On Opiates:

(There’s a twitter thread, this was my response. If you want to see the post that started it, it’s in this link.)

Yeah, no, to this whole tweet about Tylenol, CBD and ibuprofen. This is a lot of bad information packed into 280 characters.

Tylenol is less effective than placebo in multiple tests. See the Cochrane review on its effectiveness.

CBS Article


Cochrane Review

Ibuprofen is off limits for anyone with an aspirin sensitivity, which is common with asthma, so around 6% of the general population, and 20% of the population with asthma. Aspirin & Asthma

Here’s the list of more than 400 drugs that you must avoid with an Aspirin sensitivity.

Just FYI: if aspirin’s out? And Tylenol is its usually ineffective liver-damaging self? Next step must be opiates. With luck, vicodin (hydrocodone) or codeine works.

CBD oil is a crapshoot, thanks to failure of regulation. 69% of samples tested showed an inaccurate concentration vs what’s on the label (26% below, 43% above), and 21% of those tested had THC.

There’s also almost no high quality evidence that CBD is anything but a placebo for pain. (3 links to NCBI)

Way to universalize a personal experience, which is really not how we do public policy, and is completely antithetical to an equity society. Not a great look.
Also, way to be ableist, specifically sanist.

Also, this 80% of the world’s supply is completely wrong, and here’s the fact check, with a LOT of links. Please spend some time with it. At best, the US once used a large fraction of an under-patent medicine with few export buyers.

A big reason the rest of the world doesn’t use our morphine derivatives and synthetics is they use dihydrocodeine instead of morphines, and low dose codeines, which are effective! Frequently OTC in other countries! And cause way less severe Opiate Use Disorders.

If USians could walk into a pharmacy and walk out with a small bottle of Tylenol 3 to treat pain (and if we had universal healthcare) we’d probably have OUD levels comparable with the UK (1%), Canada (1.5%), Japan (.5 to 1.%) and Germany (.2%).

Problem is, in the US? We’re absurdly all or nothing, with a Calvinist streak of abstinence that has screwed up our medical system for most of a century. We put codeine in the same category as carfentanyl. They’re not the same.

With pain, you have to use double-blind, controlled studies, you cannot use self-reporting, because humans are GREAT at reverting to mean and we respond incredibly well to placebos. (Plus our brains turn down pain signals the longer the pain lasts.) (See the top study in the first paragraph!)

Anything self reported on pain? That’s marketing, not science. Sorry. You cannot use self-select/self-report, because the placebo effect confounds it.
And animal studies are… iffy, at best, because they can’t describe or rate pain.

And seriously, please do yourself a favor and do not take CBD out of the United States. It’s not legal everywhere, and even in places where it is technically legal, there’s a 1 in 5 chance you’re taking THC, which isn’t legal in most places. The rest of the world DOES NOT USE CBD as their pain relief. Most of them use codeine. (If the Russians aren’t lying/didn’t plant it on her, CBD vape with an oops, undeclared percentage of THC in her CBD would be exactly how Brittney Griner got tagged.)

Historically, the US is actually at a low in the number of people with an opiate dependence. The public perception is it’s around 1 in 3 people; that’s because people are judgy bastards. In fact, it’s 1-3% of the population. (A maximum of 11.4 million of 331 million).

This 100% does not count the people who sometimes use opiates recreationally, which is fine. Drinking kills twice as many people as opiates, alcohol can kill you all by itself, and opiates get the blame every time when it’s really the combo of booze & opiates.

The best evidence we have of opiate dependence before 1917 (when it became prescription only in the US) put the dependent population somewhere between 5 and 8% of the population, with a low of .5% and a high of 15%. (They didn’t have the language of addiction.)

Considering that opiates were LITERALLY the only drug that worked for pain until 1899, the only effective drug treatment for diarrhea (including cholera & dysentery) until well into the 1940s, and the only cough medicine? 5% actually seems low.

If you actually dig into the 1990s numbers, it’s not so much over-prescribing as the largest generation in history reaching middle age after a lifetime of poorly regulated work that failed to recognize repetitive strain injuries until the end of their working life.

And the largest generation in history has been consistently reluctant to admit they’re not 19 anymore, since they were about 20. (Sorry, but it’s kind of a thing). The Boomers inherited “tough it out” from previous generations who had minimal medical treatment, few occupational protections, and short lifespans.

Seriously, no joke — the 80s & 90s had whole ad campaigns encouraging the over-use of OTC pain meds so Brawny, Strong, Sturdy adults could get back to work, which always results in worse injuries and longer rehabilitation/recuperation.

And we don’t talk about how this large generation gutted their own unions while electing politicians to cut OSHA and social services. (That was the 80s. Most of GenX wasn’t old enough to vote yet and wasn’t in any position of professional or legal power. 60% of the voting population did that to themselves.)

Also, there was a major shift in life expectancy between the late 1970s and the mid 1990s. The median life expectancy for people born in 1935 was age 60. For people born in 1950? It was 68. That’s a huge jump in 15 years. (In comparison, 1975 to 1990? 72.5 to 75.)

Medicine itself had not entirely caught up to the fact that someone born in 1945 was, at age 50 in 1995, unlikely to die at 60-65 the way someone born 20 years earlier would. There’s a major difference in how you treat palliative care if you think someone’s in their last 10 years, versus 35 years.

So capitalism ate a generation of workers’ bodies, then spat them out with torn and eroded cartilage, torn ligaments, bone deformities from standing on concrete for 30 years. Mostly soft tissue damage, which is difficult to repair. And without health insurance or adequate local care.

There’s no physical therapy that will replace destroyed joints. Sometimes there’s surgery, but if someone doesn’t have $35K for a surgery, they’re simply not having surgery. They will fill a monthly $20 prescription for pain pills and hope they live until Medicare at 65.

Most counties in the United States do not have adequate medical facilities. You can use OBGYNs as a proxy for all medical specialists; half of all US counties do not have even one. (This has not changed significantly in the past 35 years.)

If a county doesn’t have an OBGYN, they likely also don’t have an orthopedist, an orthopedic surgeon, a cardiologist, a pulmonologist, an oncologist or physical therapists. Or really any medical specialty.

If the closest specialist medical care is more than an hour’s one way transportation away, the utilization of that specialist care drops to near zero for anything that’s not cancer or cardiovascular. The barriers to access are just too high, for both urban and rural populations.

On average, most counties that were “pill hotspots” actually dispensed around 30 days’ worth of meds per year to every adult in the county, which is about right if 10% of the population requires daily pain care (cancer, occupational injuries, traumatic injuries)

Let’s do the math: If 10% of your county of 10,000 people needs chronic pain care, that 1000 people will be responsible for consuming 1.1-1.5 million pain pills per year. That’s 3 or 4 pills a day, every day of the year, because chronic pain never gives a day off.

So when you see headlines like “8 million pain pills to one small town” please go do the math. Divide by the number of years (it’s often 10-12 years), then look up the population of the county, multiply by .75 (to get adults) and divide the pills per year by the number of adults.

Normal adult use of pain meds? Is 7-14 days at 3-4 pills a day, about once a year. So 24-56 pills per adult per year? That’s just normal, baseline consumption and doesn’t account for any chronic pain condition, including cancer. This is a root canal, having a baby, a sprained ankle, a minor broken bone, an outpatient surgery. Basic, acute medical care as a result of living.

Why population per county versus the town? Because in a lot of counties in the US, the county seat is the only place with a hospital and doctors, so that small town provides medical care for everyone in the county. In many places, that town is providing for several counties. Remember, only half of counties have an OBGYN.

Under 100 pills per adult in the county? That’s about 5% of the population needing chronic pain care. Under 200 per day? That’s about 10%. These numbers that get turned into terrifying headlines? Not that extreme, actually. It’s pretty reasonable consumption for a population that has delayed its medical care.

Especially if the population is aging, and if young people are leaving. As the median age of the population increases, there will be more pain patients as a percentage of the population and less that their doctors can do for them.

Doctors in underserved areas also do not like to do nothing for their patients. If nothing can be done surgically for a patient, pain relief is the only option. Quality of life matters, and pain patients are generally on stable doses.

Over terms of YEARS, yes, an opiates/oid patient will eventually need a higher dose, especially if the underlying disorder is untreated or untreatable. Pain medication doesn’t stop deterioration.

Tolerance is a far lesser aspect than deterioration, but all medicines do come with eventual tolerance and the need for a higher dosage. That’s biochemistry, not bad character.

Crime rates in the “hotspots” actually fell dramatically over the course of the prescription epidemic, and declined most years, but police agencies always want more funding. County officers have been caught on the record lying about crime in their jurisdiction.

Afghanistan’s cash crop has been opium for the last century, no matter what the Taliban ever said. If you think of the Taliban as a drug cartel with the ability to plausibly lie to your face, they make more sense.

Opium has always been cheaper and more available when Afghanistan is in conflict, for a lot of reasons outside of the scope of this thread. Every time Europe & North America have had a flood of cheap opium, it’s related to conflict in Afghanistan.

That is, until about 2015, when it became clear to illicit manufacturers that fentanyl is very cheap to produce at high purity, which makes it far more convenient to smuggle, and safer for all levels of dealers to conceal and transport.

The purest, most compact version of an illicit substance will always be the one that wins the black market, even if it is an inferior product. (Which fentanyl is; it’s a bad, short high & much easier to OD than proper opiates.)

(Aside: there’s some minor, mostly anecdotal evidence that wide-spectrum opiates are a generally safer version than the fractionated & purified versions (morphine & heroin being more addictive than opium paste or laudanum). It should definitely be examined.)

Young people are almost NEVER the recipients of prescription pain meds. Consistently since the 1990s, people under 25 have received between 1-2% of all prescription opiates, usually short courses for surgery, traumatic injuries, post-childbirth, or cancer. (The CDC data tables — sorry, they’re hard to find. I downloaded a big set of them a couple years ago. Will update when I manage to source the damn things again. I have Apple Numbers files, but they’re just data tables.)

Consistently since the 1990s, people over 50 have consumed the vast majority of opiate/oid prescriptions. Which is logical. Older people have accumulated more damage, and are more likely to fall ill because of it.

We also have an issue with data collection. Most county coroners are NOT medical professionals. (They’re often undertakers, but not always.) They’re an elected position, and most states only require them to be 18, a citizen, a registered voter, and not a felon. Most want a high school diploma. Statisticians, they are not. And because of that, they produce remarkably inconsistent death certificate data. The CDC has no way of creating or enforcing death certificate data standards. And even in places with a medical examiner system, their standards vary between jurisdictions. We have very poor consistency in accurately reporting causes of death. This means the data the CDC has used to track overdose deaths is fundamentally flawed and inaccurate.

Most overdose deaths occur when either the user has been in jail/rehab/recovery and their tolerance has dropped but they use their old dose (the Philip Seymour Hoffman model of overdose), or when they have mixed substances, especially with alcohol (the Heath Ledger model of overdose).

The CDC and most county coroners do not accurately report multi-substance overdoses. They don’t do sufficient testing (it’s expensive) to determine what combinations or dosages were deadly. If there’s a needle present, they blame the opiates, and don’t pay attention to the bottle of vodka nearby.

When a person mixes two or more central nervous system depressants, they potentiate each other. What should be a safe, even low dose easily becomes lethal when combined with another CNS depressant. Alcohol is the most common CNS depressant; anxiety meds (benzos) are second.

Worse, until recently, the CDC has double and triple counted some overdose deaths when two or more substances WERE detected. A person who died with both an amphetamine and an opiate in their system would be counted as two overdose deaths.

All of this is to say: we don’t actually have enough data to make informed decisions about opiate policy, because our demographics, our historical statistics, and our medical data are all corrupted.