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PaperclipPerfector  10mo ago (text post)   21848 thread views

Culture War Roundup for the week of February 14, 2024

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From people I’ve talked to opioids are amazing... They have to be if people do them.

Maybe I'm an outlier (or I was taking an insufficient dose as described in Drug users use a lot of drugs), but Opioids weren't that great unless I was in pain.

My experience made me much more sympathetic to the idea that the "opioid epidemic" is an appropriate reaction to the chronic pain epidemic (particularly among blue collar workers with physically-demanding jobs. Who would've thought.)

I haven't run into any obviously drug seeking patients myself in India, the people getting morphine or fentanyl prescriptions climb the pain ladder at the same rate anyone else does.

I was prescribed tramadol once, for severe sudden back pain and costal tenderness (?acute pancreatitis but the the enzymes came back normal), and it was a warm glow, but I never felt the urge to get more once the course was over. It did at least help with the agony, when the strongest NSAIDs didn't. The maximum I took daily was equivalent to about 10 mg of morphine, oral.

I suspect it's a lot of people trying to cure SLS (Shit Life Syndrome), and well, if you can't fix your problems you might as well not notice them.

My friend was given fentanyl at a hospital for pain relief after an injury and had completely the opposite reaction. He said it felt so good he would almost certainly have tried to get more if he’d known how. Even now, he said, when something good happens part of him is thinking, ‘Okay, but fentanyl was so much better’.

This was a young, happy man with the world at his feet. The reaction was purely physical. I think @JulianRota is right, there must be an individual difference in response.

there must be an individual difference in response.

From my subjective experience, an individual difference is everything when it comes down to psychoactive substances. People tend to differ much more neurologically then physically, which is unpleasant truth for many. But we cannot see this on the first sight, so this thought rarely comes through our minds. For my part, I get almost no pleasure or kick from drinking alcohol. And I come from heavily-drinking culture, so this is a huge social burden. I have drunk hundreds times and most of the time I get instantly sleepy and then heavily depressed. And I know people who are extremely aggressive and psychotic when drunk, so the response is indeed deeply varied.

FWIW, I was given IV morphine before surgery for a broken arm as a kid and still remember how amazing it made me feel. They could've marched a firing squad in there with my death warrant and I wouldn't have cared in the slightest.

OTOH, from a very small sample size it appears that I'm allergic to hydrocodone. I got some of those after having wisdom teeth yanked out and they just made me feel sick and unpleasantly intoxicated.

If there is a current epidemic of chronic pain, it's come in tandem with a broader shift away from physically demanding jobs and non-work activity.

My experience was similar. Sure, being zombie and staring at the wall doing nothing was better than being in infernal pain but I sure as hell prefer not being a zombie given the choice. I can’t think of a single actually pleasant thing about the experience.

I've heard from people in the medical industry that the effect of prescription opioids is roughly split in thirds - about a third get basically no effect at all or strictly bad effects, another third get effective pain relief but no desire to do more once the pain is gone, and the final third feel dangerous addictive desires in addition to pain relief and are prone to addiction and all the resulting issues if other factors in their life line up right/wrong.

Meanwhile, it seems really weird that there is suddenly a "chronic pain epidemic". Why should there be such a thing now? Humans have been doing lots of strenuous manual labor for all of recorded history - especially before the industrial revolution. Have we all suddenly got worse somehow? Is it maybe related to signs that the modern diet is mostly terrible?

and the final third feel dangerous addictive desires in addition to pain relief and are prone to addiction and all the resulting issues if other factors in their life line up right/wrong.

This may roughly correspond to estimates that 27% of Chinese males were addicted to opium as aftermath of opium wars and wide availability of the drug. To be honest, I do not get the whole idea of how decriminalization of drugs will be so fantastic with these and other natural experiments during 19th century. There was a reason why newly discovered drugs got banned in the first place.

It's probably not everything, but it doesn't help that we've gotten a lot fatter and older on average.

Pain doesn't have to be physical. Psychological pain is a thing and it is just as real a sensation as physical pain. See e.g. phantom pain which is pain experienced by an individual in a limb that has long since been amputated. Phantom pain is a very real thing we've known about for centuries so it's not some new fad or whatever.

What happens when a limb is cut off? Necessarily, the nerves that come from the central nervous system have to be cut somewhere as well. So now you have some unnatural nerve ends dangling around in your stump, which may still attempt to send signals to the brain. And since these signals are fundamentally nonsensical, they can be interpreted as almost anything - and in doubt, the brain often interprets unusual signals as simple pain.

Worse yet, even if a theoretically perfect surgeon does such a great job that these nerve ends do not send any signals whatsoever, our brain is actually wired to expect them. So now it's trying to interpret the lack of signals, which, in doubt, ....

I'm actually not against your main point - I think that modern life often does not fulfill our natural urges and fails to offer adequate alternatives, and that this can lead to depression, chronic pain and similar issues. But IMO phantom pain is quite physical in nature.

Because the pain isn't physical, it's mental/emotional/spiritual. Look up biopsychosocial concepts of pain, or for a more classic take, Healing Back Pain by John Sarno.

As someone who has experienced chronic pain for almost a decade, I can confirm that physical issues are not the cause of my pain at least. I've become convinced that the vast majority of chronic injury and pain is not a mechanical issue either.

Meanwhile, it seems really weird that there is suddenly a "chronic pain epidemic". Why should there be such a thing now? Humans have been doing lots of strenuous manual labor for all of recorded history - especially before the industrial revolution.

Tissue damage is only one part of pain.

https://www.painscience.com/articles/pain-is-weird.php

There could be other factors that might explain a higher rate of pain today.

Looks like an interesting article, thanks! I will read later. But that, and TheDag's point would imply that any "chronic pain epidemic" is just a broader symptom of, I guess I don't really know what to call it, the broad cultural sickness we have in the West and America right now, and treating with opiates is clumsy duct-tape over the real problem that mostly won't help much.

Yeah, there's something going on besides chronic pain. Opioids are also prescribed for acute pain (e.g. after an operation) despite the fact that acetaminophen and nsaids are similarly effective. When my wife got her wisdom tooth removed, the surgeon prescribed oxycodone a week before the surgery even happened. It's crazy.

I guess I'm somewhat lucky in not having many issues with serious or chronic pain. I did get my wisdom teeth removed, and I don't think I was prescribed or took anything particularly strong for that, but I don't recall very clearly. I had to get a root canal a few years ago, and I do remember that hurting pretty badly the next day. I had been prescribed Tylenol with Codeine, which I took and worked pretty well at dulling the pain, but left me pretty zonked out. Definitely not something I had any interest in taking if I wasn't in serious pain. I think I only took that for 1 or 2 days, and the pain was mild enough after that that I didn't bother.

Humans have been doing lots of strenuous manual labor for all of recorded history - especially before the industrial revolution.

And in pain much of the time. Especially as they aged. The term "backbreaking labor" isn't new.

Eh maybe. But then still, why an opioid epidemic now? Opium and derivatives have also been around for a very long time. Is it just that much more appealing in pill form and prescribed by your doctor than in smokeable or snortable form?

It is prescribed by a doctor, imparting legitimacy. And in pill form you can pop a couple in a quiet moment to yourself anywhere, something you can't do with a syringe or opium pipe. And the pharmaceutical companies only figured out in the fifties and sixties how to mass produce doses that would leave people mostly functional while still taking their pain away. Before that those drugs were prohibitively expensive and so people just drank themselves to death.

There certainly was an opium epidemic in the 19th century US, but most addicts were middle class or wealthy, predominantly women; the poor could afford neither the drug nor the doctor to introduce it to them (you could buy it over the counter, but the poor then were very poor indeed), and it was primarily injected by said physician. There was a population of civil war veteran addicts too. It was estimated that 0.5% of the population were opium addicts, a much larger percentage presumably used opioids occasionally. Apparently there are about 2.1 million opioid addicts in the US (estimated number with ‘opioid misuse disorder’) today, which is approximately 0.6% of the population. This doesn’t seem like a huge difference.

Opium smoking only became a major issue at the very end of the 19th century, and was primarily a feature of Chinatown opium dens which were necessarily not fully geographically distributed across the whole country but concentrated in major cities. As soon as opium addiction became recognized as a major problem in the 1890s it was restricted and then banned pretty quickly, physicians were shamed for prescribing it (both within and beyond the profession) and so it was never even introduced to many working and underclass communities. There were also horror stories from Western travellers in China describing the opioid epidemic there (eg half of all young men wasting away in the opium dens of major Chinese cities) such that politicians acted relatively quickly.

Today opioids are much easier to produce synthetically, much easier to sell (eg on the dark web) and ship, global trade offers far more places to hide large volume illicit imports, and a decline in communal identity means that social pressure (around almost everything) is less than it was in 1890.

So I don't really dispute any of that, but it feels like this conversation is getting a little shifted or circular, I suppose as a consequence of it being with so many people. What I'm really arguing against is ulyssessword's point that "the 'opioid epidemic' is an appropriate reaction to the chronic pain epidemic". I find it pretty hard to buy into, humans have been doing manual labor for millennia, opium has been around for millennia at varying levels of availability, but only now somehow is blue-collar manual labor so strenuous that using opiates to dull the pain is an appropriate response.

It seems more likely to me to be something like the point that sarker and TheDag are making, that the pain is actually a symptom of broader cultural disease, not a natural consequence of manual labor.

Uh, I'm pretty sure that the laboring classes who had access to a lot of drugs have proceeded to do a lot of drugs for all of recorded history. "They drink way too much" is a pretty universal blue collar stereotype, because that's a nearly universally available drug that's priced at blue-collar affordable levels in most societies.

Opium may have existed in 1890, but it wasn't widely available in the US the way it often is now. Booze was the drug of choice for construction workers and miners suffering from nonstop pain; when we decided it was a medical issue doctors of course can't say "have you considered needing some AA?" and so prescribed oxycodone instead. I suspect that the issue will fade with the normalization of medical marijuana.

I think it’s much more available now and at much greater purity. If you have a script, you can pop into any pharmacy and have 100 pills in minutes. You don’t even need to get out of the car. Unless you lived in a big city, you probably had a harder time getting patent medicines simply because it required a trip to those cities, and it came as a bottle of a couple of ounces mixed with all kinds of stuff. Modern medical insurance covers a lot of the cost of modern opioid drugs where the older patent medicines were comparatively expensive. Cheap easy pills that you can get in large quantities without leaving your car are probably going to be a bigger addiction risk than something that’s expensive and sold in small quantities.

Opioids definitely do affect different people differently. I've had them prescribed once to take after a surgery. I took one dose immediately after the surgery and decided I'd rather no pain medication at all than a second dose. (Pretty sure I took ibuprofen, not nothing.) I've discussed this with others and gather this isn't an entirely uncommon reaction, although certainly far from a majority opinion.

My experience was extremely similar. When I got my wisdom teeth removed, they gave me a massive bottle of vicodin. Dozens of doses, apparently intended to be taken daily for months. I took two doses: one several hours after the surgery once the initial anesthesia wore off, and then another two days after the surgery when the pain became very acute. The rest of the pills in that bottle went untouched.

It occurred to me how easy it would have been, and how profitable, to sell the rest of the pills. Although I’ve never used the “Dark Web”, nor do I have any familiarity with the sorts of websites or venues people use to buy and sell drugs, I can’t imagine it would have been difficult to figure out. And, sadly, there is at least one member of my family who would have taken them off my hands if I’d offered. I also did not want to throw them away in my dumpster, for fear of attracting a swarm of local homeless. I ended up returning the bottle of pills to the surgery center, over their objections, and told them to figure out what to do with it.

On the one hand, this could be read as a story about how easy it is for people to inadvertently become addicted to opioids; I went in for a minor surgery, was given a huge bottle of pain pills by a trusted medical professional, and told to use them to my heart’s content. I was fortunate in that I did not end up experiencing very much significant recurring pain as a result of my surgery, and therefore was not seriously tempted to use more than what was absolutely necessary. If my surgery had produced significant recurring pain, who’s to say that I would have had the fortitude and self-control to resist burning through that whole bottle of pills?

On the other hand, even if I had done so, I could not plausibly have claimed that it was inadvertent, or that I didn’t understand the risks. Every thinking adult with even a cursory understanding of current events is aware of the gravity of opioid addiction. Now, if there had been something laced into those pills without my knowledge - if I’d thought I was taking immunosuppressants and it turned out they had fentanyl in them - this would obviously be beyond my control. My sense is that people who talk a lot about the “opioid crisis” tend to imply that this type of situation - people taking opioids without realizing it, and becoming addicted - is very common. My naïve sense is that probably the much more common scenario is more similar to my experience, wherein people are given massively unnecessary and inflated doses of pain medication by doctors, and fail to exercise proper self-control over how much of that medication to use.

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