of patients continued to fill prescriptions between 90 and 180 days after surgery. Elective surgery patients were more likely to continue to fill opioid prescriptions after 90 days compared with trauma patients (13.5% vs 10.5%). Younger age, female gender, lower income, comprehensive insurance, higher Elixhauser comorbidity index, mental health disorders, and tobacco dependence or abuse were associated with prolonged opioid use.

CONCLUSIONS:
Approximately 13% of opioid-naïve patients continue to fill opioid prescriptions after hand surgery procedures 90 days after surgery. Preoperative interventions centered on opioid alternatives and early cessation, particularly among patients at risk for long-term use, is critical to addressing the prescription opioid crisis in the United States.

CLINICAL RELEVANCE:
The current national opioid use epidemic requires an assessment of the prevalence of hand surgery patients who receive and fill opioid prescriptions after common hand surgery procedures.

 

[Aether2000]

This study shows a one year long term opioid continued use rate of 5% in opioid naive patients.
J Gen Intern Med. 2016 Aug 2. [Epub ahead of print]
Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study.
Deyo RA1,2,3, Hallvik SE4, Hildebran C4, Marino M5,6, Dexter E5, Irvine JM4,7, O'Kane N4, Van Otterloo J8, Wright DA8, Leichtling G4, Millet LM8.
Author information

Abstract
BACKGROUND:
Long-term efficacy of opioids for non-cancer pain is unproven, but risks argue for cautious prescribing. Few data suggest how long or how much opioid can be prescribed for opioid-naïve patients without inadvertently promoting long-term use.

OBJECTIVE:
To examine the association between initial opioid prescribing patterns and likelihood of long-term use among opioid-naïve patients.

DESIGN:
Retrospective cohort study; data from Oregon resident prescriptions linked to death certificates and hospital discharges.

PARTICIPANTS:
Patients filling opioid prescriptions between October 1, 2012, and September 30, 2013, with no opioid fills for the previous 365 days. Subgroup analyses examined patients under age 45 who did not die in the follow-up year, excluding most cancer or palliative care patients.

MAIN MEASURES:
Exposure: Numbers of prescription fills and cumulative morphine milligram equivalents (MMEs) dispensed during 30 days following opioid initiation ("initiation month").

OUTCOME:
Proportion of patients with six or more opioid fills during the subsequent year ("long-term users").

KEY RESULTS:
There were 536,767 opioid-naïve patients who filled an opioid prescription. Of these, 26,785 (5.0 %) became long-term users. Numbers of fills and cumulative MMEs during the initiation month were associated with long-term use. Among patients under age 45 using short-acting opioids who did not die in the follow-up year, the adjusted odds ratio (OR) for long-term use among those receiving two fills versus one was 2.25 (95 % CI: 2.17, 2.33). Compared to those who received < 120 total MMEs, those who received between 400 and 799 had an OR of 2.96 (95 % CI: 2.81, 3.11). Patients initiating with long-acting opioids had a higher risk of long-term use than those initiating with short-acting drugs.

CONCLUSIONS:
Early opioid prescribing patterns are associated with long-term use. While patient characteristics are important, clinicians have greater control over initial prescribing. Our findings may help minimize the risk of inadvertently initiating long-term opioid use.

 

[Aether2000]

Chronic non-cancer pain patients recently initiating opioids for pain: 46% long term use rate of opioids
Clin J Pain. 2016 Jul 15. [Epub ahead of print]
A Prospective Study of Predictors of Long-term Opioid Use among Patients with Chronic Non-cancer Pain.
Thielke S1, Shortreed SM, Saunders K, Turner JA, LeResche L, von Korff M.
Author information

Abstract
BACKGROUND:
Chronic pain patients at increased risk of unfavorable pain and opioid misuse outcomes may be those most likely to use opioids long-term, but this has not been evaluated prospectively.

OBJECTIVES:
To ascertain whether pain prognostic risk, problem opioid use risk, and depression predict opioid use one year later among patients recently initiating opioid therapy with a moderate likelihood of long-term opioid use.

METHODS:
Self-report and electronic health record data were collected from patients aged 45+ years who recently initiated opioid therapy (N=762), in an integrated health care system. Logistic regression models tested whether baseline patient chronic pain prognostic risk, problem opioid use risk, depression, and expectations concerning continued opioid use independently predicted continuing use at one year (≥30 days' supply in the prior 4 mo).

RESULTS:
At one year, 46% of participants continued to use opioids. Baseline problem opioid use risk score (adjusted odds ratio 1.15, 95% confidence interval [CI] 1.04-1.26) and expectations about continuing opioid use, but not pain prognostic risk score or depression, were significant predictors of one-year opioid use. Compared with patients who thought continued opioid use unlikely, those who thought it was extremely or very likely had four times the odds of opioid use at one year (adjusted odds ratio 4.05, 95% CI 2.59-6.31).

DISCUSSION:
The strongest predictors of long-term opioid use were not patient- or medication-related factors, but expectations about using opioids in the future. Asking about such expectations may be the easiest way to identify patients likely to continue opioid use long-term.

 

[DrCommonSense]

This study shows a one year long term opioid continued use rate of 5% in opioid naive patients.
J Gen Intern Med. 2016 Aug 2. [Epub ahead of print]
Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study.
Deyo RA1,2,3, Hallvik SE4, Hildebran C4, Marino M5,6, Dexter E5, Irvine JM4,7, O'Kane N4, Van Otterloo J8, Wright DA8, Leichtling G4, Millet LM8.
Author information

Abstract
BACKGROUND:
Long-term efficacy of opioids for non-cancer pain is unproven, but risks argue for cautious prescribing. Few data suggest how long or how much opioid can be prescribed for opioid-naïve patients without inadvertently promoting long-term use.

OBJECTIVE:
To examine the association between initial opioid prescribing patterns and likelihood of long-term use among opioid-naïve patients.

DESIGN:
Retrospective cohort study; data from Oregon resident prescriptions linked to death certificates and hospital discharges.

PARTICIPANTS:
Patients filling opioid prescriptions between October 1, 2012, and September 30, 2013, with no opioid fills for the previous 365 days. Subgroup analyses examined patients under age 45 who did not die in the follow-up year, excluding most cancer or palliative care patients.

MAIN MEASURES:
Exposure: Numbers of prescription fills and cumulative morphine milligram equivalents (MMEs) dispensed during 30 days following opioid initiation ("initiation month").


OUTCOME:
Proportion of patients with six or more opioid fills during the subsequent year ("long-term users").

KEY RESULTS:
There were 536,767 opioid-naïve patients who filled an opioid prescription. Of these, 26,785 (5.0 %) became long-term users. Numbers of fills and cumulative MMEs during the initiation month were associated with long-term use. Among patients under age 45 using short-acting opioids who did not die in the follow-up year, the adjusted odds ratio (OR) for long-term use among those receiving two fills versus one was 2.25 (95 % CI: 2.17, 2.33). Compared to those who received < 120 total MMEs, those who received between 400 and 799 had an OR of 2.96 (95 % CI: 2.81, 3.11). Patients initiating with long-acting opioids had a higher risk of long-term use than those initiating with short-acting drugs.

CONCLUSIONS:
Early opioid prescribing patterns are associated with long-term use. While patient characteristics are important, clinicians have greater control over initial prescribing. Our findings may help minimize the risk of inadvertently initiating long-term opioid use.

Why were these opioid naive patients prescribed narcotic medications? I'd have to know if they had legitimate reasons to be on continued narcotic meds at 1 year.

 

[DrCommonSense]

This study shows a 13% incidence of 3 month use of opioids s/p hand surgery. It requires only 2 weeks to become chemically dependent. This was in opioid naive patients.

J Hand Surg Am. 2016 Sep 7. pii: S0363-5023(16)30427-0. doi: 10.1016/j.jhsa.2016.07.113. [Epub ahead of print]
Risk of Prolonged Opioid Use Among Opioid-Naïve Patients Following Common Hand Surgery Procedures.
Johnson SP1, Chung KC2, Zhong L2, Shauver MJ2, Engelsbe MJ3, Brummett C4, Waljee JF5.
Author information

Abstract
PURPOSE:
To evaluate prolonged opioid use in opioid-naïve patients after common hand surgery procedures in the United States.

METHODS:
We studied insurance claims from the Truven MarketScan databases to identify opioid-naïve adult patients (no opioid exposure 11 months before the perioperative period) who underwent an elective (carpal tunnel release, carpometacarpal arthroplasty/arthrodesis, cubital tunnel release, or trigger finger release) or trauma-related (closed distal radius fracture fixation, flexor tendon repair, metacarpal fracture fixation, or phalangeal fracture fixation) hand surgery procedure between 2010 and 2012 (N = 77,573 patients). Patients were observed for 6 months to determine the number, timing, duration, and oral morphine equivalent dosage of postoperative opioid prescriptions. We assessed prolonged postoperative opioid use, defined as patients who filled a perioperative opioid prescription followed by a prescription between 90 and 180 days after surgery, and evaluated associated risk factors using multivariable logistic regression.

RESULTS:
In this cohort, 59,725 opioid-naïve patients (77%) filled a perioperative opioid prescription. Of these, 13% of patients continued to fill prescriptions between 90 and 180 days after surgery. Elective surgery patients were more likely to continue to fill opioid prescriptions after 90 days compared with trauma patients (13.5% vs 10.5%). Younger age, female gender, lower income, comprehensive insurance, higher Elixhauser comorbidity index, mental health disorders, and tobacco dependence or abuse were associated with prolonged opioid use.

CONCLUSIONS:
Approximately 13% of opioid-naïve patients continue to fill opioid prescriptions after hand surgery procedures 90 days after surgery. Preoperative interventions centered on opioid alternatives and early cessation, particularly among patients at risk for long-term use, is critical to addressing the prescription opioid crisis in the United States.

CLINICAL RELEVANCE:
The current national opioid use epidemic requires an assessment of the prevalence of hand surgery patients who receive and fill opioid prescriptions after common hand surgery procedures.

This study shows a 13% incidence of 3 month use of opioids s/p hand surgery. It requires only 2 weeks to become chemically
dependent. This was in opioid naive patients.

J Hand Surg Am. 2016 Sep 7. pii: S0363-5023(16)30427-0. doi: 10.1016/j.jhsa.2016.07.113. [Epub ahead of print]
Risk of Prolonged Opioid Use Among Opioid-Naïve Patients Following Common Hand Surgery Procedures.
Johnson SP1, Chung KC2, Zhong L2, Shauver MJ2, Engelsbe MJ3, Brummett C4, Waljee JF5.
Author information

Abstract
PURPOSE:
To evaluate prolonged opioid use in opioid-naïve patients after common hand surgery procedures in the United States.

METHODS:
We studied insurance claims from the Truven MarketScan databases to identify opioid-naïve adult patients (no opioid exposure 11 months before the perioperative period) who underwent an elective (carpal tunnel release, carpometacarpal arthroplasty/arthrodesis, cubital tunnel release, or trigger finger release) or trauma-related (closed distal radius fracture fixation, flexor tendon repair, metacarpal fracture fixation, or phalangeal fracture fixation) hand surgery procedure between 2010 and 2012 (N = 77,573 patients). Patients were observed for 6 months to determine the number, timing, duration, and oral morphine equivalent dosage of postoperative opioid prescriptions. We assessed prolonged postoperative opioid use, defined as patients who filled a perioperative opioid prescription followed by a prescription between 90 and 180 days after surgery, and evaluated associated risk factors using multivariable logistic regression.

RESULTS:
In this cohort, 59,725 opioid-naïve patients (77%) filled a perioperative opioid prescription. Of these, 13% of patients continued to fill prescriptions between 90 and 180 days after surgery. Elective surgery patients were more likely to continue to fill opioid prescriptions after 90 days compared with trauma patients (13.5% vs 10.5%). Younger age, female gender, lower income, comprehensive insurance, higher Elixhauser comorbidity index, mental health disorders, and tobacco dependence or abuse were associated with prolonged opioid use.

CONCLUSIONS:
Approximately 13% of opioid-naïve patients continue to fill opioid prescriptions after hand surgery procedures 90 days after surgery. Preoperative interventions centered on opioid alternatives and early cessation, particularly among patients at risk for long-term use, is critical to addressing the prescription opioid crisis in the United States.

CLINICAL RELEVANCE:
The current national opioid use epidemic requires an assessment of the prevalence of hand surgery patients who receive and fill opioid prescriptions after common hand surgery procedures.

There's a large difference between trauma related hand surgeries and carpal tunnel release.

If 13% of carpal tunnel surgery patients that were opioid naive remained on narcotics, I would definitely consider that a problem. Hard for me to differentiate.