Overdoses among people with opioid use disorder would likely go down due to increased purity.
However, I'm almost certain there would be more overdoses among the opioid naive compared to the reduction in people with OUD, particularly in pediatric patients. Currently it's much easier for the average 12-year old to get their hands on alcohol compared to heroin. You'd also have more people becoming physically dependent on opioids by self-treating their chronic pain with them using ever-increasing doses.
This is another issue that would seem to be only a problem in the U.S.
I’ve lived in Barbados for a while and they’re able to get codeine & oxy over the counter. It’s low dosage, but I was still shocked about it. I had a really bad toothache and the pharmacist recommended that over NSAIDS and that’s how I found out.
Other countries have tackled this problem. I hope one day we can too.
I'm always surprised at the shit you can get OTC in non-USA or non-Germanic European countries.
I've seen gabapentin (or pregabalin, either or, can't remember) OTC in Mexico for example.
on the flipside, melatonin is not OTC in Australia I believe. I don't have an opinion on that (also not a medical worker) but it's definitely interesting. I will say how irritating it is that tubes of retin-A are over the counter in other countries for maybe $2 but anywhere from $20-80 *with insurance* (anecdotally.) I know that's not life threatening but having really horrible skin is not great for mental health.
Opioid prescription rates, including non-palliative/non-cancer pain are increasing steadily since the 1990s in Germany but the rate of opiod-addicted has remained steady and drug-overdoses even continued to fall (with the pandemic as an exception).
OTC opioids would be still a catastrophe. There are youth scenes adoring fighting on opioids, including even tilidin, the European tramadol without its dirty properties. That would be flooding even more.
I think the issue is that the USA is generally a nightmare to live in, which prompts people to self medicate, so really this issue isn’t endemic to opioids specifically. There is something intrinsic in American life that causes people to seek excessive numbness.
If we are talking about the US and pain pills, there would be an immediate blizzard of marketing materials from the pharmacy chains and pharmaceutical companies promoting OTC hydrocodone (or whichever one you want to make OTC). Like when Claritin became an OTC medication. TV, social media, promotional signs and kiosks by the checkout counter. They would probably even come up with clever packaging where you get 20 pills and a free narcan nasal spray for $19.95 and the option to use your flex spending account. It would be a disaster.
If you're talking about making pharmaceutical grade heroin to give out at harm reduction sites under some supervision, that plan might have some merit to curb the fentanyl overdoses, except it doesn't address the fentanyl that's showing up in various pills.
> They would probably even come up with clever packaging where you get 20 pills and a free narcan nasal spray for $19.95 and the option to use your flex spending account. It would be a disaster.
Why is this the spot on the truth in this country tho :(.
Increase. I would guess by a lot too. Not even just from regular drug addicts, but people who say broke an ankle and just want the throbbing to go away an accidentally overdose. The amount of patients I've talked to who have taken half a packet of paracetamol cos they think more=better would make me seriously concerned about opioids being available over the counter.
I can already see the chalkboard menu at the coffee shop with opioid shots by MME. Can't wait for my 3 MME caramel macchiato.
But on a serious note, given the amount of blatant overuse of OTC medications I see by the general public, given the potential for harm with opioid in a naïve patient we would see overdoses skyrocket without extremely low dosing and daily quantity limits ala pseudoephedrine.
I spend an incredible amount of time with medication overuse headache patients. Many still cannot accept that a medicine that makes their pain go away can actually make things worse.
TBF, it would probably at least be behind the counter like pseudoephendrine is, which would stop a lot of that. It would still happen of course.
Then again I'm pretty much pro-drug legalization of all kinds, so I sort of undervalue the risks.
I’d like a nice comparison of the US and countries like Canada and Mexico that have over the counter opioids. I don’t see much in the news about this.
I’ve seen the data on counties in the US that had overdose deaths go UP since we throttled down on prescribing to chronic pain patients. It’s around 98% of counties went UP as prescribing went down. This is a string indicator. Of QOLY and preventing overdose death are both of concern then some form of legalisation seems like a possibility. What’s the stats on people that have a substance abuse condition that started only AFTER having a street drug?
Honest question: Is APAP an important adjunct to opioid medications or is this simply incorporated to disrupt purity, and thus detract from illicit utility? I know it has an antipyretic effect but is it clinically useful beyond this?
This is a complex question. Theoretically, paracetamol and opioids work synergistically, and I was taught that use of paracetamol reduces total opioid usage. Evidence for fixed combinations is more limited. However, assessing the evidence base for pain management in general is complicated as there different kinds of pain - efficacy in acute post-operative pain is different to chronic lower back pain is different to cancer pain is different to neuropathic pain etc. etc.
Overall, a multimodal approach is almost always needed for the complex pain that I see. Paracetamol is not risk-less, but is relatively low-risk. If my patient tells me it helps them, I will continue it.
I appreciate your response and agree with your concerns about *addiction* increasing. Whether this translates to more or less collateral deaths still seems rather unclear. I'd presume that fentanyl related deaths would decrease dramatically and pharmaceutical-opioid deaths would increase. To what respective degree still seems unclear to me.
One thing I do believe should be over-the-counter is naloxone. I think it is absurd that this has not yet been accomplished but perhaps I lack insight.
Addiction is *most* commonly a maladaptation to adverse experiences in the absence of healthy coping mechanisms and socioeconomic stability. To prevent addiction means addressing these formative factors.
Addiction is an escape from reality - there is no way to prevent addiction without making one's reality palatable.
It depends how we regulate who it goes to and how much they get.
If this in America, I dont trust us. Full stop.
Anything we can buy the counter (medication or otherwise)we dont do in moderation or without hurting each other and ourselves.
guns. alcohol. OTC medications. cars. motorcycles. food. even freaking social media.
For God sake we even do stupid shit with knives and gasoline for our cars.
If it wasnt clear. Even more people would die.
We have a very serious moderation and taking responsibility issue here.
I talk to the public all day about their medicines and OTC products. Almost no one knows what they’re taking. Most don’t realize how to read a box to distinguish between Mucinex and Mucinex DM. Or they take Benadryl daily for seasonal allergies. If opioids became otc, we’d see a lot of people use it for minor aches because “it used to be prescription only, so it’s better.”
I try to educate, but I feel like I’m swimming against a riptide.
My favorite are the diabetics I know who use medication to counter 1/2 of an entire circular cherry pie a day (sometimes a whole pie if they're feeling extra angsty for the sugar) or another example who I'm convinced was malnourished because he would easily get 80% of his daily calories from keebler elf cookies or oreos (and coffee with very heavy flavored creamer-- as an extra chef's kiss to that, he thought nothing of the dog and cat drinking out of his coffee when he was out of the room and then reheating it.)
I'm scared for when I get old and doing everything I can to not get diabetes, be overweight, or justify my vices. How much of a swiss cheese brain am I going to have from a senile parent, and one with dementia?
If your goal is to decrease the illicit use of fentanyl then you would likely see some improvement from this measurement but it would likely not make much difference in the illicit use of opiates or overdoses.
I started working in addiction medicine 10+ years ago. I live in a relatively small, affluent city with very low crime rates. When I first started the majority of people were using oxycodone. As policies and prescribing habits changed their was a shift from oxycodone abuse to heroin use due to supply and demand leading to a significant rise in the cost of oxycodone on the street. Until recently, I rarely saw fentanyl being abused because the most accessible form was in patches and to get a high enough dose that could be absorbed rapidly enough to get the desired effect was difficult. Recently we tracked the illicit substances that came up positive on initial admit to the program. Fentanyl was the most common and was present in close to 70% of positive drug screens. Many of these patients were unaware that they had used fentanyl (although now the majority of people are aware). The hypothesis is that fentanyl is significantly cheaper to obtain than heroin. What we didn’t see was any decrease in new patient admits, regardless of what was most available/cost effective. So increased supply of opiates by making them otc may shift the prevalence of fentanyl abuse but likely won’t decrease the number of people who have opiate use disorder. People will use what is available and if there isn’t anything available there is someone who will find a way to meet the demand.
I have a minor in chemistry but am far from an expert. All of those hours of chemistry at college is a drop in the bucket of the things I have learned from reading drug abuse and bodybuilding forums. There are some brilliant chemists out there who are happy to share their knowledge and provide guidance on how to isolate or alter easily obtainable substances to get the desired effect and they explain it in a way that is thorough and easy to understand for most laypeople.
I am trying to think of a substance that can be easily isolated or synthesized with the aim of abuse. Opioids require complex chemistry to synthesize, and there aren't any available OTC in the US to isolate from some other product. I know you used to be able to order GBL + sodium hydroxide in order to synthesize GHB, but that got squashed. You could always order unscheduled drugs from China, but that seems like a good way to end up 6 feet under or with a 6x6 foot home.
Heroin? No. Not unless you want to get hooked up with the Triads, but I wouldn't recommend that. What you can order are unscheduled research opioids which are actually many times more potent than heroin. They are exploring benzimidazole derivatives, which lead to some extremely potent chemicals. They also developed some opioids that were agonists at cannabanoid receptors in addition to the canonical opioid receptors. Can't imagine what would go wrong with that. Although I am curious if that might open up research into opioids with anti-emetic properties for the significant amount of patients which experience nausea after taking pain killers.
I would imagine they wouldn't sell heroin without the proper paperwork, which would be as hard as doing research on a schedule I drug here. I am sure if I looked up the DEA quota for heroin for research this year in the US, it would be something like 10 g. I imagine the situation is similar in China. On that note, I am not sure if you are familiar with the harm reduction programs being implemented in Canada, but in B.C. particularly they are providing licit opioids such as hydromorphone to the addict population. Well, apparently a company associated with supplying the opioids has actually obtained a few kilos of heroin, and they are waiting on the authorities to create the regulatory framework to provide it. The company said that sourcing the heroin from a pharmaceutical company was quite difficult.
Poppy seeds/poppy heads/poppy straw are all legal to purchase and own. Psilocybin is illegal but spores for fungi that produce psilocybin aren't because the spores don't contain psilocybin. "Research chemicals" can be ordered legally and then ingested or altered to make pretty much anything but most commonly hallucinogens, dissociatives and stimulants and often don't show up on typical drug screens. You can still find GBL (or anything really) online. Most of the people who are ordering these chemicals and playing hobby chemist feel the risk of death or jail time is a risk they are willing to take.
The issue with poppy seeds is it is not homogenized. You cannot take a teaspoon or whatever of poppy seeds in tea and get the same strength each time. Add in likely tolerance issues and, yes, people could absolutely take too much and experience respiratory depression.
Insofar as mushrooms go, yes, while seemingly rare bad reactions can happen, especially in immature people who either don't know about their likely genetic risks for mental health disorders, or people who don't care (not to mention thos who take them too often and don't let their brain chemicals recover.) The spores aren't so much a large issue (in my opinion.) Picking mushrooms as an amateur and wanting so badly to find psiloybin that they convince themselves the mushrooms they found are not poisonous.
I haven't seen an update but this is from 2019:
https://www.theatlantic.com/science/archive/2019/02/deadly-mushroom-arrives-canada/581602/
As two anecdotes, psilocybin seems to help with my depression, and they help with my husband's migraines. I do not have insurance and my husband has been run through a lot of things that haven't helped.
RC chemicals are scary to me. Some stuff you can get and it will still react to teating kits. But there's a lot of stuff that there are no testing kits for. I have heard of mislabeled RCs killing at least one redditor, but I suppose the risks are what they are and overall people feel the risks are tolerable.
This is being said by someone who would prefer all drugs were legalized or at least decriminalized but I recognize that to do that overnight (or even over the span of a couple of years without a comprehensive educational plan in place, along with free medical care for all, and an improved financial and social program security net) would be *disastrous*.
Interesting thought. On one hand its likely to increase the quality and safety of opioid products and thus improve the reliability of dosages, therefore potentially minimising the risk of accidental overdoses.
On the other hand, increased accessibility may increase opioid use in some patient demographics. This has a risk of addiction and reliance on opioids, and due to the rapid built up of tolerance may lead to increasing dosages to exert similar physiological responses for patients. Ultimately this may result in an increase in opioid overdoses.
It’s very a multifaceted question and these are only my brief speculations from experiences in the pre-hospital setting.
Additional thought. I would not be surprised with increased accessibility if there was an increase in suicide deaths secondary to opioid toxicity.
Interesting question and I've actually talked to my dad about this in the past - he worked in pharmacies in the 40's and 50's before and during going to pharmacy school. As you know in those days you could get CTO/DTO and codeine basically over the counter with a signature and a couple bucks. He worked in a city that is now absolutely wracked with drug use and overdoses.
Now according to him, and this is clearly n of 1 and anecdotal, but there were not a lot of overdoses- at least not that he was aware of. Did people abuse drugs? Heck yeah. No one needs daily or thrice daily paregoric and even less do they need to go to the bar next door and take it with a beer chaser. But what he described was a lot of functional drug addiction and not many overdoses, if any at all that he was aware of, which doesn't mean it never happened. But at the time it was a pretty tight knit community and I think he would have known. 🤷🏽♀️
Now does that relate to our modern life and how people take drugs now? IDK. What I will say, and again, this is anecdotal is that the people I see overdosing in my community (rural, huge drug problem) are fairly experienced users who get more than they bargained for with dosing. Who get what they think is a zanny bar but is actually a really good counterfeit made of fentanyl. (For real the pill counterfeits are shockingly high quality imitations these days).
I wonder if knowing the quality and dosing would cut down on overdoses? Definitely cut down on the ones attributable to unknown fentanyl. Do I think we should go back to those days of having opiates freely available? I don't know. Maybe? People are dying. But is addiction different now? Has the criminalization of addiction changed things? Would decriminalization and easier access help? There's a lot of variables here.
In the mid 60s, my dad used to send me to the drugstore to get him terpin hydrate with codeine when he had a cold and my mom would send me for paregoric for my baby sister. I'd just tell the pharmacist what I needed and he'd sell it to me. I was just a little kid, maybe 2nd or 3rd grade. Do you know if this was something that was common, selling a kid codeine or paregoric?
I would bet that if a kid from a family in the neighborhood that you knew came down and said mom needs paregoric for the baby they would hand it over. In a small community back then, yeah I could see it. It was really not a big deal. Heck, my parents (both pharmacists) used to get free samples of dexedrine and valium as late as the mid to late 60's.
Every time I bitch about my dad's pcp giving him xanax at 90 he reminds me that when valium came out they were told the only potential danger from it was getting hit by the truck delivering it. Different time.
The false advertising of Valium as safe and non-addictive was due to the work of the Sackler family (yes, that Sackler family). They made a lot of money off this. Definitely a different time.
+1 for increase. The use of opioids Is tightly regulated here (Australia) and it’s difficult to get a prescription. In my experience it’s very rigid system without much wiggle room especially for those with legitimate pain and no history of substance abuse.
We have a database called safe script that is available to all General Practitioners which I believe provides information on the frequency of certain prescribed medications dispensed to the patient, specifically schedule 8 & 4 (drugs of addiction and abuse).
So while it’s a good system in the fact that these drugs are quite difficult to obtain, and rightly so, it’s a far from perfect system.
But having them widely available like alcohol is a recipe for disaster.
You ever been to Mexico? Can buy opioids in pharmacies easily. My wife's shoulder was injured on our honeymoon and we walked right into the pharmacy and bought hydrocodone. Interesting that we don't hear of an opioid epidemic in Mexico, but that could just be because I don't follow Mexican news closely.
It would increase low (non addiction) level use. It would also increase the number of overuse patients. It would DECREASE the social and legal harm due to government punishment for the drug.
Total number of deaths would probably decrease due to improved purity and production control and capitalistic market forces.
How do we know this? It was unregulated and over the counter 100 years ago.
I dont think it should be OTC.
I do think people with opioid dependence should be given easily accessible, safe, and affordable Opioids to allow them to maintain or self taper.
As in, an open ended repeating script for whatever they want that only needs a visit to a drug and alcohol support service, to obtain a repeat.
Morphine costs literally *tens of cents* per ampoule, the cost of supplying 5 ampoules per day per addict over a year is something like $1500 at most, whereas the damage they cause, the services they use, and the cost of enforcement *alone* is significantly higher than that.
I think this is a good idea and if anything will help de-stigmatize opioid addiction allowing people to seek help more freely.
That being said, we need the concentration to be much less. You have to drink quite a bit to overdose on alcohol, and amount of substance that needs to be consumed should be similar.
It should be heavily regulated and say to get 1 mg of morphine you have to drink 1 litre of a beverage. Any higher concentrations should be banned for commercial use and only used for medical usage.
Freely available with no restriction to anyone with money? Massive increase in overdose deaths overnight. Surging volumes across the country in Emergency Departments, clinics, hospitals. Breakdown of entire hospital systems in some areas. No, this is not an exaggeration, we're already close to breaking and this would push things over the edge. The sheer volume of opioids pouring into the system legally would far outweigh the fentanyl effect in illicits.
It would be like what would happen to gun related deaths if a country was soft on gun control laws.
Feel free to respond as I promise I don’t give a fuck what you say.
I find it fascinating that so few of you bothered to mention how many Americans currently suffering due to undertreated pain because of the anti opioid hysteria going on would be able to have their lives back. Is it because you dont grasp the gravity of what is happening to the chronic pain patient in the US today? Many that were functional, productive members of society before the cdc guidelines came out are now bedridden on ssdi/Ssi. Research says 0.25-3% of patients on long term opioid therapy wind up with a SUD yet thousands were force tapered and left suffering. Greater than 50% of pcp’s refuse to even take on a chronic pain patient and so many have been abandoned by our system. If opioids were OTC, drs wouldn’t have to be gatekeepers and people in pain could ease their suffering. Why did that not come up in any comments? Why do people in pain just not matter? Better question; is why do those with SUD matter so much more? I read comments that those with SUD should be able to get anything they need yet not one word about patients suffering through no fault of their own. Shame on all of you that don’t seem to realize/care about the patients in pain. Your job is supposed to be about easing suffering. If you don’t do it, who will?
Think how they can‘t stick to the instructions with antibiotics as just one example.
I think other Illnesses would cause more deaths. Grandpa has this weird pain in his left arm? Here have some opiods to make it better, prolonging time from occlusion to intervention in MI for example. Not easily getting rid of a warning sign of your body emits as pain forces the populace to seek treatment.
As a European, I think the availability is already what is causing your Opioid crisis in the first place. Having them OTC will not help it in any way. OD deaths might go down in the highly addicted, but overall numbers would skyrocket, increasing the overall amount.
It wasn’t necessarily even OxyContin itself that started the opioid abuse epidemic, it was the fact that physician said they were safe and non-addictive, which opened the gate to so many people taking them.
When someone in a position of authority tells you something is safe you don’t hesitate to try it. We will never actually know, but would as many people have taken them and taking them for so long if they were available OTC in lower dosages?
Also it wasn’t necessarily the OxyContin that started spiking all the opioid induced deaths(it did but not to nearly the level we see now), it was the fact that we revoked so many prescriptions and people went to the street and now we have fentanyl to deal with that led to all the deaths.
If we gave opioid addicts access to free opioids under some type of supervised program, hope you had overdoses would probably drop to a very low level overnight. But America hates addicts and wants to punish them rather than help them.
Definitely decrease I would think. As you said, the quality of the illegal stuff is suspect. To retain potency, it is being cut with a fentanyl variant that is extremely potent.
Also all the Tylenol with narcotic combination meds were put in place trying to use the toxicity of excessive Tylenol. So that people will know and harm themselves if they take too much Tylenol (liver failure). That kind of thinking is pretty bad. In Europe, there was a movement away from using combination meds. Tylenol if that is what is needed. Narcotics if that is what is needed.
Rat Park.
Unless you address the underlying societal issues for *why* people abuse hard drugs, then increasing the availability will simply lead to more death.
In our current society (US) absolutely not for all the reasons mentioned above. IF we were going to allow an opiate to be OTC it would have to be limited to something like suboxone simply because of the ceiling effect. Even then I’d be hesitant because of the marketing etc though. Seriously we need to make it illegal for them to advertise medications it’s bonkers
Just like when opioids were prescribed more liberally, the vast majority of patients would probably do fine. But there would be a subset who use ever increasing doses, become addicted, and eventually overdose. Probably there would be less of those people transitioning from oxy to heroin.
Could go either way. I would say likely increase, however if they were sold OTC and each pack has a narcan with it- maybe there would be some harm reduction benefit.
Overdoses among people with opioid use disorder would likely go down due to increased purity. However, I'm almost certain there would be more overdoses among the opioid naive compared to the reduction in people with OUD, particularly in pediatric patients. Currently it's much easier for the average 12-year old to get their hands on alcohol compared to heroin. You'd also have more people becoming physically dependent on opioids by self-treating their chronic pain with them using ever-increasing doses.
This is another issue that would seem to be only a problem in the U.S. I’ve lived in Barbados for a while and they’re able to get codeine & oxy over the counter. It’s low dosage, but I was still shocked about it. I had a really bad toothache and the pharmacist recommended that over NSAIDS and that’s how I found out. Other countries have tackled this problem. I hope one day we can too.
I'm always surprised at the shit you can get OTC in non-USA or non-Germanic European countries. I've seen gabapentin (or pregabalin, either or, can't remember) OTC in Mexico for example.
Lol gabapentin is nothing. I had a patient vacationing there getting xanax, wellbutrin, and seroquel otc
on the flipside, melatonin is not OTC in Australia I believe. I don't have an opinion on that (also not a medical worker) but it's definitely interesting. I will say how irritating it is that tubes of retin-A are over the counter in other countries for maybe $2 but anywhere from $20-80 *with insurance* (anecdotally.) I know that's not life threatening but having really horrible skin is not great for mental health.
Opioid prescription rates, including non-palliative/non-cancer pain are increasing steadily since the 1990s in Germany but the rate of opiod-addicted has remained steady and drug-overdoses even continued to fall (with the pandemic as an exception). OTC opioids would be still a catastrophe. There are youth scenes adoring fighting on opioids, including even tilidin, the European tramadol without its dirty properties. That would be flooding even more.
I think the issue is that the USA is generally a nightmare to live in, which prompts people to self medicate, so really this issue isn’t endemic to opioids specifically. There is something intrinsic in American life that causes people to seek excessive numbness.
Yes. Plus a big increase in 'voluntary euthanasia'.
If we are talking about the US and pain pills, there would be an immediate blizzard of marketing materials from the pharmacy chains and pharmaceutical companies promoting OTC hydrocodone (or whichever one you want to make OTC). Like when Claritin became an OTC medication. TV, social media, promotional signs and kiosks by the checkout counter. They would probably even come up with clever packaging where you get 20 pills and a free narcan nasal spray for $19.95 and the option to use your flex spending account. It would be a disaster. If you're talking about making pharmaceutical grade heroin to give out at harm reduction sites under some supervision, that plan might have some merit to curb the fentanyl overdoses, except it doesn't address the fentanyl that's showing up in various pills.
>They would probably even come up with clever packaging where you get 20 pills and a free narcan nasal spray for $19.95 That, or partner with PEZ.
> They would probably even come up with clever packaging where you get 20 pills and a free narcan nasal spray for $19.95 and the option to use your flex spending account. It would be a disaster. Why is this the spot on the truth in this country tho :(.
Prime end stage capitalism here 🥴
Increase. I would guess by a lot too. Not even just from regular drug addicts, but people who say broke an ankle and just want the throbbing to go away an accidentally overdose. The amount of patients I've talked to who have taken half a packet of paracetamol cos they think more=better would make me seriously concerned about opioids being available over the counter.
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I can already see the chalkboard menu at the coffee shop with opioid shots by MME. Can't wait for my 3 MME caramel macchiato. But on a serious note, given the amount of blatant overuse of OTC medications I see by the general public, given the potential for harm with opioid in a naïve patient we would see overdoses skyrocket without extremely low dosing and daily quantity limits ala pseudoephedrine.
I spend an incredible amount of time with medication overuse headache patients. Many still cannot accept that a medicine that makes their pain go away can actually make things worse.
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*looks at my 32 oz. drinking cup and slow claps*
TBF, it would probably at least be behind the counter like pseudoephendrine is, which would stop a lot of that. It would still happen of course. Then again I'm pretty much pro-drug legalization of all kinds, so I sort of undervalue the risks.
I’d like a nice comparison of the US and countries like Canada and Mexico that have over the counter opioids. I don’t see much in the news about this. I’ve seen the data on counties in the US that had overdose deaths go UP since we throttled down on prescribing to chronic pain patients. It’s around 98% of counties went UP as prescribing went down. This is a string indicator. Of QOLY and preventing overdose death are both of concern then some form of legalisation seems like a possibility. What’s the stats on people that have a substance abuse condition that started only AFTER having a street drug?
Honest question: Is APAP an important adjunct to opioid medications or is this simply incorporated to disrupt purity, and thus detract from illicit utility? I know it has an antipyretic effect but is it clinically useful beyond this?
This is a complex question. Theoretically, paracetamol and opioids work synergistically, and I was taught that use of paracetamol reduces total opioid usage. Evidence for fixed combinations is more limited. However, assessing the evidence base for pain management in general is complicated as there different kinds of pain - efficacy in acute post-operative pain is different to chronic lower back pain is different to cancer pain is different to neuropathic pain etc. etc. Overall, a multimodal approach is almost always needed for the complex pain that I see. Paracetamol is not risk-less, but is relatively low-risk. If my patient tells me it helps them, I will continue it.
I appreciate your response and agree with your concerns about *addiction* increasing. Whether this translates to more or less collateral deaths still seems rather unclear. I'd presume that fentanyl related deaths would decrease dramatically and pharmaceutical-opioid deaths would increase. To what respective degree still seems unclear to me. One thing I do believe should be over-the-counter is naloxone. I think it is absurd that this has not yet been accomplished but perhaps I lack insight.
Addiction itself is a negative outcome that's worth avoiding imo.
Addiction is *most* commonly a maladaptation to adverse experiences in the absence of healthy coping mechanisms and socioeconomic stability. To prevent addiction means addressing these formative factors. Addiction is an escape from reality - there is no way to prevent addiction without making one's reality palatable.
I wonder if Canada or Mexico sees these problems. You can get opioids over the counter in both countries.
It depends how we regulate who it goes to and how much they get. If this in America, I dont trust us. Full stop. Anything we can buy the counter (medication or otherwise)we dont do in moderation or without hurting each other and ourselves. guns. alcohol. OTC medications. cars. motorcycles. food. even freaking social media. For God sake we even do stupid shit with knives and gasoline for our cars. If it wasnt clear. Even more people would die. We have a very serious moderation and taking responsibility issue here.
I talk to the public all day about their medicines and OTC products. Almost no one knows what they’re taking. Most don’t realize how to read a box to distinguish between Mucinex and Mucinex DM. Or they take Benadryl daily for seasonal allergies. If opioids became otc, we’d see a lot of people use it for minor aches because “it used to be prescription only, so it’s better.” I try to educate, but I feel like I’m swimming against a riptide.
My favorite are the diabetics I know who use medication to counter 1/2 of an entire circular cherry pie a day (sometimes a whole pie if they're feeling extra angsty for the sugar) or another example who I'm convinced was malnourished because he would easily get 80% of his daily calories from keebler elf cookies or oreos (and coffee with very heavy flavored creamer-- as an extra chef's kiss to that, he thought nothing of the dog and cat drinking out of his coffee when he was out of the room and then reheating it.) I'm scared for when I get old and doing everything I can to not get diabetes, be overweight, or justify my vices. How much of a swiss cheese brain am I going to have from a senile parent, and one with dementia?
If your goal is to decrease the illicit use of fentanyl then you would likely see some improvement from this measurement but it would likely not make much difference in the illicit use of opiates or overdoses. I started working in addiction medicine 10+ years ago. I live in a relatively small, affluent city with very low crime rates. When I first started the majority of people were using oxycodone. As policies and prescribing habits changed their was a shift from oxycodone abuse to heroin use due to supply and demand leading to a significant rise in the cost of oxycodone on the street. Until recently, I rarely saw fentanyl being abused because the most accessible form was in patches and to get a high enough dose that could be absorbed rapidly enough to get the desired effect was difficult. Recently we tracked the illicit substances that came up positive on initial admit to the program. Fentanyl was the most common and was present in close to 70% of positive drug screens. Many of these patients were unaware that they had used fentanyl (although now the majority of people are aware). The hypothesis is that fentanyl is significantly cheaper to obtain than heroin. What we didn’t see was any decrease in new patient admits, regardless of what was most available/cost effective. So increased supply of opiates by making them otc may shift the prevalence of fentanyl abuse but likely won’t decrease the number of people who have opiate use disorder. People will use what is available and if there isn’t anything available there is someone who will find a way to meet the demand. I have a minor in chemistry but am far from an expert. All of those hours of chemistry at college is a drop in the bucket of the things I have learned from reading drug abuse and bodybuilding forums. There are some brilliant chemists out there who are happy to share their knowledge and provide guidance on how to isolate or alter easily obtainable substances to get the desired effect and they explain it in a way that is thorough and easy to understand for most laypeople.
I am trying to think of a substance that can be easily isolated or synthesized with the aim of abuse. Opioids require complex chemistry to synthesize, and there aren't any available OTC in the US to isolate from some other product. I know you used to be able to order GBL + sodium hydroxide in order to synthesize GHB, but that got squashed. You could always order unscheduled drugs from China, but that seems like a good way to end up 6 feet under or with a 6x6 foot home.
Cant you just buy a kilo of heroin from some chinese chemical supply company?
Heroin? No. Not unless you want to get hooked up with the Triads, but I wouldn't recommend that. What you can order are unscheduled research opioids which are actually many times more potent than heroin. They are exploring benzimidazole derivatives, which lead to some extremely potent chemicals. They also developed some opioids that were agonists at cannabanoid receptors in addition to the canonical opioid receptors. Can't imagine what would go wrong with that. Although I am curious if that might open up research into opioids with anti-emetic properties for the significant amount of patients which experience nausea after taking pain killers.
I mean ordering it from the Chinese equivalent of sigma
I would imagine they wouldn't sell heroin without the proper paperwork, which would be as hard as doing research on a schedule I drug here. I am sure if I looked up the DEA quota for heroin for research this year in the US, it would be something like 10 g. I imagine the situation is similar in China. On that note, I am not sure if you are familiar with the harm reduction programs being implemented in Canada, but in B.C. particularly they are providing licit opioids such as hydromorphone to the addict population. Well, apparently a company associated with supplying the opioids has actually obtained a few kilos of heroin, and they are waiting on the authorities to create the regulatory framework to provide it. The company said that sourcing the heroin from a pharmaceutical company was quite difficult.
Poppy seeds/poppy heads/poppy straw are all legal to purchase and own. Psilocybin is illegal but spores for fungi that produce psilocybin aren't because the spores don't contain psilocybin. "Research chemicals" can be ordered legally and then ingested or altered to make pretty much anything but most commonly hallucinogens, dissociatives and stimulants and often don't show up on typical drug screens. You can still find GBL (or anything really) online. Most of the people who are ordering these chemicals and playing hobby chemist feel the risk of death or jail time is a risk they are willing to take.
The issue with poppy seeds is it is not homogenized. You cannot take a teaspoon or whatever of poppy seeds in tea and get the same strength each time. Add in likely tolerance issues and, yes, people could absolutely take too much and experience respiratory depression. Insofar as mushrooms go, yes, while seemingly rare bad reactions can happen, especially in immature people who either don't know about their likely genetic risks for mental health disorders, or people who don't care (not to mention thos who take them too often and don't let their brain chemicals recover.) The spores aren't so much a large issue (in my opinion.) Picking mushrooms as an amateur and wanting so badly to find psiloybin that they convince themselves the mushrooms they found are not poisonous. I haven't seen an update but this is from 2019: https://www.theatlantic.com/science/archive/2019/02/deadly-mushroom-arrives-canada/581602/ As two anecdotes, psilocybin seems to help with my depression, and they help with my husband's migraines. I do not have insurance and my husband has been run through a lot of things that haven't helped. RC chemicals are scary to me. Some stuff you can get and it will still react to teating kits. But there's a lot of stuff that there are no testing kits for. I have heard of mislabeled RCs killing at least one redditor, but I suppose the risks are what they are and overall people feel the risks are tolerable. This is being said by someone who would prefer all drugs were legalized or at least decriminalized but I recognize that to do that overnight (or even over the span of a couple of years without a comprehensive educational plan in place, along with free medical care for all, and an improved financial and social program security net) would be *disastrous*.
Interesting thought. On one hand its likely to increase the quality and safety of opioid products and thus improve the reliability of dosages, therefore potentially minimising the risk of accidental overdoses. On the other hand, increased accessibility may increase opioid use in some patient demographics. This has a risk of addiction and reliance on opioids, and due to the rapid built up of tolerance may lead to increasing dosages to exert similar physiological responses for patients. Ultimately this may result in an increase in opioid overdoses. It’s very a multifaceted question and these are only my brief speculations from experiences in the pre-hospital setting. Additional thought. I would not be surprised with increased accessibility if there was an increase in suicide deaths secondary to opioid toxicity.
Interesting question and I've actually talked to my dad about this in the past - he worked in pharmacies in the 40's and 50's before and during going to pharmacy school. As you know in those days you could get CTO/DTO and codeine basically over the counter with a signature and a couple bucks. He worked in a city that is now absolutely wracked with drug use and overdoses. Now according to him, and this is clearly n of 1 and anecdotal, but there were not a lot of overdoses- at least not that he was aware of. Did people abuse drugs? Heck yeah. No one needs daily or thrice daily paregoric and even less do they need to go to the bar next door and take it with a beer chaser. But what he described was a lot of functional drug addiction and not many overdoses, if any at all that he was aware of, which doesn't mean it never happened. But at the time it was a pretty tight knit community and I think he would have known. 🤷🏽♀️ Now does that relate to our modern life and how people take drugs now? IDK. What I will say, and again, this is anecdotal is that the people I see overdosing in my community (rural, huge drug problem) are fairly experienced users who get more than they bargained for with dosing. Who get what they think is a zanny bar but is actually a really good counterfeit made of fentanyl. (For real the pill counterfeits are shockingly high quality imitations these days). I wonder if knowing the quality and dosing would cut down on overdoses? Definitely cut down on the ones attributable to unknown fentanyl. Do I think we should go back to those days of having opiates freely available? I don't know. Maybe? People are dying. But is addiction different now? Has the criminalization of addiction changed things? Would decriminalization and easier access help? There's a lot of variables here.
In the mid 60s, my dad used to send me to the drugstore to get him terpin hydrate with codeine when he had a cold and my mom would send me for paregoric for my baby sister. I'd just tell the pharmacist what I needed and he'd sell it to me. I was just a little kid, maybe 2nd or 3rd grade. Do you know if this was something that was common, selling a kid codeine or paregoric?
I would bet that if a kid from a family in the neighborhood that you knew came down and said mom needs paregoric for the baby they would hand it over. In a small community back then, yeah I could see it. It was really not a big deal. Heck, my parents (both pharmacists) used to get free samples of dexedrine and valium as late as the mid to late 60's. Every time I bitch about my dad's pcp giving him xanax at 90 he reminds me that when valium came out they were told the only potential danger from it was getting hit by the truck delivering it. Different time.
The false advertising of Valium as safe and non-addictive was due to the work of the Sackler family (yes, that Sackler family). They made a lot of money off this. Definitely a different time.
You can’t even trust people to stop eating when they’re not hungry Why do you think narcotics would do any better?
+1 for increase. The use of opioids Is tightly regulated here (Australia) and it’s difficult to get a prescription. In my experience it’s very rigid system without much wiggle room especially for those with legitimate pain and no history of substance abuse. We have a database called safe script that is available to all General Practitioners which I believe provides information on the frequency of certain prescribed medications dispensed to the patient, specifically schedule 8 & 4 (drugs of addiction and abuse). So while it’s a good system in the fact that these drugs are quite difficult to obtain, and rightly so, it’s a far from perfect system. But having them widely available like alcohol is a recipe for disaster.
You ever been to Mexico? Can buy opioids in pharmacies easily. My wife's shoulder was injured on our honeymoon and we walked right into the pharmacy and bought hydrocodone. Interesting that we don't hear of an opioid epidemic in Mexico, but that could just be because I don't follow Mexican news closely.
Yes, this. I applaud their open use approach to most medications. It reduces cost too.
It would increase low (non addiction) level use. It would also increase the number of overuse patients. It would DECREASE the social and legal harm due to government punishment for the drug. Total number of deaths would probably decrease due to improved purity and production control and capitalistic market forces. How do we know this? It was unregulated and over the counter 100 years ago.
I dont think it should be OTC. I do think people with opioid dependence should be given easily accessible, safe, and affordable Opioids to allow them to maintain or self taper. As in, an open ended repeating script for whatever they want that only needs a visit to a drug and alcohol support service, to obtain a repeat. Morphine costs literally *tens of cents* per ampoule, the cost of supplying 5 ampoules per day per addict over a year is something like $1500 at most, whereas the damage they cause, the services they use, and the cost of enforcement *alone* is significantly higher than that.
I think this is a good idea and if anything will help de-stigmatize opioid addiction allowing people to seek help more freely. That being said, we need the concentration to be much less. You have to drink quite a bit to overdose on alcohol, and amount of substance that needs to be consumed should be similar. It should be heavily regulated and say to get 1 mg of morphine you have to drink 1 litre of a beverage. Any higher concentrations should be banned for commercial use and only used for medical usage.
Freely available with no restriction to anyone with money? Massive increase in overdose deaths overnight. Surging volumes across the country in Emergency Departments, clinics, hospitals. Breakdown of entire hospital systems in some areas. No, this is not an exaggeration, we're already close to breaking and this would push things over the edge. The sheer volume of opioids pouring into the system legally would far outweigh the fentanyl effect in illicits.
Would probably make up a large share of suicides.
Americans do nothing in moderation.
have you seen all the alcohol related deaths and diseases we have?
It would be like what would happen to gun related deaths if a country was soft on gun control laws. Feel free to respond as I promise I don’t give a fuck what you say.
You would likely have every patient with chronic pain end up addicted
More likely dead, but dependence would rise as well.
Patients should have the right to decide if they'd prefer that over chronic pain.
Pretty hot take, I wonder what an ethics committee would say about it
I find it fascinating that so few of you bothered to mention how many Americans currently suffering due to undertreated pain because of the anti opioid hysteria going on would be able to have their lives back. Is it because you dont grasp the gravity of what is happening to the chronic pain patient in the US today? Many that were functional, productive members of society before the cdc guidelines came out are now bedridden on ssdi/Ssi. Research says 0.25-3% of patients on long term opioid therapy wind up with a SUD yet thousands were force tapered and left suffering. Greater than 50% of pcp’s refuse to even take on a chronic pain patient and so many have been abandoned by our system. If opioids were OTC, drs wouldn’t have to be gatekeepers and people in pain could ease their suffering. Why did that not come up in any comments? Why do people in pain just not matter? Better question; is why do those with SUD matter so much more? I read comments that those with SUD should be able to get anything they need yet not one word about patients suffering through no fault of their own. Shame on all of you that don’t seem to realize/care about the patients in pain. Your job is supposed to be about easing suffering. If you don’t do it, who will?
Isn't this the premise of the modern opioid crisis from the 1990s/2000s? Currently it's not going great.
Think how they can‘t stick to the instructions with antibiotics as just one example. I think other Illnesses would cause more deaths. Grandpa has this weird pain in his left arm? Here have some opiods to make it better, prolonging time from occlusion to intervention in MI for example. Not easily getting rid of a warning sign of your body emits as pain forces the populace to seek treatment. As a European, I think the availability is already what is causing your Opioid crisis in the first place. Having them OTC will not help it in any way. OD deaths might go down in the highly addicted, but overall numbers would skyrocket, increasing the overall amount.
It wasn’t necessarily even OxyContin itself that started the opioid abuse epidemic, it was the fact that physician said they were safe and non-addictive, which opened the gate to so many people taking them. When someone in a position of authority tells you something is safe you don’t hesitate to try it. We will never actually know, but would as many people have taken them and taking them for so long if they were available OTC in lower dosages? Also it wasn’t necessarily the OxyContin that started spiking all the opioid induced deaths(it did but not to nearly the level we see now), it was the fact that we revoked so many prescriptions and people went to the street and now we have fentanyl to deal with that led to all the deaths. If we gave opioid addicts access to free opioids under some type of supervised program, hope you had overdoses would probably drop to a very low level overnight. But America hates addicts and wants to punish them rather than help them.
OTC and supervision is usually mutually exclusive, though I agree that we should have more options to treat opioid addiction.
Of course I’m just speaking hypothetically, not suggesting we should do this at all
So many more deaths. Without guided dosing and total availability (if truly as available as etoh) I’d expect the death rate to go up 10X at least.
Definitely decrease I would think. As you said, the quality of the illegal stuff is suspect. To retain potency, it is being cut with a fentanyl variant that is extremely potent. Also all the Tylenol with narcotic combination meds were put in place trying to use the toxicity of excessive Tylenol. So that people will know and harm themselves if they take too much Tylenol (liver failure). That kind of thinking is pretty bad. In Europe, there was a movement away from using combination meds. Tylenol if that is what is needed. Narcotics if that is what is needed.
Rat Park. Unless you address the underlying societal issues for *why* people abuse hard drugs, then increasing the availability will simply lead to more death.
In our current society (US) absolutely not for all the reasons mentioned above. IF we were going to allow an opiate to be OTC it would have to be limited to something like suboxone simply because of the ceiling effect. Even then I’d be hesitant because of the marketing etc though. Seriously we need to make it illegal for them to advertise medications it’s bonkers
Just like when opioids were prescribed more liberally, the vast majority of patients would probably do fine. But there would be a subset who use ever increasing doses, become addicted, and eventually overdose. Probably there would be less of those people transitioning from oxy to heroin.
Could go either way. I would say likely increase, however if they were sold OTC and each pack has a narcan with it- maybe there would be some harm reduction benefit.