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Old 20th July 2019, 02:54 PM   #1
JeanTate
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Employees of opioid drug companies - what did they think?

Maybe not the best board, what would be a better one?

In the US, the opioid crisis has claimed ~200k lives.

Recently the Washington Post won a lawsuit to make a huge database of prescribing info public. Their reports of their analyses are shocking (to me anyway).

In this thread Iíd like to discuss what employees of the companies which dispensed most of the opioids so recklessly thought about what they were doing or what they could be fairly sure about what their fellow employees were doing.

For sure, many genuinely knew nothing.

But many obviously did know. For example, the staff at the pill mills (not all were drug pushers in white coats), and pharmacy departments of CVS, say, in some counties in WVa. Or a big subset of middle management in the biggest distributors.

Did they feel queasy? Were they troubled?
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Old 20th July 2019, 03:18 PM   #2
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I think most of them just wanted to help people with their pain..

Opioids are real good for that...

You could save a lot more lives by making the legal driving age 21 than by making it such a hassle to get effective pain medication.. ....
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Old 20th July 2019, 06:48 PM   #3
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John Oliver did a main segment on this recently, including some vid from a few manufacturer shareholder meetings. It was rather vile. There was little or no "helping people with their pain" in the celebratory thought processes on display.

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Old 21st July 2019, 10:20 AM   #4
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Shareholders are not caregivers, and probably had little if anything to do with encouraging the dispensing of the drugs.
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Old 21st July 2019, 01:31 PM   #5
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Originally Posted by Skeptical Greg View Post
Shareholders are not caregivers, and probably had little if anything to do with encouraging the dispensing of the drugs.
I don't know what to tell you about how ecstatic they were about supplying the ongoing prescription opioid crisis. Even Gordon Gecko would have cringed.
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Old 21st July 2019, 01:43 PM   #6
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What does that have to do with caregivers addressing the needs of people in pain?
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Old 21st July 2019, 01:43 PM   #7
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Depends what you mean by 'employees'.

High level staff were/are cynical ***** who don't give a damn about the harm they do as long as they maximise profit.

Lower level staff might well have bought in to the propaganda that the higher levels spewed.
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Old 21st July 2019, 02:25 PM   #8
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OxyContin paved the way for prescribing truly massive amounts of opioids, and it was sold as suitable for chronic pain because less addictive than short-acting formulations. Which was horse**** IMO. You can't put the equivalent of 32 Percocets into one pill and market it as less addictive. It's nonsense. No matter what the drug company said, doctors should have known better. All you had to do to make the pills instant-release was crush them. The stage was set for people to either die abusing the pills or develop massive tolerances to oxycodone even if used as directed.

At the time (1990s) under-treatment of pain was in the news so the industry IMO badly over-corrected. Now it's probably over-correcting again in the opposite direction. What was Purdue Pharma thinking? That it was about to get very rich. What really stumps me is, what were doctors thinking? Any opioid abuser could have told them that there were going to be problems with OxyContin.
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Old 21st July 2019, 03:09 PM   #9
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In the case of Subsys (which supplied/supplies an under-the-tongue fentanyl spray), the trial (trials?) etc revealed that quite a few of the employees knew exactly what they were doing, knew that they were getting many patients addicted, and at least some of them knew there were opioid-related deaths. Some of those employees who knew have expressed remorse ... but many of those in prison (or awaiting sentence) have not (not just Subsys employees, but also corrupt doctors).

Some of the material that appears in various news articles - both re Purdue and the latest trove the WP (+another news org) worked so hard to make public - strongly suggests that many managers were focussed on sales and revenue, and knew many of those sales were ending up in pill mills (etc). From their emails (assuming they're true and that the context shows they're accurate), it's very clear some of those managers - right up to CEO level - just didn't care. There seems to have been a widespread "it's all entirely legal" mentality.

To Skeptical Greg's point: yes, there are surely many, mostly lower-level employees, who thought they were helping patients. And in many places, there's not much evidence of over-prescribing etc. It is unlikely that folks there could have learned - via internal company chatter etc - about the vast quantities of pills going to pill mills in Florida, West Virginia, etc.

But what about the manager of a pharmacy in a county where the number of prescribed opioids amounted to more than one pill per person per day, for a year, for the entire county (the database now public shows that there are several such counties)? The folks who work/worked in such pharmacies? The admin staff of doctors' practices where almost nothing but opioids were prescribed?

I've been looking, but haven't yet found any articles where a journalist interviews some of these "front line" employees. Or lower level managers in one of the handful of companies which have been identified as being directly involved in the vast majority of cases (surprisingly, Purdue was only a bit player, at ~3%); these are the drug manufacturers and the distributors, along with CVS, Walgreens, and Walmart (pharmacies).
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Old 21st July 2019, 03:40 PM   #10
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I'm going to post this here, for the record, as I did in the thread about the criminal proceedings.
March 7, 2019

Purdue University statement re: Purdue Pharma

WEST LAFAYETTE, Ind. - Purdue University is not and has never been affiliated in any way with Purdue Pharma. The pharmaceutical company was founded in Manhattan in 1892 by John Purdue Gray and George Frederick Bingham as the Purdue Frederick Company. Purdue University was founded in 1869 as Indianaís land-grant institution, named for benefactor John Purdue.
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Old 21st July 2019, 10:24 PM   #11
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People are not killed by the use of opioids. People are killed by the misuse of opioids.
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Old 22nd July 2019, 02:28 AM   #12
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Originally Posted by arthwollipot View Post
People are not killed by the use of opioids. People are killed by the misuse of opioids.
Be nice if it was so black and white, but it isn't. For example opioids are often given at the end stage of terminal disease in such quantities that it is known it will reduce respiration (for example) and thus hasten death.

The USA in particular (as my very much over generalised opinion) seems to struggle in getting pain management right. I remember on this forum a decade or more ago being gobsmacked how difficult it was for USA folk to get good treatment for their pain.

One really hopes the avarice of some won't mean many thousands and thousands of people have to forgo good treatment for their pain.
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Old 22nd July 2019, 02:37 AM   #13
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Full disclaimer, I've been using a variety of pain treatments for about 40 years, often including opioids so I have a very personal connection to this story as it has had an effect over here in the UK.

So much so I had to have a review with "my" GP for my prescriptions for the first time in about 10 years only a few months ago. The GP is a youngish GP, late twenties and because one of my repeat prescriptions is an opioid the "system" flagged it up to her as an alert. I mention her age as she is recently qualified and the difference in her understanding and attitude of managing chronic pain is quite different from my older GP who retired about 5 years ago. Much more concerned about addiction/dependency but also a better understanding that pain management is not just about drugging a patient into a stupor until they feel nothing!
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Old 22nd July 2019, 07:46 AM   #14
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Originally Posted by Skeptical Greg View Post
Shareholders are not caregivers, and probably had little if anything to do with encouraging the dispensing of the drugs.
None of the people working for the drug company are care givers they are salesmen. And they were moving a lot of product so that is always good for salesmen.
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Old 22nd July 2019, 07:50 AM   #15
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Originally Posted by arthwollipot View Post
People are not killed by the use of opioids. People are killed by the misuse of opioids.
Ah that is exactly the line that the corporate leaders chose to pursue.
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Old 22nd July 2019, 10:21 AM   #16
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Originally Posted by arthwollipot View Post
People are not killed by the use of opioids. People are killed by the misuse of opioids.
Mostly true, but OxyContin's formulation and marketing at the time created an almost perfect product for misuse and diversion into a black market.
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Old 22nd July 2019, 11:17 AM   #17
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Originally Posted by Darat View Post
The USA in particular (as my very much over generalised opinion) seems to struggle in getting pain management right.
It's a weird mix - puritanical and yet overmedicated. I don't mean that no chronic pain patients should get opioids, because obviously they should, but they need to be carefully managed for tolerance and IMO the sheer quantities in the OC formulations were on the high side for anyone who would need open-ended pain management with opioids.

It also turned out that a key marketing point - dosing once every 12 hours - was not working as well as the drug company said it was. For proper pain management dosing every 8 hours worked better for some patients. The Rx company wouldn't admit to that which some people think set the stage for breakthrough pain and withdrawal symptoms and therefore possible misuse (taking it differently that prescribed).

OxyContin was submitted and justifiably approved by the agency as a 12-hour dosage form
Quote:
This translates to using higher doses at 12-hour intervals or supplementing with IR; however, when considering patient uniqueness, it is plausible that neither option is optimal.
In 2004 the FDA tried to get OC labeled as OK once every 8 hours but I don't know if that ever happened. Extended-release morphine is labeled for once every 8 hours if needed.
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Old 22nd July 2019, 11:47 AM   #18
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Originally Posted by Minoosh View Post
Mostly true, but OxyContin's formulation and marketing at the time created an almost perfect product for misuse and diversion into a black market.
That was also the main argument from the family in control about the deaths associated with their products.
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Old 22nd July 2019, 12:14 PM   #19
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Originally Posted by JeanTate View Post
...But what about the manager of a pharmacy in a county where the number of prescribed opioids amounted to more than one pill per person per day, for a year, for the entire county (the database now public shows that there are several such counties)? The folks who work/worked in such pharmacies? The admin staff of doctors' practices where almost nothing but opioids were prescribed?

I've been looking, but haven't yet found any articles where a journalist interviews some of these "front line" employees. Or lower level managers in one of the handful of companies which have been identified as being directly involved in the vast majority of cases (surprisingly, Purdue was only a bit player, at ~3%); these are the drug manufacturers and the distributors, along with CVS, Walgreens, and Walmart (pharmacies).
What, exactly, do you think the manager of pharmacy should do when the doctor prescribes a medication and all the paper work has been filled out correctly - not give them the medication?
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Old 22nd July 2019, 12:59 PM   #20
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Not every one who dies from an opioid overdose, used prescription drugs.

I do not know if there is a national average ... but I'd say around half of the people I know who died in this manner ... didn't use prescription opioid pills at all.
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Old 22nd July 2019, 01:26 PM   #21
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Originally Posted by Ron Swanson View Post
Not every one who dies from an opioid overdose, used prescription drugs.

I do not know if there is a national average ... but I'd say around half of the people I know who died in this manner ... didn't use prescription opioid pills at all.

But in the US a lot of them got started with prescription drugs before they switched to the more economical heroin.
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Old 22nd July 2019, 02:00 PM   #22
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Originally Posted by Elagabalus View Post
What, exactly, do you think the manager of pharmacy should do when the doctor prescribes a medication and all the paper work has been filled out correctly - not give them the medication?
Possibly, give the DEA a heads up. It's not about a given patient; more about a doctor's prescribing patterns.
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Old 22nd July 2019, 02:18 PM   #23
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Originally Posted by ponderingturtle View Post
That was also the main argument from the family in control about the deaths associated with their products.
I get why arthwollipot said that, though. Opioids are incredibly useful and don't have to kill anybody. I think a lot of the OxyContin deaths were down to ignorance of just how much oxycodone could be in one pill.

As long as a person is taking them within his/her own tolerance level they're pretty safe drugs. But OC160 was like no other pill that had ever existed.
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Old 22nd July 2019, 03:15 PM   #24
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Having spent most of the past 20 years taking prescribed pain medicine, things are different now then when I first started. The doctors would allow me to see them every few months, and make an 'office-fee' to drop in and get an - often early refill. But that has changed.

I have been on everything out there. Percodan's, morphine, methadone, Norco, and finally now, a low dose of Oxycodone. But my doctor has me sign a contract now. I must see her every 6 weeks. My urine is checked about once a month, my blood every three. So yes, it has changed a great deal.
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Old 22nd July 2019, 06:04 PM   #25
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Originally Posted by wasapi View Post
Having spent most of the past 20 years taking prescribed pain medicine, things are different now then when I first started. The doctors would allow me to see them every few months, and make an 'office-fee' to drop in and get an - often early refill. But that has changed.

I have been on everything out there. Percodan's, morphine, methadone, Norco, and finally now, a low dose of Oxycodone. But my doctor has me sign a contract now. I must see her every 6 weeks. My urine is checked about once a month, my blood every three. So yes, it has changed a great deal.
This probably won't do you any good because it is not commonly used for pain in the U.S., but have you ever tried buprenorphine (Subutex/Suboxone)? It's regulated as a CIII drug, one notch below CII which is what all the medications you listed are. But except as a transdermal patch its use is considered off-label for pain, so insurers won't cover it.

Despite long presence, buprenorphine for pain is still a mystery
That article quotes one doctor saying that insurers would rather cover fentanyl patches than buprenorphine patches which he thinks is a shame.

On the other hand if you ever need surgery again, buprenorphine can make planning for pain relief a major hassle. To complicate matters it is sometimes formulated with naloxone. Post-surgical patients may need higher doses of opioids to control pain.

To Stop or Not to Stop, That is the Question

Since you and your doc seem to have a handle on the oxycodone use it may not be of much use to you. But I think it's probably worthwhile for some patients. Effective pain relief with a much lower potential for abuse.

When I see studies like this, from 2004, I wonder how many lives could have been saved. This was a study of people not having success with regular dosing of full-agonist opioids. (Pain got worse; functional ability dropped).

Buprenorphine is a funny drug. Even without the naloxone it has a ceiling effect. You can't just take more to get more effect - at a certain level it starts blocking itself. That also makes it much safer as far as respiratory depression goes.
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Old 22nd July 2019, 06:49 PM   #26
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Originally Posted by Darat View Post
Be nice if it was so black and white, but it isn't.
Yeah, when you summarise a complex and difficult situation in less than 20 words, you're going to miss some nuance.
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Old 23rd July 2019, 03:40 AM   #27
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Originally Posted by Minoosh View Post
I get why arthwollipot said that, though. Opioids are incredibly useful and don't have to kill anybody. I think a lot of the OxyContin deaths were down to ignorance of just how much oxycodone could be in one pill.
And of course doctors giving them out like candy at the behest of Purdue pharma.

Last week tonight did a great show on Purdue pharma and the Sackler family.

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Old 23rd July 2019, 03:41 AM   #28
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Originally Posted by arthwollipot View Post
Yeah, when you summarise a complex and difficult situation in less than 20 words, you're going to miss some nuance.
I get it you support the sackler family.
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Old 23rd July 2019, 11:20 AM   #29
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Catching up ... There are many WP articles on the database and what it shows; here's just one:
76 billion opioid pills: Newly released federal data unmasks the epidemic

Release of this database had been strenuously resisted; but the persistent efforts of the WP and HD Media, which publishes the Charleston Gazette-Mail in West Virginia, finally bore fruit.

The accompanying map is horrifying. Yes, there are counties where the number of opioid pills prescribed seems quite reasonable, of the order of a small handful per person per year (on average), perhaps in line with honest attempts to help people in pain. However, there are counties where this is manifestly not the case ... unless perhaps if you think that ~half the population of a county needs an opioid a day to manage their pain.

A useful document is the CDC Guideline for Prescribing Opioids for Chronic Pain.

It has this, of relevance to several posts in this thread:

Originally Posted by CDC
Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care.
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Old 23rd July 2019, 11:27 AM   #30
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Originally Posted by Elagabalus View Post
What, exactly, do you think the manager of pharmacy should do when the doctor prescribes a medication and all the paper work has been filled out correctly - not give them the medication?
I am not a pharmacist.

However, I have read that there are guidelines for what to do in such circumstances, both internal company ones and from the professional organisation to which many pharmacists belong. After all, this sort of case/scenario is hardly rare, and not restricted to prescriptions of opioids; surely it's something you learn to deal with, as part of your training to become certified as a pharmacist.

In any case, for quite a lot of pharmacists, it was not (and may still be so) one doctor's single prescription. Instead, it was (for example) a doctor's practice writing hundreds of opioid prescriptions a day (and nothing else), sometimes for dozens of the same people as were given prescriptions just the previous day.

What did they think?
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Old 23rd July 2019, 11:46 AM   #31
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Originally Posted by ponderingturtle View Post
None of the people working for the drug company are care givers they are salesmen. And they were moving a lot of product so that is always good for salesmen.
As has become clear, it's just a small number of drug manufacturers (SpecGx, a subsidiary of Mallinckrodt; Actavis Pharma; and Par Pharmaceutical, a subsidiary of Endo Pharmaceuticals, collectively account for 88%) and distributors (McKesson Corp., Walgreens, Cardinal Health, AmerisourceBergen, CVS and Walmart account for 75%). Most are not household names ... except for the distributors CVS, Walgreens, and Walmart.

The newly released documents, together with what's already been made public, show that senior execs in many of these handful of companies worked extremely hard to lobby Congress to pass a law that effectively neutered a great many of the DEA's investigations into illegal distribution of prescription opioids. These people - and the lobbyists - surely knew exactly what they were doing.

A handful of cases have already been tried, and fines handed out to several of this vile coterie ... they show, among other things, a very deliberate effort to not create, not use, de-fang, etc internal systems meant to identify suspicious orders (which were supposed to lead to the DEA being notified). The managers etc responsible for this surely knew exactly what they were doing.

What did these people think, at the time?
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Old 23rd July 2019, 11:52 AM   #32
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Originally Posted by Minoosh View Post
Mostly true, but OxyContin's formulation and marketing at the time created an almost perfect product for misuse and diversion into a black market.
And internal company documents, made public in one of the cases against Purdue Pharma, reveal that at least some managers knew exactly what would happen - widespread addiction - and were quite OK with it. Some apparently blamed those taking the drug for their addiction; all seemed to think that as long as no laws were explicitly broken, their behavior was entirely appropriate.
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Old 23rd July 2019, 11:56 AM   #33
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Originally Posted by Ron Swanson View Post
Not every one who dies from an opioid overdose, used prescription drugs.

I do not know if there is a national average ... but I'd say around half of the people I know who died in this manner ... didn't use prescription opioid pills at all.
It's certainly complicated.

However, the rise in deaths due to "street market" (i.e. illegal) heroin and, more recently, fentanyl, seems to track the rise in prescription of opioid pills (with a delay). This is consistent with people becoming addicted to an opioid pill, say, and then moving on to heroin and fentanyl when they could no longer get the prescription drug.
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Old 23rd July 2019, 12:05 PM   #34
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Originally Posted by Elagabalus View Post
What, exactly, do you think the manager of pharmacy should do when the doctor prescribes a medication and all the paper work has been filled out correctly - not give them the medication?
This actually happened once. A couple of years ago, I had a small stroke and was recovering at home. Needing my oxycodone, I had a friend take me to the pharmacy.

I had 'bed-head', and had thrown on some old clothes, and looked like a mess. They refused to fill it for me, based on my appearance. But I went next door to Safeway, where it was filled without question.
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Old 23rd July 2019, 12:07 PM   #35
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Originally Posted by Minoosh View Post
I get why arthwollipot said that, though. Opioids are incredibly useful and don't have to kill anybody. I think a lot of the OxyContin deaths were down to ignorance of just how much oxycodone could be in one pill.

As long as a person is taking them within his/her own tolerance level they're pretty safe drugs. But OC160 was like no other pill that had ever existed.
It bears repeating that the use of opioids in a hospital setting rarely results in addiction. I'm not sure if it's known why this is so (as in, detailed, scientific, studies).

I can personally attest to this; over many, many years, I've had at least four different opioids while in hospital; all were injected (one - fentanyl! - was an epidural). Upon discharge, I've had at least three different opioids prescribed (to manage post-operative pain, mainly); in all cases, I didn't use the full prescription as I was able to transition to non-opioids faster than the doctors thought.

From all that I've read, the opioid crisis in the US has nothing to do with opioids used in hospitals, for palliative care, for end-of-life situations, or for managing chronic pain in cancer patients. Of course, humans being human, there must certainly be some cases of abuse/diversion in the above settings; however, it seems it's not significant.
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Old 23rd July 2019, 01:06 PM   #36
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My wife has had chronic pancreatitis for ~20 years now.

Initially, she was on immediate release opioids like vicodin. Those, in my opinion, are not very good for chronic pain as they do not adequately manage continuous persistent pain. They are good for short term or breakthrough pain. But even then, they tend to wear off before you are supposed to take the next one. This, in my mind, is more likely to lead to abuse than the extended relief medications.

While on vicodin, she would end up in the hospital a couple times a year.

Seeing the the Vicodin was ineffective, her doctor put her on Fentanyl patches. Those worked great. One caveat of patches, however, is that they have a ramp up and ramp down period. The patches are designed to last three days. Her doctor had her put a new patch on the third day to overlap with the previous one so as one was ramping down the next was ramping up. the only problem with the patches (other than having spots on her back from the glue) was that if she forgot to put one on it took a while for the medication to get in her system. It's not very flexible.

When her doctor moved to another area, her new doctor wasn't a fan of the patches, basically because it's hard to maintain and manage medication levels with them. So he switcher her to Morphine ER. She was on that for ten years without modifying the dose. The morphine eliminated the hospital visits completely and the only side effect was constipation. There was no drowsiness, euphoria or anything else like that. Basically, she could lead a normal life.

The worst part of morphine is that some people in the medical field treat you ...unprofessionally.

That, and it is a hassle to fill the prescription. Can't fill it early, but if you realize on friday afternoon that you will be out on sunday, you're screwed. (When this happened, we reduced dose to spread it out to get through.) Later, we found that if she missed a dose it wasn't that bad.

She's been off of it for about a year. Why? Because accidentally violated her pain contract when she went to the dentist. She had an infected tooth and the dentist called in a prescription. I went to pick up what we expected to be an antibiotic only to find that it was Vicodin. It didn't occur to me when I picked it up, but we got a call a couple weeks later that because of that they were taking her off morphine. Withdrawal wasn't really that bad.

Now she's on gabapentin, for which she says the withdrawal is a lot worse.

So why am I laying all this out? Because in all this fear of abuse what is being forgotten is that opioids allow a lot of people to live normal lives.

In many ways the paranoia about abuse and the measures for prevention, in my opinion, lead to abuse. Prescribing inadequate dosage leads to abuse. (Adequate dosage does not lead to a desire for more. Desperation for pain relief does.) Treating patients like criminals (Drug tests, assuming that patients are drug seekers, etc.) leads to abuse. Pain contracts that punish patients by withholding healthcare...lead to abuse.

For those who suffer from chronic pain, opioids are a miracle. Patients should not be forced to jump through hoops like criminals on probation for their healthcare. So find a solution that doesn't do that.
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Old 23rd July 2019, 01:51 PM   #37
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It's an ugly story no matter which part of it you review - patients that had an absolute need for opioid meds had a difficult if not impossible time getting them/affording them, and the middle men that were sending millions of pills into public circulation w/ -0- oversight.
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Old 23rd July 2019, 02:23 PM   #38
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Originally Posted by JeanTate View Post
It bears repeating that the use of opioids in a hospital setting rarely results in addiction. I'm not sure if it's known why this is so (as in, detailed, scientific, studies).
One reason is hospital stays are self-limiting. Probably most people taking opioids for short-term pain aren't really on them long enough to get heavily dependent. Even for longer-term pain, it's pretty easy to taper off once the pain is gone or being controlled by other means.

Another theory I've heard is that it's much easier to quit something you're taking for physical pain vs. emotional pain. If you've got a broken leg, your body is healing. When it's time to get off you can just stop or undergo a short taper. If you're medicating because you feel icky most of the time, and you've found the magic potion that "fixes" you, you might be getting temporary relief but you're not really dealing with the emotional pain. Withdrawal becomes not just physical symptoms to be managed but a return of all the feelings you've been using to suppress.

Not sure if that's scientific but I've seen it anecdotally.
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Old 23rd July 2019, 02:58 PM   #39
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Originally Posted by JeanTate View Post
Catching up ... There are many WP articles on the database and what it shows; here's just one:
76 billion opioid pills: Newly released federal data unmasks the epidemic
The number of pills dispensed is only part of the story. One OC 80 = 16 Percocet.

Also, one person with severe chronic pain can skew the numbers quite a bit. Because of tolerance and pain levels some people are on doses that would kill a lot of people several times over. In doing the math remember that a chronic pain patient is not going to be taking just one pill a day. Six or 12 is not unusual. As long as the pills are not loaded with acetaminophen, ibuprofen etc. it's not a problem for someone with a tolerance.

ETA: This is bizarre. When I click your link I get this back: "Sorry, we can’t find what you are looking for.
Take a deep breath. Everything’s going to be okay."

Last edited by Minoosh; 23rd July 2019 at 03:03 PM.
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Old 23rd July 2019, 03:15 PM   #40
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Originally Posted by Minoosh View Post
<snip>

ETA: This is bizarre. When I click your link I get this back: "Sorry, we canít find what you are looking for.
Take a deep breath. Everythingís going to be okay."
Yeah, me too. Sorry, I donít know what went wrong; Iíll try and get a link which works ...

How about this: https://www.washingtonpost.com/inves...1e9_story.html

I have no idea what the 5f29 ... stuff is, or means ...

Last edited by JeanTate; 23rd July 2019 at 03:19 PM.
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