Some of those questions will be hard to answer definitively. Here are what the pain scientists (i.e. guys in lab coats/nerds who are studying these things) are saying in regards to that person/patient who initially had a tissue injury but 2 years later is still taking pills for it.

1) The pain threshold continues to lower the longer they have pain, meaning it won't take much to trigger the nervous system and brain to produce pain. Pain is 100% created by the brain not our tissues. Nociceptors in tissues don't produce pain (contrary to popular belief)

2) Patients will begin to have a fear/worry that "I'm going to be in pain forever" and the nervous system becomes more sensitive from that fear (at a physiological level). Again, lowering the threshold.

3) Pain lasting more than 6-9 months is really no longer about tissue injury, its a nervous system/brain chemical problem.

So, the medical professional in the past would:

1) Keep prescribing pills

2) Blow them off as "Your pain isn't real". But the patient still can find grandma's percocet from her hip replacement surgery.

So, I think you would be surprised how many folks who continue taking opioids are doing so because their pain mechanisms are very dysfunctional and its getting them at least "some" relief.

I feel that the medical professionals (Docs, therapists, PT's, chiros) need to continue to evolve and learn about how to take more of a cognitive behavioral approach which is being shown in clinical data to be very successful in treating chronic pain. This would start helping a majority of these folks (I'm not saying ALL). I've used some of the methods with patients, including chronic pain in runners and triathletes, and have had good success with several.

Here is great clip from a pain scientist. https://www.youtube.com/watch?v=XwBYkw-iZdQ. Give it a go.



The true addicts who seek pills who don't and never had pain...that involves a different approach most likely.[/quote]

Well said.

The only thing i'd say, which has probably been said already is that opioids are seemingly being thrust upon people. I replied to someone else's post about my experience just this morning after hitting a raccoon. My shoulder pain was manageable, and I was acting completely normal with the nurse and she offered me a prescription to percocet, I said no, she said 'are you sure? it could be a lot of pain' even while I am sitting there using my cell phone with both hands. Granted, if I try to raise my arm it hurts like hell but I'll let the orthopedist tell me what's up. If I didn't have my brother's experience to learn from, I probably would have taken it. No pain? So I can use my arm more and end up fucking it up more because I can't feel the pain? Yeah sure! This was offered to me in the ER, when most people aren't thinking all that clearly or are are still experiencing the worst pain from the accident. In my view, it was certainly thrust on my brother who had chronic shoulder pain (one small wrong move would dislocate it) and it seemed to me this morning it was being thrust on me.

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808 > NYC > PDX > YVR
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Ditto this. Dreamland is an excellent book

My wife unit is a State Trooper up here, and this is a hot topic now in the State. What seems to be the common theme as mentioned in a previous post: hospitals are QUICK to hand these out. So much so that locally we've had a few Docs discharged because of it. But that is the easy "take this to feel better" solution and that is "success" for a doctor (treating the patients ailments and taking away the pain), though that isn't what is really happening. The over prescribing of these because someone says they are in "great pain".

Now some personal experience: I had reconstructive shoulder surgery. That fucking sucked. I have a high tolerance of pain, so much that when I had knee surgery I barely took pain meds (pain wasn't good...but it reminded me I had surgery and I could deal with it). However on my shoulder IT WAS UNBEARABLE. Toss in some pain meds and it was good...but I didn't like the "high" feeling I had as well. I don't like to be "out of control of my senses" and when I was on them, I was. So I quickly got off of them...and then the pain came back. That pain...as I mentioned, was unbearable. I can see how living a life in constant pain a person would do whatever it takes to take that pain away...and those meds do just that. Toss in that getting off the meds brings back pain (withdrawls) and that person now things "fuck, I'm going to live my life in all that pain again w/o these meds" and the cycle is now on. Living in constant pain...would be unbearable and I could see the search for the pain relief...add in abuse of the meds, and now you need more and more...and the dependency is just too great (trying to "stay away from pain").

I had a buddy that got hooked after a car accident. He got fixed up, but would always have nagging injuries. And he'd jump right to the heavy stuff. But then he started hurting himself (that isn't what he would say if asked) and always in a straight bee-line to the pharmacy for the hardest shit they had because he was "in so much pain". I'm talking a rash: "worst pain ever!" type stuff. Got to the point where he lost his job, and was constantly a mess. Had to get shipped off out of state to rehab and is still in the process. I've talked him a few times and he says he is doing better, but every day he thinks of taking a pill because he'll "feel better" if he does. But he knows he isn't in pain anymore...but he is creating pain to give him justification for the meds. A nasty cycle.

But ultimately I think it stems from being over prescribed by Doctors. Like someone stated before: you failed as a Doctor if I'm sitting at home and still in pain. Even if that isn't the case.

+1

My wife is a Nurse Practitioner. She remember seeing a show on 20/20 that showed an educational video that she saw in the the early 90s as a young nursing student. Video showed a bunch of people telling how great it was that they were pain free. Flash forward 20 years and everyone in the video is a drug addict.

There are all sorts of patient satisfaction scores that drive how we deliver health care. One of those is pain. Prior to the past 2-3 years the goal was not to have pain hence docs would prescribe a lot of narcs. Plus some docs got kickbacks to do so. The pendulum has finally swung back. We are now educating patients that some pain is okay.

Finally the opioid epidemic has been brewing for a few years. Too little funding especially in rural communities to combat this. My NP wife works in an inner city government funded clinic. Most of her addicts the past 4-5 years have been from rural and suburban America. It's not an inner city problem like it was in the 80s and that's what made it a crisis. It's white, affluent young suburbanites who are dying although I don't have figures. I'm not certain but most opioid ODs I see in the ICU seem to be disproportionately white that's made this into a national epidemic.

The short answer is easier access in the last few years, which is multifactorial. I have an interest in this area because I work in infectious disease and unfortunately take care of too many heroin addicts with serious infections as a result of dirty needles.

1) Pharmaceuticals pushed the medications and a lot of prescribers were wooed. There were big marketing campaigns (https://www.ncbi.nlm.nih.gov/...articles/PMC2622774/). Narcotics were being falsely advertised as being non addictive.

2) Government, lobbyist, lawyers, etc. allowed this to happen. The Washington Post and 60 Minutes just had a report on a DEA whistle blower who recognized the rise in opioid abuse and pushed for stricter regulations. He ended up getting pushed out. His former colleagues ended up being hired by law firms who worked for pharmaceuticals and protected them. It's a good read (https://www.washingtonpost.com/...m_term=.65b8b0042ca7) or watch the 60 min episode, it was about 2 weeks ago.

3) Pill mills. There's been more crack downs, so I'm not sure if there really are any still. However there would be a small town mom and pop clinic where they would be getting truckloads of narcotics. The report above talks about this briefly.

Here are some additional points.

1) Heroin is cheaper. Most heroin addicts start off with prescription narcotics, but then either get cut off or ends up being too expensive and turn to heroin.

2) I'm not sure about overprescription now. Because of all the media coverage, a lot of prescribers are hesitant to give narcotics. Unfortunately, some people who really need narcotics are probably under medicated. The good news is that the healthcare industry is looking to alternative methods to pain management. My ortho friend pushes for mobility, activity, PT, etc. which has shown to reduce and sometimes eliminate need for narcotics after surgery.

One observation I've made in my previous career as a pediatric ICU nurse was seeing how narcotics affect kids. Most of the time when they receive narcotics is their pain is under control and they get sleepy and drowsy. However, there are a few that you can obviously tell they are high. They are goofy, euphoric, etc. The best comparison for me is with alcohol. For some of my friends its an upper (goofy, uninhibited, etc) then downer and for others its just a downer.

Apologies for the hijack.

Though not about Opiod addiction, Matt Samet (rock climber) wrote a tremendous book about his addiction to Benzodiazepines which were prescribed to counter anxiety and depression.

Death Grip: A Climber's Escape from Benzo Madness

Death Grip chronicles a top climber's near-fatal struggle with anxiety and depression, and his nightmarish journey through the dangerous world of prescription drugs. Matt Samet lived to climb, and craved the challenge, risk, and exhilaration of conquering sheer rock faces around the United States and internationally. But Samet's depression, compounded by the extreme diet and fitness practices of climbers, led him to seek professional help. He entered the murky, inescapable world of psychiatric medicine, where he developed a dangerous addiction to prescribed medications―primarily "benzos," or benzodiazepines―that landed him in institutions and nearly killed him.

It's a wild ride !

The other issue I think we are seeing is that those folks who are turning to street opiates aren’t getting heroin, they are getting fentanyl or carfentanyl. The likelihood of overdose and death with these substances is significantly higher.

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"When the going gets weird, the weird turn pro."
Hunter S. Thompson

not to beat a horse, but the major shift in the past decade or so is to a model of substance use or behavioral disorders (eating, sex, gambling . . .) as chronic brain diseases, for which there is treatment, but as others have said, interdisciplinary. for most substances, the core is medication treatment, but in my perspective, the individual and group therapies, exercise, social engagement, forgiveness and self-love.

although substance use does cross all boundaries, it is not surprising that some of the areas with the highest incidence and prevalence also have the highest prevalence of hopelessness.

BBC article on the opioid crisis in the USA here which some might find interesting. I certainly can say that here in the UK you just don't hear about people with problems arising from prescription painkillers. This doesn't mean it doesn't happen at all, of course, just that it is rare. There are obviously issues with addiction to opioids, and increasing issues with the synthetics like fentanyl, but as far as I know people here who are addicted usually arrive there via different routes.

Rob

There is also the "Rat Park" study (http://brucekalexander.com/...e-view-from-rat-park is a good start), which showed that for the most part (not all cases, but the majority), addiction to any sort of drug is given a foothold by a lack of other stimuli. The studies cited by DARE etc for "get hooked on heroin after one use" were from rat studies observing that rats, alone in a featureless cage, preferred heroin-laced water to clean water. However, rats in a large cage with lots of other rats and lots of interesting activities, for the most part, preferred to be sober to enjoy all that Rat Park had to offer. The same tends to be true of humans: people who are well-connected to others through work, church, hobbies, family, or whatever, and have fulfilled lives don't typically get addicted to painkillers even when prescribed for a period of a few weeks. It's not just a saying that people "fill the hole in their life with drugs"; it's reality. There is a non-zero number of ST members who, were it not for being able to fill their lives with an obsessive focus on triathlon, would fill the hole with drugs ("or alcohol", as the saying goes, as if alcohol is not a drug used for the exact same purpose).

To be perfectly honest, my first four years of triathlon were exactly that - I had nothing else going on in my life other than family across the country. Train all the time, race every weekend all summer, and winter was a long, slow, depressing slog. Eventually I made enough friends and met my wife and now endurance sport is fun rather than compulsion, but it would have been easy to turn to liquor in those first years without it (this country boy has no idea where to get heroine or the like).

Triathlon saves lives from more than obesity.

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The point is, ladies and gentleman, that speed, for lack of a better word, is good. Speed is right, Speed works. Speed clarifies, cuts through, and captures the essence of the evolutionary spirit.

"Addiction is a symptom of a failing society, not a moral failing"

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like most other chronic disease, substance use and problematic behavioral patterns are multifactorial, so that a lack of things to do, poverty, trauma, and other external factors combine with internal factors (mental health problems, genetic risk) to produce disease. that being said, not enough research is done on resilience, and someone can have high risk and not develop addiction, and have what appears to be low risk and develop it.

Yeah, Surprised this was not mentioned until 3rd page of this thread. Much more than just forming addictions after prescribed pain meds ... the big farma and distribution companies turned a blind eye to what was going on and evidence shows they flooded the market with pain meds for $. DEA's crack down on companies like Cardinal Health were encumbered by Obama administration. I heard this on NPR and was "Fair and Balance Reporting" ....... here is an example...

https://www.cbsnews.com/...dustry-and-congress/

"Jim Geldhof, a 40-year DEA veteran, ran pharmaceutical investigations from dea's detroit field office. Frank Younker supervised the agency's operations in Cincinnati. Joe Rannazzisi was their supervisor. They saw distributors shipping thousands of suspicious orders. One example: a pharmacy in Kermit, West Virginia, a town of just 392 people, ordered nine million hydrocodone pills over two years. "

We can also look at what different countries are doing and what are the results.
I know it is easier for me to get pain medication here in the USA than where I am from.
The structures we build in healthcare will impact the outcome.
I do not think anyone should be surprised by the problem we currently have with pain medication.

If you have a system that push a lot of pain medication into the population, you know what the outcome will be.

I had hip replacement surgery yesterday. Wanna know what they wanted to prescribe for pain? 120 oxycodones!
I told them absolutely not. Ended up leaving with 30 tramadols but don't intend to use them. I seem to be fine with ice and tylenol. Sheesh! How soft to physicians and pharmacist think we are that we need all that pain medication?

step 3: profit !

At the same time as the pharma companies started aggressively marketing and promoting opioids we have the continuing immiseration of the US middle class.

"Wright is correct that in the nineties patients suffering from chronic pain often received inadequate treatment. But the call for clinical reforms also became a flexible alibi for overly aggressive prescribing practices. By the end of the decade, clinical proponents of opioid treatment, supported by millions in funding from Purdue and other pharmaceutical companies, had organized themselves into advocacy groups with names like the American Pain Society and the American Academy of Pain Medicine. (Purdue also launched its own group, called Partners Against Pain.) As the decade wore on, these organizations, which critics have characterized as front groups for the pharmaceutical industry, began pressuring health regulators to make pain “the fifth vital sign”—a number, measured on a subjective ten-point scale, to be asked and recorded at every doctor’s visit. As an internal strategy document put it, Purdue’s ambition was to “attach an emotional aspect to noncancer pain” so that doctors would feel pressure to “treat it more seriously and aggressively.” The company rebranded pain relief as a sacred right: a universal narcotic entitlement available not only to the terminally ill but to every American.

Flush with cash, Purdue pioneered a high-cost promotion strategy, effectively providing kickbacks—which were legal under American law—to each part of the distribution chain. Wholesalers got rebates in exchange for keeping OxyContin off prior authorization lists. Pharmacists got refunds on their initial orders. Patients got coupons for thirty- day starter supplies. Academics got grants. Medical journals got millions in advertising. Senators and members of Congress on key committees got donations from Purdue and from members of the Sackler family."

http://www.esquire.com/...er-family-oxycontin/

On despair -
http://www.nytimes.com/...ans-study-finds.html
and
"Case and Deaton published a second paper last month, in which they emphasized that the epidemic they had described was concentrated among white people without any college education. But they also searched for a source for what they had called despair. They wondered if a decline in income might explain the phenomenon, but that idea turned out not to fit the data so well. They noticed that another long-running pattern fit more precisely—a decline in what economists call returns to experience.

Case emphasized that the connections between the deaths from despair and the declining returns to experience are still at the hypothesis stage. But, if you wanted to spool out the hypothesis, you could find a compelling story. The chronology matched some general changes in the nature of working-class work, which grew less skilled over time and therefore provided lesser returns to experience. If you focused on white workers without a college degree, the decline in returns to experience began with those born around 1955. This matched the story of despair deaths, whose appearance Case and Deaton pinpointed at 1990, just when the 1955 birth cohort passed into early middle age. As that group’s declining wages helped usher them out of the labor force, it made sense that more of them might turn to drugs, alcohol, and suicide. The pattern, begun thirty-five years ago, has not abated."

http://www.newyorker.com/...ce-no-longer-matters

and,



I have hoarded some percocet from a prescription my son got - the opioids make him feel sick, so he doesn't take them. It's expired by now.. so just buy McClellands by the jug, since 11/9.

Got fentanyl when I went in for a colonoscopy. It was absolutely wonderful and I'm looking forward to my next colonoscopy already. My Puritan soul won't let me enjoy that much pleasure so easily, my law-abiding side won't let me go seeking street drugs - those are likely the only reasons I'm not addicted.

I have chronic pain from a condition hemicrania continua. It's mostly dealt with by a prescription NSAID, indomethacin. Unfortunately it only deals with the pain, no blissful side-effects, dammit.

good for you.. a real black dog is a great help with the other black dog..
"But what will you do to keep away the black dog that worries you at home?
The great direction which Burton has left to men disordered like you, is this: Be not solitary; be not idle—which I would thus modify: If you are idle, be not solitary; if you are solitary, be not idle."

my dog is 10 next year, we hunted yesterday in mixed rain sleet and snow with 20-30mph winds. He eventually sat down in the long grass out of the wind and refused to go any further, had to carry him a mile or so back to the car. I realized then I can no longer live without a dog - need to get a puppy now or a rescue spaniel, just in case. My friend Ken said after his father died, he was up to 3 springer spaniels.. a different kind of addiction I guess, fur therapy, as my younger son calls it..

Sometimes things don't just happen, people make them happen:


https://www.newyorker.com/...lt-an-empire-of-pain

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Amateur recreational hobbyist cyclist
https://www.strava.com/athletes/337152
https://vimeo.com/user11846099

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"What's your claim?" - Ben Gravy
"Your best work is the work you're excited about" - Rick Rubin

Here is the thing.

Its been 3 weeks since i stood up straight

I am in constant pain

This period is an aberration in so far as it tends to happen every 2-3 years for maybe 2 weeks. I do not know what i did this time

Usually i am simply limited with low grade pain and limited range of motion.

No NSAID does anything for me. Codeine and Para does a little. Opiates offer relief.

As a early 40 something with chronic pain i am an outlier. I suffered a trauma and serious pain comes and goes but i am rarely comfortable

The consequence is you change your posture and behaviour to avoid movements that exacerbate it.

Living with chronic discomfort in every aspect of your life is pretty debilitating.

Drugs that manage it are very attractive. Few drugs manage it. The problem is you only really need them for a short period but that is rapidly overcome by drugs becomming the problem.

Of course as stated earlier. Those that never had pain that take them are a diffent problem.

as someone who treats people with opioid and other substance/behavioral disorders, i would say that as long as there is full informed consent (tolerance/dependence, random drug screens, checking of prescription database, treatment agreement, regular monitoring of functional status), short courses or low doses of opioids can work for some people. we can't generalize, because there always exceptions to the generalizations (chronic opioids generally don't work, etc.).