The Other Opiate Problem

The Other Opiate Problem By Ted Noel, MD – March 2019

Dr. Noel shows us again that overprescribing isn’t the problem – it’s an “overdose crisis” from street drugs, often contaminated with deadly illicit fentanyl.

On February 24, 60 Minutes did a segment …  calling out drug companies for “corrupt,” “immoral,” and “depraved” actions in marketing opioids.

David Kessler, former Commissioner of the FDA said, “There are no studies on the safety or efficacy of opioids for long-term use.”

Case closed! We need to restrict opioids to two or three days at most. Anything longer than that is bad medicine and gets people killed. But…    

First, opioids have been used for millennia. Chinese workers on the transcontinental railroad used opium on a weekly basis for years, without any notable adverse effects.

American soldiers used them in Vietnam, and their performance in the field was not affected.

Overdoses were unusual, since the usual heroin had well known potency. With 20% of the Army on drugs, you’d think that bad effects would be easy to find. Curiously, there was no evidence of mass addiction, either.

This is worth mentioning because it’s conveniently forgotten by all the anti-opioid crusaders. So few of the soldiers that became heroin users during their deployments continued their use at home.

Using heroin (an opioid) was a temporary method to deal with the atrocity of the situation they were thrown into. As soon as they came home and were removed from that situation, their opioid use stopped.

Second, while there may be no studies on extended use, those of us in medicine are painfully aware that while some patients do well without opioids, others require what Dr. Kessler would call “extended” use.

This is a result of the Bell curve, or “normal distribution” of response to drug.

The person whose knee replacement requires zero opioids is on the left side of this curve, while the one who needs them for two weeks is on the right. Most of us fall somewhere in the middle.

Every surgeon and every anesthesiologist lives with this curve every day. Importantly, the difference between the left and right sides of the curve isn’t two or three pain pills. The range is from zero to a hundred or more. And that leads to a key piece of information that 60 Minutes completely ignored.

The long-term benefits of opioids have been well known for a very long time. The long-term side effects are equally well known.

But the key side effect that is creating the panic does not come from long-term medical use.

You heard me right. In spite of all the noise about “overprescribing,” that simply is not a problem.

• Less than 1% of the addicts on the street got their start with prescription opioids.
• And chronic pain patients rarely die of overdoses.

These days, pain patients aren’t dying from opioids but dying from suicide when opioid pain relief is discontinued.

With the “morphine pump,” a patient was able to give himself lots of little doses of an opioid to help with pain after surgery.

The PCA  (patient controlled anesthesia) was rigged to prevent a repeat dose until 6 minutes after the previous dose, giving it time to work. We never saw overdoses with PCA if the patient was the only person to push the button. Never. As in “not once.”

In fact, patients automatically weaned themselves off opioids. This was so safe that now the Acute Pain Service no longer exists in most hospitals.

The same thing happens when patients have pain pills at home after surgery. They taper off without thinking about it as the pain level subside.

The first thing to note is that all opioids are, in a sense, the same drug. They all work at the same receptor, and they all have the same family of side effects.

The primary differences revolve around

• how fast they start working (onset),
• how long they last (duration), and
• how much is required to reach a standard level of effect (potency).

Of importance, the more potent a drug is, the more it binds only to the intended receptor, and the fewer side effects it will have (for example, nausea). That means that fentanyl is safer during surgery than morphine and explains why we rarely use morphine in surgery today.

The next factor is that all the opioids are dirt cheap to manufacture.

Even the Drug Enforcement Agency has noted that prohibition creates massive profits for bad guys.

That should raise alarms. If prohibition starts this vicious cycle, and a national experiment with decriminalization (Portugal) has basically eliminated ODs, shouldn’t we start looking in that direction?

In maintenance programs, known-potency drugs are given to patients with extreme safety. And over time, Portugal has seen that about half of addicts will wean themselves off their drugs. And over time, Portugal has seen that about half of addicts will wean themselves off their drugs.

And over time, Portugal has seen that about half of addicts will wean themselves off their drugs.

60 Minutes is complicit in the fear-mongering that is killing large numbers of Americans through poorly considered laws. The only way to eliminate the overdoses is to eliminate the laws. That will bankrupt the drug cartels. 

We will likely be seeing more and more examples of Einstein’s Maxim:

“Insanity is when you do something over and over and expect a different answer.”

Author: Ted Noel, MD is a retired anesthesiologist. He comments on political issues in the Vidzette podcast at vidzette.libsyn.com.