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Spoondick posted:Again. We tried it and it didn't go so good. Unless those addicts are deliberately looking to overdose (the vast vast majority aren't) then prescription schemes of metered standard doses massively decreases overdose deaths. There wasn't a single overdose death during the running of Marks's clinic program. After it was forcibly closed, of the 450 clients, there were about 40 overdose deaths within two years. "by giving addicts exactly what they want, free of charge" didn't kill anyone there, and is massively different to overprescription, inappropriate prescription, or allowing addictive drugs to be mass marketed and pushed onto opiate-naive individuals, which is a serious problem.
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Jun 7, 2016 14:08
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Spoondick posted:Yes. Those tricky addicts hoodwinked all these unsuspecting doctors into writing them lethal prescriptions. If only doctors were given some sort of training on how to determine if a patient requires treatment or not and how to provide treatment without killing patients. If only there were resources they could utilize to independently and objectively verify their patients clinical histories. If only these doctors didn't have to book 45 patients and take on 30 more walk-ins every day to make 7 figures a year. If only... we could have saved so many lives. Granted, addiction therapy in America needs a shitload of work and it's difficult for people suffering from addiction to get competent help. But. You sure as gently caress aren't helping by giving addicts exactly what they want, free of charge, plus refills. We tried that. Hundreds of thousands are dying. I'm not convinced an addict is better off with a doctor than a street dealer given the number of people prescription drugs are killing. The most insidious aspect of the whole thing is that a lot of prescription drug addicts either don't realize how addicted they are or feel safe or legitimized in their addiction because they're assuming that since their doctor is a trained professional their dosages and medication combinations must be safe, when in fact their doctor isn't paying attention because they don't give a flying gently caress if their patients live or die. And saying "no" is a skill. It's a tough one for most doctors to learn because it's so different from everything else you're taught; the current focus of medical education is 'patient-centered care', in part to prevent us from turning into uncaring autists unless you're a surgeon. It can be a bit jarring to switch from being solicitous of what meets a patient's needs to telling them to gently caress off when they request a month of PRN dilaudid. Not that you don't have to say no - you absolutely loving have to - but it's a skill and one that should be taught early in the education process.
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Jun 7, 2016 14:36
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Spoondick posted:Yes. Those tricky addicts hoodwinked all these unsuspecting doctors into writing them lethal prescriptions. If only doctors were given some sort of training on how to determine if a patient requires treatment or not and how to provide treatment without killing patients. OK I know you're being sarcastic here, but surely you realise that addicts will actually do and say anything to trick doctors into writing them prescriptions? And as a doctor myself, most of medical school focuses on how to diagnose and treat people based on what they are telling you. We genuinely don't get much training on how to spot people who are deliberately trying to mislead us, or on how to deal with it. Yes pill factories are unethical and the doctors that work in them are probably knowingly contributing to harm for money. But you are going way overboard with the idea that A) it's easy to differentiate an addict from a genuine patient, B) it's easy to say no in these days of patient satisfaction based reimbursement and C) doctors are writing 'lethal' prescriptions. Most of the prescriptions I write could be fatal if they aren't taken as directed. I get that you are pissed off with doctors for some reason, and like I said there is plenty to blame them for like unnecessarily creating new addicts in the first place. But the idea that there are thousands of heartless psychopaths knowingly murdering people for money is a bit much. Especially when you consider that giving addicts a safe route to get their drugs actually reduces harm considerably, but you will still get people who overdose even with strictly monitored dosing. Since you mentioned it, what do you do?
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Jun 7, 2016 14:37
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jabby posted:B) it's easy to say no in these days of patient satisfaction based reimbursement
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Jun 7, 2016 14:42
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Albino Squirrel posted:I agree with most of what you're saying, except your implication that doctors are given adequate training on how to manage opioid use. They really aren't. The amount of teaching I got on pain management, and on addiction treatment, was essentially zero. I finished residency in 2008 and I don't think the formal teaching has improved much, though I'll ask the med student at work this week. Isn't it also a common problem that people who don't get the answer they want from their current doctor just switch doctors? I seem to remember reading things about morbidly obese people switching doctors until they get somebody that just doesn't mention it or people who didn't get the meds they wanted switching until they did. Yeah one doctor can say no but what if there's one that will prescribe whatever you want? Then word gets around and the only way to get enough patients to maintain your practice is to hand out opiates like candy.
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Jun 7, 2016 15:26
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ToxicSlurpee posted:Isn't it also a common problem that people who don't get the answer they want from their current doctor just switch doctors? There is no risk to your practice in saying no, however. There is always more than enough work to go around. And the majority of patients aren't on opioids, so if word gets around that you're a tightass with opioids and benzos then your days suddenly get much more pleasant.
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Jun 7, 2016 16:50
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something that always strikes me as sort of funny in a really dark way: the original marketing blurb for Heroin was that Bayer said it would be less addictive and less abuse prone than morphine, because it was more potent and faster acting. Fast forward a hundred years: America is up in arms about Valium, and Upjohn says "hey, we've got you covered, we have this new molecule that we're branding Xanax, and it's totally less addictive and abuse prone than valium because it's more potent and faster acting, so you take less!" I realize this thread is about opioids, but benzos are similar in a lot of ways, and Xanax is still the #1 drug in the US in terms of annual prescriptions as far as I know. And, the addition of a benzo has been the thing that's made an opioid overdose lethal in many cases.
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Jun 7, 2016 22:26
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Yeah oxy was similarly pitched as a "less addictive opiate", and a bunch of new opiate drugs or drug combos are abuse resistant, and there's the anti constipation Super Bowl ad etc. For profit pharma isn't always going in a great direction.
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Jun 7, 2016 22:44
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Are they more prone to causing addiction without the user trying to use them recreationally? Like, if you're committed to not becoming addicted and just using them to treat pain or anxiety, are the faster acting variants better or worse in terms of causing long-term addiction?
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Jun 7, 2016 22:56
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pangstrom posted:For profit pharma isn't always going in a great direction. yup. The glowing pharma success stories of the last century are antibiotics and vaccines, and now we have on the one hand 80% of antibiotics being used as livestock growth hormones leading to human contraction of AB-resistent infections, and dumb poo poo like Merck getting sued by the government for pretty blatantly lying about the efficiency of one of their staple vaccines on the other. It's all hosed, and consumers get ground in the gears.
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Jun 7, 2016 22:57
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Guavanaut posted:That would be a problem of overprescription or inappropriate prescription, which is completely different to giving prescription grade drugs to addicts who would like to get those drugs somewhere other than the street. Giving opioid addicts opioids in a supervised clinical setting to specifically ameliorate the effects of opioid abuse is very different than writing a prescription to someone who clearly presents as an addict, knowingly giving them such high doses and quantities of drugs they would likely die if they actually took them (perhaps taking small consolation knowing that most of them will be diverted (and kill someone else)), and calling it pain management. The former works pretty well. The later kills a lot of people. I understand doctors weren't given enough training on opioids and addiction, and it didn't help that the fine folks at Perdue were talking up how not addictive their opioids were. When the dust settles on this whole thing maybe 10 years from now, I think we're going to see a large majority of the opioid prescription overdoses are linked to a small number of doctors. While your naive GP and metric-obsessed ambulatory care provider weren't helping by giving out too many opioids, I really think pill mills did most of the damage by far. jabby posted:OK I know you're being sarcastic here, but surely you realise that addicts will actually do and say anything to trick doctors into writing them prescriptions? And as a doctor myself, most of medical school focuses on how to diagnose and treat people based on what they are telling you. We genuinely don't get much training on how to spot people who are deliberately trying to mislead us, or on how to deal with it. I'm fully aware. I've been living inside of pharmacies for the last 10 years. After patients trick doctors into writing them prescriptions they try to me to trick me into filling them. I have no medical training whatsoever. My last job was making pizza. I paid $100 to take a test, passed, and got a job in a pharmacy. I prevent a lot of inappropriate prescriptions from being dispensed every day because I pay attention to what I am doing and what is happening. A provider with a medical degree in a clinical setting has far more resources to evaluate the patient and their clinical history, yet they continually make the same mistakes because they are not paying attention to what they are doing and what is happening. Patients are going to lie to you about anything and everything. They will lie to you about losing their clonidine when in fact they are using it to poison neighborhood cats. You take what they say into account, but you also independently verify what you can. The words from the patient's mouth are part of the evidence, not all of it. When you practice this during patient encounters, there is much more contrast between appropriate and inappropriate. When something is inappropriate you can have objective evidence to bring to the patient, you can say no and tell the patient specifically why not. When you're cutting corners though, the easiest thing to cut is independent verification. quote:Yes pill factories are unethical and the doctors that work in them are probably knowingly contributing to harm for money. But you are going way overboard with the idea that A) it's easy to differentiate an addict from a genuine patient, B) it's easy to say no in these days of patient satisfaction based reimbursement and C) doctors are writing 'lethal' prescriptions. Most of the prescriptions I write could be fatal if they aren't taken as directed. I'm not pissed off with doctors, I'm pissed off with murderers who played doctor. Very specifically these pill mills. You don't kill 165,000 people 30 leftover Vicodin at a time. You don't kill 165,000 people with prescriptions and then assume the prescriptions weren't lethal. Those are war crime numbers. You only get that from large quantities of wildly inappropriate prescriptions. Sorry if thousands of medical providers being sociopaths is unbelievable to you, but I can spam this thread with thousands of public documents showing exactly that if that's what you need to see.
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Jun 8, 2016 15:50
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Spoondick posted:Giving opioid addicts opioids in a supervised clinical setting to specifically ameliorate the effects of opioid abuse is very different than writing a prescription to someone who clearly presents as an addict, knowingly giving them such high doses and quantities of drugs they would likely die if they actually took them (perhaps taking small consolation knowing that most of them will be diverted (and kill someone else)), and calling it pain management. The former works pretty well. The later kills a lot of people. I understand doctors weren't given enough training on opioids and addiction, and it didn't help that the fine folks at Perdue were talking up how not addictive their opioids were. When the dust settles on this whole thing maybe 10 years from now, I think we're going to see a large majority of the opioid prescription overdoses are linked to a small number of doctors. While your naive GP and metric-obsessed ambulatory care provider weren't helping by giving out too many opioids, I really think pill mills did most of the damage by far. The addiction treatment doctors are already stained with the stigma of addicts, and tend to get steamrollered, or forced into using 'maintenance' type opioids that have lower success rates than Marks's program of "They want heroin? Okay, let's give them pharmaceutical grade heroin* and clean gear for as long as they want and make sure they don't sell any of it on." Even for people who don't give a poo poo about addicts the reduction in property crime and gangs sells the method. *Which is drat near impossible in the US anyway currently, due to being Sched I.
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Jun 8, 2016 16:15
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Corpus Smegma fucked around with this message at 20:43 on Jun 8, 2016 |
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Jun 8, 2016 19:32
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I wish you could go to the doctor, say to him what you just posted here, and get help that might eventually give you a more positive outlook on life, but recognize that's not the reality we live in. So good luck.
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Jun 8, 2016 19:35
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waitwhatno posted:Why isn't there stronger regulation of opioids in the US? I assume that you guys have special prescription systems for scheduled drugs, just like any other country. Can't you just limit opiates to only be prescribable for specific diagnosis and only in small amounts? This is the most infuriating thing about the whole system to me. Any other class of drugs with even a tenth of the fatalities that opioids have caused would have been pulled from the market or put on a special REMS program that required providers to complete an educational course and put strict rules on prescribing/monitoring standards. Vioxx got pulled completely from the market, generated huge lawsuits and criticism directed at the FDA, and its estimated that Vioxx contributed to 30,000 deaths. We're up to 40k deaths every year as a result of opioids, but they keep trucking along. Drugs like Clozapine or Tikosyn require(d) a special certification before doctors can even prescribe them due to rare but potentially dangerous side effects. Acne medications like Accutane require the patient and the prescriber to register, complete education, and submit regular pregnancy screenings due to risks of birth defects if a pregnant woman took the medication. Why the gently caress isn't a similar system in place for the controlled substance class that is killing people on an industrial scale? Any provider with a DEA number can write as many opioid prescriptions as their heart desires with no special training required. Contrast that with the medication Suboxone. If you want to give a patient Suboxone to actually try to control their opioid dependency you need to obtain a special physician buprenorphine waiver, complete 8 hours of training on how to manage patients on the medication, maintain a unique X-DEA number, and treat no more than 30 unique patients with Suboxone in the first year after receiving this waiver. Our system is beyond hosed.
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Jun 9, 2016 00:19
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Loving the pharmacy education in here. Respect.
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Jun 9, 2016 02:25
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So is it at all possible to develop an opioid analgesic that doesn't cause fatal respiratory depression if overdosed? For all the effort that drug companies have put into developing more and better opioids I would think something like this would be a high priority? Seems like drug companies could be making money hand over fist with something like that, and no one would really give a poo poo how many people were dependent on prescription opioids if they weren't dropping dead so often.
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Jun 9, 2016 05:24
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Morbus posted:So is it at all possible to develop an opioid analgesic that doesn't cause fatal respiratory depression if overdosed? For all the effort that drug companies have put into developing more and better opioids I would think something like this would be a high priority? That's a good idea. But as long as they're making that opioid they should also make sure it doesn't shut down your bowels, or suppress your testosterone, or cause substance dependence via dopamine release in the nucleus accumbens, or generate a euphoric effect independent of analgesia, or generate tolerance to dose effect over time, or make you sedated, or cause terribly unpleasant withdrawal symptoms, or cause opioid induced hyperalgesia. But yeah, once you get rid of those minor defects, opioids would be a wonderful class of medication!
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Jun 9, 2016 05:44
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Morbus posted:So is it at all possible to develop an opioid analgesic that doesn't cause fatal respiratory depression if overdosed? For all the effort that drug companies have put into developing more and better opioids I would think something like this would be a high priority? There are four big classes of opioid receptor: Mu1 (mostly peripheral), Mu2 (mostly central nervous system), Kappa, and delta. Mu1 is responsible for the central interpretation of pain and mediates much of the analgesic effect (also mediates constipation). Mu2 has a nearly identical ligand binding profile to Mu1 and mediates most of the negative effects (respiratory depression, physical dependence) in addition to analgesia and euphoria. Kappa receptors provide mild analgesic effects and no respiratory depression, but are associated with feelings of dysphoria. Delta receptors are a regulatory receptor that modulate the activity of Mu receptors. If you could target Mu1 exclusively then you might get decent analgesia without most of the side effects. I am not sure if peripheral agonism alone would and a cursory literature search doesn't really seem like anyone knows the answer to that in humans. Morphine and all of its derivatives are highly lipid soluble, meaning that they can easily enter the central nervous system and will act on both central and peripheral Mu1 and Mu2 receptors, providing strong analgesia but also all of the negative side effects. Moreover, the active metabolites for all of these drugs (ie what they are converted into in the body and what they exert most of their action as) are also highly lipid soluble and readily enter the brain. It may be possible to design a drug that acts as a peripheral Mu2 agonist only and isn't lipid soluble and can't be metabolized to something that enters the CNS, but there isn't anything like that on the market AFAIK. There are some mixed agonists on the market: Nalbuphine (Nubain) is a kappa agonist and mu antagonist, which acts as an analgesic in an opioid naive patient but can precipitate withdrawal in the presence of morphine or other opioids. It can cause nausea and sedation and a number of other side effects but minimal respiratory depression. The biggest problem - no oral dosing available. It is only available in IM/IV/SQ form and isn't particularly popular. Butorphanol is a similar drug that does have an oral preparation but also doesn't see a lot of use, probably because its analgesic effects are just not as good as opioids. Buprenorphine (with naloxone - Suboxone; or by itself - Subutex) is a partial mu agnostic and kappa/delta antagonist that is mostly used for treating opioid addiction. There is a patch version that can be used to treat chronic pain but in general it doesn't have a high degree of anelgesic efficacy.
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Jun 9, 2016 06:44
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Subvisual Haze posted:That's a good idea. But as long as they're making that opioid they should also make sure it doesn't shut down your bowels, or suppress your testosterone, or cause substance dependence via dopamine release in the nucleus accumbens, or generate a euphoric effect independent of analgesia, or generate tolerance to dose effect over time, or make you sedated, or cause terribly unpleasant withdrawal symptoms, or cause opioid induced hyperalgesia. But yeah, once you get rid of those minor defects, opioids would be a wonderful class of medication! Respiratory depression is a uniquely bad side effect of opioids compared to everything else you listed. And those other side effects certainly don't stop them from making money on these drugs, or encouraging their over prescription. What *does* threaten to put the brakes on the money train is the increasing body count from people OD'ing. Thank you tehliama for the explanation. It seems like if you really just wanted to design a less dangerous opioid there would be routes apart from trying to selectively target Mu1. Like if a drug acting on the CNS can cause respiratory depression, can't a drug also do the opposite of that? I guess maybe the answer is either 1.) no not really or 2.) yes but mixing drugs to try and cancel side effects with each other probably just makes a giant mess and doesn't work.
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Jun 9, 2016 07:13
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I thought the constipation was caused by something different? Imodium is an opioid that doesn't cross the blood brain barrier, and it's entire purpose is to prevent making GBS threads. Some opioid users self medicate with large doses of it while in withdrawal to help with some of the symptoms.
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Jun 9, 2016 08:05
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Subvisual Haze posted:That's a good idea. But as long as they're making that opioid they should also make sure it doesn't shut down your bowels, or suppress your testosterone, or cause substance dependence via dopamine release in the nucleus accumbens, or generate a euphoric effect independent of analgesia, or generate tolerance to dose effect over time, or make you sedated, or cause terribly unpleasant withdrawal symptoms, or cause opioid induced hyperalgesia. But yeah, once you get rid of those minor defects, opioids would be a wonderful class of medication!
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Jun 9, 2016 09:50
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Guavanaut posted:I'm interested why you think this would be a major downside. Do you think an analgesic that generated a euphoric effect other than pain relief would be a bad idea even if it didn't affect the bowels, hormones, caused dependence, generated tolerance, sedated, had terribly unpleasant withdrawal symptoms, or caused hyperalgesia? My point that I was awkwardly making was these effects aren't seperable, because this is what mu opioid receptors do. Asking for an opioid without a those effects is a fairly pointless exercise. Like asking for a nuclear power reactor that doesn't utilize those pesky subatomic reactions. You'd be better off starting from scratch and hoping to discover a whole new moa of drugs entirely.
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Jun 9, 2016 14:24
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Konstantin posted:I thought the constipation was caused by something different? Imodium is an opioid that doesn't cross the blood brain barrier, and it's entire purpose is to prevent making GBS threads. Some opioid users self medicate with large doses of it while in withdrawal to help with some of the symptoms. Loperamide is a Mu agonist just like morphine, but it isn't really absorbed from the gut very well and what little does is largely inactivated by the liver before reaching the bloodstream. It is pumped out of gut epithelium by a protein that also exists in the blood brain barrier, though it can enter the brain in very small quantities. Its oral bioavailability (the amount of an oral dose that reaches the blood in an active form) is only 0.3%, so yes there have been reports of people taking extremely high doses to get some of the central effects. There are also opioid addicts who have tried injecting very high doses it and have died - it isn't designed to be taken IV and can have unpredictable effects. Morbus posted:Respiratory depression is a uniquely bad side effect of opioids compared to everything else you listed. And those other side effects certainly don't stop them from making money on these drugs, or encouraging their over prescription. What *does* threaten to put the brakes on the money train is the increasing body count from people OD'ing. Some of the mixed agonist/antagonists I mentioned do essentially do that. There are also opioids packaged with stuff that makes them unpleasant to abuse - Lomotil (diphenoxylate and atropine) causes nasty anticholinergic side effects when taken at supratherapeutic doses becauses of the atropine packaged with it, but still causes respiratory depression etc.
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Jun 9, 2016 14:40
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waitwhatno posted:Why isn't there stronger regulation of opioids in the US? Because when we do that, we get heroin outbreaks.
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Jun 9, 2016 14:41
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Yeah, unfortunately a drug is going to have to get into the pain pathways at some point and the low-hanging pharma fruit has been plucked. Hopefully one of the next gens will work but the good news for the US at large is that when it comes to opiates, the BULK of the answer is already pretty clear. We just need to use way fewer opiates. Not easy, of course, but it's not a R&D problem that's going to fail in clinical trials or something.
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Jun 9, 2016 14:49
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computer parts posted:Because when we do that, we get heroin outbreaks. pangstrom fucked around with this message at 15:23 on Jun 9, 2016 |
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Jun 9, 2016 14:57
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tehllama posted:Loperamide is a Mu agonist just like morphine, but it isn't really absorbed from the gut very well and what little does is largely inactivated by the liver before reaching the bloodstream. It is pumped out of gut epithelium by a protein that also exists in the blood brain barrier, though it can enter the brain in very small quantities. Its oral bioavailability (the amount of an oral dose that reaches the blood in an active form) is only 0.3%, so yes there have been reports of people taking extremely high doses to get some of the central effects. There are also opioid addicts who have tried injecting very high doses it and have died - it isn't designed to be taken IV and can have unpredictable effects. Yeah it looks like loperamide overdoses are becoming a thing. I bet we'll see it restricted like pseudoephedrine before much longer.
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Jun 9, 2016 15:54
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smg77 posted:Yeah it looks like loperamide overdoses are becoming a thing. I bet we'll see it restricted like pseudoephedrine before much longer. There was a TCC goon that died of an overdose of Imodium as I recall.
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Jun 9, 2016 16:27
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Rhandhali posted:There was a TCC goon that died of an overdose of Imodium as I recall. In the middle of watching a movie at the cinema, IIRC. Subvisual Haze posted:Any provider with a DEA number can write as many opioid prescriptions as their heart desires with no special training required. Contrast that with the medication Suboxone. If you want to give a patient Suboxone to actually try to control their opioid dependency you need to obtain a special physician buprenorphine waiver, complete 8 hours of training on how to manage patients on the medication, maintain a unique X-DEA number, and treat no more than 30 unique patients with Suboxone in the first year after receiving this waiver. Our system is beyond hosed. I wonder if this has anything to do with the fact (from The Valuum's A/T Prison Thread) that suboxone was the drug of choice for prison inmates, since it comes in flat strips and therefore can be smuggled into prison inside of things like letters and birthday cards. Morbus posted:So is it at all possible to develop an opioid analgesic that doesn't cause fatal respiratory depression if overdosed? For all the effort that drug companies have put into developing more and better opioids I would think something like this would be a high priority? Making new versions of opiods is a pretty bad bet for making money, since there is already an entrenched market of cheap drugs and the FDA and overseas regulators are very fussy about their requirements for any new opiod drug hitting the market. A lot of companies have been scared off since the last few attempts at tamper-proof or alternative opiods were shot down for not providing sufficient value over existing drugs, especially considering that there isn't a huge market for these drugs (at the moment, anyway). Companies are having better luck with complimentary drugs, like ones that alleviate some of the side effects of opiods like nausea, since that can provide value without having to supplant cheap, established generic drugs at the high price point of a patented drug. MikeCrotch fucked around with this message at 17:42 on Jun 9, 2016 |
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Jun 9, 2016 17:28
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smg77 posted:Yeah it looks like loperamide overdoses are becoming a thing. I bet we'll see it restricted like pseudoephedrine before much longer.  Also, apparently oxybutynin is the new hotness in jail, presumably because if the hallucinations. I did have a patient inject it into his jugular vein once, but to be fair he thought it was related to oxycodone.
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Jun 9, 2016 17:45
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Albino Squirrel posted:People will use the most surprising things to get high. There's been an outbreak of bupropion injection out west for a while now; I'm not sure what the high is supposed to be but maybe it'll help with the smoking? Bupropion is structurally related to amphetamines, so I always thought of it like a weaker amphetamine. But one that would induce a seizure before you reached anything close to euphoria. So label me surprised but not shocked that people are injecting it now. When I read my CE chapter on drugs of abuse for this year I remember feeling really depressed that the hot new drugs of abuse were things like Seroquel, Gabapentin, Loperamide, and anticholinergics. It's like the pharmacological equivalent of an alcoholic drinking hand sanitizer.
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Jun 9, 2016 18:01
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Rhandhali posted:There was a TCC goon that died of an overdose of Imodium as I recall. You can die from an overdose of basically anything. Having too much water in your body kills you.
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Jun 9, 2016 18:13
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smg77 posted:Yeah it looks like loperamide overdoses are becoming a thing. I bet we'll see it restricted like pseudoephedrine before much longer. Probably not, but its hard to say in the current climate. PSE was restricted because it was being made into meth which had a big community effect. There are other OTC drugs that do weird things at high doses (DXM robotripping for example), but the FDA hasn't felt the need to crack down on them yet. I doubt there are many medications that wouldn't have the potential to gently caress you up if you took 15x the recommended dose of them. MikeCrotch posted:I wonder if this has anything to do with the fact (from The Valuum's A/T Prison Thread) that suboxone was the drug of choice for prison inmates, since it comes in flat strips and therefore can be smuggled into prison inside of things like letters and birthday cards. No it's just the incredibly backward-rear end nature of the DEA, and the piecemeal legislation on the books that is completely disconnected from reality. The DEA still has a huge guiding principle in force that controlled substance medications are not to prescribed to sustain an addiction. There have been minor legal exceptions added to this allowing Methadone to be used at methadone clinics, and Suboxone in outpatient settings under the requirements I previously described for addiction treatment, but the requirements are still much more onerous than just giving the patient a truckload of Oxycontin. Because the Oxycontin is for "pain", while the suboxone is for addiction (and thus requires a shitload of hoops to jump though). However, if the doctor specifies that the Methadone or Suboxone is being used to treat "pain" (not addiction), then we can dispense the prescription with no extra requirements at all. Hooray! Please note that the fact that a patient could have both pain and an unhealthy dependence on opioids isn't really accounted for. Because our healthcare system is AWESOME.
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Jun 9, 2016 18:23
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Another large factor in the epidemic people are mostly unaware of is insurance disbursements to pharmacies. A retail pharmacy maybe makes $5 to $10 per prescription they dispense on average, with independents on the low end and major chains on the high end. When you go to a retail pharmacy and hand them a $5 bill for the copay of a 90 day supply of lisinopril, that is almost guaranteed to be the only money the pharmacy will see for that prescription. When I was doing independent pharmacies they were understandably very concerned about maximizing profits. The invoice for the drugs you buy is due in 30 days when insurance takes 6 weeks on average to pay you. You need liquid cash, and higher margin prescriptions are preferable. Schedule IIs had higher margins because of the additional risks and expenses in dealing in them. The Medicaid reimbursement for oxycodone and hydrocodone tablets was about 30% to 50% above cost, with pharmacies usually making hundreds per fill. In an environment where you're barely scraping by on filling routine maintenance medications and narcotics are a windfall, guess which patients pharmacies start bending over backwards for. The California Board of Pharmacy has been massacring independent pharmacies in recent years largely because they yielded to the temptation.
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Jun 9, 2016 18:51
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smg77 posted:Yeah it looks like loperamide overdoses are becoming a thing. I bet we'll see it restricted like pseudoephedrine before much longer. Retired pharmacy tech here. When I was working, loperamide was only available by prescription and was Schedule V narcotic. I was amazed when it was taken off Rx and became OTC. It's probably going back to it's old status before long.
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Jun 9, 2016 22:41
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Subvisual Haze posted:Bupropion is structurally related to amphetamines, so I always thought of it like a weaker amphetamine. But one that would induce a seizure before you reached anything close to euphoria. So label me surprised but not shocked that people are injecting it now. The weakest prescription diet pill is Tenuate, whose generic name is diethylpropion. (Schedule IV) Even though it's low-octane stuff compared to the others of it's kind, I could tell you some interesting stories about what people were willing to do to get some.
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Jun 9, 2016 22:48
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hi guys i keep up with this sort of issue kind of often (my avatar was not bought by me tho) and was wondering how many of you are aware of U-47700 it is a new grey-market opioid that is 7.5x the potency of morphine and is INCREDIBLY caustic, no matter if you're snorting it, putting it up your bum, or IVing it. it also has an incredibly short duration of action, leading users to need to redose every 1-2 hours, forcing their tolerance sky-high and making them need to put more and more of this nasty stuff into their body. you can find someone detail the myriad of health problems they developed from it here: https://www.reddit.com/r/researchchemicals/comments/4m0z0q/u47700_my_ultimate_guide_and_experiences/ "U-47700 has caused me WAY more health problems then even 10+ years of IV heroin use. I used u47 for only 3 months, it gave me- A heart murmur, 4 blood clots, damage from iv'ing in my hand causing partial numbness and difficulty/pain when tightly grasping things even now after 3 months off of it.... and when using it, "falling out" (technically overdosing) 5-10 times a day regularly. Insane respiratory depression and constant dances with death await for anyone who tries this drug." he is not alone, there are other reports of people having done alarming damage to themselves in only a few months of use. U-4 is just the latest in a long line of opioid analogs. there was MT-45, which made people's hair fall out, AH-7921, which wasn't very euphoric, there's ortho-desmethyltramadol which ironically might be the safest of all of them due to being a tramadol metabolite. u-4 is legal everywhere in the USA except ohio, and after it is banned there will simply be more new opioids developed, and i believe that they'd just get worse and worse with regards to overwhelming potency / dramatic health problems. people seem to fail to account, for example, the fact that when heroin is laced with "fentanyl," it isn't necessarily Fentanyl the prescribed drug, it can also be acetylfentanyl, furanylfentanyl, 4-fluorobutyrfentanyl... analogs that are usually a little less potent than their parent compound, but, seeing as how powerful fentanyl is, that doesn't make them a whole hell of a lot safer. megadosing loperamide is also becoming an issue now due to the effects of a megadose of it on the heart. narcan would probably not save someone from the cardiotoxicity of loperamide megadosing. http://www.innovationsincrm.com/car...amide-ingestion another large factor in this epidemic, IMO, is how many people got started with and then still request oxycodone. oxycodone is a fairly short high, you've mostly come back down only 4 hours after you've eaten it. i believe that shorter-acting opioids are more psychologically addictive, partially due to the mental roller coaster of being high then on the verge of being sick several times in a day. i believe that the best solution to this problem is to institute a system like what is available in switzerland, but i'm fairly sure none of us will live to see such a thing happen in the USA. sea of losers fucked around with this message at 18:32 on Jun 12, 2016 |
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Jun 12, 2016 18:13
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Research chemicals are just fascinating to me. It's crazy how reckless people are with these drugs and how helpless governments are in fighting them. It seems like as soon as some drug is found to be semi-somewhat-safe it goes mainstream and idiots start dropping like flies because they don't know how to use it or don't care. This is probably only going to become worse and worse, with better understanding of biochemistry and rational drug design.
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Jun 12, 2016 18:43
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reagan posted:Loving the pharmacy education in here. Respect.
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Jul 18, 2016 04:51
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