OxyContin's 12-hour problem

The public just basically needs to push grassroots research projects to combat big pharma's countermeasures. That will also be the only way we get any real value from other drugs like MDMA, LSD, etc.

Opiates are usually not a good option for long term pain relief for many patients. They can work well in the short term but long term use can ruin a person's life (I've seen it happen, it's awful) and they lose effectiveness long term and end up causing more problems than they solve. Switching opiodes from a short term option to a long term one in the 90s was a huge (and largely failed) experiment.

Long term pain control is a complicated and multi facaded beast. We need to invest in it. "Just take a pill" is clearly not the solution that works.

I am not sure what "addiction can be managed" is supposed to mean.

http://www.news-medical.net/news/20130415/New-research-shows...

The prevailing medical notion was that there was this bright line involving the opioids — that they were great for patients but the problems happened when they went out on the streets and were abused by kids and others. But today it’s clear that the long-term use of these drugs can not only be ineffective for chronic pain, but they also create bad side effects for patients. Not just addiction but powerful psychological dependency, depression of hormone production, lethargy and listlessness and sleep apnea, among others. These drugs do work well for some patients, but for many other patients, they’re not working well at all.

One leading expert said: “We thought the big problem with these drugs is addiction. Now we realize the problem is with patients who take them and basically opt out of life.” There is a general realization that while they do work for some patients, using them on a massive scale to treat chronic pain has had really disastrous consequences.

For instance, back pain is probably the leading workplace injury. What insurers and workers’ comp agencies are discovering is that when workers are treated with high doses of opioid drugs fairly soon after these injuries, it’s the leading predictor for them not coming back to work for long periods of time, or ever.

When you take a narcotic painkiller it sets off a natural reaction called tolerance, which means your body adjusts to it. You have to take more of the drug to get the same painkilling effect. Patients would come back to doctors and say, “This drug was working really well for me, but now I’m feeling pain again.” The doctor would increase the dose. The prevailing ideology during the war on pain was that these drugs had no ceiling dose. You could keep increasing them. The doctors kept boosting them every six months. People started taking higher and higher doses of these drugs. At a certain point it appears they create a change in the neurological system where people develop hyperalgesia and they become far more sensitive to pain than when they started out on these drug

How is it moralistic?

We know in the UK that self poisoning is the second most common method of suicide after hanging, strangling and suffocation. (and that's likely to change with the next release of numbers - self poisoning is likely to overtake hanging strangling and suffocation).

the list of meds used in self poisoning is something like

  1) Opiates
  2) Anti-psychotics
  3) Tri-cyclics
  4) Paracetamol
  5) Paracetamol and opiate combination

> However, physiologically it remains an actual treatment path

But that's the point, it doesn't.

> are actual people with actual suffering involved here, remember that

That's entirely the point! Opiates are not effective for most of those people. Opiates work in the short term, but the patient develops tolerance and needs to take more. Opiates are not suitable for long term use. A patient can very quickly build up to dangerous harmful levels of opiate use, and they're not getting pain relief.

Calling a medication dangerous and ineffective, and pointing out safer more effective alternatives, is not moralising, unlike your "remember there are people suffering" comment.

First, and I want to make clear that I am strongly against any drug rep presence in any medical institution, and have advocated against it in institutions I've been affiliated with: let us draw a hard line between three levels of behavior, because conflating them is ... well, not ridiculous, not quite, but misleading. It's not ridiculous to group "slapping someone" with "beating them with a baseball bat," but it loses something.

Additionally, I'm putting a firm "no" on "informal quid pro quo." Though you, I, and ever psych major on the planet knows better, most physicians firmly believe they're just being advertised to, but are not swayed by the pharmaceutical company ads. Very few of my colleagues believe they're susceptible to this sort of shenanigans. Very few would knowingly consent to partake in a "quid pro quo" arrangement of fringe benefits for prescriptions, and most would be earnestly outraged at any such suggestion. You can claim the outcomes are the same, but they're not - it speaks entirely different volumes of the characters of the people involved, and approach needed to reform.

So, 3 levels:

1) Direct pay-offs from drug companies to docs This is something that has never been as commonplace as people seem to believe (eg, speaker fees), and is very nearly dead since physicians that get this money are now publicly monitored for it. It's always been rare, and remains so. So when we say "docs profit," which implies this level 1, well, let's not.

2) Physician frills paid for by drug companies This used to be quite common, and has grown much less so. It used to be "let us subsidize your trip to the bahamas for a 5-day medical conference (during which you will be pitched regularly)." That's been on the down-trend for about 2 decades, and is generally pretty rare these days. You're pretty much down to getting lunch brought to your office - and you had better believe this isn't ubiquitous, but depends on your practice (good private insurance practice of patients with lifelong autoimmune disease, and your co. has a new mAb out? Why, yes, lunch will be arriving soon. Standard PCP w/ 50% medicare, 20% medicaid, 30% private blend, general population of disease? eh, not so much). And, sure, occasionally dinner - subject to the above. Again, these have grown increasingly rare since these are now public numbers subject to scrutiny. No one wants to show up on that database, and definitely no one wants to be one of the docs that shows up in the local papers as one of the top 10 pharma whores for the year. More common is:

3) Drugs in the background Branded pens. Branded clipboards. Bullshit journals of carefully curated studies. Donations to org. meetings, which result in huge banners and the like. The chance to "educate" docs on new results: these are carefully put together study analyses meant to show the drug in its best light, not overt pitches. They're generally very well done studies earnestly presented, with their biases baked in deep in the fundamental study design (e.g., subject selection), so there's nothing for casual audience members to be able to nitpick at. It takes an old hand to catch the trickery here.

3 is really the big one. It's the tickle at the back of your brain; the easy prescription of familiarity, avoidance of the discomfort of getting that sad look from your local rep. But it's reasonably subtle, and unless you think docs are making bank on those free pens, it's not really what you'd call "profiting" in any meaningful sense.

1 & 2 are profiting, and inflammatory, and mostly a relic of the 80s and early 90s. They're also a shit-ton less effective than #3.

In a transparent environment, advertising is a lot more effective than bribery. As a strong advocate for complete absence of pharma-to-MD relationships, I don't worry about the occasional bit steak lunch that most docs sit through playing on their phones; I worry about the never-ending barrage of advertisements. If you look at where pharma drops their big bucks, you'll see they share my priorities.

For profit medicine at its best.