How come, the US has an opiate crisis?
Opiates also do what they're supposed to, but the fact that they're addictive wasn't a mystery. They're safe if taken and prescribed as instructed. The failure is more on the DEA and other enforcement bodies for not dealing with the obvious prescription abuse. The FDA doesn't make controlled substance decisions.
Figuring that out wouldn't necessarily be an up front trial kind of thing though.
It never spoke out either. Like Pontius Pilate, it washed its hands of the matter.
So, naturally, he sat around with nothing to do during recovery but to play video games, drink beer and pop pills.
Pain management is definitely not taken seriously enough by some doctors, and too many people are too trusting that their overworked doctors and nurses know better.
Both myself and my wife also have chronic pain from past injuries (back pain mostly, plus some arthritis for me) but we manage with stretching, liberal amounts of tiger balm, and the occasional ibuprofin.
I have to be honest, I was really hesitant to fill that prescription. I did after a few hours when the pain got unbearable (at 1 in the morning, they filled it in 5 minutes which also makes me worried that pharmacy would be an easy robbery target...), and damn they did work quite well. I only needed them for 2 days, and I didn't get the sense of being high that I expected, and had no issues stopping them. I can't say I didn't wonder what would have happened if I needed them for a week or more, or if I had previously been addicted to opiates.
It just seems hard to believe in modern times there's nothing in between NSAIDs/Tylenol and full on opioids for managing pain, especially for this sort of post-op temporary use case.
I'd much rather have the slight load on the liver that paracetemol has than the issues with the stomach that NSAIDs bring.
The fact is we seem to be damned if we do or damned if we don't. We desperately need a reasonably effective and safe painkiller. If 100,000 actually die from paracetamol per year then there's a reasonable excuse for banning it. But what do we replace it with given that many cannot take NSAIDs for various reasons?
- Pharmacists and doctors repeatedly say paracetamol/acetaminophen is very safe if taken according to directions, the trouble is, that in excess, it shuts the liver down and it cannot recover/clear the drug in time before real trouble sets in. Moreover, it's not very effective as a painkiller.
- NSAIDs, ibuprofen and aspirin, cause bleeding of the stomach and other major issues, even hearing loss in high doses.
- The newer COX-2 selective NSAID Rofecoxib, aka Vioxx, was very effective at certain forms of pain relief but was banned by the FDA after it was found to cause cardiac effects in susceptible people including heard attacks. (Another criticism I have of the FDA is the inordinate length of time it took for the FDA to remove Vioxx from the market after its cardiac effects became known—this was around three years. (I recall reading a paper in the AAAS journal Science that outlined Vioxx's cardiac effects and thinking to myself that the drug would have to be banned. That was some three years before the FDA actually banned it).
- Celecoxib, also a newer COX-2 selective NSAID that is in the same class as Vioxx, hasn’t yet been banned but it still has the potential to cause cardiac effects. Moreover, it is not as effective a painkiller as Vioxx was.
- Then there's the dangerously addictive opioids.
- Once we had another rather effective painkiller but it too has been long banned. APC was a mixture of aspirin, phenacetin and caffeine and it was rather effective except for the fact that it rotted one's kidneys, many instances of kidney disease were attributed to its use
Alas, there's precious little else, especially anything that's safe.
It's a pathetically inadequate a list, isn't it?
I'm not sure why they stopped selling it OTC though.
And even if there is, would we really expect requiring a prescription to fix that problem? That doesn't seemed to have kept opiates from ruining people's lives.
From personal experience, it would seem that permanent damage is the norm more than it is the exception. But at large I don't know.
> That doesn't seemed to have kept opiates from ruining people's lives
NSAIDs are not addictive.
> to what benefit?
Better public health. But I concede that in the US, that's heresy.
A bunch of years ago I broke two ribs, and decided not to go see a doctor, after a doctor friend told me they wouldn't be able to do anything about it, aside from prescribing pain medication and telling me to try not to move much (with the caveat that if at any point I started to have trouble breathing, I must call 911 and get myself to the ER). It wasn't a particularly fun 6-8 weeks of healing, and I took the max recommended dose of OTC ibuprofen many of the days, but I got through it. Would it have been nicer to have zero pain? Sure. But I don't think the addiction risks of something like an opiate would have been worth it, and the healing process serves as a reminder to me to take better care of my body.
(Just to be clear, because I'm sure someone will put words in my mouth otherwise: no, I don't think this "grin and bear it" method works for all situations! When it's possible and reasonable to get by with minimal pain medication, I think people are better off. But I think many people -- aided and abetted by overzealous prescription-writing by some doctors -- go too far in trying to remove all pain, to their detriment.)
Opiods are available at many different magnitudes of strength.
For instance, on a per milligram basis, Oxycodone is about 1.5 times stronger than morphine.
Codeine, which is actually available OTC in some countries (Including Canada, but NOT the US), is about 1/20th as strong.
Now, there also is stuff such as tramadol (WHO ladder step 2). But it also can be abused, and is indeed sold on the streets.
Right, and as you say it'd be a good practice to stop using it, especially if it's OTC, which, as mentioned above, it still is in some countries.
It used to be OTC where I am but it's now only available by script. I recall decades ago taking combination codeine/paracetamol (aka acetaminophen) for headaches and the codeine definitely exacerbated them, moreover it was not very effective as a painkiller.
It turned out that whilst paracetamol wasn't very effective by itself the headaches didn't rebound as they did with the codeine mixture. All up, NSAIDs—aspirin, ibuprofen—were better even though they caused minor stomach upset.
Maybe I'll try again this spring or summer when I get back into doing some light forestry, but I almost prefer to not mask the pain so I know I'm not making things worse.
(Looks like episodes 402 and 403, from a quick search.)
In some cases it seems like peoples' trust in those regulators may be fueled by nostalgia, but the FDA does seem like one of the few agencies that has retained some measure of independence.
Looking at what has happened in this nation's other industries and institutions, only one crippling decades-long medical crisis doesn't seem all that bad.
So I offered it as an explanation for why the FDA could be well-respected and reasonably functional, while the United States fails to address some acute public health issues.
Things could be much worse; at least they don't turn a blind eye when huge sums of money are not involved. It's still very rare for a drug's approval to be pushed through via fraud, and there are a lot of diseases that need treating. They have a solid track record, even now.
Once something is approved for something (or grandfathered!), it’s a free-for-all for prescribing and usually insurance coverage.
My 2c.
That and opiates do what they say on the tin - it's more of a policy problem than a specific thing you can just FDA-away.
Unlike much medical/drug research, knowledge about opioids and opioid addiction is well known.
The FDA irresponsibly failed to act on a no-brainer.