Wednesday 7 August 2019

It's not really an opioid (/medication) epidemic

Here's a common misconception about medication: that the "default" state is necessarily one of not being medicated.

This is a bold claim, as it is common knowledge that medications produce an altered state in people. Surely medication must be an addition, and consequently the default state of a person is one without medication! —Of course most people can get along fine without any medication, but the perceived "balance" is not right. Most people do not have constant unnecessary pain, and most people do not have crippling depression or anxiety.

In these cases it makes a lot more sense to understand illness as a sort of lack, rather than as something that a person has in a positive quantity. People in pain lack the ability to not be in pain. People with depression or anxiety lack energy, lasting happiness, focus, and whatnot. In fact in many cases it's absolutely visceral: people with depression simply do not have the requisite neurotransmitters to feel happy and normal and satisfied.

What does medication do in this instance, then? It restores a balance. The right medication will restore the right balance of neurotransmitters to a depressed person to help ver get on with vis day. An anxiolytic will restore the confidence that an anxious person had lost. A painkiller will restore functionality—and so, so much more—to a person with chronic pain. A stimulant will restore focus and several basic executive functions to someone with ADHD.

So what about this opioid epidemic? The media reports on it constantly, breathlessly, and neither mainstream nor "alternative" outlets have really questioned the basic premises underlying the reporting. And what about the general epidemic of overmedication that we hear about all the time, with SSRI-drugged young zombies only able to care about their phones and legions of Ritalin-addled kids with the souls sucked out of them?

Well, actually investigating the causes tends to paint a different picture.

Personal experience with the medical system is the primary thing making me want to investigate this. I've had chronic pain since I was a kid and I've only ever been prescribed a one-off dose for Tramadol once. I've lived with and around many people who have chronic pain and the stories I've seen and heard play out in real time are in grinding conflict with the story that gets told on cable TV.

The story I see on cable TV goes like this: In the 1990s, Big Pharma sold doctors across the country on the brazen lie that prescription opioids such as OxyContin would not be addictive and have few side effects. Under this belief, doctors began prescribing it in massive amounts, their consciences seemingly clear. Despite this lie being exposed soon after, completely frivolous opioid prescriptions received an uptick sometime in the past 10-odd years, and now patients with no good reason to be taking drugs are not only getting these frivolous prescriptions but, when they run out or want something stronger, taking to the streets to get more and more powerful drugs, drugs which they frequently overdose on and die from.

The stories I know in real life are so different that one is reminded of the "reality is unrealistic" effect. The people I know who have chronic pain are more often than not undermedicated. They have lasting injuries or autoimmune diseases and can barely do normal tasks due to the pain. When they do get prescriptions it's for acute increases in the pain, and after that they get no more. Many of them are actually relieved when they get a visible injury, as it provides a pretext for their regular constant pain to be relieved for a while. When they explain their troubles, hoping to get more treatment, they're branded drug-seekers. They are viewed not as people in pain needing treatment for pain but as people who need to learn to just "accept" what makes their lives impossible and do some yoga to ease it somewhat.

The case is often similar with anxiety. Many anxiolytics, including the benzodiazepines, have various troublesome side effects. Due to these side effects—and do not mistake this, the one they are most afraid of is people getting high—many prescribers opt for more ostensibly "safe" options. When I was in hospital once, dealing with psychomotor agitation, anxiety, and paranoia partly caused by an antipsychotic I was on, I requested anxiolytics. I got another antipsychotic and Benadryl. To be clear, the long-term side effects of benzodiazepine use are quite serious and may include cognitive impairment, paradoxical effects, and similar effects to those of prolonged alcoholism. By contrast, the immediate potential side effects of antipsychotics—which are worsened when you're on more than one at the same time—include akathisia (which I experienced), dystonia (which I also experienced), various neurological problems, and brain damage, frequently including tardive dyskinesia (despite what my prescriber assured me; apparently she had mixed up tardive dyskinesia with tardive psychosis).

The doctors I hear about and have dealt with in all these cases are far from the stereotype of a relentless pill-pusher. (To be sure, those doctors exist, but all the chronic pain sufferers I've known have had very little luck in finding any, even though they're apparently supposed to be everywhere.) Generally speaking they're cautious, for one of two reasons: One, they strongly believe in the latest movement of not prescribing things; they believe that medication should be prescribed with regards to safety first, with effectiveness a secondary concern, and rarely. They try every possible means to treat the patient without medication, their first medication of choice is an antidepressant, and if the patient complains that the antidepressant isn't working, they'll tell the patient ve has to work on accepting the pain, very hesitantly prescribe a medication that works (if the patient is lucky), or label the patient a drug-seeker and refer ver to an addiction clinic. Or two, they're doctors who want to prescribe what they think will be adequate in treating the patient, but they know that they're being monitored at all times, and if the DEA catches wind of that, they'll be hounded and possibly stripped of their licence to practise for being one of those no-good lousy pill-pushers. More often than not they lie between these two extremes.

I want to reiterate: the chronic pain sufferers I've known would rather not be on medication. They would rather just not have the pain at all. Many of them do not like anything about painkillers other than that they reduce the pain. They worry about being labelled as drug-seekers. They live with stigma due to that: to many of them it feels like the default assumption by many doctors today is that the patient is lying about vis pain until proven otherwise, a conundrum if there ever was one as pain cannot be "proven". They don't like using medication, but it helps them do their work and sleep at night. They're not using it to feel high. They're using it to feel normal.

So what to make of the media coverage? I think that the point made in the epidemic narrative that's most worth focusing on is the fact that more and more patients are moving to illegal drugs because they cannot get opioids via legal and safe means. The National Institute on Drug Abuse has pointed out that the sharpest spike in deaths from drug overdoses is with fentanyl and fentanyl analogues, with the second-sharpest being heroin:

Note that while deaths from prescription opioids have been climbing as well, they are not spiking, and they are growing at a rate similar to drugs in general—the line for them is nearly the same shape as that for benzodiazepines.

This is not surprising: fentanyl is an especially powerful drug, and it and its analogues are among the most readily available on the streets. Someone who is not well-versed in the differences between drugs will easily underestimate how powerful fentanyl actually is—100 times as potent as morphine and about 10 times more potent than heroin. Add to that the problem that many other drugs are cut with fentanyl to lower costs: tragically and perhaps most infamously, the acclaimed rapper Lil Peep died in 2017 due to an overdose involving multiple drugs, primarily a dose of Xanax which was later revealed to have been mixed with fentanyl. Part of this is that fentanyl is relatively cheap and easy to manufacture or get a hold of, along with its even more potent analogues such as carfentanil, a single touch of which may be enough to kill someone. I won't get too much into the deep politics of this—that's a subject for another time—but to illustrate, it is believed that carfentanil was one of the subduing agents used in the 2002 Moscow theatre crisis. For those of you who aren't aware, this crisis involved a group of 40 Chechen separatists seizing the Dubrovka Theatre in Moscow, holding 850 people hostage with guns and explosives, making the demand that Russia withdraw its military from Chechnya within one week. A spetsnaz (special forces) team was dispatched to handle the situation, but due to the theatre's layout, it would've been exceedingly difficult for them to get to the room holding most of the hostages. After 2.5 days and the murder of two female hostages, the spetsnaz unit decided to pump a gas into the theatre to subdue the militants; this ended up killing all 40 militants and up to 204 of the hostages. The identity of the gas has never been officially confirmed or released, but chemical tests from the clothing and urine of three British hostages revealed the presence of two fentanyl derivatives.

And another thing to consider about these deaths is how many of them are actually suicides. Suicides and attempted suicides by overdose are often underreported, as they are lumped in with accidental overdoses. This gets into something that I will discuss later.

Heroin likely experienced the second-steepest uptick for similar reasons: it's an illegal drug staple, providing the gold standard for overdoses, and is as such the traditional second choice for those who ran out of prescription opioids or want to move to something stronger. Heroin is probably the most famous single opioid in existence. And it's also important to note that due to many drugs being cut with fentanyl, as mentioned above, many of the deaths from heroin overlap with those from fentanyl.

Multiple sources, including Vox, have mentioned that it's likely that cutbacks in painkiller prescriptions led to much of the current problems with fentanyl and heroin. This is invariably mentioned only once and as only one possible cause, rather than probably one of the biggest causes. People seek out drugs to feel normal. If you're in pain of some kind, and the pain won't stop on its own, and you no longer have the one thing that makes the pain stop for a while, it's only natural to seek out more of it, even if there is danger in doing so. Much is made of the cases of people who received months-long prescriptions for broken legs and switched to street drugs when those ran out because they got addicted, but it seems unfair to lump these cases in together. Both are suffering, but the root causes of their suffering are different. One got introduced to a problem by an irresponsible doctor; one has had their problem for a long time and is now in another problem because a more "cautious" doctor removed the thing that alleviated their problem. These are not the same.

(This is not to mention the results of the War in Afghanistan, which helped flood the US with heroin, but as I said earlier, the deep politics of this is a subject for another time.)

On that note, another look at the graph: Deaths from overdoses on all drugs are on the rise. I've talked a lot about the pain problem a lot of people have. A 2017 forecast concluded that 650,000 people will die in the US from opioid overdoses over the next decade. According to the CDC, 50,000,000 people—that is 20% of the total population—suffer chronic pain, of which 20,000,000—or 8% of the total population—have pain severe enough that it impairs their daily life and work significantly. That is a pain epidemic. And let's take it further a bit. Let's factor in the growing number of people who feel hopeless and the general anomie: according to NIMH, 6.7% of the population suffers from major depression, with that number jumping to nearly 11% for younger people.

Suddenly it doesn't look like an opioid crisis. The facts of the case are true on their own but the narrative—of evil pharma executives enlisting irresponsible doctors who hand out pills like candy to people who don't really need them and get hooked on them—is completely misleading. Zoom out a lot and it becomes apparent that we have a pain crisis, compounded by an undermedication crisis, a despair crisis, and, to be clear, several cases that fit the traditional narrative. A few decades ago and it would've been a stimulant crisis. To a great extent, many of the underlying causes are the same, but the drug of choice has changed.

Then why does this narrative prevail? I can think of a few reasons: first of all, it sells. People want a compelling story with clear Good Guys and Bad Guys. People hate Big Pharma, so whoever's opposing them gets to be the Good Guy. This kind of story gets engagement, and so media outlets will use it as much as possible.

Second of all, going a bit deeper, it satisfies the liberal thought that more regulation will fix things and the conservative thought that more law and order will fix things. If Big Pharma and their legions of pill-pushing quacks are the villain, then we just need to regulate the industry more, or put more restrictions on prescribing, or put them all in jail. Problem solved.

But being a lefty freak who loves cultural Marxism, my favourite reason is this: it channels attention away from deeper systemic issues. If undermedication and pain are primary factors, then trying to regulate it away will just do more damage, and the whole way we approach medical problems is fucked and we need to reevaluate a whole lot of assumptions about treatment. (The very word "patient" means "that which is acted upon". Think about this.) If despair and anomie are primary factors, then the only thing we can do is question why so many people are in despair and anomie—and then we're well on the way to calling the whole damn system into doubt.

My proposed solution is simple: legalise everything. Make informed consent the only criterion for obtaining any drug. Let people choose how to treat themselves. And build up an infrastructure that can actually handle problems of pain, mental health, and addiction at no cost to the patient. Portugal decriminalised (although not legalised) all drugs in 2001 and has seen dramatic drops in overdoses and addiction. Taking it a step further will also reduce anomie by lessening the control that the state has over people, restoring a degree of trust in government.

(Although that can only go so far. If we want a permanent solution...)

Chronic pain is quiet because people who are in chronic pain make terrible self-advocates.  Not only are you physically crippled, which impairs mental functioning – I have trouble speaking in sentences sometimes – but you walk into any doctors’ office, any specialist, even the guy that is supposed to be responsible for “pain management” knowing that your every move and every word are being judged, because you are guilty until proven innocent.  You are guilty of being a drug addict.




You are screwed.  Evidently, many of the people that starting obtaining oxycodone for “recreation” were among my same age and gender demographics, and had similar body types (I was taunted for being skinny from age eleven and still am to this day) – you know the story, “it all started with one prescription before you started getting them off the street, spending hours and days at emergency rooms and doctors’ offices feigning pain”, a story that one blows my mind, because I never want to see the inside of another ER or medical office again, so if I am present, which I despise, it is not for a quick buzz.  The story is over, though, as Miss “Victim” of “One Prescription” could not afford a $300/day pill habit forever, and then heroin returned, since it was far cheaper (single pills go for $30), and provided drug addicts a time-trusted, and, evidently, best option for those seeking an opiate high.
Heroin is actually a very poor painkiller.  It gets you high.  I am not interested in a high, and would really like to know what on Earth the fact that some people spend their weekends crushing up the pills that save me from being tortured from my own body and inhaling them or smoking them or whatever, should have any affect on how I – someone that spends weekends working, writing, reading, and once in a blue moon watching a movie or going out to eat – am treated by physicians.
 —Jennifer Lauren Reimer (rest in power), Practice of Madness