Heroin now kills more people than guns:

[Dashinka 24,811]

On ‎3‎/‎10‎/‎2018 at 9:42 AM, Il Mango Dulce said:

I am not really sure why we are comparing heroine and guns but Japan had one gun murder last year and 1/5 the murder rate of the US. 

Since Japan is in the conversation, I thought this was interesting.  More people killed in this attack in Japan than in Florida and no gun was used.

 

https://en.wikipedia.org/wiki/Sagamihara_stabbings

[Dashinka 24,811]

7 hours ago, bcking said:

Battling addiction to opioids is far more challenging than cigarettes.

 

You could argue no one should take that first drag of tobacco. Tobacco is a carcinogen and serves no purpose.

 

Opioids, unfortunately, serve a purpose. Even if you could identify the 10% who are sensitive to addiction, some of those will still truly need the medication. How do you weigh risk of addiction with the potential benefit? 

Interesting, it seems the purpose of opioids is a little misleading.

 

https://www.reuters.com/article/us-health-opioids-backpain-arthritis/opioids-no-better-than-nsaids-for-chronic-back-or-arthritis-pain-idUSKCN1GI2T2

[bcking 3,157]

38 minutes ago, Bill & Katya said:

Interesting, it seems the purpose of opioids is a little misleading.

 

https://www.reuters.com/article/us-health-opioids-backpain-arthritis/opioids-no-better-than-nsaids-for-chronic-back-or-arthritis-pain-idUSKCN1GI2T2

I'm not surprised. Arthritis is inflammatory, so NSAIDs would always come first in my mind.

 

For those indications opioids could still act as an additional option, for those who don't get good pain control on the first line meds.

[bcking 3,157]

45 minutes ago, Bill & Katya said:

Since Japan is in the conversation, I thought this was interesting.  More people killed in this attack in Japan than in Florida and no gun was used.

 

https://en.wikipedia.org/wiki/Sagamihara_stabbings

Not to sound cruel but it was at a care home for disabled people...I imagine many of them couldn't really get away.

 

I doubt you would see that repeated very often, unless crazies start specifically targeting that population.

[bcking 3,157]

6 hours ago, Póg mo said:

The way I understand it is, a lot of people who use heroin etc, start out on prescribed legal drugs, but are forced to buy illegal drugs because they get cut off. I feel that decriminalizing drugs is probably the best solution. Why make people with a natural tendency to abuse drugs into criminals, especially when drug addiction can be managed, or even helped. Also, marijuana may not be a silver bullet for everything, but it seems to me that allowing doctors to prescribe it might be a better option than prescribing pharmaceutical grade heroin. I agree opioids have a use, but perhaps they should be reserved for certain situations where they are truly needed, and like a couple of years ago when my wife's doctor hander her a script for sixty hydrocodone pills with little or no questions asked.

Absolutely.

 

One of the biggest changes that need to be made is to prescribing practices. We just need to have proper expectations. We won't be able to get rid of opioids, but we need to use them properly. We have to get the number of people who are prescribed them down to the "minimum", whatever that number is.

[Dashinka 24,811]

1 hour ago, bcking said:

Absolutely.

 

One of the biggest changes that need to be made is to prescribing practices. We just need to have proper expectations. We won't be able to get rid of opioids, but we need to use them properly. We have to get the number of people who are prescribed them down to the "minimum", whatever that number is.

I completely agree.  I had surgery once and even though my post assessment was that I was not in very much pain (2-3 on the 10 scale) the Dr. prescribed Tylenol 3s.  I never got that prescription filled.  Seemed kind of reckless to me to be so cavalier with pain killers.

[bcking 3,157]

17 minutes ago, Bill & Katya said:

I completely agree.  I had surgery once and even though my post assessment was that I was not in very much pain (2-3 on the 10 scale) the Dr. prescribed Tylenol 3s.  I never got that prescription filled.  Seemed kind of reckless to me to be so cavalier with pain killers.

Tylenol 3 used to be very common in post op children, mostly ENT procedures.

 

It's even more reckless in that population. Addiction isn't your biggest concern. Codeine ha a very variable half-life based on genetic factors that we can't screen for pretreatment. Certain children would be overdosed accidentally because the standard dose, for them, stuck around longer than in other patients and you had no way of identifying which patient would be like that.

Edited March 12, 2018 by bcking

[Póg mo 1,749]

5 hours ago, bcking said:

Absolutely.

 

One of the biggest changes that need to be made is to prescribing practices. We just need to have proper expectations. We won't be able to get rid of opioids, but we need to use them properly. We have to get the number of people who are prescribed them down to the "minimum", whatever that number is.

Unfortunately like so many other things, health related, there is too much money to be made to properly correct the problem. 

[Dashinka 24,811]

5 hours ago, bcking said:

Not to sound cruel but it was at a care home for disabled people...I imagine many of them couldn't really get away.

 

I doubt you would see that repeated very often, unless crazies start specifically targeting that population.

Kind of like killing several thousand helpless people with some box cutters and airplanes?

[The Nature Boy 7,659]

4 minutes ago, Póg mo said:

Unfortunately like so many other things, health related, there is too much money to be made to properly correct the problem. 

Maybe we need to look into more background checks,  and mental health evaluations for those prescribing these drugs . Also a quarterly review of how many pain scripts they are writing. 

 

Also a registry for any patient getting them, and perhaps a waiting period 

 

 

[bcking 3,157]

2 minutes ago, Bill & Katya said:

Kind of like killing several thousand helpless people with some box cutters and airplanes?

Well airplanes can be used to administer mass deadly force. 

 

If the point was that "mass murder" can occur with knives...yes it is possible but obviously there were other aspects to the situation that allowed to escalate to the level that it did. In the vast vast majority of scenarios an assailant armed with a knife is not going to be able to do as much damage as an assailant with a gun.

 

That alone isn't a good argument for me to completely get of guns, but I would consider it in the realm of "facts". 

 

7 minutes ago, Póg mo said:

Unfortunately like so many other things, health related, there is too much money to be made to properly correct the problem. 

I'm not sure to what extent the "money" really plays a role, if I'm honest. It may be because I tend to assume the best in people and in situations.

 

I've seen the large study (i believe we discussed it in a prior thread) about prescribing practices and payments from pharmaceutical companies. The study is incredibly flawed, at least when making the assumptions and interpretations people want to make. We can get into here since it is on subject, but as I said I'm pretty sure we've discussed it already in the past. 

 

Do pharmaceutical companies have a vested interest in maintaining current prescribing practices? Yes

Do physicians have a vested (financial) interest in maintaining current prescribing practices? Perhaps a small minority, but for the vast majority no

 

I think the lay public overestimates the "power" a pharmaceutical company has on the average physician's prescribing practice. It was definitely more an issue in the past but there is now a lot of regulation and structure to our interactions. They may pay for a lunch in my office, but then the lecture will be completely unrelated and not sponsored by them at all. The only opportunity they will have to share information is while we are in queue for the lunch. You almost feel bad for them because you can tell clearly no one cares what they have to say, they just want free lunch. However by accepting that free lunch, we are recorded as having received a "payment" from that pharmaceutical company. 

[bcking 3,157]

6 minutes ago, Nature Boy Flair said:

Maybe we need to look into more background checks,  and mental health evaluations for those prescribing these drugs . Also a quarterly review of how many pain scripts they are writing. 

 

Also a registry for any patient getting them, and perhaps a waiting period 

 

 

Many of those options sound quite reasonable.

 

There are already monitoring programs for how physicians prescribe, as well as monitoring programs for individual patients. New York State had a prescription drug monitoring program where you could look the patient up and see every prescription of a narcotic they've received. It wasn't that effective since it only included NY and in NYC people can go to Jersey easily and it won't be recorded. So there is definitely room for improvement.

 

Background checks for the patients, for sure. That is already done, or should be done, but in a much more fluid way. Every doctor should take a history from their patient, and that should include a social history that would include any past difficulties that may be red flags. Again we could definitely do better. Background checks for the doctors already happen. Every hospital requires them (in my experience), most including drug tests. 

 

As for mental health evaluations for the prescribers - You'd have to show even case reports of situations where a prescriber "over-prescribed" opioids, and was also suffering from a significant mental health problem that would have contributed to their lack of judgment. If you have those, then maybe we can discuss it more.

[smilesammich 10,727]

13 minutes ago, bcking said:

I'm not sure to what extent the "money" really plays a role, if I'm honest. It may be because I tend to assume the best in people and in situations.

 

I've seen the large study (i believe we discussed it in a prior thread) about prescribing practices and payments from pharmaceutical companies. The study is incredibly flawed, at least when making the assumptions and interpretations people want to make. We can get into here since it is on subject, but as I said I'm pretty sure we've discussed it already in the past. 

 

Do pharmaceutical companies have a vested interest in maintaining current prescribing practices? Yes

Do physicians have a vested (financial) interest in maintaining current prescribing practices? Perhaps a small minority, but for the vast majority no

 

did you review this? https://www.cnn.com/2018/03/11/health/prescription-opioid-payments-methodology/index.html 

anecdotal but the people i know who are in daily pain (hemorrhaged disks, etc) have had their insurance companies offer to pay for a minimal amount of physical therapy. once that ran out, the only option given was a prescription for pain killers. 

[bcking 3,157]

25 minutes ago, smilesammich said:

did you review this? https://www.cnn.com/2018/03/11/health/prescription-opioid-payments-methodology/index.html 

anecdotal but the people i know who are in daily pain (hemorrhaged disks, etc) have had their insurance companies offer to pay for a minimal amount of physical therapy. once that ran out, the only option given was a prescription for pain killers. 

Ya that is the study I was talking about. I thought we had a thread about it a couple months ago.

 

I can go into detail again, but it'll have to be later. In a conference now and just started service today so I'm busier than usual.

 

Reimbursement for therapies is a different issue from that CNN study. I completely agree that insurance reimbursement for it is horrible. Even in my patients, private insurance can be very difficult to cover therapies for premature infants. Medicare is even worse.

 

I don't think the reimbursement issue is because insurance companies want to pay for opioids, or they are "in" with big pharma. It's just because coverage if medications tends to be easier to manage. Outpatient  services in general are undersupported compared to medicines and hospitalizations. That is a huge issue with our healthcare system as a whole, not just for this topic.

[yuna628 9,718]

18 hours ago, IDWAF said:

No.  The primary reason for suicide in Japan is bullying.  Not much honor in that, nor is there in avoiding it by killing oneself.  (Personal failure is another motivating factor, though less so today than in the past.)

 

Suicide in Japan is considered “normal”.  Just as gun crime is in America.  No one wants it, no one is proud of it, but it exists.  Their suicide rate is twice ours, roughly.  That’s a LOT of self-killing.  And it’s sad, no matter what culture it is in.  

 

I don’t understand how anyone, in any country, can see suicide as “honorable”.  

Can you find an official list of reasons what the primary reasons are in Japan? Again, your ideas about suicide are largely going to be based on personal reasons yes, but also the western culture we live in. It is vastly different in other countries. You'd need to study their history to see why suicide can be seen to be honorable. It may be truly strange and horrific to you, but not to others.

12 hours ago, TBoneTX said:

Even something like oral prednisone can be "addictive" for people who are in pain.

Then, unless they taper off, they end up hosing their adrenal glands or something, which apparently leads to serious trouble.

I know someone with back pain who actually went doctor-shopping for more and more methylprednisolone injections.

This has caused me to wonder about the psychological aspects underlying the need for relief of physical pain.  Insights?

Pred is a hideous drug. When I had a bad reaction to new antibiotics they hit me with a pack. Messed me up for weeks. Side effects terrible. And when you stop taking them, the pain in joints was all over. My old dog took daily pred, along with a monthly injection for AD. The side effects, as you can imagine are just as bad in animals. A lot of vets also give A-dogs a flat dosage that far exceeds what a tiny dog should be handling, and unless you really research you won't know there is a greater push to find ways to give a low-dose protocol to mitigate side effects and shortened life expectancy.

 

I cannot say that steroids ever made my mother feel any better either.

6 hours ago, Bill & Katya said:

Since Japan is in the conversation, I thought this was interesting.  More people killed in this attack in Japan than in Florida and no gun was used.

 

https://en.wikipedia.org/wiki/Sagamihara_stabbings

Again stabbings are going to be the method of choice, due to the lack of guns being easily available. Also use of a blade will be more of a cultural thing too - it will be seen as less cowardly. And while there will be large numbers of deaths that could happen, there will be a greater chance of survival and perhaps less success on part of the perp in a good many of the incidents.

6 hours ago, Bill & Katya said:

Interesting, it seems the purpose of opioids is a little misleading.

 

https://www.reuters.com/article/us-health-opioids-backpain-arthritis/opioids-no-better-than-nsaids-for-chronic-back-or-arthritis-pain-idUSKCN1GI2T2

NSAIDs worked no better than steroids for my mom. The side effects for her pretty much scratched both out of the question. I have a hard time with this study. We know what they complained of but we don't know their medical history. There's a big difference in general arthritis issues and those with bigger arthritic conditions like RA or severe degeneration. The group that was given NSAID, could eventually move up to treatments like Lyrica or a lower tier opioid like Tramadol. How many in this group chose that option? Several of the drugs in this study are ones that my mother is very resistant to try, due to side effects concerns. My FiL though is on several combinations of drugs in this study. It helps him 'function' but I'm not convinced how well.

3 hours ago, bcking said:

Tylenol 3 used to be very common in post op children, mostly ENT procedures.

 

It's even more reckless in that population. Addiction isn't your biggest concern. Codeine ha a very variable half-life based on genetic factors that we can't screen for pretreatment. Certain children would be overdosed accidentally because the standard dose, for them, stuck around longer than in other patients and you had no way of identifying which patient would be like that.

When they took my wisdoms out, they gave me a script for Codeine, enough for probably ten days. I felt 100% high as a kite when I woke up from sedation and no pain at all. Thought I didn't need any pills, and would tough it out. Ended up passing out and came to in agony. The codeine worked really well, scary well, and I decided that on the third day against dentist advice would discontinue. No pain afterwards, and no idea why they wanted me to keep taking it so long.

24 minutes ago, Nature Boy Flair said:

Maybe we need to look into more background checks,  and mental health evaluations for those prescribing these drugs . Also a quarterly review of how many pain scripts they are writing. 

 

Also a registry for any patient getting them, and perhaps a waiting period 

 

 

As bcking has mentioned some of these things already kind of happen.

 

26 minutes ago, smilesammich said:

did you review this? https://www.cnn.com/2018/03/11/health/prescription-opioid-payments-methodology/index.html 

anecdotal but the people i know who are in daily pain (hemorrhaged disks, etc) have had their insurance companies offer to pay for a minimal amount of physical therapy. once that ran out, the only option given was a prescription for pain killers. 

Same here. In fact, in order for her insurance to approve and authorize her spinal op, my sister had to first receive injections and PT to see if it 'helped' even though it was the opinion of her surgeon, the doctor who administered the injections, and the therapist that she was in urgent need of surgery. They also gave her Tramadol which prompted an allergic reaction. The insurance was happy to keep her 'maintained' on pills instead of just giving her surgery. After waiting far longer than needed, she had her surgery and they sent her home with heavy painkillers. She took one tablet and felt so freaked out she never touched it again, and went through the rest of her recovery without meds. Medicare has refused any further PT for my mom, but is still happy to provide pills.... I mean she's improved from looking like a stroke victim to being able to move more, but I think if they had stuck it out, perhaps she'd be in an even better place physically.