*A Nation in Pain*

by on May 12, 2014 at 3:40 am in Medicine, Philosophy, Uncategorized | Permalink

The author is Judy Foreman and the subtitle of this excellent book is Healing our Biggest Health Problem.  Here is one excerpt:

In those not-so-old days when Jeffrey was born, as a preemie, many doctors mistakenly believed that babies’ nervous systems were too immature to process pain and that, therefore, babies didn’t feel pain at all.  Or, doctors rationalized, if babies did somehow feel pain, it was no big deal because they probably wouldn’t remember it.  Besides, since nobody knew for sure how dangerous anesthesia drugs might be in tiny babies, doctors figured that if surgery was necessary to save a child’s life, they’d better operate anyway — and comfort themselves with the hope that the child wouldn’t feel pain.  As one scientific paper from those days intoned, “Pediatric patients seldom need medication for relief of pain.  They tolerate discomfort well,”

That’s preposterous, obviously.  But doctors had to have these self-protective beliefs for their own emotional survival, says Neil Schechter, a pediatric pain physician at Children’s Hospital in Boston. “Doctors were not sure how to do anesthesia in babies.  In response, they had to believe  that the babies couldn’t feel pain.  They were too scared of the anesthetics.”

Here is part of the Amazon summary:

Out of 238 million American adults, 100 million live in chronic pain. And yet the press has paid more attention to the abuses of pain medications than the astoundingly widespread condition they are intended to treat. Ethically, the failure to manage pain better is tantamount to torture. When chronic pain is inadequately treated, it undermines the body and mind. Indeed, the risk of suicide for people in chronic pain is twice that of other people. Far more than just a symptom, writes author Judy Foreman, chronic pain can be a disease in its own right — the biggest health problem facing America today.

This book will make my best of the year list.

Thanatos Savehn May 12, 2014 at 4:06 am

Anyone else starting to have the hairs stand up on the back of your neck, wondering if the next time you come here you’ll see TC, looking for all the world like Donald Sutherland, staring back at you and pointing; doing that alarm-like scream?

uffs May 12, 2014 at 4:27 am

What?

Regardless, this seems like a quite reasonable look at an important issue. Yet another reason to end the radical “war on drugs” but also a needed reappraisal of medical institutional norms.

andrew' May 12, 2014 at 5:09 am

He may need a treadmill desk, just like everyone else. Unlike everyone else he can do it and in fact would earn quirkiness points for it. Kevin Smith swears by weed and after the kids are grown I might try it.

prior_approval May 12, 2014 at 4:31 am

’100 million live in chronic pain’

That figure does not sound particularly credible, though oft repeated. Possibly even self-serving considering the various sources, though I’m sure that Endo Pharmaceuticals would disagree with that – http://www.painmed.org/patientcenter/facts_on_pain.aspx.

Unless one is engaging in the now deep set American tradition of making really broad definitions with meaningless threshholds – any woman between 15 and 45 who has menstrual cramps, for example. Recurring regularly enough, though not necessarily at every menstrual cycle, could easily cover more than a quarter of all women in America, especially when using a broad time line, making them chronic pain sufferer (there is no objective measure of chronic pain, a point mentioned by the author). Not to mention all the associated economic costs, right?

Which, since it is reasonable to assume that American women are not particularly unique, would mean that possibly a billion other women could fit into this definition of chronic pain, making menstrual cramps an even larger problem than diabetes. Well, except for the fact that diabetes leads to things like limb amputation and blindness, while in many cases, hormonal therapy (aka birth control pills) can alleviate much of the problems associated with menstruation.

Or possibly, considering just how obesity and physical inactivity leads to joint (including spinal) problems, a significant amount of chronic pain is merely another symptom of America’s obesity/inactivity problem, and thus should be included along with another symptoms, like diabetes.

And an aging population would also be expected to make its presence felt – something happening in most societies at this point, not just the U.S., it should be noted.

But then, America is a nation that bravely struggles its way forward, in the face of crippling problems that other places seem not to recognize. Or maybe those other societies, burdened as they are with essentially universal health care coverage, are unaware of how much pain they are in? Or the fact that taking time off from work when sick is part of employment law in those societies, and not a reason for being fired?

Here is how it works in the socialist hell of Germany – ‘In Germany, employers are legally required to provide at least six weeks of sick leave at full salary if the employee can present a medical certificate of being ill (which is issued on a standard form).[41] After this six weeks, the employee receives about 70% of his last salary, paid by the statutory health insurance. According to § 48 SGB V (social civil code 5) the health insurance is paying for a maximum of 78 weeks in case of a specific illness within a period of 3 years. In case another illness appears during the time when the employee is already on sick leave then the new diagnosed illness will have no effect on the maximum duration of the payment. Only if the patient returns to work and falls sick again with a new diagnosis / illness, then the payment will be extended.

Fathers and mothers raising a child younger than 12 years also have the right for paid leave if the child is sick. The governmental health insurance pays for a maximum of 20 days for single parents and 10 days each for married couples. (Source §48 SGB V / http://de.wikipedia.org/wiki/Krankengeld_(Deutschland))’ http://en.wikipedia.org/wiki/Sick_leave

Urso May 12, 2014 at 11:22 am

Wow, you’re an ob/gyn too.

Mark Brophy May 12, 2014 at 2:01 pm

Germany is a very poor country. The only places in the USA that are as poor are Arkansas and Mississippi. The federal government pays 50% of the medical bills, or, in other words, both countries are socialist hells in the case of health care. If the feds withdrew, the states could compete against each and those that had the best medical systems would attract the most citizens.

Rahul May 12, 2014 at 4:32 am

I find it very hard to believe that 40% of Americans live in chronic pain. Is this some semantic jugglery? I’m assuming this isn’t qualified with “at some point in their life”?

So 1 out of 3 people I meet today will be secretly in the throes of agony?

Adrian Ratnapala May 12, 2014 at 6:16 am

“chronic” means it must have been a reasonably long point in their life.

I suspect the semantic jugglery is that chronic symptoms don’t have to be very great. Perhaps people have constant recurring headaches, or a stiff backs or a rashes that doesn’t go away etc.

dearieme May 12, 2014 at 6:42 am

Quite. I have a chronic pain in one foot. It’s a bloody nuisance but it isn’t a big deal in the grand scheme of things. On the other hand when I had a nasty acute pain last year I was very glad to be treated in the UK not the US – a strong opiate did the trick.

Z May 12, 2014 at 7:32 am

I had a chronic pain in my arse for a long time, until he moved out of the neighborhood. Then, with out drugs, the pain went away!

Rahul May 12, 2014 at 8:09 am

Sounds like ringworm.

Z May 12, 2014 at 7:35 am

One of the tells of the fanatic is when they are determined to expand the definition of their cause to everyone. Way back in the olden thymes, anti-smoking fanatics claimed 1-in-3 died from smoking. Drunk driving fanatics used to claim 1-in-3 were “effected” by drunk driving. The one third threshold has some magical powers over the mind of the fanatic.

dan1111 May 12, 2014 at 7:51 am

Yes, the number seem suspect. Especially with the over-the-top language:

“Ethically, the failure to manage pain better is tantamount to torture.”

No, it isn’t. That is absurd.

Norman Pfyster May 12, 2014 at 9:35 am

Try thinking over the age of 40 and you probably get a different answer. Just thinking of my close relatives over the age of 40, it’s more than half. I have chronic pain in my foot and so I could probably have answered yes to the survey question, but as dearieme said above, in the grand scheme of things (and in comparison to the members of my family I noted), it’s not that big of a deal.

Rahul May 12, 2014 at 10:05 am

An interesting offshoot question is:

Over time, say the last 200 years, has the proportion of adult Americans in chronic pain increased or decreased?

Norman Pfyster May 12, 2014 at 10:57 am

Some offsetting variables (people died younger, so less time to develop pain), but I’m guessing decreasing. Farming is brutal on the body.

Yancey Ward May 12, 2014 at 10:59 am

Yeah, pretty much everyone I know over the age of 50 suffers from osteoarthritis.

“Are you in chronic pain?”

“Only when I move.”

zbicyclist May 12, 2014 at 12:37 pm

I guess I’m one of the 100 million. I’m over 60. I have chronic pain in my knee, recurring gout in my big right toe, foot pain in my left foot when I walk over a mile without orthotics in my shoes, a mysterious thing in my mid right thigh, and arthritis in my left hand due to broken fingers years ago. Maybe I count multiple times, if this 100 million figure is based on summing together various conditions, ignoring overlap.

But I do nothing for these — other than regular exercise, which helps with many of these issues. Minor pains are the price of living a normal life for a normal lifespan. The issue is how many people have serious pain, something that gee-whiz 100 million number doesn’t address.

Chakolate May 12, 2014 at 1:24 pm

“Try thinking over the age of 40…”

Exactly. I have chronic knee pain, and have had since I was 50 or so. Chronic but intermittent neck pain as well. I don’t let those things stop me, but I would certainly be grateful for relief.

Of just the people on my block who have or have had chronic pain, it’s 100% of all the seniors. (It’s a very mixed neighborhood, age-wise.) We’re pretty tough though, so we slog through it, complaining as needed to ease the pain. ;-)

So Much for Subtlety May 12, 2014 at 4:50 am

I always assumed, rightly or wrongly, most people complaining of pain, pediatric patients being operated on without anesthetic aside, were simply drug seeking. It is the polite, middle class form of the crack addict. Is this book going to change my mind? I look forward to reading it. However, this does not suggest it will:

For many people, the real magic bullet, Foreman writes, is exercise. Though many patients fear it will increase their discomfort, studies show it consistently produces improvement, often dramatic.

I am extremely dubious about any genuine medical condition that can be improved dramatically by exercise. Which suggests in turn that neither the doctors involved in pain, nor this author are considering the real causes.

Rahul May 12, 2014 at 4:53 am

Indeed exercise often helps. I think one difference is in pain perception. Endorphins are implicated I thought.

Doug May 12, 2014 at 5:18 am

The modern understanding of pain is that there’s no intrinsic physical basis for it. There actually are no “pain receptors” only other nerves. Pain is entirely generated by the central nervous system. Many people have slipped disks or other back conditions and experience no pain, while others are in agonizing pain. Simply understanding pain as a mental phenomenon actually reduces pain in many people. In fact many people even after entirely losing a body part still experience pain in the limb.

The reason exercise helps many people is because people learn how to do the movement in a safe and controlled manner. This reduces the anxiety the brain generates related to that body part or movement. That trains their brain not to generate pain.

http://www.exercisebiology.com/index.php/site/articles/what_should_fitness_professionals_understand_about_pain_and_injury/

andrew' May 12, 2014 at 5:05 am

Are you putting us on?

I assume people seek drugs for various types of pain. People don’t get hooked on heroine because the junkie lifestyle appeals to them. They start because it makes them feel good.

So Much for Subtlety May 12, 2014 at 7:34 am

Well I am very partial to heroines, but no, people use heroin because the junkie life style appeals to them. Not because the drugs feel good, although that helps. Everyone knows the consequences of using. Everyone. Anyone who does it is making a clear statement about what they want. They have to seek out an experienced user. They have to find a dealer. They have to get the cash together to buy the drugs. Then they have to use for a couple of months before you can even begin to talk about a habit. They don’t accidentally fall into it. They are like Bart Simpson in that they want an alternative and cooler life style.

The parallel is probably with barbiturates. If they were more readily available lots of people would be using. As they did when doctors were handing them out like candy. The doctor provided lots of good middle class people who would not dream of using illegal drugs with an excuse. Because they liked the drugs, they suddenly discovered that they were stressed and so needed them.

Urstoff May 12, 2014 at 9:39 am

Addition: How Does It Work

or

Projecting: An Internet Comment

Thor May 12, 2014 at 11:41 am

Bart Simpson and heroin addiction: a memoir

Subtlety: So Much for It.

Matt Flipago May 12, 2014 at 2:21 pm

“Everyone knows the consequences of using. Everyone.”

Did you know not every drug user gets addicted to drugs, and not every addict is affected severely by their day to day life. Many drug users are and continue to functional members of society, with stable jobs and families. To think every person who uses drug just becomes a junky is ridiculous, overly simplistic and inaccurate.

Is the behavior dangerous, risky, and potentially deadly? Yes.
Is there a way to know whether you’ll be a lucky functional one? Not really.

Michael B Sullivan May 12, 2014 at 2:25 pm

I don’t think that you understand very much about how people start using drugs. To be clear: no, most people do not start out by “seeking out an experienced user” and then “finding a dealer.” And of course, it is completely ludicrous to imagine that people are seeking out the heroin junkie lifestyle.

To draw from my own experiences (not with heroin): I went to some parties. People at the parties were doing drugs — not just marijuana, but MDMA, ketamine, LSD, mushrooms, and, yes, cocaine and heroin. People (not dealers) offered the drugs, either for free because they were friends, or at the cost they bought them for (for the more expensive drugs). The party provides a relatively safe place to experiment with drugs: lots of people there who are experienced with drugs and can help provide any paraphernalia needed and any minding needed. And indeed there is social pressure to take the drugs.

And some people (like me) do indeed partake from the drugs at the party and then do not get an active drug habit. I suspect — but am not sure — that that includes heroin. Others probably first seek to increase their exposure to such parties, and then eventually, as they get more addicted, seek out a dealer — probably initially getting a friend to buy more from their friend’s dealer and split with them, and then eventually cutting out the middle-man.

People understand that the junkie lifestyle exists, of course: but they see that not everyone who does drugs is presently in the junkie lifestyle, and they believe — possibly unrealistically — that they will be able to enjoy the benefits without the costs. And, speaking from decades of knowing people who are much more heavily into drugs than I ever was: indeed, there are people who recreationally use a bunch of fairly “heavy” drugs for years without descending into the junkie lifestyle. I suspect, but can not prove, that there are people who have a moderate heroin habit throughout their adult life without ending up in the junkie lifestyle.

So Much for Subtlety May 12, 2014 at 6:44 pm

Michael B Sullivan

I don’t think that you understand very much about how people start using drugs. To be clear: no, most people do not start out by “seeking out an experienced user” and then “finding a dealer.” And of course, it is completely ludicrous to imagine that people are seeking out the heroin junkie lifestyle.

I am sorry but did you just try to prove I am wrong by recounting your experience of seeking out experienced drug users and dealers?

It is not remotely ludicrous to think people are seeking out the junkie lifestyle. I could introduce you to half a dozen nice middle class people who did just that. People aren’t idiots. They know the consequences of using.

To draw from my own experiences (not with heroin): I went to some parties. People at the parties were doing drugs — not just marijuana, but MDMA, ketamine, LSD, mushrooms, and, yes, cocaine and heroin. People (not dealers) offered the drugs, either for free because they were friends, or at the cost they bought them for (for the more expensive drugs). The party provides a relatively safe place to experiment with drugs: lots of people there who are experienced with drugs and can help provide any paraphernalia needed and any minding needed.

So you sought out a cool venue full of drug users, nice experienced drug users with drugs they were willing to share, and you sought to use drugs. How is this anything other than exactly what I said?

And indeed there is social pressure to take the drugs.

Although someone who chooses to hang out with the cool kids has made half the choice already. You chose to go to that sort of party. You sought out experienced drug users. You chose to use.

And some people (like me) do indeed partake from the drugs at the party and then do not get an active drug habit.

As I said, you have to use, devoutly, for months before you can get any sort of decent habit. I am sitting here wondering what it is precisely that offended you so much you felt a need to disagree and recount your experience of doing exactly what I said?

People understand that the junkie lifestyle exists, of course: but they see that not everyone who does drugs is presently in the junkie lifestyle, and they believe — possibly unrealistically — that they will be able to enjoy the benefits without the costs.

Or they have seen Sid and Nancy and think, like, the Velvet Underground was totally cool. People are not idiots. They may know one or two people who aren’t so bad right now, but the number of people they know who are very bad indeed – from experience and the media – is vastly greater. No one, not one single dairy farmer’s daughter fresh off the bus, is so stupid to think otherwise.

Michael B Sullivan May 12, 2014 at 6:56 pm

So Much for Subtlety:

I am sorry but did you just try to prove I am wrong by recounting your experience of seeking out experienced drug users and dealers?

Nope! I proved you were wrong by recounting my experience of going to parties.

Words have meanings, and “encountering” experienced drug users is not the same as “seeking out” experienced drug users (and, indeed, “knowing that you are likely to encounter” experienced drug users is STILL not the same as seeking them out). Similarly, knowing about the junkie lifestyle and thinking (perhaps wrongly) that you are not at risk of falling into it is not the same as being “appealed to” by the junkie lifestyle.

Incidentally, it’s also rather ridiculous for you to ingenuously suggest that when andrew’ said, “junkie lifestyle,” you thought he meant, “Rockstar parties,” rather than “living in your own shit in a tiny squat, not eating for days at a time.”

Michael B Sullivan May 12, 2014 at 7:05 pm

Oh, and since you seem to have some kind of crazy, 80′s-esque idea of what’s going on here: of course I “chose to use.” And, more so, I chose not to use drugs, like heroin, that I thought had risks that were not commensurate with the rewards they offered. And indeed, in retrospect, I do not regret my decisions — drugs can be a lot of fun, man.

Nobody is arguing here that people were dragged, volitionless, into drug use. But somewhere between “people made some decisions” and your bizarre inhuman idea of some dude saying, “I find the idea of starving friendless and alone in a crack-house somewhere, so now I think I will tactically seek out an entree into the drug culture which will satisfy my desire for a decade-long suicide,” there exists a gulf of excluded middle.

LJM May 13, 2014 at 1:01 am

Not only does every drug user not get addicted to drugs, but the majority of all drug users – heroin, meth, cocaine, you name it – are not addicted and use responsibly.

So, indeed, the idea that everyone knows that using will lead to addiction, or that people don’t use drugs because they feel good, is utterly baseless.

Tracy W May 12, 2014 at 8:23 am

Out of curiosity, why do you assume that? I don’t believe the 100 million figure but this assumption of yours seems bizarre.

dead serious May 12, 2014 at 8:43 am

As a sufferer of cluster headaches – which are billed as about the most painful condition known – I can tell you that no amount of exercise, dietary change, lifestyle change, workload reduction, etc. will improve the situation.

The only thing that works for me is a prescription med that is intended for lowering blood pressure. So perhaps the answer to certain types of pain is medication, but not necessarily pain medication.

Doug May 12, 2014 at 5:13 am

It’s simply inconceivable why low-grade opiods, like codeine, are not available over-the-counter. To begin with most non-narcotic painkillers are actually worse for your health when taken on a regular basis at high doses. To further the point, much fewer than 1% of people in hospitals taking strong and high doses of narcotics to clinically treat physical pain end up addicted. Finally most risk of recreational overdose (which is already very low for codeine) could be eliminated by making narcotic antagonists widely available.

Opiods are incredibly safe, well-studied and highly effective at treating pain. They should be handed out like candy. A change in drug policy would only potentially negatively affect a very small subset of people with high propensity to addiction and/or underlying mental or emotional problems. Even then almost all of this sub-class is probably already self-medicating with much more dangerous black market opiods or much less healthy but widely available hard alcohol.

While we’re on the subject of insane US drug policy, doctors should be free to prescribe and administer heroin as they are in civilized countries like Hong Kong or the UK. Heroin is a superior IV narcotic to morphine, particularly for cancer patients suffering from nausea.

Rahul May 12, 2014 at 5:38 am

There’s a strong case for liberalizing opioid prescribing but I’m not sure “handing them out like candy” is the right strategy. For one tolerance develops & unless you are in an end-of-life situation that’s important to avoid.

Doug May 12, 2014 at 6:08 am

Why is tolerance an issue to avoid? Literally the only negative health consequence of opioid tolerance is constipation. This is in contrast to alcohol or benzo tolerance where the threshold of lethal dose does not increase with tolerance. But all opioid tolerance does is change the number on the bottle. Someone with a 4x tolerance taking 40 mg of hydrocodone experiences the same physiological effect as a non-tolerant taking 10 mg.

If you’re referring to withdrawal that’s a related but separate issue. Someone can experience withdrawal but still have relatively low tolerance, and someone can have very high tolerance but few to no withdrawal symptoms. Regardless withdrawal is not the same as addiction. Most people who take opiates for chronic pain would experience withdrawal at sudden discontinuation, but very few exhibit any classical signs of addiction. Withdrawal for the non-addict can easily be managed by gradually decreasing the dose if desired (whereas for the addict this is an issue, because compulsion to take more presents a self-discipline challenge when tapering).

Overall it’s easy to conclude that a marginal increase in cultural acceptance of opiate tolerance would almost assuredly produce net positive utility.

Chris DeLa May 12, 2014 at 11:46 am

I take it you are not a physican. As a doctor working at the VA and at a university hospital, I assure you that opioids are not benign.

“Literally the only negative health consequence of opioid tolerance is constipation.”
This is literally not true. I suggest reading an introductory textbook on medical physiology, followed by the research journals Pain Medicine and Journal of Pain and Symptom Management.

“Withdrawal for the non-addict can easily be managed by gradually decreasing the dose if desired ”
Again, false. Withdrawal is often a nightmare, whether they are taking their narcotics po or iv. Plenty of suburban college educated soccer moms get admitted to my hospital (or the er) for withdrawal, precisely because withdrawal is often so miserable.

“Overall it’s easy to conclude that a marginal increase in cultural acceptance of opiate tolerance would almost assuredly produce net positive utility.”
Easy to conclude if one is a sociology professor college sophomore. Why do you think the leading American professional societies don’t advocate liberal use of narcotics for chronic pain?

errorr May 12, 2014 at 12:11 pm

The word you are looking for is dependence. On of the problems is that ‘addiction’ is used in regular parlance to describe 2 separate phenomenon. As a term of art o believe dependence is the physiological condition where cessation can cause withdrawal. Addiction is the (mostly) physiological disfunction of the brain that drives people to take drugs in spite of consequences.

The problem is that many drugs can cause or create both addiction and dependence. Alcohol, heroine, marijuana (for most but not all), create both problems although heoine withdrawal is miserable but not harmful while alcohol withdrawal is deadly. Dependence seems to come from the bodies reaction to the persistent presence of a certain drug. The body adapts to the drug and alters the natural level of certain products created in vivo. There are many drugs that cause withdrawal but are not addictive like caffeine or many antidepressants.

There is a conceptual issue here in that addiction could be thought of as a dependence based physiological change of a very specific part of the brain where reward seeking behavior is influenced. Of course only a limited number of people have the genetic makeup necessary to be susceptible to addiction while everyone will experience some type of dependence.

The problem is that the US fear of opiate abuse seems driven more by fear of addiction rather than withdrawal avoidance which can be controlled by slow tapering of any medication. This is shown in the studies where the race of the patient affects how likely a doctor is to prescribe opiates. Of course this racial perception is ridiculous and based on social perceptions based on race which we usually just describe as racism.

Urso May 12, 2014 at 11:26 am

“Handing them out like candy” is an interesting phrase; I would predict that in the US we’d see candy kept behind the counter cigarette-style – “must be 16 or over to purchase Hershey’s Bar” – before we’d see opiates sold without a prescription. (Note that is a relative prediction, not an absolute one; I have used the subjunctive with care).

Matt Flipago May 12, 2014 at 2:30 pm

At it’s most liberal I could see maybe they have a system where people buy opiates like pseudophedrine, behind the counter, highly monitored, without a prescription, though that’s a incredibly unlikely.

Have no clue why anyone would think that opiates should be handed out like candy. Clearly shows that the person has no ability to see a downside to a certain thing they support.

Jan May 12, 2014 at 6:41 am

No, Rx opioids aren’t incredibly safe, they kill about 16,000 people per year, and rising. The problem with opioid painkillers is chronic use, not a one-week dosing in hospital or after surgery. Also problematic is that they actually _are_ handed out like candy, mostly to responsible people, and then left sitting in med cabinets across the country to be found by likely abusers.

Black market opioids are actually almost all Rx opioids that make it onto the market b/c docs are so willing to prescribe them (also because people are happy to deceive well-meaning physicians). The majority of new heroin abusers (I think it was about 85% most recently) move to that drug only after abusing Rx opioids. Vicodin is the gateway drug of our time.

GS May 12, 2014 at 10:00 am

Do you by any chance have a citation for this 1% number? I don’t mean to be accusatory, just curious.

Al May 12, 2014 at 11:14 am

I’ll second the idea that RX opioids are _not_ incredibly safe, based on the words of one regional head of Pharmacy from Kaiser medicine I have spoken with, and also based on personal observations of their effects on people around me.

Here’s a Wikipedia excerpt, for what it’s worth: “Prescription opioid overdose was responsible for more deaths in the United States from 1999-2008 than heroin and cocaine overdose combined”
http://en.wikipedia.org/wiki/Opioid_overdose

One of the problems with opioids is the tendency for the patient to increase their own dosage to a level beyond that specified by their medical doctor. This problem is significant enough to warrant the creation of devices like these:
http://www.amazon.com/Automatic-Medication-Dispenser-dispenser-Shipping/dp/B001LNYFDS
http://www.amazon.com/Automatic-Dispenser-pill-MedSmart-institutional/dp/B001PZ33LC

In some prescription opioid users, there’s a tendency to permanently shift conscious focus away from absolutely anything else in life to the source and timing of their next medication dose.

Opioid pain relievers are great and have a lot of positive benefits, but, er, they’re not ALL positive. There are some important risks and downsides.

Chris S May 12, 2014 at 12:34 pm


In some prescription opioid users, there’s a tendency to permanently shift conscious focus away from absolutely anything else in life to the source and timing of their next medication dose.

I think the relevant thought experiment is: IF opiates were readily available in sufficient quantity, such that the source and timing of the next dose were never in doubt, what would be the remaining negative consequences?

Al May 12, 2014 at 1:25 pm

I guess sufficient time has elapsed. What is the result of your thought experiment?

Tracy W May 13, 2014 at 4:02 am

When I was 11 I was in severe pain from an infection in my heel bone that had been originally misdiagnosed as a growing pain. At the time doctors were very reluctant to prescribe strong painkillers, particularly to a child, so the only treatment I had was paracetamol. I was extremely fixated on the timing of my next dose. Once I was finally successfully treated and the pain slowly went away I lost interest.

Tracy W May 12, 2014 at 5:55 am

Like others, I find the 100 million figure in the US alone unbelievable.

Doug May 12, 2014 at 6:10 am

50 million people alone have arthritis. 100 million in chronic pain is quite believable.

http://www.arthritis.org/files/images/newsroom/Arthritis_Prevalence_Fact_Sheet_5-31-11.pdf

Tracy W May 12, 2014 at 8:30 am

I don’t find 50 million people having arthritis believable either. Maybe 1 in 5 will develop arthritis during their/our lives. And yes I do know people with arthritis. Just nowhere near 1 in 5 of the people I know.

dead serious May 12, 2014 at 9:52 am

There are 50 million people in the US over the age of 65. Certainly not all of them have arthritis but I’d bet many do. Plus there are certainly people under 65 who suffer from it. It may be off but not by orders of magnitude.

Tracy W May 12, 2014 at 10:22 am

According to the US census bureau there’s about 42 million people over 65. It’s the figure I checked before stating my skepticism.

Matt Flipago May 12, 2014 at 2:40 pm

Maybe 1 in 5 will develop arthritis during their/our lives – See more at: http://marginalrevolution.com/marginalrevolution/2014/05/a-nation-in-pain.html#comment-158203046

Since arthritis is mostly found in elderly 1 in 5 developing it at some point would be like 1 in 25 in total.

Anyway here’s the paper they are probably citing.

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6244a1.htm

Unless there is a reason for people to lie about a doctor telling them they have arthritis during a survey, I can’t think of reason why this would be far off.

Bruce Cleaver May 12, 2014 at 6:32 am

In the 1980s I dated a nurse (in Chattanooga, TN) who worked at the NICU of the local children’s hospital. She reported at least one case of a physician believing the preemies did not feel pain, and was aghast at how such a thing was possible.

Jan May 12, 2014 at 6:44 am

Ugh. That’s terrible. They certainly experience withdrawals after they are born to mothers addicted to opioids, a huge a growing problem.

Jan May 12, 2014 at 6:34 am

100 million is fairly ridiculous on its face, though one if you define chronic pain loosely enough you can get there. Some people have legitimate need for opioid pain medications, but Americans take more narcotics per capita than any country in the world. In 2010, enough prescription painkillers were prescribed to medicate every U.S. adult around-the-clock for one month. The problem is not enough drugs — it’s poorly targeted use of them.

Tracy W May 12, 2014 at 8:31 am

I find your statistic here also deeply unbelievable.

Jan May 12, 2014 at 8:36 am

“Deeply unbelievable,” but true: http://www.cdc.gov/vitalsigns/painkilleroverdoses/

Vicodin is the #1 prescribed drug in the US.

Tracy W May 12, 2014 at 10:27 am

Okay you’ve definitely upped my assessment of its reliability. Touche.

prior_approval May 12, 2014 at 3:48 pm

This statistic from that link is damning – ‘The quantity of prescription painkillers sold to pharmacies, hospitals, and doctors’ offices was 4 times larger in 2010 than in 1999.’

Al May 12, 2014 at 11:20 am

Interesting stuff. I’m definitely _not_ disagreeing with you. A footnote to this is that Vicodin is especially dangerous to the liver when used excessively because it contains acetaminophen.
http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=21ff13de-6633-4dd3-728e-dc21e574ea7b

Chris S May 12, 2014 at 12:35 pm

The only reason it has acetaminophen is to try to dissuade people from taking too much, as it will kill their liver. Might as well be arsenic.

albatross May 12, 2014 at 1:27 pm

Is this true? I thought there was also some benefit for pain management to combining the tylenol with the codeine.

Jan May 12, 2014 at 2:24 pm

I actually think both are true.

There are fewer regulatory burdens for hydrocodone combination products compared to pure opioid medications. The more relaxed regulations give manufacturers and physicians somewhat of an incentive to push Vicodin. However, DEA is now rescheduling the hydrocodone combination products to apply the same level of oversight as oxycodone receives. And FDA is trying its best to get manufacturers and prescribers to not use combo products with > 325mg of Tylenol in them: http://www.propublica.org/article/over-the-counter-pills-left-out-of-fda-acetaminophen-limits

Slocum May 12, 2014 at 6:53 am

This classic from Michael Pollan seems potentially relevant to the discussion:

http://michaelpollan.com/articles-archive/opium-made-easy/

Axa May 12, 2014 at 9:02 am

Anyone saying the 100 million statistic is not true because you and your friends are OK, please tell your age. Age bias?

Tracy W May 12, 2014 at 10:37 am

Anyone believing any statistic is true no matter how much it contradicts your day-to-day experience, do go and read “How to lie with statistics” by Darrell Huff.

Tracy W May 12, 2014 at 10:49 am

Not to mention all the problems with just collecting data in the first place. Always ask yourself what would happen if the people collecting this data were getting it completely wrong? Who would naturally notice and what would their incentives be?

prior_approval May 12, 2014 at 3:44 pm

See below for the simple number based response to vetr, but I’m over 50, just like Prof. Cowen.

And there is no way that in my daily life in Germany, one in every three people I meet between the age of 15 and 65 is in chronic pain, as defined in vetr’s comments. (And I don’t believe that about NoVa, but I’m more than willing to accept the explanation that NoVa is not representative of the U.S.)

But as with the idea that obesity causing much more problems in the U.S. than expected in the 1970s, I’m equally willing to entertain the theory that America’s health care system is directly responsible for amounts of human suffering unknown in countries with essentially universal health care systems.

careless May 14, 2014 at 8:45 pm

You really can’t do anything worse to the reputation of George Mason than just being yourself.

Asher May 12, 2014 at 9:20 am

Instead of handing out opiates like candy, perhaps we should regulate candy like opiates? I imagine there is some lobby out there trying to convince us that a third of American are victims of sugar consumption.

NPW May 12, 2014 at 9:58 am

Yeah. I’ve heard more than one of the “Mother Jones is as good as peer reviewed medical studies” crowd say that sugar is the source of all evil.

http://www.forbes.com/sites/jacobsullum/2013/10/16/research-shows-cocaine-and-heroin-are-less-addictive-than-oreos/

http://www.nydailynews.com/life-style/health/white-poison-danger-sugar-beat-article-1.1605232

Jason B May 12, 2014 at 9:28 am

100 million is quite clearly a first world problem.

Anyone telling me that 1 in 3 people around them is suffering under such chronic physical pain that they must have easy access to opiods on a daily basis to live a humane life is clearly living in the first world and has not ever experienced true pain and suffering. I love a good narcotic as much as the next man, but we really need to work on our definition of “chronic pain”. Also, if, in the unlikely event, that statistic is true, handing out opiods like candy is certainly *not* the solution. Clearly there is a public health crisis, most likely driven by the current demon of our time (obesisty), which I believe is not best treated with narcotics.

In other news, I hear Soma is almost ready for prime time.

All the advantages of Christianity and alcohol; none of their defects.

vetr May 12, 2014 at 9:28 am

As I understand it “living with chronic pain” means you have had unresolved distress-causing pain for more than 3 months from a source that has a significant probability of recurring in the future (and which might be causing a low or ignorable level of pain every day in the present). (Chronic pain syndrome is another issue). Therefore someone who is 30 who has felt a few twinges of arthritis does not count. Given the thousands of health related conversations I have had with people over 40, I would guess that the five percent incidence bar is easily surpassed by each of the following four in people over 40 – (1) arthritis; (2) obesity or sports-induced joint failure; (3) BPH in men and vaginal/uterine problems in women; (4) nerve related disorders to include fibromyalgia, MS, Parkinson’s and sciatica; as well as untreated headaches, sinus and jaw disorders. The five percent incidence bar would be a good estimate for the next three – (5) lingering effects of STDs, drug abuse, and medical mistakes (6) diabetes-related pain, and pain from various genetic diseases that are not, each one, common, but taken as a group are not rare and (7) pain from problems processing food. So, doing the numbers, while the 100 million figure is certainly high (and I believe it is based on findings made by an advocacy group) it is almost certainly not an absurd figure.

prior_approval May 12, 2014 at 3:37 pm

‘it is almost certainly not an absurd figure’

Current population of the U.S. – around 320 million http://en.wikipedia.org/wiki/Demographics_of_the_United_States#Demographic_statistics

Under 14 – around 60 million

15-65 – around 200 million

Over 65 – around 40 million

Median – 36.8 years

Definition – ‘unresolved distress-causing pain for more than 3 months from a source that has a significant probability of recurring in the future’

We’ll ignore 60 million kids, while assuming that everyone over 65 is in chronic pain. Leading to the result that basically one in three of everyone you meet between the age of 15 and 65 is in chronic pain.

The number is absurd, unless one dumbs down ‘distress-causing’. But this is an American based number, so I’m confident that team USA will be able to do it.

Or else the effects of obesity/inactivity in terms of joint damage are worse than one would have predicted back in the 1970s, a theory I’m certainly willing to entertain.

B Cole May 12, 2014 at 10:49 am

Whatever, if I want to tame painkilling drugs that should be my decision and no one elses….

Chris S May 12, 2014 at 12:36 pm

Do you use a chair and a whip?

Marc May 12, 2014 at 11:04 am

Disentangling this discussion from the culture that is our “War On Drugs” is impossible. As one previous commenter linked to a piece by Jacob Sullum at Reason, I’d suggest a broad search of his writings on pain medication and all the political and regulatory implications of such drugs. Our messed up system has essentially criminalized doctors treating patients with serious chronic pain.

Bill Reeves May 12, 2014 at 11:22 am

One of the moral issues that this thread illustrates (and on a libertarian leaning site no less!) is the willingness of all of us to make judgements about other people’s experiences. This many have pain , no that many do, that’s pain but I can ‘hande’ it (so by implication so can everyone else). The next step in the logical progression is to define some kinds of pain as not real and then to define treatment as ‘recreational’ and then ‘criminal’.

I’m 53 and if I’ve learned one thing is that we know far less than we think we know about ourselves much less the people around us. Yet most of us believe we have the right to impose our subjective belief about their subjective experience on them with the force of all the cruelty that the modern coercive administrative state can muster.

We are truly a cruel and arrogant species.

Tracy W May 12, 2014 at 11:37 am

Out of curiosity, what comments illustrate this? As a frequent commentator on this thread it strikes me that most of us are arguing about how plausible the statistics are. I suppose you could describe this as making judgments about other people’s experiences, but it seems very illogical to then assert that we’re defining some pains as not real.

If, it were, say, an argument about how many people are over 6 feet high, it would be highly illogical to assert therefore that the participants didn’t believe that some people were really over 6 feet.

Bret May 12, 2014 at 1:45 pm

For example, from dan1111 May 12, 2014 at 7:51 am: ‘… Especially with the over-the-top language: “Ethically, the failure to manage pain better is tantamount to torture.” No, it isn’t. That is absurd.’

Looks like a subjective belief to me.

Of course, believing that it is torture is also subjective, but given a couple of back pain episodes I have had, I can tell you subjectively it’s hard for me to imagine torture being any more painful.

The Engineer May 12, 2014 at 2:03 pm

The number of OD’s is a pretty objective number. The number of prescriptions is too.

Knowing those objective facts, does it make sense that so many people are on painkillers, when by any objective measure our lives are far less rigorous than even in the recent past?

Where is this pain coming from? Not backbreaking labor, that’s for sure.

Who is ODing on prescription painkillers? Not people under a doctor’s care, presumably.

The Anti-Gnostic May 12, 2014 at 3:41 pm

We are older, fatter, and if we complain a lot, we get more pills and money.

Bret May 12, 2014 at 5:31 pm

The Engineer asked: “…does it make sense that so many people are on painkillers…?”

Does it make sense to whom?

It seems to me that each individual should the determination of whether or not it makes sense to take painkillers for themselves. It seems extremely odd to me that someone else should make that determination. “I hereby command you to bear the pain” is a remarkably strange thing to be able to decree, in my opinion. Advise maybe. Decree no.

Pain is simply not an objective thing.

Jan May 12, 2014 at 8:08 pm

A lot of the ODs are people under a doctor’s care, often times under many doctors’ care. People who become dependent often start doctor shopping to obtain multiple scrips per month unbeknownst to the physicians they are seeing.

Tracy W May 13, 2014 at 5:30 am

Aging, wealthier population with better access to better painkillers? I’ve had a general anaesthetic twice in my life, over two decades apart and the second time was much easier to recover from. While no one has GAs for day-to-day pain relief it does indicate some technical progress.

Personally after a very bad pain situation at age 11 my opinion on pain is that I’ve been there, done that, and I have no desire to prove that I can cope again.

Tracy W May 13, 2014 at 4:12 am

We all have subjective beliefs. That’s not the same as defining some kinds of pain as not real. In this particular case it’s a difference of opinion about what’s ethical – for example it’s quite common in ethics to make a distinction between actively doing something horrible and allowing that horrible thing to occur when you didn’t cause it. (Eg one can think that a doctor should refrain from murdering people but is permitted to say go on holiday even if some people will dir from the doctor’s absence. )

Dan’s comment wasn’t exactly well-argued but it’s not committing the fault you decried above.

Matthew May 12, 2014 at 11:49 am

Pain medications of any kind carry serious risks, especially when used regularly. I don’t think any doctor would find the notion that 1 in 3 americans should be on chronic painkillers to be remotely defensible. That’s way past the MC=MB point.

Donald Pretari May 12, 2014 at 12:20 pm

Excellent recommendation. I don’t normally express anger in my comments, but the irrational pain policy in this country itself pains me, literally. This issue is so important to me that I’ve considered leaving this country. Donations accepted, but probably taxed.

Mesa May 12, 2014 at 12:46 pm

This is as preposterous as the current figures of “rape” on campus making the rounds.

Chakolate May 12, 2014 at 1:29 pm

I was one of those babies who underwent surgery without anesthetic. At six weeks, I’d lost weight, and a new procedure was available to open up a valve in the stomach. My parents weren’t told about the problem of anesthesia, and when I told my dad, he was horrified.

I have wondered from time to time if it changed me in any substantial way. I differ from my siblings in some important respects. I’ll probably never know.

Rahul May 12, 2014 at 1:57 pm

Differ in good ways or bad?

The Engineer May 12, 2014 at 2:04 pm

“Some day you will ache like I ache”

carlospln May 12, 2014 at 10:35 pm

@ Jan @ 8:08 pm “A lot of the ODs are people under a doctor’s care, often times under many doctors’ care. People who become dependent often start doctor shopping to obtain multiple scrips per month unbeknownst to the physicians they are seeing” (snip)

That’s not ‘care’.

Ask Michael Jackson.

Jan May 14, 2014 at 5:21 pm

But if the patient is doctor shopping and the docs don’t know about the other prescriptions, who is to blame?

Floccina May 15, 2014 at 10:04 pm

Worrying about pain in preemies is getting close to worrying about aborted babies.

Chiropractor Exeter May 16, 2014 at 3:51 am

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