Thanks for commenting Kendra. As we state in the article, the wellspring of the problem is an opioid prescription. We are significant outliers in our widespread opioid prescribing practices. Here is a recent study that compared three common surgeries in hospitals in the US and the rest of the world. They found, "Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients." Their conclusion, "US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US." Indeed. See..https://journals.lww.com/annalsofsurgery/abstract/2020/12000/opioids_after_surgery_in_the_united_states_versus.1.aspx
What follows is opioid dependence and then addiction. Eventually, our medical complex cuts the patient off and the individual then turns to the street for their opioids. They ultimately succumb to a fentanyl overdose.
The key here is “unnecessary” prescriptions. The patient is genuinely in pain & needs relief. Our profit-driven healthcare system prioritizes quick & cheap over time-consuming & effective. Physicians & other providers are under immense pressure to limit care & often don’t have time to properly investigate & get to the actual source of the pain. Proper PT & rehab is costly & time consuming. Instead, they wind up simply treating the symptom - cheap & easy.
The problem was doctors, on the advice of Purdue, were prescribing strong opioids for moderate pain like broken bones etc. Now, with the change in not prescribing pain meds, many severe chronic pain patients are suffering horribly. Their bodies get worn down and they die of the flu or pneumonia. Over the counter pain meds, like Tylenol and NSAIDs have issues also. How many people die from alcohol-related deaths yearly?
The article was not referring to chronic pain patients nor suggesting to limit their access to these medications which can greatly impact their quality of life. What we are suggesting is a strategy to avoid the creation of chronic pain patients. There is good data to show that opioids affect our immune response which can increase our chances of developing dangerous infections, difficulty fighting cancers, etc.
Mainly -- your assertion that the majority of opioid overdoses are from patients taking their prescribed medication. I believe that has been disproven by many sources.... who have concluded that illicit fentanyl is the driver of the opioid overdose crisis. I think the risk profile of Tylenol far exceeds the risks of properly prescribed opioids. And a lethal dose of Tylenol is available over the counter with no restrictions. Meanwhile, I know of several people who stepped in front of trains to end their suffering when they couldn't access appropriate medical care.
Opinion pieces such as this do a grave disservice to both the people experiencing substance use disorder (and their loved ones) and to chronic pain patients (and their loved ones and care providers).
There are much better ways to prevent addiction including adequate access to physical and mental health services, safe supply, and reduction of stigma associated with mental illness and substance use.
Please leave the those suffering with chronic pain alone, especially those with terminal illness. Allow them some quality of life, please.
It's not a good look when people write articles that cite sources that don't exist, misrepresent the intent AND content of other sources, cite outdated research, or flat out make things up. It looks like . . . propaganda.
1) You state that "according to the CDC, after only five days of opioid use, our bodies start developing opioid dependence". The article says NO SUCH THING. It makes NO CONNECTION between 5 days of use and what our bodies are doing. You are conflating their research and your opinion to create a narrative that completely misrepresents the article.
2) Then there is your claim that "Surgery alone accounts for nearly 3 million new opioid addicts per year." I'm sorry, that just is not true. You didn't even provide a citation for that lie because the situation doesn't exist.
3) Also, you quote "in labor-intensive jobs where injuries are common, roughly 25% of workers are on opioids while on the job." While all of these words exist in the article, they are not in the same sentence. Did you even read the article?
4) And this claim: "We are 4.6% of the world’s population, but we consume 80% of the world's opioids." The article cited here was from 2011. Here's an excerpt from a 2021 study published by The Lancet. "The global opioid consumption rate declined by 30% between 2009 and 2019. The reduction in global consumption was primarily driven by decreased opioid consumption in the US and Germany. In 2009, Germany had the highest consumption rate , followed by the US , and Canada. The consumption rate declined by 58·3% in Germany, 48·0% in the US, and 36·8% in Canada from 2009 to 2019. In 2019, these three countries were still among those with the highest consumption rates in the world, but the UK had the highest rate"
2. That's the number and I was being conservative because studies vary. Approximately 6-10% of Americans will develop new persistent opioid use after elective surgery. See this study from UM in 2017. https://jamanetwork.com/journals/jamasurgery/article-abstract/2618383. If we average around 50,000,000 surgeries per year that would be about 3M-5M per new users per year.
3. I am a consultant for big labor. These are the numbers that they share with me. These big organizations "self-fund" their healthcare benefits and they now how many opioid prescriptions are filled. They have this data. I've given talks at factories and the talks end with them passing around a 5 gallon bucket filled with Narcan nasal sprays. Every worker is instructed to put one on their keychain so that they can resuscitate a worker if need be. Tragic.
4. That 4.6%/80% consumption comment was from the WHO. I could not find the original quote. Here is what ChatGPT said when I asked.."What percentage of the worlds opioids does America consume? Answer..."As of my last update, the United States consumes a substantial proportion of the world's opioids, accounting for a significant percentage of global opioid consumption. The exact percentage might vary from year to year due to changes in consumption patterns, but historically, the U.S. has consumed a disproportionate amount compared to its population size. In some estimates, it has been reported that the U.S. consumes around 80-90% of the world's opioid supply. This high consumption rate has been associated with various factors, including prescription practices, healthcare policies, and issues related to addiction and pain management."
I do not disagree that our healthcare system needs to do a better job at promoting methods of pain relief other than opioids. There are many additional ways to treat post-surgery pain either without or in combination with short term opioid prescriptions.
Your article started out so well with "Treatment for people addicted to opioids is good, but what about doing something to keep people from getting addicted to opioids in the first place?" In fact, I was encouraged to continue reading even after the first several paragraphs. But it quickly went off the rails and into the weeds of tired old tropes that perpetuate stigma and cause harm to opioid users from all walks of life.
I abhor the twisting of facts to fit a particular narrative until it becomes disinformation. This piece is filled with examples of data and statistics taken out of context and then used to create a false narrative. Not all opioid users are people with opioid use disorder or "addicts" as you call them. It's deceptive and promotes fear and "othering". Yet we all know that when it's your turn to have surgery, you are going to want to (at the very least) know that opioids are available if needed.
1) This second citation (why not just cite this to begin with?) also does not say what you think it says. Here's what you said: "after only five days of opioid use, our bodies start developing opioid dependence" Here is what the article says: "The probability of long-term opioid use increases most sharply in the first days of therapy, particularly after 5 days or 1 month of opioids have been prescribed, and levels off after approximately 12 weeks of therapy. The rate of long-term use was relatively low (6.0% on opioids 1 year later) for persons with at least 1 day of opioid therapy, but increased to 13.5% for persons whose first episode of use was for ≥8 days"
Notice the differences in language, meaning, and tone. Use vs dependence. 5 days of use vs a 5-day prescription. As a scientist, I'm sure you see it.
2) It's irresponsible to state that "Surgery alone accounts for nearly 3 million new opioid addicts per year." Continued or persistent use is NOT the same as your antiquated "opioid addict" label. And while I'm in that paragraph, where does it say that "20% of women undergoing a mastectomy" remain on opioids? Not in the article you cited. In fact it says that, in fact "Only 28% of the prescribed pills were taken" by women. And "Less than 2% of patients obtained refills." I'm confused. Please help me understand where you found the numbers you quoted.
3) Don't you dare cite an article to substantiate a "fact" that was "shared with you" by the "big labor" you consult for. You know better than that. Does big labor also share with you their policies for time off, sick pay, and access to short term disability? Is this something that OSHA really should be looking at? Does the employer actually know how many people are using those prescriptions and how they dose them? Perhaps we would all have a better understanding of why the 25% was shared with you if we had answers to these questions. And kudos to this company for providing Narcan to their employees, as I hope they have defibrillators and other life-saving tools in case of emergency.
4) AI? That's who you trust for health data? *sigh* I cited more current and thorough statistics. Please refer to them.
If your intent is to curb opioid prescribing after surgery as originally stated, fine. That's great. And you actually came back to a bit of reality with a sound conclusion in the paragraph prior to the Ben Franklin quote.
The meat in this sandwich, however, is terrifically misguided, misrepresented, and often incorrect.
It's a big wheelhouse and you're not standing alone in it.
The entire medical establishment seems to prefer treatment to prevention as well as to cures for a wide range of diseases and disorders. The breast cancer business especially seems to have the this attitude. Of course this makes financial sense. Treatment means ongoing medical intervention, a cure means the money spigot is turned off. Can't have that, now can we! /sarc
But, I have a question. Given a Stage IV cancer patient with a consistent high level of pain interfering with their work and life activities and having a prognosis of three to six months to live, what is the cost/benefit analysis of this patient becoming dependent or addictive to opioids.
Yes, that describes my situation. I have so far avoided pain management, but my ability to do so is limited. Any advice or input would be welcome.
God Bless you John. I am sorry to hear that. This circumstance calls for a completely different strategy. Comfort and quality of life are paramount and the priority here. I'd start with NSAIDS and consider altering with Acetaminophen around the clock. If more is needed consider gabapentinoids which are good for neuropathic pain. I'd then add CBD/THC and advance as tolerated. Finally, and of course, opioids would be indicated if the preceding strategies don't work but they are fraught with many more side effects vs the others mentioned (cognitive changes, constipation, can't pee, nausea, dizziness, etc.) . A Palliative Care specialist can help with these varied approaches. Back at you on staying safe (and comfortable).
Gabapentin, especially at higher levels, is also a dangerous medicine. You cannot stop it without severe side effects, including suicidal ideation. I know several people who have committed suicide after stopping this drug. I’m currently titrating and have been for 15 months and have only been able to go down .5 mg every 14 days. I think gabapentin is overprescribed and doctors are not aware of its danger.
Thanks for commenting Lisa. So true. All meds have their side effects, you need to be careful. Too much of any of them can cause problems. I was impressed with adding gabapentin after a root canal and after Tylenol/motrin were not cutting it. One gaba and the pain was gone.
Thank you for responding, Dr. McCord, and for your kind words.
More context: I had a dependence problem for a few years up until the end of 2010. Since then I have been on Suboxone, which gives me some relief. I add aspirin as needed, and I've been a constant cannabis smoker for 55 years. I tried gabapentinoids in the past and found them ineffective. The opiate side effects you mention have never been an issue for me.
I'm trying to avoid opiates like the plague, but the time will come. What I'm worried about is convincing my physician that he will need to prescribe enough to overcome my body being acclimated to a certain level of opiates in order for them to provide relief.
Thanks John. Yes, eventually you will have to transition from Suboxone to opioids. Oncologists, Palliative Care, or Chronic Pain docs understand these dosages so I'd track them down and develop a relationship before you'll need them. Best wishes.
Thanks for commenting Kendra. As we state in the article, the wellspring of the problem is an opioid prescription. We are significant outliers in our widespread opioid prescribing practices. Here is a recent study that compared three common surgeries in hospitals in the US and the rest of the world. They found, "Ninety-one percent of US patients were prescribed opioids, compared to 5% of non-US patients." Their conclusion, "US physicians prescribe alarmingly high amounts of opioid medications postoperatively. Further efforts should focus on limiting opioid prescribing and emphasize non-opioid alternatives in the US." Indeed. See..https://journals.lww.com/annalsofsurgery/abstract/2020/12000/opioids_after_surgery_in_the_united_states_versus.1.aspx
What follows is opioid dependence and then addiction. Eventually, our medical complex cuts the patient off and the individual then turns to the street for their opioids. They ultimately succumb to a fentanyl overdose.
The key here is “unnecessary” prescriptions. The patient is genuinely in pain & needs relief. Our profit-driven healthcare system prioritizes quick & cheap over time-consuming & effective. Physicians & other providers are under immense pressure to limit care & often don’t have time to properly investigate & get to the actual source of the pain. Proper PT & rehab is costly & time consuming. Instead, they wind up simply treating the symptom - cheap & easy.
Exactly.
The problem was doctors, on the advice of Purdue, were prescribing strong opioids for moderate pain like broken bones etc. Now, with the change in not prescribing pain meds, many severe chronic pain patients are suffering horribly. Their bodies get worn down and they die of the flu or pneumonia. Over the counter pain meds, like Tylenol and NSAIDs have issues also. How many people die from alcohol-related deaths yearly?
The article was not referring to chronic pain patients nor suggesting to limit their access to these medications which can greatly impact their quality of life. What we are suggesting is a strategy to avoid the creation of chronic pain patients. There is good data to show that opioids affect our immune response which can increase our chances of developing dangerous infections, difficulty fighting cancers, etc.
I will forward this article to some experts. It makes some really outrageous discredited claims. I hope one of the experts can respond.
Glad to respond, Ms. Cuyler. Can you be specific about which really outrageous discredited claims you took issue with?
Mainly -- your assertion that the majority of opioid overdoses are from patients taking their prescribed medication. I believe that has been disproven by many sources.... who have concluded that illicit fentanyl is the driver of the opioid overdose crisis. I think the risk profile of Tylenol far exceeds the risks of properly prescribed opioids. And a lethal dose of Tylenol is available over the counter with no restrictions. Meanwhile, I know of several people who stepped in front of trains to end their suffering when they couldn't access appropriate medical care.
Opinion pieces such as this do a grave disservice to both the people experiencing substance use disorder (and their loved ones) and to chronic pain patients (and their loved ones and care providers).
There are much better ways to prevent addiction including adequate access to physical and mental health services, safe supply, and reduction of stigma associated with mental illness and substance use.
Please leave the those suffering with chronic pain alone, especially those with terminal illness. Allow them some quality of life, please.
It's not a good look when people write articles that cite sources that don't exist, misrepresent the intent AND content of other sources, cite outdated research, or flat out make things up. It looks like . . . propaganda.
1) You state that "according to the CDC, after only five days of opioid use, our bodies start developing opioid dependence". The article says NO SUCH THING. It makes NO CONNECTION between 5 days of use and what our bodies are doing. You are conflating their research and your opinion to create a narrative that completely misrepresents the article.
2) Then there is your claim that "Surgery alone accounts for nearly 3 million new opioid addicts per year." I'm sorry, that just is not true. You didn't even provide a citation for that lie because the situation doesn't exist.
3) Also, you quote "in labor-intensive jobs where injuries are common, roughly 25% of workers are on opioids while on the job." While all of these words exist in the article, they are not in the same sentence. Did you even read the article?
4) And this claim: "We are 4.6% of the world’s population, but we consume 80% of the world's opioids." The article cited here was from 2011. Here's an excerpt from a 2021 study published by The Lancet. "The global opioid consumption rate declined by 30% between 2009 and 2019. The reduction in global consumption was primarily driven by decreased opioid consumption in the US and Germany. In 2009, Germany had the highest consumption rate , followed by the US , and Canada. The consumption rate declined by 58·3% in Germany, 48·0% in the US, and 36·8% in Canada from 2009 to 2019. In 2019, these three countries were still among those with the highest consumption rates in the world, but the UK had the highest rate"
I could continue refuting, but I'll stop here.
Chris, thanks for commenting.
You are in my wheelhouse.
1. See this article from the CDC, MMWR. Note Figure 1 and how the probability of being on opioids ramps up significantly after 5 days. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5657867/
2. That's the number and I was being conservative because studies vary. Approximately 6-10% of Americans will develop new persistent opioid use after elective surgery. See this study from UM in 2017. https://jamanetwork.com/journals/jamasurgery/article-abstract/2618383. If we average around 50,000,000 surgeries per year that would be about 3M-5M per new users per year.
3. I am a consultant for big labor. These are the numbers that they share with me. These big organizations "self-fund" their healthcare benefits and they now how many opioid prescriptions are filled. They have this data. I've given talks at factories and the talks end with them passing around a 5 gallon bucket filled with Narcan nasal sprays. Every worker is instructed to put one on their keychain so that they can resuscitate a worker if need be. Tragic.
4. That 4.6%/80% consumption comment was from the WHO. I could not find the original quote. Here is what ChatGPT said when I asked.."What percentage of the worlds opioids does America consume? Answer..."As of my last update, the United States consumes a substantial proportion of the world's opioids, accounting for a significant percentage of global opioid consumption. The exact percentage might vary from year to year due to changes in consumption patterns, but historically, the U.S. has consumed a disproportionate amount compared to its population size. In some estimates, it has been reported that the U.S. consumes around 80-90% of the world's opioid supply. This high consumption rate has been associated with various factors, including prescription practices, healthcare policies, and issues related to addiction and pain management."
I hope that helps.
Matt
Matt,
I do not disagree that our healthcare system needs to do a better job at promoting methods of pain relief other than opioids. There are many additional ways to treat post-surgery pain either without or in combination with short term opioid prescriptions.
Your article started out so well with "Treatment for people addicted to opioids is good, but what about doing something to keep people from getting addicted to opioids in the first place?" In fact, I was encouraged to continue reading even after the first several paragraphs. But it quickly went off the rails and into the weeds of tired old tropes that perpetuate stigma and cause harm to opioid users from all walks of life.
I abhor the twisting of facts to fit a particular narrative until it becomes disinformation. This piece is filled with examples of data and statistics taken out of context and then used to create a false narrative. Not all opioid users are people with opioid use disorder or "addicts" as you call them. It's deceptive and promotes fear and "othering". Yet we all know that when it's your turn to have surgery, you are going to want to (at the very least) know that opioids are available if needed.
1) This second citation (why not just cite this to begin with?) also does not say what you think it says. Here's what you said: "after only five days of opioid use, our bodies start developing opioid dependence" Here is what the article says: "The probability of long-term opioid use increases most sharply in the first days of therapy, particularly after 5 days or 1 month of opioids have been prescribed, and levels off after approximately 12 weeks of therapy. The rate of long-term use was relatively low (6.0% on opioids 1 year later) for persons with at least 1 day of opioid therapy, but increased to 13.5% for persons whose first episode of use was for ≥8 days"
Notice the differences in language, meaning, and tone. Use vs dependence. 5 days of use vs a 5-day prescription. As a scientist, I'm sure you see it.
2) It's irresponsible to state that "Surgery alone accounts for nearly 3 million new opioid addicts per year." Continued or persistent use is NOT the same as your antiquated "opioid addict" label. And while I'm in that paragraph, where does it say that "20% of women undergoing a mastectomy" remain on opioids? Not in the article you cited. In fact it says that, in fact "Only 28% of the prescribed pills were taken" by women. And "Less than 2% of patients obtained refills." I'm confused. Please help me understand where you found the numbers you quoted.
3) Don't you dare cite an article to substantiate a "fact" that was "shared with you" by the "big labor" you consult for. You know better than that. Does big labor also share with you their policies for time off, sick pay, and access to short term disability? Is this something that OSHA really should be looking at? Does the employer actually know how many people are using those prescriptions and how they dose them? Perhaps we would all have a better understanding of why the 25% was shared with you if we had answers to these questions. And kudos to this company for providing Narcan to their employees, as I hope they have defibrillators and other life-saving tools in case of emergency.
4) AI? That's who you trust for health data? *sigh* I cited more current and thorough statistics. Please refer to them.
If your intent is to curb opioid prescribing after surgery as originally stated, fine. That's great. And you actually came back to a bit of reality with a sound conclusion in the paragraph prior to the Ben Franklin quote.
The meat in this sandwich, however, is terrifically misguided, misrepresented, and often incorrect.
It's a big wheelhouse and you're not standing alone in it.
Good analysis, Mr. Potter.
The entire medical establishment seems to prefer treatment to prevention as well as to cures for a wide range of diseases and disorders. The breast cancer business especially seems to have the this attitude. Of course this makes financial sense. Treatment means ongoing medical intervention, a cure means the money spigot is turned off. Can't have that, now can we! /sarc
But, I have a question. Given a Stage IV cancer patient with a consistent high level of pain interfering with their work and life activities and having a prognosis of three to six months to live, what is the cost/benefit analysis of this patient becoming dependent or addictive to opioids.
Yes, that describes my situation. I have so far avoided pain management, but my ability to do so is limited. Any advice or input would be welcome.
Y'all stay safe out there,
God Bless you John. I am sorry to hear that. This circumstance calls for a completely different strategy. Comfort and quality of life are paramount and the priority here. I'd start with NSAIDS and consider altering with Acetaminophen around the clock. If more is needed consider gabapentinoids which are good for neuropathic pain. I'd then add CBD/THC and advance as tolerated. Finally, and of course, opioids would be indicated if the preceding strategies don't work but they are fraught with many more side effects vs the others mentioned (cognitive changes, constipation, can't pee, nausea, dizziness, etc.) . A Palliative Care specialist can help with these varied approaches. Back at you on staying safe (and comfortable).
Gabapentin, especially at higher levels, is also a dangerous medicine. You cannot stop it without severe side effects, including suicidal ideation. I know several people who have committed suicide after stopping this drug. I’m currently titrating and have been for 15 months and have only been able to go down .5 mg every 14 days. I think gabapentin is overprescribed and doctors are not aware of its danger.
Thanks for commenting Lisa. So true. All meds have their side effects, you need to be careful. Too much of any of them can cause problems. I was impressed with adding gabapentin after a root canal and after Tylenol/motrin were not cutting it. One gaba and the pain was gone.
Thank you for responding, Dr. McCord, and for your kind words.
More context: I had a dependence problem for a few years up until the end of 2010. Since then I have been on Suboxone, which gives me some relief. I add aspirin as needed, and I've been a constant cannabis smoker for 55 years. I tried gabapentinoids in the past and found them ineffective. The opiate side effects you mention have never been an issue for me.
I'm trying to avoid opiates like the plague, but the time will come. What I'm worried about is convincing my physician that he will need to prescribe enough to overcome my body being acclimated to a certain level of opiates in order for them to provide relief.
Thanks John. Yes, eventually you will have to transition from Suboxone to opioids. Oncologists, Palliative Care, or Chronic Pain docs understand these dosages so I'd track them down and develop a relationship before you'll need them. Best wishes.
Great advice, Doc. It's going on my to do list. Thank you.