The Law Of Unintended Opiates

You’ve likely heard of the Law of Unintended Consequences, which states that every human activity has consequences unforeseen and unintended by those participating in the activity.

I got to thinking about this after talking to my doctor about the opioid epidemic in the US. I remarked that I and other folks have no idea how the opioid epidemic started. So he laid it all out for me … and it turned out to be something that I’d never heard of.opioid epidemic i

Now, my doc is an amazing guy, wicked-smart and endlessly compassionate. In Japan, they have people who are designated as “Living National Treasures” … and if he lived in Japan, my doc would have that title. Here’s what he told me.

He said the epidemic was started with what is generally acknowledged to be the finest paving material for the road to the place of perpetual perdition … that old standby, “good intentions”. The Government decided that doctors weren’t taking their patients’ pain seriously enough, especially poor patients. So they decided to change that by regulation … hey, when you have a hammer, everything looks like a nail. They decided on the following guidelines for their new regulations:

  • Make pain “visible.”
  • Give practitioners “bedside” tools for change to guide physicians and nurses to initiate and modify analgesic treatments.
  • Assure patients a place in the “communications loop.”
  • Increase clinician accountability by developing “quality assurance guidelines,” improving care systems, and assessing patient satisfaction.
  • Facilitate innovation and exchange of ideas.
  • Work with narcotics control authorities to encourage therapeutic opiate use.

Gosh, that sounds wonderful. It’s got the good feelz, it has the proper buzz words, it wants to “facilitate the exchange of ideas”, it encourages “therapeutic” opiate use … what could possibly go wrong with that?

In the event, California was the first state to go nuts on the question, no surprise there. In 1999 there was a new addition to the California Health and Safety Code stating:

Every health facility licensed pursuant to this chapter shall, as a condition of licensure, include pain as an item to be assessed at the same time as vital signs are taken. The pain assessment shall be noted in the patient’s chart in a manner consistent with other vital signs.

And in 2000, the US Congress passed a similar bill, establishing the “Decade of Pain Control and Research”.

The problem, according to my doc, was that because this had become part of the law, doctors were being strongly pressured by the Government to prescribe more pain pills … so they did. In fact, the Government began to assess each hospital based on whether or not they were prescribing what the Government thinks is an adequate amount of opiates … and if they are not prescribing enough opiates, they can lose their accreditation.

Among other things, a numeric pain scale became mandatory in the post-anesthesia care unit, and before the patient can be discharged, they have to have an “acceptable” pain score or … they get more opiates.

Yeah, that’s the ticket … force the doctors to hand out happy pills before they are allowed to let their patients out the door …

Again I have to ask … what could possibly go wrong with forcing hospitals and doctors to prescribe more opiates?

Well, what could go wrong is that the average opiate consumption per patient went up by 15% in the first two years after the new standards came into existence, from 2000 to 2002 … I’ll quote from a very good history of the new pain standards:

Pain had become the enemy that needed to be eradicated.

Many organizations implemented treatment policies and algorithms based on patients’ responses to numerical pain scales. One study reported that the incidence of opioid oversedation increased from 11.0 to 24.5 per 100,000 inpatient days after the hospital implemented a numerical pain treatment algorithm. Soon after this, the Institute for Safe Medication Practices (ISMP) linked overaggressive pain management to an alarming increase in oversedation and fatal respiratory depression events.

Seeing this, the authors of the various regulations started cutting back on the recommendations. From the site linked to above:

The 2001 Example of Implementation that said “Pain is considered a ‘fifth’ vital sign in the hospital’s care of patients” was changed in 2002 to say “Pain used to be considered the fifth vital sign.” By 2004, this phrase no longer appeared in the Accreditation Standards manual, although the phrase remained in some Joint Commission educational materials for several years after that. All Examples of Implementation were completely eliminated a few years later.

However, this attempt to fix things ran headfirst into the First Law of Worm Cans, which states:

If you open a can of worms, to get them all back in you’re gonna need a bigger can.

Unfortunately, to date we haven’t found the bigger can. The hospitals are still bound to pay too much attention to peoples’ pain, and not enough attention to their addictability. The demons have been loosed, and now, the opioid crisis is far beyond the ability of doctors and hospitals to deal with it. Here’s a profile of the typical 2017 opioid addict:

opiod epidemic ii

And as you might imagine, my doc is not happy about any of this. He feels, and with good reason, that doctors and hospitals are the ones getting screwed in the deal. His point is that politicians oughta keep their dang bureaucracy out of medical decisions, and let the doctors manage the pain as they best see fit … but NOOOO, the Nanny State was unable to keep their hands off.

Now, of course, the politicians are blaming everyone for the problem, saying it’s the fault of the greedy manufacturers, and of the overprescribing doctors, and of the weak-willed addicts, and of the money-driven pill-mills, and of the careless pharmacies, and lots more. Somehow, it’s the fault of … well … anyone at all except for the politicians who actually created the problem.

Ah, well, success has many parents, but failure is an orphan …

Best to all, and my compassion to all addicts everywhere,

w.

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27 thoughts on “The Law Of Unintended Opiates

  1. Excellent analysis. I’m in the UK and generally speaking what happens in the States makes it over here in due course. One can only hope that this becomes a ‘fail’. Brutal test-bed mind you.

    Liked by 1 person

  2. The Eighteenths Amendment (the Prohibition) [1920] was finally repealed in 1933. By then the organized crime was firmly established. Was alcohol really a huge problem? Are drugs really a huge problem? Does Coca-Cola really contain Coca or Cola?

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  3. We know that the nanny state is the source of most (if not all) misfortunes falling onto the unaware citizen. Wake up, fellers, run to the hills and stay there. 🙂

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  4. You sure brought some things to light.. five years ago I had shoulder surgery, I was given a bottle of OxyContin and told to take them regularly BEFORE the nerve block wore off and keep taking them. Well two days in.. I wanted off so I stopped. Then three years ago I had open heart surgery and everytime the nurse came in to check the vitals I got asked my pain number, and bingo a shot of morphine.. after two days again I said no mas.. I’d rather have the pain then what always followed.. big time constipation…. but I have always wondered why they were so insistent on giving me the narcotics.. and I also see now they are advertising a drug that will alleviate opiate constipation… isn’t that special .. the one thing that makes the stuff undesirable is now removed..

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  5. I disagree. As a patient, I want to know that I will be free of unnecessary pain. The medical authorities are cracking down on codiene, which means that one of the most effective form of pain relief won’t be available in Australia in the new year. Yes, there are other, less effective pain medicines, but they interact with other important medicines, such as blood pressure controls.

    It obviously doesn’t affect the well paid public servants and doctors that make these rules, but some people have trouble paying $80 for a doctor’s appointment on top of $38 for a prescription for codeine.

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    • hivemind November 20, 2017 at 7:18 pm

      I disagree. As a patient, I want to know that I will be free of unnecessary pain. …

      Great. You disagree … but you disagree WITH WHAT? With the story as I’ve laid it out? With my liking for my doc? With the claim that success has many parents but failure is an orphan? With the idea that the government should take a less aggressive attitude and let the doctors decide? I laid out dozens of statements and ideas above. Are you disagreeing with one of them? Or are you disagreeing with the commenter just above you?

      In these situations, I refuse to guess what your meaning might be. That’s a mug’s game.

      To repeat what’s just above the text entry box, please QUOTE THE EXACT WORDS YOU ARE DISCUSSING so we can all be clear on your subject.

      Thanks,

      w.

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    • @hivemind

      No, as a patient, you are now denied opiates, or forced to go to the doctor every few weeks to get the prescription renewed If you forget them when you are traveling, you now get them dispensed one pill per pharmacy visit. And if you manage to loose a partial bottle, you just have to live with the pain until your next scheduled refill, they won’t let you have any more (as a patient, you are assumed to be a addict, just trying to get your fix, until and unless you can somehow prove different)

      That’s assuming that there is anyone in your area who is allowed to prescribe opiates any longer.

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  6. “If you open a can of worms, to get them all back in you’re gonna need a bigger can.”

    I like that. Sadly, it’s too optimistic. Nobody will ever get them back into anything. We can only wish that nuclear weapons had never been invented, just to mention one other example.

    “Ah, well, success has many parents, but failure is an orphan …”

    Nobody claims the failure, but usually everybody had a role in it. It’s never simple.

    For opioids, we started with morphine 200 years ago. Or opium even before that.

    “Endogenous opioids include endorphins, enkephalins, dynorphins, and even morphine itself. Morphine appears to mimic endorphins. Endorphins, a contraction of the term endogenous morphines, are responsible for analgesia (reducing pain), causing sleepiness, and feelings of pleasure. They can be released in response to pain, strenuous exercise, orgasm, or excitement.” (Wikipedia)

    Morphine was then “improved”, again and again, and now there is a whole range of opioids. They have the same useful effects and dangerous side effects, including addiction and increasing tolerance and withdrawal effects. Improved to be more powerful. The “bad” effect is the same as the “good”, just too much of it.

    “The opioid system controls pain, reward and addictive behaviors.”
    “Due to their effect on the part of the brain which regulates breathing, opioids in high doses can cause respiratory depression and death.”
    The OD victim “forgets” to breath and the heart slows down.

    I’ve taken a short Naloxone training course. One memorable thing from that is the warning that once you save someone’s life, they might respond by fighting you, “Hey, man, you ruined my high. I paid a lot of money for that!”

    Which brings me back to how the opioid epidemic started. Part of it is because doctors started prescribing opioids without any good plan for stopping the opioids. That’s like selling a car with a gas pedal and no brakes. As anyone who has had an addiction knows, it’s easier if you don’t start. Stopping is hard. Hotel California: you can check out but you can never leave.

    Then, after you’ve become addicted and have increasing needs, you are tempted to turn to drugs from the street. No FDA label on those, you have absolutely no idea what you are taking. On top of that, add in the new powerful cheap drugs like Fentanyl (50 to 100 times stronger than heroin) which might or might not be mixed in, and you have absolutely no idea how big a dose you are taking. It’s a wonder there are not more ODs than there are. On top of that, Fentanyl is not in a form which is easy to cut, so whoever is cutting it into your lesser opioid doesn’t have any idea of the amount in each batch either. And don’t mix opioids with alcohol either. Opioids are a can of worms for all involved.

    The CDC has guidelines for prescribing opioids.
    https://www.cdc.gov/drugoverdose/prescribing/guideline.html

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  7. I’m reminded of the saying: “Life is pain. Anyone who says different is trying to sell you something.” Seems somewhat apt. I’m also reminded of the intended use of soma from Brave New World. Either way, I feel the need to wonder if it was truly an accidental development.

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  8. “Pain makes man think; Thought makes man wise; and Wisdom makes life more endurable.” Author Schopenhauer.

    Those who choose to avoid life’s pain; ie, not cope with life’s ups and downs, turn to addiction. Numb the mind and miss the developmental milestones of growth through successful experiences; overcoming obstacles; being able to say: “Yes I can.”

    Pain messes with the mind. The drugs that treat pain also mess with the mind. Pain management requires addressing both: pain and its treatment meds. A therapeutic goal requires a provider/patient relationship. Such a partnership is predicated upon the patient possessing: self-awareness, coping skills, decision making, relationship building, conflict resolution skills, as well as a willingness to address the obstacles ahead. A tall order for someone who hides (as opioid drug promote) from life challenges as a coping mechanism.

    Chronic pain management strategy is not necessarily to eliminate all pain meds; rather, to proceed with life agendas. Nodding off is not a life skill. Life requires insight.

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    • Part of pain management needs to address how to help the patient to overcome their fear of pain. My wife manages a dental practice and there are a large number of patients that have such a fear that their visit might be painful that they are prescribed Zanax BEFORE they get to the office for their appointment.

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  9. YMMV, the guys who were going to storm ashore on Japanese beaches were very happy nuclear weapons had been invented, as am I, as I have never wanted to be an infantryman in a bigger, better re-run of WW2.
    The opioid problem seems to be another example of how government can create a non solution to a minor or non existent problem and everybody ends up worse off.

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    • “the guys who were going to storm ashore on Japanese beaches were very happy nuclear weapons had been invented.”

      No doubt. I think the inventors intended it to be used against Hitler, so maybe the use against the Japanese was unintended. Certain Japanese cities were spared from firebombing in anticipation of testing the atomic bomb on them later, so there was intention somewhere. The unintended consequences came later, when enemies started getting nuclear weapons too. MAD, mutually assured destruction, what a TLA! (nothing is assured)

      That’s the whole point of the law of unintended consequences (together with Murphy’s Law). Be careful what you wish for — it might not work out as you expected.
      https://en.m.wikipedia.org/wiki/Unintended_consequences

      The junky gets the instant gratification and discounts the future consequences. That’s easy to see. It’s not so easy in general. Nuclear weapons, activism about climate change, the push for renewable energy and the elimination of fossil fuel use, the opioid epidemic, these are not easy problems, the future is cloudy, even muddy.

      Giving out opioids to “fix” the immediate problem while not thinking of the future, or thinking “it’s not my problem”, that’s a problem.

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  10. I know many folks who suffer from chronic pain. A large proportion of them are over weight and do not exercise at all. Many that started to lose weight and exercise, also lost much of their pain over time. I am not saying there are not people who need help with pain, I am saying there are many ways to find relief beyond drugs, in particular when your lifestyle is part of the source of such.

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  11. At he VA clinics I have been asked to give a pain number from 1 to 10. My answer is “What do you consider a 10? A nail in the foot or a gunshot wound to the head?” Such a system is so subjective it is meaningless.

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  12. The costs of anti- drug hysteria are borne by everyone. Let drugs be unregulated and the costs are borne by the drug abuser. In the often brutal calculus of freedom, the irresponsible and stupid will suffer. That’s life.

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  13. “Part of pain management needs to address how to help the patient to overcome their fear of pain” (Tom in Florida)
    Too true. I recently had prostate cancer (now removed). The only accurate method of diagnosis is by biopsy, for which samples are taken by inserting a 25mm (1 inch) diameter instrument where the sun don’t shine then shooting about 20 needles from it into the prostate. I could have had the procedure under general anaesthetic but didn’t because I thought I was pretty tough. Bad decision. Worst pain I’ve ever known- probably due to psychological fear. Then after the major surgery, they kept asking what my pain level was, and I said “What pain?” A bit of discomfit but nothing to worry about. The worst was over and I was ready to get better.
    So I agree: pain is subjective and is made worse by fear.
    My advice: ask for general anaesthetic for the biopsy, and get your PSA checked regularly.

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  14. It’s not clear to me what drug the opioid overdose patients are taking that kills them. There are a number of non-pharmaceutical grade drugs on the streets. Are these drugs the actual killers? If an addict doesn’t know the true strength of the drug, it’s easy to OD. An opioid agonist can be any number of drugs. We hear in the news about overprescription, but is this true news?

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  15. Being married to a Registered Nurse (now retired) I used to hear much of this first hand. There is an element that drove the policy though, and that is the real poisonous fruit. Beginning well before anyone contemplated allowing the patients more “say” in their medications, “healthcare” systems began to be driven by marketing types. In talks to staff, administration would emphasize “customer” satisfaction to nurses and physicians (note that ‘management’ rarely included more that one medically trained member on the board, doctors look good on hospital boards, and the rest with MBAs from prestigious business schools). The major private “healthcare” systems were increasingly emphasizing profit, even the non-profits. What that really means was that fewer and fewer genuine, trained medical people were in charge of your health. And even if you interacted with them, their opinions and recommendations were being overridden by “case managers” and actuarial tables.

    The cause of this was a flurry of genuinely unhappy results as new, “miracle” technologies were offered in the hopes of keeping Great Aunt **** alive long enough to sign her will, with a bevy of howling lawyers chasing the ambulance and the main chance. These new technologies and additional insurance, as well as bidding wars for “superstar” specialist doctors, drove costs up many fold and hospitals that were “non-profit” to begin with, found themselves foundering. Business management types hove into view with “tried and true” business solutions. Reduce the staff, close the emergency room, hire better “qualified” management, get rid of unnecessary “cost centers” like LVNs, the kitchen and caffeteria (farm out the work to contractors who manage vending machines) and well – who cares about things like staff morale? This works after a fashion, but healthcare is a very specific and very tricky area. Hospitals use hazardous materials, dispose of hazards biological products you really never want to meet, breed truly frightening bugs, and generally really aren’t places where you safely take shortcuts in care or hazard management. So less staff, means extra work, or more diverse work with tricky little ‘gotchas’ if you goof even a little, quite likely executed by a less well-trained staff. Pocket disasters occur. Politicians see opportunity flashing.

    After focus groups have their say (no nurses, doctors or medically trained members thank you very much), what do the politicians come up with? Why, ways to make the patient “happier.”

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    • Thanks for a very interesting comment, JW. You see it from the inside. As to making the patient happier, it’s a meaningless quest made easy by the fact that opiates make people happy long enough to score well on the mandatory pain score …

      Regards to you and your partner,

      w.

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  16. Deadly synthetic opioids like fentanyl and carfentanil caused more overdose deaths than even heroin in 2016, but illegal use of those three drugs accounted for more than half of all fatal drug overdoses, according to data from the U.S. Centers for Disease Control and Prevention.

    Prescription painkillers like OxyContin, Vicodin, Percocet and codeine caused more than 20 percent of the 64,000 opioid deaths last year.

    Combinations of drugs, cocaine and prescription drugs that were not opioids were responsible for the rest of the deadly overdoses.

    And drug overdoses are now the major cause of all accidental deaths in the United States, more than suicide (which is also rising), car accidents, murders and shootings, according to the CDC.

    In the last 17 years, drug overdoses have claimed more than 700,000 American lives —  more than 34 years of the AIDS epidemic, and more than the combined losses of life seen during the Vietnam War, World War II or World War I.

    http://lancasteronline.com/news/local/report-compares-drug-overdoses-to-other-causes-of-death-in/article_24efaa58-dc50-11e7-869e-f39fbf46bfa2.html

    Other sites report the death rate is up 40% this year over last year, probably as a result of fentanyl and carfentanil becoming available. That and the fact that deaths have moved into suburbia show that something changed.

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