I’m not a doctor, and I don’t know much about the opioid crisis. I’m a user. I’m on the demand side of the business. There are probably more than 100 million people like me in the United States and perhaps a billion worldwide. I want to tell my story, hoping it will influence the conversation.
I use narcotics and have for decades. Here is how I classify the drugs I have used:
- Entry level: Codeine, Darvon, Valium, Vicodin
- Mid-level: Oxcyontin, Percoset, Morphine
- High-level: Fentanyl
Fentanyl is my favorite. Fentanyl killed Prince, Tom Petty, and now kills about 30,000 Americans a year.
Before I continue, I want to mention that I drink about one glass of red wine a month. For some genetic reason, all hard alcohol tastes like battery acid to me. I have never smoked, taken heroin or cocaine, and I can’t stand the taste and smell of marijuana.
What Drives me to Use Narcotics
Here is my dirty little secret: I am an adrenaline junkie. I always have been. I ski, rock climb, ice climb, run, bike race, scuba dive, bungee jump, rollerblade competitively, jump out of airplanes, and do stupid things when given the opportunity to jump off something or tear a ligament. I’ve had shoulder surgery, two knee surgeries, ankle reconstruction, two broken hips with titanium inserts, over 100 stitches above the neck, and had two vertebrae fused. At age 49 I was diagnosed with AFIB, possibly as a result of my extreme sports habit. I have had my heart shocked twice and had two ablations. I’ve broken all my foot bones at least once. I have chronic knee pain in both knees and still run 20 miles a week. I suffer from chronic pain in one shoulder. Because my teeth are so sensitive to temperature, I’ve had about eight root canals and as many crowns. I have one molar implant.
I’ve seen the ceilings of a lot of hospital emergency rooms. Whenever I have the chance to get a prescription for a bottle of narcotic pills, I take it. I hoard them.
How I Use Narcotics
Now, here’s the important part: I use narcotics as effective painkillers. Once the pain is gone, I have no desire for more. I have had oral and injected morphine in the hospital and didn’t miss it after several days of constant injections. Once the pain stops, I am done. I hoard them because I self-medicate: when I can’t stand the pain any longer, I get a pill from my stash and take it. I can’t remember ever taking two pills on two days — I usually just need enough to get me through the night.
I have a friend who feels nervous being in the same room with a bottle of Morphine. He tells me that if he starts he can’t stop. He recently had wrist surgery with no anesthetic, because both he and his doctor believed he would be worse off in the long run if he got any narcotics into his body.
That’s not me. I live for adventure. About every ten years, I have major reconstruction of some part of my body. I’m used to it and don’t mind paying the price for my habit.
I get exactly the use of a narcotic it was designed for and no more.
A Big Piece of the Puzzle
The opioid crisis is very complex. Smart people disagree about the numbers, because it’s tricky to determine what actually causes death in many cases. The many causes of “abuse” or “misuse” of drugs is not well understood. Still, in the United States, we might conservatively estimate that more than 100 people die daily from an overdose of narcotics.
Here’s the key statistic, from that document I just linked to:
Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them.
So perhaps as many as 75 percent of patients are more like me. Without breaking it down carefully, there could be more than 100 million people in the United States who don’t have chronic pain and can safely use them for pain relief as needed. It’s gotten more and more difficult for us to get painkillers when we need them.
Finding a Supplier
When I fell 30 feet off a rock in Central Park, I went to the emergency room, where they refused to give me any pain killers, fearing I was just telling them a story to get narcotics. My knee was badly swollen, yet the hospital rules would not let me get pain relief without a doctor’s exam, which had to be postponed until the next day. That night was agony.
When I fell ice skating in Zurich and couldn’t get up because my hip was broken, the ambulance person came and started a line of Fentanyl immediately, waited for it to kick in, and then moved me onto the gurney and into the ambulance. That was when I learned how amazing Fentanyl is. It’s a wonder drug. It removed the pain, yet it left me clear-headed enough to do research on my phone about the upcoming operation, call family, and manage my medical affairs. The Zurich hospital kept me comfortable until I went into the operating room.
Two years later when I broke the other hip in London, the idiot ambulance driver made me hop up the ladder into the ambulance, causing me some of the most intense pain I have ever experienced. I told him I have an intertrochonteral fracture of the left femur, and he said I probably just had a bruise or a sprain. I asked for Fentanyl, but he laughed and gave me 400 mg of Tylenol. At the hospital, they gave me a bit more Tylenol. They said they never give Fentanyl to patients — it’s too expensive. I asked for Codeine (cheap) and was denied until it was time to go to the operating room.
Moving a patient with a broken femur sounds like this:
“Okay everybody, one … two … three!”
Been there. Done that.
So I hoard these pills and travel with them. I never know when I’ll need them. Many years ago, a friend gave me an old bottle of Vicodin he didn’t need. That bottle lasted me ten years. In my experience, a ten-year-old pill is about 80 percent as effective as a new one. I would gladly give a pill to a friend who was in pain but have never had to.
Most days, I have shoulder pain and work through it. Last week I had diabolical shoulder pain. I can’t work and can’t sleep when it’s that bad, which is about 3–4 times a year. So I took an Oxycontin. It let me keep working through the evening, stay clearheaded through a complex banking transaction, and get to sleep easily. I didn’t need another one the next day.
I had three separate oral surgeries this year to install an implant. The doctor said I should take some Tylenol. Thankfully, I had my narcotics and was able to take a pill on three separate evenings, spread several months apart.
I don’t have many Oxycontin left. I can’t ask a friend who is a doctor to write me a prescription — all narcotics are now very carefully controlled. It would be foolish to order pills from India or China, because these days they could simply be deadly. That means I can’t get a bottle of pills unless I get really hurt again. I should start taking more risks!
The Problem with Opioids
In the old days of Codeine, Valium, and Darvon, narcotics were agricultural products. They were often derived from poppies in Afghanistan and other far-off places. These days, we have Carfentanyl, a synthetic narcotic:
Short acting and with fast onset, Carfentanyl has, weight for weight, around one hundred times stronger effects than fentanyl and thousands of times stronger than heroin. It is more effective at reducing pain response in rats than any other opioid.
Carfentanyl is made by many labs and in many different strengths. It’s cheap. It’s easy to get into the country. At its most concentrated, the amount in a normal size suitcase could kill everyone in Boston. This is what makes the opioid epidemic so deadly — people easily kill themselves with uncut or poorly dosed Carfentanyl.
It’s not the Drugs that Are the Problem
Two important things to take home about the opioid crisis:
First, it’s mostly not people’s fault. The number of people using drugs for fun or just to relax is very small. Many people die each year as a result of chronic pain and a dysfunctional system that leaves people lonely and in despair, coming back for more drugs — and getting them — when that’s not what they need. Listen to Alex Cahana break it down:
Second, it’s still not people’s behavior. Genetics are a huge driver. Here are some relevant papers:
- Are there genetic influences on addiction: evidence from family, adoption and twin studies
- Genetic influences on impulsivity, risk taking, stress responsivity and vulnerability to drug abuse and addiction
- Epigenetics of drug abuse: predisposition or response
We see much the same thing with alcohol abuse. Danielle Dick tells the story of her research on the genetic causes of addiction. We are learning more and more that addiction is more driven by genetics than by some “addictive” properties of the substances.
For me, it’s definitely genetic. I don’t seek meds. I seek adrenaline, and we know there’s a genetic component to that.
Addicts vs Patients
It’s extremely difficult to tell addicts from patients in pain, because both report the same symptoms. As Scott Alexander says,
The average doctor treats “addiction” and “drug-seeking behavior” as synonymous. This paper lists signs of drug-seeking behavior that doctors should watch out for, like:– Aggressively complaining about a need for a drug
– Requesting to have the dose increased
– Asking for specific drugs by name
– Taking a few extra, unauthorised doses on occasion
– Frequently calling the clinic
– Unwilling to consider other drugs or non-drug treatments
– Frequent unauthorised dose escalations after being told that it is inappropriateYou might notice that all of these are things people might do if they actually need the drug.
Those of us who actually need the drug are severely underrepresented, because the pendulum has swung too far toward “preventing the opioid epidemic.”
An App to Take Pills?
I don’t have the perfect solution, but if I had an insurance or doctor app that knew my track record, I could just ask it to help me get the meds I need. I wouldn’t need to hoard pills if I could easily get a few of them before going on a trip or having oral surgery. It could check for drug interactions. I could have a few pills at home and tell the app I’m taking one. The system could see if I’m getting six a week or six a year, so it could prevent me from passing pills to others. With my track record, I should be able to walk into any drug store on a Saturday afternoon and come out with two Oxycontins. That’s all I need. The ambulance drivers could start me on Fentanyl, because my app will tell them I get hurt more often and more badly than average, I have osteoporosis, and I’m not there to get drugs for other purposes.
The app would be part of my primary-care physician’s services. Today, a physician can’t give me a prescription for even one pill without a doctor’s visit and a lot of justification on his end. (Doctors are under intense scrutiny as a result of a small number of doctors prescribing far too many opioid pills as a service to junkies.) The app should help me determine what I need. For example, a headache could just be a headache, but it could also be a concussion. The app could get me to the right doctor, emergency room, or specialist, or it could just give me a prescription and send me to the pharmacy.
Ideally, we discover new drugs that are more effective and less likely to lead to harm. Eventually, we may use DNA tests to help. In the meantime, those on the front line of the opioid epidemic struggle to create a reasonable framework of diagnosis, treatment, and life-saving interventions.
If we were to draw a Venn diagram of opioid use, it would be very complex and very blurry, and it would probably need to be updated as soon as it was finished. Despite strongly increased regulation, tens of thousands of Americans die of prescription opioid overdose each year. A lot of people suffer from both acute and chronic pain. Many have complex family histories and genetic tendencies toward addiction. Many don’t. It’s impossible to make a single set of rules that fits even fifty percent of cases.
I’m speaking for those of us who can successfully self-medicate and have been discriminated against. There could be hundreds of millions of people worldwide who would benefit from easy access to pain meds. Yet the system is making it increasingly difficult — and dangerous — for everyone.
David Siegel is a thought leader in blockchain and an expert on digital money. He is the author of The Token Handbook and the Digital Money Book. His new project can be found at Permissionless Finance. You can find all of his writing at www.dsiegel.com