Saturday, April 28, 2007

War on Drugs

The way that our country treats chronic pain sufferers who use too much pain medication seems insane to me. I can't find any evidence that Oxycontin, say, is anywhere near as dangerous as alcohol -- i.e., tens of thousands of fatalities every single year. But we don't make people get a prescription to buy a beer, let alone throw people in jail for 25 years for having a bottle of vodka in the house. Given that stories like the above seem to come and go with no noticeable effect on public policy, I have to wonder why early 20th-century Americans were so much quicker to realize that Prohibition wasn't a good idea.

13 Comments:

Blogger Allison said...

Apples and oranges.

You can't find any evidence that oxycontin is as widely available as alcohol either, so you can't tell if the lack of oxycontin-related deaths is because it's not as deadly, or if it is the very fact of its prohibition that leads it to be less available to become so deadly.

Your argument is a bit like "crime down despite more criminals in prison!" Perhaps the lack of ability to get oxycontin is precisely the reason for less deaths.

The issue I think is different: how many junkies should a society be willing to tolerate in order to help those in chronic pain.

You don't seem to have any familiarity with narcotics junkies. Watch The Wire on HBO. It's a darn good depiction of junkie life. Then ask yourself how many hellholes and junkhouses you'd want on your block, and how many suffering folks you'd be alleviating vs. how many you'd be creating.

10:00 PM  
Blogger Lou Minatti said...

"I have to wonder why early 20th-century Americans were so much quicker to realize that Prohibition wasn't a good idea."

I was gonna say that modern politicians are more stupid than they were 100 years ago. Then I remembered Jim Crow and Smoot-Hawley.

It's all about money. Modern politicians are all whores. Just follow the cash. The prison industry is big in this country. So is the lawyer industry. These special interest groups prefer the current situation because it enriches their bank accounts.

10:46 PM  
Blogger billo said...

While I generally agree with your sentiment, I'm not sure using oxycodone as an example is a good idea. In fact, oxycodone is a common feature in deaths in my jurisdiction as a Forensic Pathologist. Unlike alcohol, it is not uncommon for people to "forget" how much they have taken, or worse, continue taking increasing doses until they feel better. Often they die first.

More important, however, is the epidemic of polypharmacy deaths -- in which people don't die of just one drug. Instead, they die because they are taking multiple drugs, many of which have uncertain interactions. There may not be a lot of deaths due to oxycodone alone, but I commonly see folk with a bit of oxycodone, and/or a bit of hydrocodone, and/or a bit of methadone, and/or a bit of morphine, and/or a little alcohol, etc. It all adds up, and it adds up in ways that are often not intuitive -- for instance, methadone can kill from causing cardiac arrhythmia when taken in combination with other drugs well before a classic "overdose" occurs.

As one study noted (OXC here means oxycodone)


"Over 135 drugs that were considered to be plausibly contributory to enhanced toxicity were identified in body fluids and tissues. Evaluation of mean OXC blood concentrations in cases that contained one, two, three, four, five, and six or more contributory drugs in combination demonstrated consistently lower mean OXC concentrations than those cases in which OXC was the only drug identified. A smaller number of cases were evaluated in the multiple-drug-induced groups in which OXC was paired with a single other contributory drug. The overall mean OXC concentration for these cases was 0.71 microg/mL (N = 90) as compared to 1.64 microg/mL (N = 27) for the cases in the single drug-induced groups. The consistent finding of lower mean OXC blood levels associated with multiple-drug-induced fatalities supports the stated hypothesis that OXC in combination with other centrally active drugs is more toxic than when OXC was the only drug involved. It was concluded that in cases of multiple-drug fatalities, cause of death (COD) should not be attributed to any single drug. Rather, the unique combination of drugs, the pattern of drug use/abuse, and individual factors, such as tolerance to the respiratory depressant effects of opioids, must be taken into account in arriving at a valid COD statement."


(see: Cone EJ, et al. Oxycodone involvement in drug abuse deaths. II. Evidence for toxic multiple drug-drug interactions. J Anal Toxicol. 2004 Oct;28(7):616-2)dr

12:44 AM  
Blogger M. Simon said...

It is worse than that Stuart. The whole idea of "addiction" is rank superstition.

Is Addiction Real?

Addiction Is A Genetic Disease

Heroin

PTSD and the Endocannabinoid System

2:16 AM  
Blogger Scott said...

Amen on your post. I'm a chronic pain sufferer on 120mg of morphine 4 times a day just to be able to function halfway normally. There are still times that the pain breaks through even at that dosage, but not often. Thank goodness there are doctors who understand pain! Now to get the govt. morons to understand it!

5:00 AM  
Blogger Oligonicella said...

"I can't find any evidence that Oxycontin, say, is anywhere near as dangerous as alcohol -- i.e., tens of thousands of fatalities every single year."

There are several reasons you can't. Alcohol isn't a controlled substance. If Oxy wasn't, you'd most likely see similar percentages amongst users.

My wife is in chronic pain and takes Oxy.

Numbers are from CDC. It most certainly causes disorientation as severe as alcohol. I certainly wouldn't want her driving, boating or operating heavy machinery (13K). It has caused her to have suicidal thoughts (7K). It makes her clumsy (5K) and sometimes belligerent (8K).

The case you linked to was about perscription fraud and while I have first-hand compassion for those in chronic pain, it does them no service to conflate issues or ignore percentages.

The US has some literally millions of alcohol consumers. Using a low figure of 10M for consumers and the total stats from CDC (which include deaths from diseases with alcohol implicated as a possible contributing factor (~10K) and accidents (~40K), that's .7 percent of users.

You would need to compare similar stats of Oxy users, not overall population.

7:48 AM  
Blogger Stuart Buck said...

In response to several commenters, let me put it this way: I can't seem to find any actual evidence that if the population of Oxycontin users was as high as the population of alcohol users, there would be a similar number of fatalities and pathologies. What's the evidence for that?

In any event, even if Oxycontin can be dangerous if overused, that still doesn't explain why society should treat it so differently from alcohol. For one dangerous item, you can buy as much as you want, no questions asked. For another dangerous product, you can get thrown in jail for the rest of your life just for having too much in the house. How does that make sense?

how many junkies should a society be willing to tolerate in order to help those in chronic pain.

How many winos does our society currently tolerate in order to have the benefit of . . . how would you finish this sentence? I can't think of a beneficial use of alcohol that comes anywhere near the benefit of alleviating mind-shattering pain.

1:21 PM  
Blogger Allison said...

---How many winos does our society currently tolerate in order to have the benefit of . . . how would you finish this sentence?

The benefit of enjoying alcohol freely. That's how you finish the sentence.

Generally speaking, winos don't *die* from a night of boozing. They die from decades of it. Oxy kills the first time user, the fifth time, the fiftieth time.


---I can't think of a beneficial use of alcohol that comes anywhere near the benefit of alleviating mind-shattering pain.

Really? Hundreds of millions of people world wide drink wine and beer to alleviate pain every day. They do it to improve their mood, to enjoy their food, their company, their life.

But why isn't your argument "alcohol shouldn't be readily available, since the social harm is greater than what I consider to be the social value" ?

It doesn't follow that you should deregulate oxycontin or other narcotics.

Greater access to alcohol has made winos and drunks. But even most alcohol abusers don't live in their own filth. junkies are a lot worse for society.

8:43 PM  
Blogger cognitorex said...

I'd like to second Allison, particularly her statement that "You don't seem to have any familiarity with narcotics junkies."

Your premise and conclusions are naive.

The ravages and criminality stemming from an oxy abuser are both scary and horribly sad.
cognito_rex

7:04 AM  
Blogger Stuart Buck said...

The benefit of enjoying alcohol freely. That's how you finish the sentence.

So that answers your question: we should tolerate a few Oxycontin junkies in order to have the benefit of enjoying Oxycontin freely.


Hundreds of millions of people world wide drink wine and beer to alleviate pain every day. They do it to improve their mood, to enjoy their food, their company, their life.

I'm aware of this, but I don't think it even remotely compares to the alleviation of real pain. There are plenty of ways to improve your mood other than alcohol -- regular exercise, for example. As far as I know, there are not plenty of (legal) ways for someone in excruciating pain to have a moment of relief. So that weighty interest should count for a lot more in the balance.


The ravages and criminality stemming from an oxy abuser are both scary and horribly sad.

Lung cancer and drunk driving deaths are horribly sad too. But again, we don't throw people in jail for 25 years for having too many packs of cigarettes or a bottle of vodka.

I notice that no one is actually willing to defend long prison terms here. Why is that? If you want Oxycontin to be basically illegal, what prison term is appropriate for a sick person who gets his hands on a bottle? 1 year? 5 years? 10 years?

8:09 AM  
Blogger Oligonicella said...

"If you want Oxycontin to be basically illegal, what prison term is appropriate for a sick person who gets his hands on a bottle? 1 year? 5 years? 10 years?"

Legally, or by forging perscriptions?

11:38 AM  
Blogger cathyf said...

Legally, or by forging perscriptions?

So, the policy of many "pain management" clinics is that patients are allowed enough painkillers for 5 days per month, and anyone who begs for more is automatically an addict and so is cut off completely. So, yeah, I think that there are circumstances where the forging of prescriptions is justified.

I find the language choice appalling, too. A person with Type 2 diabetes has insulin resistance; a person whose body resists the metabolism of narcotics is called "dependent". And the magical thinking on the part of the medical profession is truly amazing. I know one woman in unremitting agony from adhesions caused by her (unnecessary) hysterectomy. Five years after the hysterectomy, the doctor sat behind his desk and with his smug little condescension said, "You know, you can't stay on the drugs forever." As I told her at the time, her response should have been, "What part of permanant injury don't you understand, a**hole?!?!?" Suppose this woman had instead been left a parapalegic by anesthesia in the surgery (a rare complication of spinal/epidural anesthesia). Do you think the a**hole would have sat behind his desk and said, "You know you can't stay in the wheelchair forever." You want to see the sheer ugly viciousness of modern medicine? Try being the victim of an incurable, untreatable, iatrogenic injury. Every doctor you meet is horrified to contemplate the amount of not-fixable damage that can be inflicted even by well-meaning doctors practicing to the highest standards of their profession. Like a child who has broken mommy's favorite vase, and hides the pieces in the trash, they want nothing more than to dispose of you. Whether by "treatments" which only make things worse, or refusing you pain medications until you commit suicide, whatever, as long as you just go away and no longer are there confronting them with the limits of their power.

And lots of pain patients are not even "dependent" in the sense of undergoing withdrawal -- if they are relieved of the pain in some way, many simply stop taking the painkillers cold turkey and are overjoyed to experience nothing more than the relief of the vicious constipation that narcotics cause. There are several theories as to why this happens. One theory is that only a small fraction of the population will experience withdrawel, and so most pain patients aren't in the group. Another theory is that the biochemical effects of the pain somehow prevent addiction. A third theory is that for people with a long history of undertreatment and nontreatment of excruciating pain, the withdrawel symptoms ("like the worst case of flu you've ever had") were beneath their notice.

11:27 PM  
Blogger Oligonicella said...

Sorry about whomever you know not finding the pain clinics my wife did, where the doctor(s) prescribed far more than 5 days per month worth. Four times per day worth, actually.

Her condition, by way, was caused by doctor screw up. So, I relate.

2:22 PM  

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