Tragic Reality: Suicide, Pain & Opioids

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Suicide is a top 10 killer in Australia (1a). Age is the most important risk factor. Many of you will know, the age bracket most at risk is . . . huh (?!) ~85 years and older (1a*, 1)!!

Further, age can also be protective. The safest group to be in, going by the sheer numbers, is . . . teenagers?! I’ll just double check my numbers here; ok teen suicide, age 15-19 years, yes: the least likely to actually self harm resulting in death.

Men account for 75% of the suicides, the median age of onset is ~45 years old. Prognostically, the 7 year survival rate, for successfully completed suicide, is  (understandably) poor (4). Similar statistics can be found throughout the western world (B).

Well, this must be the work of the “opioid epidemic”, right?

Actually, no.

Let’s not bury the lead here: All indications are that the suicide epidemic IS what is being “confused” for the “opioid epidemic“.

It would be cynical indeed to suggest that an ability to significantly over-charge for previously over the counter opioid pro-drugs, or a push to contract sell mass anti-narcotics, like naloxone, to police departments and EMS (along with aggressively marketing anti narcotic/opioid combinations (eg Suboxone) was playing any role here. When, even though  generics still make massive amounts of money, especially when sold at these scales and pushed by institution guidelines, none the less – it would be cynical. Even if right now, companies are being sued  to keep these generic drugs on patent for an artificial length of time – it would still be cyn. . . well, no single action, or single arbitrarily clustered data points, defines an entire industry anyway.

And this is the industry which considers it a reasonable practice to approve 600% overnight increases in the price of life saving emergency medications; routinely refuses to release trial data; misdirects (blatantly) about known medication side effects; and is consistently settling out of court fines in sums* ranging from hundreds of millions to billions of dollars – without ever changing practice (*paid not to patients, but to government regulators, in the majority of cases. Which the same corporations often then get back in grants and tax relief). Even so, it would still be far too cynical to posit the above as driving forces, compelling drug companies to mislead the public, in this specific case. Leaving physicians and medical staff (*cough* and, just as an after thought, patients, *cough*) stuck in the middle.

Is it honestly rational to anticipate that these same beneficiaries would use their established influence in other ways? More insidious ways? Say, to drive pressure targeted at changing medical association guidelines, which are notoriously full of ignoble nonsense (in no small measure for reasons just like these), at the best of times anyway?

Ignoble nonsense that the majority of physicians, knowingly or not, do indeed (rightly) ignore in most of daily practice. “Rightly” because these guidelines are already well known for. . .um. . . not always being based on the highest quality of un-marred evidence. Rather, each sentence requiring a squint, a little head shake, a “triple literature check“, and more than a little clinical framing. This owing to association boards, and even alarmist “safety” advocacy groups, often being stacked with one too many, not uncommonly OPENLY DECLARED (is it still conspiracy when it is admitted?) drug company shills [B1;B2;B3;B4;B5].

Well documented, absolutely. Obvious, arguably. And openly declared – usually. But a cynical conclusion, none the less.

And why trust clinical reason over that rich legacy? Why trust what is known about real world applications of a medication, gleaned from your own expert clinical experience and dynamic theoretical pharmaceutical knowledge? Or forensic monitoring data of  the actual medication sales, and scripts filled, by individual patients? Or personal experience reported, from your own actual patients, in your own treatment community? Why indeed.

How could anyone do such a thing, when a puritanical fear of accidentally making a patient feel good, when stopping them from feeling so bad, HAS to be considered. Ye Gawds! And when there is a far easier bate-and-switch narrative in the media. And it doesn’t require interrogating any data at all! Sign me up. This narrative aims to pin the whole “opioid epidemic” (taken as granted without any further debate from the first line of any article) on a single competitor among the drug companies. These companies would not turn on one of their own? They aren’t all part owned by each other? Conspiracy, I say! All of it! Evidence based conspiracy has no place in clinical medicine. In fact, evidence based anything takes a back seat to an ever increasing oscillation, back and forth, of near monthly changing pop-fads of how to approach different ailments.  But that is not what this vent entry is about.

Instead, let’s take a break and look at some data. Just observe what it says. For example, if there was a sudden “opioid epidemic” you would see a statistically significant change in opioid related deaths, when comparing the recent years:

+1 change in most states nont statistically sig

As is clearly indicated in the chart above…oh. The majority of US states showed no significant change? Huh. However, this is only one data point. Metaphorically speaking. I mean clearly, it is actually a lot of data points. But you wouldn’t see other grave errors, that is all I mean. Such as including massive inappropriate categories – like, say, everyone over 55+yrs being put in one homogeneous group. This would incredibly unbalance the data, because the older someone is, the more likely they are to require pain relief. And all people who die of leading diseases, like cancer for example, will naturally also all have opioid pain killers in their system at the point of death. Yet, if you look at the table below:

+1 age matters when you take everyone on meds older than 50 as one group

you can clearly see that…oh no. That is embarrassing for Kaiser. But surely, if you look at the ICD codes included in the research, they will have found a way to clean the data in every other way that matters. They won’t have left things in like “multiple cause”, or “murder”, or “undetermined” or “all suicides” to pretend that any of these have anything to do with opioid death or use. Lets have a look:

+1 Kaiser Caveats opioid epiddemic 018

Whoops! That seems like another completely legitimate oversight. Instead of opioid overdoses, they counted pretty much everything – including suicide, which in the older age brackets, is a problem that would single-handedly account for the proclaimed “opioid epidemic” deaths! Though, people kill themselves in many ways, using whatever is on hand. If it wasn’t opioids* (*here observed “in the system” post-mortem, not even causal); it would be something else. Suicide IS a problem. Not opioids.

+1 Scuicide not opioids is a problem 018

Wow. That suicide data completely accounts for all the claims of overdose deaths from opioids! That is interesting. Except not anymore! Because lack of adequate pain control; fear of being treated by doctors as a “drug seeker”; and insufficient ability to manage breakout pain interfering with the ability to plan, to work, and engage successfully in family life has caused an increase in suicides, only since the opioid hysteria began. It is almost as if all of this has absolutely NOTHING to do with patient care.

There has also been an increase in alcohol sales, and other drug use, since doctors have been failing to help their patients.

The real question is: why would anyone with a working clinical knowledge believe that OTC products, or ED visits, or a day at the dentist, was causing a problem in the first place? Every state has always monitored both script and purchase, closer than we have pseudo-ephidrine, so why the pretense? To what benefit? And where could these claims be coming from all of a sudden? It is as if there was no research question defined – only an answer that was expected in the outcome. It is like that. I am not saying that is what is going on. Rather, only that this is what it would look like, were that what was what was going on. There are other trials, but they all show the same thing –  ie nothing.

Mixed data, in a way that is so far beyond inept, it can only be intentional. Counting one death multiple times. Drug in system, causal or not, devoid of context, driving policy:

+1 opioid epidemic deaths nvolving multiple Rx derp

NIH themselves concluding that deaths from opioid overdoses have remained relatively stable since 2011 (!!), yet drawing the final conclusion there is an epidemic explosion:

+1 opioid epidemic no increase since 2011 NIH derp

And no legitimate efforts towards patient care, eg addiction medicine funding and realistic pain control replacements, are being given more than lip service. So it is a good thing that the opioid epidemic writ-large is pretend. Just a shame the fact patients are now routinely left to suffer, by medical staff who are following medical guidelines, is not pretend.

Patients are now being left in pain at all levels of care and condition: ranging from being abandoned by their medical team to be left in sub-optimal function at one end, and left in down right criminal suffering at the other. All to stop a problem that isn’t real, that also just happens to redirect massive amounts of pharmaceutical income by federal and state mandates [B1;B2;B3;B4;B5]. Not that it matters if there is a connection between the two or not. It just happens to be the case.

Indeed, the only actionable discussions that can be heard on the topic of opioid anything, are regarding the redistribution of medication sales targets (and the guidelines that drive them). Does Should that sound like medicine or evidence based science to you?

Why would any reasonable clinician believe claims that caring for patients, using a long tested and shown to be safe, best first choice drug class, in the opioids, has suddenly become an unmitigated problem? Regardless of dose, duration, supervision, setting, shared decision making? Why would some shotty drug company funded pseudo-research know anything about the patient in front of you? Has listening to the patient gone the way of the fifth vital sign? Why see the patient at all! If treatment interventions have so little to do with the joint decision of the patient and treating physician, trying to achieve the optimal outcome – why not just send the pharma representative directly to the patient’s house with whatever recommendations happen to be popular that given month. Cook-book pseudo medicine nonsense.

Opioids have been examined, in real life/with follow up/large samples/across subgroups, and are established as safe and effective. Abuse levels low to non-existant on the whole. Overdose low to non-existant on the whole. With chronic pain management, the data are the same. Ask the patient how they feel, don’t tell them how they feel. Or get out of medicine, and open a Tarot reading store.

And opioid direct clinical effectiveness goes along with the psychological relief brought to patients. Being helped with their pain management and self efficacy has a multitude of downstream impacts. The confidence to be able to plan their life, knowing they can control breakout pain, if need be. Or that their pain is being managed by their time dosed daily titrate.

Opioids are long established as the go-to pain control class in the clinical setting – short or longer term. And they are almost the ONLY class. So, why suddenly cause a panic without evidence? Really ask the question. Is forcing people to be left suffering through short hospital stays, medical staff under treating their pain “for the greater good: does that fit with the amount of life destroying addiction and overdose you have honestly been seeing in your clinic? It has been everyone, this whole time, but you just never did anything about it until a drug company told you to? Or is treating everyone as if they are that rare exception perhaps not the best front-line policy, for optimal patient care.

A similar set of non-sensical arguments comes from clinical staff using other drugs of abuse (and less effective analgesics) like ketamine along with benzodiazipines? Or suggesting nerve injections: as though these are options for most kinds of pain, for most people, in most settings, most of the time.

Instead, what is being seen are these measures and guidelines, deployed to combat the “opioid epidemic“, are leaving outpatients turning to more available options. More available, but less effective (and arguably far more dangerous) drugs like…oh, just whatever the dealer (who is now more reliable than the doctor) happens to have.

And, of course, alcohol is predominantly being used. Along with all the impacts on a life which that drug brings. Oh well. That is medicine for you, I guess. If we allow it to be. Besides, when has alcohol ever hurt anyone:

+1 Alcohol is a problem not opioids tho the data is not separated

Oh. Oh no. Why, that is double some of the most alarming lies about opioid deaths! Well. That is not any good. Hang on a second, though. What about getting back to the patient perspective for a minute. I mean, you do have to trust your doctors at some point, right?

Even if we accept “big pharma” is pulling something shady, to sell different drugs in a manufactured crisis: that does not mean all doctors are ‘bad’. Or ‘inept’. I’m sure if you just print out some of these data, and take them in to your doctor, they will understand. They have just been too busy, very likely, to look into it all.

I know my doctor just loves it when I print out pages from the internet, bring them into the clinic or emergency room, and question their decisions! They Love it! They do. And at the end of the day – doctor knows best! They have the medical degrees, after all. And, besides: name a single time, where it has even been credibly suggested, that medical paternalism has ever gone wrong on such a large scale:

+1 medical err & medical paternalism 3rd leading cause of death opioid epidemic

Oh. Oh dear, third leading cause of death? That is orders of magnitude more dangerous than the most alarmist claims about opioids! I should really look at these slides before I write the paragraph. Well, at least this doesn’t look at the medical history of physicians leaving patients in pain in the past. Caught a break there.

Pain having to be taught as a “Fifth Vital Sign“, to practicing physicians, because they lacked that level of basic empathy, and skill, in their own craft would be a humiliation to a point beyond mortifying! People may start to disrespect the entire discipline! Something closer to how physician-barbers were viewed in the dark history of early medicine. Or during the physician fight against analgesics for surgery, when they were first discovered. Surely, we’ve learnt from that horrifying past. Especially since all physicians, and their families, will one day be the victims of these same policies. And the down-stream effects.

At least it isn’t the teenagers killing themselves though. So, there is that. That being said, teenagers do grow into adults.

Before you ask, the most common way to die is hanging, or a hanging variant. Yeah, the majority. Overdose is next, but three to four fold less common.  I know. Blew my mind as well.

So, to keep overdose death numbers in context; simply begin by thinking of how many hanging deaths you know of. That number is substantially higher.

The rest are as follows: 8.5% by alcohol/car exhaust. Guns are at 7%. But get this – jumping off something is grouped with “and other“: that is how rare it is (5).

It is worth remarking, that the median age of female suicide is also ~45 years. About on pa with the men. #EqualityOfOpportunity

In June of 2018, CDC reports that suicide as a cause of death alone has risen 25% in the last two decades; something the “opioid epidemic” deaths have not done. Because they are separate markers of different entities.

In the USA, the “method of death” picture is predictably different. Suicide by firearm leads at ~55%. However, aside from this initial discrepancy, the data reads similar. Men lead, with ~85% of suicides being male, with ~30% being female. Hanging/suffocation ~30%. Jumping off something and “other” is only 8%.

And most crucially here: death by overdose or poison is only ~15%. ~15% of a large number, true. However, when asked to look at suicides – not opioids – these same data base sets are somehow providing differing, and I posit conflicting, results. And in any case, this serves to highlight the point.

It is completely inappropriate to include suicide deaths, who happen to have an opioid in their system, when the total suicide numbers are ~40’000-60’000 lives lost, and the claims of opioid deaths are ~20’000-60’000 lives lost.

And keep in mind, suicides are not the only illegitimate inclusion in the “opioid epidemic” death data. They just happen to be enough to show this whole things is a fraud. The counting multiple opioids in a single body, as essentially multiple deaths, for the final tally; the counting “all drug overdose deaths”, for all drugs, but then only talking about “opioids” in the following sentence – and switching back and forth; the including of non-fatal “overdose” numbers, but intentionally not making the distinction clear; the counting opioids in the blood, when they are not the known cause of death; or the counting opioids found in the bodies of murder victims – and on it goes.

Suicidal ideation, and mental health (and, frankly, general health) resources should be made more available. Suicide risk needs to be mitigated. Suicide, as a cause of death, and the surrounding precipitating factors, are a genuine problem. But one that has to be teased apart from all claims relating to opioid harms.

Because if there were no opioids tomorrow – the suicide numbers would remain the same. With the exception of the increased suicides, from under treated pain patients, that we are already beginning to see. This is in addition to chronic pain patients already being twice as likely to commit suicide, when compared to the general population.

So on suicide, and the “opioid epidemic” hysteria***, consider casting your attention towards the actual concerns, that are born out by the data, which are still serious, and really do require intervention:

1. The high risk suicide groups are ~45 year olds – especially middle age white men (so say the data, don’t @ me) and the over ~85 year olds who have watched their friends and family die, while a slow moving disease devours their body from the inside (1b*,1c*). Often they will use opioids, or have them in their system at the time of death. This is not “opioid death. It is suicide, or just “death“. And it is important to note that;

2. Addiction is not caused from over the counter low dose pro-drugs, single night emergency department visits, doses to see a patient through to the next follow-up appointment, or a few days of dental surgery. At All. Further;

3. Even long-term chronic pain management, under physician guidance, is not a problem, because of the systemic, multiple (ie script log/pharmacy) government monitoring systems. We know where prescription drugs go. Hence the data. However;

4. There is a genuine suicide problem, that is being masked (and likely worsened) by a pretense about an “opioid problem”, leaving patients suffering, all to sell different drug company wares. And all of these policies ignoring street drugs entirely. And finally;

5. Take special note: there is not now, nor has there ever been, any “opioid epidemic” or “crisis” in any widely applicable clinical context.

There is, however, an “opioid hysteria”. One that flies in the face of both common clinical sense, and evidence based medicine.

JCR

*JCR is currently undertaking the Harvard Extension Program in Opioid Addiction Medicine. JCR is the psychiatry & research science investigator for the Chronicle LS.

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JCR (2018). Tragic Reality of Teen Suicide & Opioid Overdose Deaths (An International  Perspective), JchronLettSc: ADPT014, 7(4). 0180617. Ed18/Org8.

***And do not even start with any “loperimide epidemic”, you gosh darn cretins. The MOA hasn’t changed suddenly. You people should have your license revoked. Everything is toxic by dose. Some people will drink shampoo – this is not a clinical (and is barely a policy) problem.

[+++] Research Blog Marker

1a* In males only is suicide a top 10 killer. Female 14th.
1b* Hyperbole; soul not confirmed by 3303.0 data set.
1c* Also, people can live to 120 years relatively as healthy as any other time in their life: and you never know where you are on the spectrum. And neither do specialists. Ask them.

Refer:
A1) CtrMedEdu2018: “Nobody Seems to Care About Opioid Treatment” – https://bit.ly/2tbAai4
B1) CDC JUN2018 “USA Suicides Up 25%: Natl Crisis” – https://bit.ly/2sFp0BJ
C1) NIH Opioid Death Stable 2011-2018: https://goo.gl/V6YqLe
D1) TEDMed Why doctors kill themselves – https://bit.ly/2tba6nc
E1) CDC-OD: https://goo.gl/3G9UCr
F1) Kaiser Opioid Overdose Deaths by Age: https://goo.gl/PMQx4N
G1) Statistics: Mortality risk: https://goo.gl/AH4GZG
H1) CDC Leading Causes of Death and Injury: https://goo.gl/BvBIV7

EMA 2018:
(Restricted to physicians and clinical staff part of the HIPPO CME Program)
*The Opioid Free ED – An Abomination: https://bit.ly/2KGK3Lo
*Fun With Numbers – But Not So Funny: https://bit.ly/2ML28sn
*Opiate Addiction Treatment: https://bit.ly/2MHj7vn
*Money and (Academic) Medicine: https://bit.ly/2lQtba2
*Danger Within Us – Revisiting the Role of the Modern FDA: https://bit.ly/2MGXKuc
*Drug Prices in the USA: https://bit.ly/2KFUjDo
*Methods Matter – Reviewing Chart Reviews: https://bit.ly/2IN0zYd
*Clinical Judgement vs Clinical Decision Aids: https://bit.ly/2KAFDJd
*The Opioid Crisis and How it Relates to Emergency Medicine: https://bit.ly/2IJUdsQ

Raw Data Sets:
DS1) NIH Opioid Death Stable 2011-2018: https://goo.gl/V6YqLe
DS2) CDC-OD: https://goo.gl/3G9UCr
DS3) Kaiser Opioid Overdose Deaths by Age: https://goo.gl/PMQx4N
DS4) Statistics: Mortality risk: https://goo.gl/AH4GZG
DS5) CDC Leading Causes of Death and Injury: https://goo.gl/BvBIV7
DS6) CDC JUN2018 “USA Suicides Up 25%: Natl Crisis” – https://bit.ly/2sFp0BJ

Auxiliary Refs:
J3) NEJM 2018 Suboxone Market Creation – https://bit.ly/2lgw0RB
QQ) CERTA Concept of [Impractical Sub Analgesia] – https://bit.ly/2Br0Z8D
QQb) CERTA Opioid Alternatives as [Impractical Sub] Analgesics – https://bit.ly/2Br0Z8D

K3) Lightning Safety: https://goo.gl/VMLjt5
L3) Au Accident Fatality Statistics: https://goo.gl/tQeQOZ
M3) WHO ICD10 Ref: https://goo.gl/5vM1eb
N3) BMJ Medical Err 3rd Lead Death Cause: https://goo.gl/94H2mz
O3) Best Chance of Death (Graphic): https://goo.gl/fR9KEJ
P3) NSC Odds of Dying: https://goo.gl/eZQ3VF

(1)(ABS 3303.0, Released March, 2014) – http://tinyurl.com/pxdjbfv
(2) 3303.0 Overall Mortality – http://tinyurl.com/o97broc
(3) 3303.0 Key characteristics – http://tinyurl.com/mgey8ab
(4) 3303.0 Age – http://tinyurl.com/o2vnbnx
(5) 3303.0 Method – http://tinyurl.com/pk5659c
(6) Carlin (2008) – http://tinyurl.com/o99y3zc
(7) WHO Methods for Divining Cause of Death, WHO Bulletin v(84, 4, 297) (ac2014) ~ http://tinyurl.com/ldfbnuy
(8) Criminal Code 28-291-311/2, QLD, (1899) – http://tinyurl.com/o8eznnc

 

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Crisis helplines

Lifeline: 13 11 14

Suicide Call Back Service – 1300 659 467

Kids Helpline – (for young people aged 5 to 25 years): 1800 55 1800

HopeLine UK – 0800 068 4141

USA Natl Helpline – 1-800-273-8255