a historians solution to the current opiate crisis

[clinton (OP)]

http://m.huffpost.com/us/entry/5655f0afe4b079b28189efcd



WASHINGTON -- David Courtwright, the nation's leading historian on drug use and drug policy, has published an article in the New England Journal of Medicine arguing that physicians must heed the lessons of the 19th and 20th centuries in order to successfully combat today's opioid epidemic.
The professor of history at the University of North Florida recounts how the medical and pharmaceutical communities had successfully worked to control the epidemic on their own by reducing the number of opiate prescriptions across the country. Doctors "had succeeded through primary prevention, creating fewer new addicts as existing addicts began quitting or died of old age," he writes.
Meanwhile, Courtwright adds, a prejudice that began more than a hundred years ago has yet to be fully defeated by modern science. As the first opioid epidemic was underway, some doctors and some municipal governments engaged in what would now be called a form of "harm reduction" -- an approach known as maintenance. Where an addiction was deemed to be unbreakable, at least at that moment, doctors would maintain the supply of narcotics so that addicts would avoid withdrawal, which can be deadly, and would not resort to crime or the black market to continue using.
As Courtwright recounts, the Progressive movement strongly condemned vice, and led the push for prohibition of the non-medical use of narcotics and alcohol. The federal government carried over that mentality, with the narrow blessing of the Supreme Court, eventually prohibiting doctors from prescribing for the purposes of maintenance. That bias against maintenance continues today within the U.S. treatment system, even as advances in science have developed effective treatments such as methadone and buprenorphine. Methadone was proven an effective long-term treatment decades ago.

"The key objectives — reducing fatal overdoses, medical and social complications, and injection-drug use and related infections — are difficult to achieve if abstinence-oriented treatment is the only option available," the historian writes. "Yet that remains the situation in many places, particularly in rural locales, where officials dismiss methadone and buprenorphine as unacceptable substitute addictions."
To help tell the contemporary history, Courtwright in his NEJM article cites a Huffington Post investigation into the treatment industry from January.
"We need more and better treatment for addicts, including medically assisted recovery, and that's where your article and mine really intersect," Courtwright told HuffPost. "I made the point that general prejudice against maintenance has spilled over and exacerbated the failure to provide adequate medically assisted recovery."
The HuffPost investigation showed how Kentucky’s scarce access to such recovery methods was exacerbating the current epidemic. In 2013, the majority of fatal overdose victims in the northern part of the state had tried an abstinence-only treatment -- which bars the use of medications like buprenorphine -- before their deaths.
“What your article helped people to understand and what a lot of people still don't get, is there's a difference between an opioid addict who goes into treatment and somebody who's an alcoholic or a heavy cannabis user who goes into treatment, because the truth is that if that a cannabis user or that alcoholic comes out of treatment and relapses, they're probably not going to immediately kill themselves," Courtwright said. "Whereas the opioid addict comes out of treatment and because they've lost their tolerance and because they're overconfident about the size dose they can safely take, they're going to die.”
The historian admitted that for a long time he had thought the extent of any opioid problem would be limited to those buying heroin on the black market. When he began his research in the 1970s, he did not dream that there would be another opioid epidemic -- one twice as prevalent as the one in the early 20th century. This fall, he recalled seeing an ad for a medicine that could relieve opioid-induced constipation. The ad had aired during an NFL football game.
“I fell out of my chair,” Courtwright said. “I was just astonished. It was certainly a sign of how common the condition has become in American society.”

[Thoms]

What a stupid fuck less scrips means more h.

[duck]

yeah i totally disagree thoms. 

Especially in florida where this guy is from, opioids between 95-2005 were prescribed in a pretty extreme amount for people and issues that did not warrant the (amount of) opiates.  Did their pain deserve to be alleviated?  Of course.  but at what cost?  the addiction potential of opioids is so high that the risk/reward must be considered with the utmost care.   I know this was not not done all the time, ive seen it.   The problem was only multiplied by the dead horse that is Perdue pharma who as we all know mislead doctors on the addictiveness of oxycontin.

Furthermore, the guy calls for more treatment options for addicts as opposed to criminalization.  Most people here would agree that is absolutely paramount in the current legal framework. 

Most CPP who ended up on smack started with hyrdros and then went up from there, got cut off or it got too expensive then went to smack.  Very few people go straight to H for their chronic pain.  So if you cut out  a large part of the potential, i.e. prescribing strong opiates for non-extreme pain,you probably would have less smack addicts being spawned via the cpp/PM doc route.

[Snout]

David courtwright is not a "stupid fuck" as stated above, rather he is the best writer about drug history/policy in the USA. I have all his books and I highly recommend "addicts who survived" , it's the most interesting book about opiAte use I've seen, and I've read a lot of them "forces of habit" is also a great book

[Thoms]

I can admit when I'm wrong, I jumped to a conclusion without really thinking about the article with an open mind. God it's great to see you on the board duck, I was hoping you would show up.

It was foolish of me to skim an article and jump to a conclusion that truly made an ass of myself.

[makita]

I dunno, I haven't done enough research (I only have one article so far to back me up) but while I agree with most of this article I feel like the origin story of the pill epidemic (ie, it was the overprescribing Drs fault we're all in this mess) is faulty and smells of moral panic.  Even when enlightened writers acknowledge that the DEA crackdown on pills caused the heroin spike (and that part I believe is true), almost all of them still seem to believe that without the Drs overprescribing we would not have had that many opioid addicts to begin with. 

I just don't buy it, that all of a sudden that many Drs lost their minds.  I think the Drs who were just glorified drug dealers were probably in the minority (although they did move a huge number of pills).  I think the street sellers were being supplied by people further up the chain as much if not more so than individual patients of pill mill Drs.  I think the image of pill mills and epidemic overprescription was latched onto by the press and it created an epidemic that wasn't there...until the DEA got involved and started squeezing the law enforcement end of the tube. 

I think pain was undertreated to begin with, and there were some very important widespread socio-economic factors that created more demand for opiates (more legit pain, physical and psychological), which was at first met as it should have been, by Drs, and then within 5 years was quickly and severely cut off at the source.  I think if the DEA had left Drs and their patients alone we would see not only less overdose, pain and suffering, etc (and WAYYYY less heroin use) but also the situation would have been gradually managed by the people who (as this article does say) were best situated to handle it in an effective manner, over a number of generations, and perhaps begin to study and address some of the underlying stuff around pain and desperation and coping through substances as well. 

But then again I also don't think there's anything morally or medically wrong with being on opiates to begin with, or informed and mindful use of any substances to help cope with various forms of physical and psychic pain...the only consideration (up to you and your Dr) should be how well they are working.

But if you're starting from a position where opiates = bad, then it's pretty easy to find fault with the Drs and go from from there. 



 

[Dhedmo]

I'd be surprised if any of us believed there was anything "wrong" with opioid use from a moral perspective.

But I also know how much regret and pain addiction can create.

Personally, I just got tired of no "days off"-- I seriously needed to stop or lose absolutely everyone and everything...or die.

All of my drugs were Rx...including nearly 2 years on fentanyl (75mcg x 48hrs)
Over the years I was prescribed hydrocodone, oxycodone, morphine sulphate, & methadone.

The real reason I needed such strong medication was tolerance.

And for me, that all started with hydrocodone, specifically vicodin.

I don't know if I'd blame the rank and file doctors as much as Big Pharma: they promoted hydrocodone as a front line solution for moderate to severe pain. Not to say there weren't bad doctors, but my GP, e.g., was very uncomfortable with my climbing tolly on oxycodone, especially with the alprazolam and clonazepam I needed every month at that time. He didn't want me to be without relief, or to go into wds, but at the same time, he was worried I might od or croak. Was he glad when I got insurance and was referred to a pain clinic!

Here's an idea: why not start back (and other muscle-type) pain with lidocaine patches instead of hydrocodone?

Because, let's face it, a TON of the New Junkies started with vicodin and gradually escalated.

Once many developed a high oxy tolerance, they had the rug was pulled out from under them with the crackdown.

So I agree that to address the problem on the front end, you start with the doctors.
How many back patients could use lidocaine patches instead of Norcos or other opioids?
They cost a ton, but with an increase in popularity should come a reduction in price.

OTOH, to suggest that long-term CCPs and others receiving Rx opioids should find another solution is CRAZY.

Because stopping opioids is not going to be that other solution for most patients. Alternative sourcing will be, as pointed out above.

Good article.

[theluciddreamers]

I agree with Dhed - Big pharma is way more to blame than Drs.  Giving out free week long trips for prescribing xxx scripts per month.  Shit even the free lunches and smooth talking Reps have a bigger push on this than Dr.  They make up all sorts of crap.  Shit thats why you hear Drs come up with ------- is non addictive.   

I see the articles point in limiting the number of new patients.  I too started with a hydrocodone prescription. From that to oxy, methadone, fent, seeds, and pods.  Put me right into my current situation being on suboxone maintenance.   

The thing to consider is looking at other country's drug polices.   If we made this shit all legal, we would have less addicts, crime, and all the black market shit that comes with it.  I know this will never happen in the US because thats just us as a nation. 

[Snoop]

The author of the article is very educated and versed in his area of study... Yes, this is certain.

But, to dismiss the skyrocketing availability of H on the street, ever since the decline in availability of meds like Oxycontin and other high dose, highly addictive Pain Killers is also foolish.

The struggle could not be more real....