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Thread: Avoid opioids for chronic back/knee/hip pain

  1. #11
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    Quote Originally Posted by Jonathon Sullivan View Post
    Plenty of blame to go around here: policy makers, doctors, drug companies and, yes, many of the fatalities as well.
    But is there really an opioid epidemic? Different in some fundamental way from the previous meth epidemic, and before that the crack epidemic, and before that the heroin epidemic, and before that the ice epidemic, and before that the PCP epidemic (when everyone was beating up the cops), and before that the cocaine epidemic, and before that the brown heroin epidemic, and before that the freebase epidemic, and before that the Asian white heroin epidemic, ad infinitum ad nauseum. Why is there a new epidemic to enforce against and elect officials who will finally get tough on crime every five fucking years?

  2. #12
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    Quote Originally Posted by Mark Rippetoe View Post
    I keep a few hydrocodone at home for cough medication, but they have absolutely no analgesic effect on me, so I'd make a shitty addict anyway. At any rate, most physicians are lazy bastards, just trudging through the day, doing what they've been trained to do, never attempting to rethink anything, and never doing anything that could be called into question even though all of it should be called into question. You know this better than we do.
    Most physicians are caught in a lousy, broken system using a lousy, broken model of health, disease, and healing, confronted by mandates to make bricks without straw, and tasked with helping people who literally will not help themselves. You know what? It tends to flatten a body.

    But "most physicians are lazy bastards?" Here we part ways, Rip.

    Even the most ossified, arrogant, shitty doctors I know are still hardworking AF. It's just that they're spending their energy on mostly the wrong shit. That's not entirely their fault, but it IS their fault that they have not advocated for their patients and their own profession on the level of anything besides political clout and lucre. For marching themselves and their patients to their own exploitation by a truly vile system they deserve our derision. But laziness? I think not. I walked through the clinic and the ER today after Grand Rounds. I saw people running hard to stand still. My erstwhile colleagues just trying to keep their heads above water. Some really brilliant people who are being physically gutted and having their effectiveness dissipated by a system that is designed to function more like a 21st century sweatshop than a hospital.

    The profession of medicine displays the same sort of distribution of talent and fuckery as any other, with perverse incentives that sometimes keep the good ideas and necessary changes from rising to the top. It's fucked up. It's also complicated.

    And I've mostly washed my hands of it.

  3. #13
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    I was referring to the intellectual laziness reflected in most of their practices. That was me being lazy with my typing. Sorry. I understand the hours, the call, the years in school, the frustration, the swimming in a sea of fat slobs who want a pill and that's all. But I also am disappointed by most of the reports I hear from people who should have been better served by doctors who assumed that we're all the same fat slobs, and who didn't take the time to think with us when we asked them to.

  4. #14
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    Quote Originally Posted by Mark Rippetoe View Post
    But is there really an opioid epidemic? Different in some fundamental way from the previous meth epidemic, and before that the crack epidemic, and before that the heroin epidemic, and before that the ice epidemic, and before that the PCP epidemic (when everyone was beating up the cops), and before that the cocaine epidemic, and before that the brown heroin epidemic, and before that the freebase epidemic, and before that the Asian white heroin epidemic, ad infinitum ad nauseum. Why is there a new epidemic to enforce against and elect officials who will finally get tough on crime every five fucking years?
    I'm going to duck any discussion of the semantics or the politics. But yes, we are definitely seeing more deaths from prescription opioids than we used to, and we've been watching this problem unfold for a long time. What politicians and the public elect to do about that is above my paygrade, and rational discussion about public policy seems to be impossible in America in 2018 anyway. And yes, in my opinoin, physicians (including me) helped create this problem, in part because of our generally well-intentioned response to the very real issue of hypoanalgesia that became a Thing in the early 90s. Hypoanalgesia is still a problem, but as has been pointed out, use of opiates is not appropriate for chronic pain (except cancer and a few other conditions), but they are appropriate for acute pain (trauma, acute abdomen, MI, etc).

    So again, it's complicated.

    For example: my hospital is on the verge of running out of parenteral opiates. Not sure why.

  5. #15
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    Quote Originally Posted by Mark Rippetoe View Post
    I was referring to the intellectual laziness reflected in most of their practices. That was me being lazy with my typing. Sorry. I understand the hours, the call, the years in school, the frustration, the swimming in a sea of fat slobs who want a pill and that's all. But I also am disappointed by most of the reports I hear from people who should have been better served by doctors who assumed that we're all the same fat slobs, and who didn't take the time to think with us when we asked them to.
    It disappoints me, too.

    Especially when I've caught myself making the same assumptions during an understaffed 12-hour midnight shift at 6 patients/hour, including major trauma codes. Not an excuse, just a reason.

    There are ways to fix this. As with most effective solutions to complex techno-socioeconomic problems, they are palatable to exactly nobody, particularly the people who make obscene profits from healthcare without actually delivering any healthcare, and therefore they won't happen.

    Color me disillusioned. Dr. McCoy, Ben Casey, and Joe Gannon talked me into med school when I was, like, 8. It didn't turn out as advertised.

    I run a gym now.

    /whine

  6. #16
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    Don't know if there is an epidemic, but something is going on

    http://www.pnas.org/content/pnas/112/49/15078.full.pdf

    Deaton and Case have documented some disturbing trends

  7. #17
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    Rip, which analgesic is the most efficient for you?

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    Quote Originally Posted by Pluripotent View Post
    I had some other thoughts on this issue. I think the use of opioids for chronic pain, which is a bigger problem for men than for women is a sign of nihilism. Nihilism is not just a philosophical idea, not even primarily a philosophical idea. How do you know if you are a nihilist? Are you participating in self sabotage? People who engage in nihilistic behavior are essentially destroying themselves. This includes all the drug and alcohol addictions, smoking and even less obvious behavior, such as fragility from the lack of physical training. Essentially, I think people engage in nihilist behavior when they lack clear goals for the future, either because they are unable to make goals, or because they have no hope that they could ever achieve goals even if they did make them. The problem affects men and women, but currently more men, because men are being inundated with the idea that masculinity is somehow "toxic" and they are being told that their contributions are not wanted. Most of the time this is implicit rather than explicit, although it is becoming increasingly explicit. And so men retreat into activities that can only be described as slow suicide (or they just do it outright). People need to make goals. The act of making goals for the future is the best antidote for nihilism because it is its opposite. And, assuming that those goals aren't also nihilistic (such as to shoot up a high school or concert), then the goals themselves are going to be incompatible with the self destructive behavior. You cannot get to a 315 lbs squat for 3 sets of 5 and smoke or do drugs (or at least it's very unlikely and it would be much better if you didn't). Making goals forces people to decide between self destruction and self improvement. So if we could just get people to lift...
    Just... damn. New poster for when I rebuild the flooded-out gym.

  9. #19
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    Quote Originally Posted by Mark Rippetoe View Post
    But is there really an opioid epidemic? Different in some fundamental way from the previous meth epidemic, and before that the crack epidemic, and before that the heroin epidemic, and before that the ice epidemic, and before that the PCP epidemic (when everyone was beating up the cops), and before that the cocaine epidemic, and before that the brown heroin epidemic, and before that the freebase epidemic, and before that the Asian white heroin epidemic, ad infinitum ad nauseum. Why is there a new epidemic to enforce against and elect officials who will finally get tough on crime every five fucking years?
    Essentially, it's all the same problem. It also depends somewhat on the town. In residency, it was mostly heroin with some meth. Where I am now, it's mostly meth with some heroin. Results are the same, nearly 100% mortality. My residency program was in a small industrial town where the three largest employers, all car manufacturers, left about 5 years prior. Now the largest employers are the university and the hospital. I can't even tell you how many older nurses I've met who are raising their grandchildren. The 20-30 somethings are just gone. All of them. They are dead or in jail. Bottom line is more people are doing drugs than in these prior "epidemics."

  10. #20
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    Quote Originally Posted by Jonathon Sullivan View Post
    It disappoints me, too.

    Especially when I've caught myself making the same assumptions during an understaffed 12-hour midnight shift at 6 patients/hour, including major trauma codes. Not an excuse, just a reason.

    There are ways to fix this. As with most effective solutions to complex techno-socioeconomic problems, they are palatable to exactly nobody, particularly the people who make obscene profits from healthcare without actually delivering any healthcare, and therefore they won't happen.

    Color me disillusioned. Dr. McCoy, Ben Casey, and Joe Gannon talked me into med school when I was, like, 8. It didn't turn out as advertised.

    I run a gym now.

    /whine
    Interesting to read this perspective. I've come to believe that there is disillusionment in a lot of professions where the goal is to do good things. The reality is that clients/patients are flawed. Their family members are flawed. Conflicts of interest are omnipresent. And then you have greed and the fear of malpractice.

    And I'm talking about my experience working as an estate planning attorney. I'll bet it sounds familiar! The reality is that you just have to do your best to do the right thing all the time. But the right thing, when it comes to money or health or POWER/CONTROL, varies depending upon the perspective. One example I have is the vulnerabilty of the aging population of being exploited. Mostly this happens by family, second would be fellow church members (my experience), and lastly it's unemployed Sam next door who is willing to drive his elderly neighbor to the grocery store, the doctor's office, the bank, and the attorney's office. Look up asset protection and exploitation online and the internet tells you to go to your estate planning attorney to protect against it. But attorneys are generally afraid to limit their client's control over their own assets. The potential liability of drafting something that would work is huge. I did a presentation on this issue to my colleagues a few years back. None of us ever talk about it. Mine was the first to discuss it, and it was well received. But nothing has changed, really. And we have an aging population. Most people think they're safe from this sort of thing because they have a revocable trust. One colleague I talked to told me that he didn't feel comfortable telling a client that he has to protect him from himself. So, next up comes the daughter, Sally, who thinks that 86 y/o mom isn't smart enough to make her own decisions. And she's convinced mom of that as well. And mom is afraid of being alone without support, she doesn't want to upset Sally, so she leans in. And Sally is calling to set up a meeting to discuss her...err...I mean her mom's assets. In any event, we value people's autonomy for as long as possible. I have fought for people's right to make their own decisions in guardianship courts. Unfortunately, people's capacity, the legal sort, diminishes well after the kind that creates undo influence. Anyhow, all that to say, I totally get you Dr. Sullivan. I believe that you do your best with bad facts.

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