Talk:Opioid/Archive 1

No title
I have merged the previous text for opiate into this expanded entry for opioid, and created a redirect from opiate.

As the article says, the word "opioid" is now the preferred general medical and scientific term for any drug, natural or synthetic, that behaves like opium on the central nervous system. "Opiate" is a more restrictive term that applies only to natural and semi-synthetic opioids, so I thought it made sense to perform this restructuring.

User: karn

I have now also merged in the contents of opioid analgesic, added some text, and created a redirect. The list of opioids is not complete, and the various classifications need checking.

User: karn

I am not particularly happy with the opening sentence referring to opium. I think this is a little unfortunate to imply all drugs listed below are opium derivates or opioid receptors are in any way sensitive to opium. It'd be better to mention opium later on in the article. Kpjas

How would you reword it? The definition of "opioid" *is* in fact any drug that mimics the effects of opium in the body, whether or not the drug is actually made from opium. Perhaps it would be better to say that an opioid is any drug that mimics the effects of *morphine*, the primary alkaloid in natural opium? User:Karn

Okay, I've reworded the opening to drop the first reference to opium, and to then refer to it as a source of morphine. I also added brief references to the three subtypes of opioid receptors. How does that look? User:Karn

Two questions:

1) Should I create a redirect from pentazocine (on this page) to Talwin? (I know Talwin is not the best entry for the subject - but I don't have the knowledge to improve on it)
 * I think Talwin>>>pentazocine is better, best to have the article under the chemical name, since the patent on Talwin will eventually expire, but the chemical name will not. 'think long term'.  cheers.Pedant 22:49, 2004 Nov 11 (UTC)
 * Thanks. [for doing it and for educating me] (I'm learning as I go.) CJewell 14:51, 26 Nov 2004 (UTC)

2) Aren't there 5 opioid receptors, not 3?
 * I remember the two pages mismatching to the point of being contradictory. They're clearer (and they match) now. CJewell 14:51, 26 Nov 2004 (UTC)

CJewell

Hi Fugg: recreational use of opioids is abuse. Period. JFW | T@lk  13:50, 5 Nov 2004 (UTC)

taken from here

Jfdwolff: I object to 'abuse' because it is pejorative. I see no reason to use it when 'recreational use' is a perfectly useful and neutral term. Fugg 03:01, 6 Nov 2004 (UTC)


 * See your talk. JFW | T@lk  11:42, 11 Nov 2004 (UTC)

"Recreational use"

 * I have reworded the article slightly for neutral point of view, not all addicts are 'recreational users' and not all recreational users are 'addicts', changed to user in one case rather than either recreational user or addict /changed another instance to chronic user as, addiction is not required for "ramp effect" and "ramp effect is not typically noted in the mere 'recreational user', furthermore, the term "recreational" is misleading , see Recreation would prefer either simply user, when appropriate, or chronic user, or even non-medical user, but I think this version should feel good for all of us.Pedant 22:45, 2004 Nov 11 (UTC)


 * I'm quite happy with Pedant's re-write Fugg 05:18, 12 Nov 2004 (UTC)


 * Use of opioids for anything but analgesia is inappropriate use, whether recreational or not. I'm happy with Pedant's rewrite, but the article now needs more structure. JFW | T@lk  22:51, 13 Nov 2004 (UTC)


 * Agreed. I've done a subedit with a more clinically-oriented narrative and structure - hopefully it's still relatively NPOV. Techelf 03:45, 22 Nov 2004 (UTC)


 * Assume the opioid in question to be loperamide. With no further discussion, your viewpoints are proven invalid (to save you time, loperamide's 'on-label' use is to relieve diarrhoea).  Now please immediately and completely recant them.  It's safest to take no viewpoint -- also please know that darvocet can help hypersalivators or hypersecretors and any opioid can prevent a person from dying of dysentery.  DrMorelos 00:38, 25 November 2006 (UTC)


 * Stating that non-medical use of opioids is abuse is clearly a POV statement -- namely the point of view of prohibitionists. Of interesting note is that during the Temperance movement, a number of alcohol prohibitionists found absolutely no problem with using opium and morphine as a replacement for alcohol.  The only way to properly handle this NPOV issue is (as Wikipedia policy promotes) to provide both sides of the argument.  That is that some consider all non-medical use of opioids as abuse, and others believe that responsible recreational use of opioids is a reality (of which there is plenty of historical literature to back up).  --Thoric 21:09, 30 Nov 2004 (UTC)


 * If I may interrupt, I am presently a clinical physician (secret: I want out), but my education began with two degrees in mathematics. The number of fallacies I read below this is greater than three, but I would appreciate if you folks would consider the following isuse: while we are sitting around trying to agree on a definition for the word abuse, the actual definition on which we should focus is medical versus non-medical.  Abuse is too open to interpretation and bizarre rationalization to be made tangible even by a bunch of intellectuals such as yourselves; the medical versus non-medical discussion has some legal starting points and plenty of wiggle room for employment of the socratic method to find a reconcilable dividing line.  Do you find this a reasonable approach?  DrMorelos 00:57, 25 November 2006 (UTC)

There's POV and there's POV. From a legal AND medical view, opioid abuse is exactly that. Why do we need to lend credence to those who dispute those well-held opinions? Cool, their opinion deserves mention, but I'm not aware of a society/group that promotes decriminalisation of opioid abuse. UNTIL it has been decriminalised, the moniker "abuse" is not POV, pretty much as "speeding" is defined by the speed limit on the road you're driving on. JFW | T@lk  21:51, 30 Nov 2004 (UTC)


 * Laws are constantly in a state of flux, as are scientific and medical views. Opium has over 5000 years of recreational use.  80 years of anti-narcotics legislation is a small blip in comparison.  Noted historical authors, philosophers, scientists and doctors have used and abused opioids.  Certainly it is to the interest of prohibitionists to black out all research on the grey area of recreational use between drug addiction and medicine, but that doesn't erase it from history.  As for groups that support it, there is a growing movement to legalize all drugs.  I can provide links to several groups, political parties and organizations if you are interested.  --Thoric 22:35, 30 Nov 2004 (UTC)

Under the present legislation, "abuse" is pretty well defined. Your attempt at NPOV is laudable, but a bit overdone. Do we also need to NPOV murder to allow for the thousands of years that killing for the sake of religion was considered a virtue? Again, I am not intent on suppressing the views of the political/users' groups, but I do not want you to suppress the perfectly reasonable use of the word "abuse" where this is utterly obvious. Wikipedia is not a vehicle to overthrow legislation. JFW | T@lk  08:44, 1 Dec 2004 (UTC)


 * How on Earth were you granted authority over the validity of using words like "abuse?" I would like to apply for some words, myself.  DrMorelos 00:57, 25 November 2006 (UTC)

I would have to agree with JFW. In attempting to form NPOV, it forms an implied legitimisation of an activity that the vast weight of medical opinion deems to be detrimental. Medical professionals are not "prohibitionists" - we endorse the safe, efficacious and judicious use of medicines including opioids. We should not fall victim to the fallacy of appeal to tradition - just because something has been done for 5000 years does not legitimise it. By all means mention of recreational uses should be made, but Wikipedia should not be seen as endorsing abuse of opioids. -Techelf 09:23, 1 Dec 2004 (UTC)


 * First of all, please stick to the topic at hand -- opioids, not murder. There is, and always has been a distinction between abuse and ludibund use of opiates and all other drugs.  Your political bias, and those who share it cannot change this.  Documenting the ludibund use of opioids distinctively from drug abuse should not only exist subject to your opposing POV, and NPOV documentation should not be misconstrued as "endorsement" of said activity.  A warning that ludibund use of opioids can often lead to addiction and hence abuse is perfectly fine, but to suppress the truth goes against NPOV policy.  If you still deny the existance of ludibund use of opioids, I suggest checking out some books on the subject, such as The Heroin User's Handbook.  --Thoric 17:27, 1 Dec 2004 (UTC)

I am not planning to read a book to understand your POV, especially because you have utterly failed to understand and address my two good metaphors (the speed limit and the murder example). "Recreational use" of opioids is dangerous enough for governments worldwide to forbit it, defining it as abuse. Most people using opioids for non-medical uses are using them because they are addicted, not because they want a carefully planned kick with naloxone on the side in case they get comatose, drop their respiratory rate or get so constipated they need phosphate enemas. You cannot for one moment claim that your activism is an act of NPOV. JFW | T@lk  20:32, 1 Dec 2004 (UTC)


 * Alas, if you insist to stray off topic. First of all, the fact that exceeding the posted speed limit on a public road or highway (or speeding) is against the law does not nullify the existence of legitimate car racing, and certainly shouldn't block the mere mention of street racing as if it legitimized or even advocated the activity.  Murder, while illegal is justified by governments in the case of war, self defense, capital punishment (which, as you should note has supportive and opposing views despite the opposition being the majority view) or euthanasia.  Most rational people do not consider drug use to be equatable with murder.  The ludible use of opium has a huge history.  Heroin has an a documented addiction rate of about 20% (many claim less).  For those not mathematically inclined, 20% is not "most people".  You cannot claim that a mere brief definition of recreational use is somehow my personal biased "activism".  How about doing some research outside of the prohibitionist propaganda camp. --Thoric 21:02, 1 Dec 2004 (UTC)


 * Excuse me for not being a recreational drug user - but what is "ludibund" supposed to be exactly? At any rate, you ignored what I said earlier so I will repeat it for your benefit - anything that is not safe, efficacious and judicious constitutes inappropriate use. This includes recreational use of opioids - how can you argue that it is appropriate to cause self-harm? Even if the addiction rate is only 20%, opioid-use always produces a range of detrimental effects which JFW alluded to. Also, opioids produce a physical dependence-syndrome in all users - it has been proven that continuing misuse of addictive agents is almost-always to prevent the negative effects of withdrawal (negative reinforcement). Unlike those with right-wing political agendas to push, as health-professionals, we act in the best interests of our patients and using established best-practice. We do not judgmentally tell users that they are "wrong" - instead we explain the dangers and consequences associated with inappropriate use, and offer help if they want. That is NPOV. You clearly do not understand NPOV or indeed the term prohibition. Current established best-practice is harm minimisation - noone in their right mind is here to promote prohibition. So, rather than dismissing everyone else as a member fof the big prohibitionist conspiracy, perhaps you should consider that your activism is itself a biased POV. -Techelf 03:44, 2 Dec 2004 (UTC)

For the record, I'm not a recreational drug user, I am a drug researcher. Ludibund comes from the Latin ludibundus, meaning playful, sportive. Anyways, the safety of an activity does not detract from its recreational value, in fact for some, this adds to its appeal. Think mountain climbing, extreme sports, motorcycle racing, even downhill skiing is a dangerous activity. A common element between these activities, and drug use is that the danger factor is greatly increased by the lack of education and instruction with that activity. The detrimental effects of opioids stem primarily from their legal status. On a completely level playing field with alcohol, heroin turns out to be less detrimental. Scientifically alcohol is slightly more addictive compared to heroin (see Relative Addictiveness of Various Substances). Physically, alcohol causes far greater damage to the body -- cirrhosis of the liver, damage to other organs, shrinkage of the brain, etc. Opioids cause constipation. If a hard core alcoholic is suddenly deprived of alcohol, they can die from the resulting delirium tremens. Death from opioid withdrawl is virtually unheard of. Now, for the real topic at hand, the NPOV of this article: The ludible use of drugs POV is a known and long existing POV. Your opinion to label ludible use of drugs as "inappropriate", or even worse as "abuse" is an act of imposing your POV onto the article. According to the NPOV policy, articles are not supposed to have a POV -- only present a collection of known points of view. As for the uses of drugs, there are five different categories, ordered from most approved to least approved of:
 * Medicinal - used to treat an illness
 * Therapeutic - used as a tool in therapy
 * Experimental - used for experimental research to prove or disprove the above two uses
 * Recreational - used purely for pleasure and enjoyment
 * Abuse - where the user has lost self control over his or her usage of the drug, has developed a dependence on the drug, and where the use of the drug has a significantly detrimental impact on the user, and possibly also a negative impact on the user's friends and family

You say that you don't judgmentally tell users that they are "wrong", yet you advocate labeling recreational use as abuse. I am only advocating that you maintain the NPOV policy by not wording the article in an opinionated way. You are certainly free to point out that the current majority political and medical communities view all non-medical use as abuse (highlighting the opinion of those groups), but this opinion should not be held by the article itself.

I am in full accordance with wikipedia's NPOV policy to note the distinction between recreational drug use and abuse. For you to label recreational use as abuse is to impose your non-neutral point of view onto the article. --Thoric 14:53, 2 Dec 2004 (UTC)

Also, if you truly support harm minimisation as you state, then how about adding a section on it, and heroin maintenance? --Thoric 17:18, 2 Dec 2004 (UTC)


 * I do apologise for my implication that you're a recreational-user - I took the accusation of being a prohibitionist to heart too much given my left-leanings. However, I have not said that recreational-use is abuse, and if it was implied then I should clarify that it was not my intended meaning. I had only meant to express, above, that you can only "neutralise" an article to a certain point beyond which it becomes a POV itself (and this POV seemed to be suggested in some of your earlier comments on this page). There is also a fine-line between what constitutes recreational-use and misuse; and therein the danger lies. I agree that, all things considered, ethanol is probably more dangerous; and certainly the social-cost of ethanol misuse far exceeds that of opioid misuse; and that the danger is vastly underestimated by most. I have personally had the experience of being prevented from rendering first-aid to a collapsed casualty by a person too drunk to differentiate between a penlight and a camera; so I know this all-to-well. The reason I have not added a section on harm minimisation is that it is not my field of expertise. Certainly I am an advocate of harm minimisation, and have attempted to convince certain individuals in my field (pharmacy) of its value. Also, we do not to my knowledge have an established heroin-maintenance therapy in Australia - the standard approach used here for the management of opioid dependence is methadone-maintenance. Hope that clears things up a bit. (btw, I figured lundibund might've been Latin-derived, but I can't say I've heard it used anywhere...) -Techelf 12:56, 4 Dec 2004 (UTC)


 * I also apologize for the name calling, it gets us nowhere. I would certainly rather work together than argue :)  --Thoric 21:30, 6 Dec 2004 (UTC)

Thoric, you've failed to convince me. Most opiate addiction starts as "recreational use". Alcohol, when had in moderation, is not very dangerous, while a large segment of recreational opioid users end up using a lot and getting all the complications, ranging from abcesses on injection sites to repeated emergency room attendance with coma. The best prevention of opiate addiction remains the ban on recreational use. I have never said that recreational use is impossible, but in the present paradigm of law and medicine it is a tautology. JFW | T@lk  10:39, 5 Dec 2004 (UTC)


 * It is well documented that addicts can and do switch their vices (i.e. from alcohol, to drugs, back to alcohol or even to gambling or other non-substance related addictions). Scapegoating the problem onto the drug takes the focus off of the real underlying problem.  As a doctor you know that most normal healthy people can use opioids to manage acute pain without becoming addicted.  I will agree that the people who most often come to use opioids "recreationally" make it their drug of choice because it fills a void in their life -- but these people have issues that existed long before the drug use.  They could have just as easily became alcoholics, but just because alcohol is a socially accepted drug does not make being an alcoholic any "better" than being a junkie.  I'm not proclaiming that patterns of responsible recreational use of opioids are comparable to that of alcohol in the western world, but historically opiate use has played a major part in the rest of the world.  Islamic nations banned alcohol in favor of opium.  Asian countries banned smoking of tobacco, and allowed smoking of opium.  Favoring one drug while demonizing another has been a very common theme throughout history.  The time approaches to get past this nearly superstitious tendency.  --Thoric 03:24, 6 Dec 2004 (UTC)

I have little problems with the paragraph in its present form, although I've toned it down a little bit. There are various POVs, and I hope yours is now represented adequately. JFW | T@lk  08:17, 6 Dec 2004 (UTC)


 * It is good that we were able to find middle ground. I do respect the work and expertise of both Techelf and yourself even if I get a little heated in debate ;)  --Thoric 21:30, 6 Dec 2004 (UTC)


 * Sometimes a nice heated debate keeps out the cold :-) JFW | T@lk  23:06, 6 Dec 2004 (UTC)

This may have been 'sorted out' here already, but I get the impression from the article that it wrongly assumes that use of the drug while physically dependant must always be 'abuse'. Peoplesunionpro June 29, 2005 02:44 (UTC)
 * Typically, physically dependant, non-medical use of opiates would be seen as abuse by most people... although if it had no negative impact on your life and loved ones, then it would be little different than caffeine addiction (social stigmatism aside). This is a really touchy subject in the current political climate, mainly because opiates are highly demonized, and anti-drug propaganda is standard fare.  It's a very small percentage of the population who will avoid even drugs such as wine, chocolate, coffee, tea or an aspirin... but they are still all drugs.  If you want to get really technical, our bodies and brains are constantly producing "drugs"... natural chemicals, which currently have medical names which are named after the drugs that affect the same receptors -- endorphins (endogenous morphine), endocannabinoids (endogenous cannabis alkaloids), nicotinic  acetylcholine receptors (nicotine from tobacco), muscarinic acetylcholine receptors (amanita muscaria mushroom), etc, etc.  --Thoric 29 June 2005 23:12 (UTC)


 * Folks, I would like to point out that this argument became specious paragraphs ago. Audience members who actually read the discussion pages are probably not judging you, but are probably recognizing that reading the whole argument is reading an argument and not a debate.  You are all obviously intelligent, educated and sharp; the discussion here is laudable as philosophic waxing if the emotion were simply removed.


 * Also, what do you think of the fact that substances like cocaine have been designated "narcotics?" If you want philosophy, discuss the differences between legal and medical definitions of, oh, anything.  DrMorelos 01:03, 25 November 2006 (UTC)

diamorphine (heroine)
Why does diamorphine have its streetname commented next to it? Should other opioids have their most common name next to them? such as Oxycontin - OxyCodone, Vicodin - HydroCodone, etc..
 * There is a difference between a "street name" and a brand name. Oxycontin and Vicodin are brand names for oxycodone and hydrocodone respectively. Heroin was once the brand name for 3,6-diacetylmorphine. Diamorphine is the International Nonproprietary Name (INN), and is the preferred naming convention for Wikipedia drug articles (see WikiProject Drugs). The name heroin, however, has come into common medical use over the last century as a generic name for diamorphine, hence the dual-naming presented on this page. I do not feel is is practical or necessary to place the "most common" brand names beside the INNs listed because these vary internationally and would prove unwieldy to list on this page. They are already listed on most of the individual pages, however, and thus a Wikipedia search would easily find the relevant page. Techelf 10:28, 31 Mar 2005 (UTC)
 * Ok, that makes sence.
 * No, it really doesn't. Many street drugs, even well-established and high-volume street drugs, such as diamorphine (why they leave the '-cetyl-' out is beyond me) or methamphetamine, have multiple street names even in one language.  This problem is prevalent especially in the USA where a Floridian teenager buying 'crip' from a Californian 'grape' dealer will get the product he desires.
 * Moreover, Oxycontin is a brand name for controlled-release oxycodone; the typically used US brand name for stand-alone oxycodone is generally Roxicodone. DrMorelos 01:17, 25 November 2006 (UTC)

Motion Euphoria
Can opiates cause Motion euphoria?

Future Uses of Opioids
Another future use of opioids might be to protect against ischemia/reperfusion injuries, particularly in the heart. The proposed mechanisms involve actions on potassium pumps, protein kinase C, or potentially nitric oxide synthase. I'm doing a literature review on this aspect at the moment, but if someone who's already up to speed on the issue (and who knows that they want to jump in and include this in the current article) wants to put a line or two in, go right ahead :)

While this is still relatively cutting-edge stuff, it might also give readers an idea of how opioid receptors act in non-neural tissue.

For a review on opioids & cardioprotection, I'd recommend Schultz & Gross, 2001. Pharmacology & Therapeutics 89:123-137.

Cheers; Potatophysics 09:48, 9 September 2005 (UTC)

receptor types
I was reading the discussion of the definition of 'opioid' and what I was thinking is that in the age of pharmacogenomics, an opioid is any ligand that binds an opioid receptor (is that tautological?). To that end, I added some brief info on receptor types and subtypes to give a summary of info that is presented in greater detail on the pharmacology page. One other thing: in the reading I have done, the sigma opioid receptor mediates some properties of dysphoria and hallucinations and is listed as having specific agonists such as pentazocine, yet on the pharmacology page, it says that the sigma receptor has been found not to be a true opioid receptor. Am I behind the times? Thanks! Awolf1 16:46, 22 November 2005 (UTC)

anti-dysphoric effect
I found no discussion of clinical use of opioids in cancer patients without pain, so I added this paragraph: "Opioids can be used to anti-dysphoric effect (that is, to neutralize anxiety and depression) in cancer patients and other disease victims who suffer from misery but not from pain." Here's why:

I saw cancer patient A, during chemotherapy, suffer from 18 weeks of nausea, unremitting fatigue, and I-wish-I-could-die misery (but no pain, so no Vicodin).

I saw cancer patient B, during chemotherapy, feeling "pretty good" and running errands six days after the infusion. B had pain during the three worst days after infusion, but otherwise no pain before or after. Despite the lack of pain, B took 4 Vicodin (5/500) a day (doubling or tripling during the three worst days after infusion). One day B forgot to take his Vicodin for over 8 hours, and found himself curled up in a fetal position, with debilitating fatigue and a feeling of pervasive misery. This dysphoria lasted until one hour after he realized he had forgotten his Vicodin, and swallowed one pill. Two hours later he swallowed a second Vicodin and an hour after that he was running errands again. B later experimented with himself and confirmed the inverse relationship between Vicodin and debilitating misery.

I saw cancer patient C, asymptomatic, not in chemotherapy -- glum, anxious, and brooding when not on Vicodin, relatively cheerful and fully productive when on Vicodin (4 per day, 5/500). C says that SSRIs seem to do little for him; Ativan 1 mg helps; but nothing quite does the job like Vicodin. He also says that he feels no urge to increase his dosage.

I have no medical training. I have researched this issue because some friends have cancer. I leave it to the experts to correct the paragraph I added. I hope no one would simply remove my paragraph and leave the issue unaddressed. - TH
 * You hope too much as someone already removed it even though opioids are effective at blocking emotional pain. This is why unhappy people become hooked on them.  I might suggest your friends look into psychedelic therapy using MDMA, LSD, psilocybin or ayahuasca.  --Thoric 23:34, 29 November 2005 (UTC)

Thanks for the breath of humanity, Thoric.

I'll just keep replacing and improving my paragraph until (a) some owner or moderator (if such exists in the Wikipedia world) stops me, or (b) someone provides a better explanation than mine of the issue of non-pain-targeted clinical use of opioids -- an issue heretofore ignored by this Wikipedia article.

A better explanation will minimally cover all the questions discussed in this Discussion since my earlier post.

Jfdwolff's imperious and dismissive treatment of my initial paragraph inspires me to promote myself to be the judge of whether any explanation is better than mine, again unless some Wiki owner or moderator overrules me.

Those psychedelics you mention, Thoric -- they aren't big guns in the anti-misery department, are they? I mean like the "18 weeks of nausea, unremitting fatigue, and I-wish-I-could-die misery" that I mentioned. Statements such as "there is no upper limit to the dosage and the achievable pain relief" (what Wikipedia - Opioid says about opioids) don't apply to them, I believe.

Folks, help me out here. I have no medical training, as I said. So tell me "your friends A, B, and C are atypical -- opioids wouldn't help most chemo patients against non-pain chemo misery". Or tell me that "it probably would work". Or tell me that "we don't really know, but it's worth six Vicodin pills one day to see what happens".

And tell me "your issue might be valid but it's confined only to the chemo period. After the last chemo period, terminal patients feel no negative symptoms except for anxiety and depression (prescribe anxiolytics and anti-depressants) and physical pain (prescribe opioids) and miscellaneous other complaints (nausea, constipation), which opioids won't help -- but they never feel just non-pain I-wish-I-could-die misery". Or tell me otherwise.

And tell me what jfdwolff's "rv NOR" means.

I think that the medical world is afraid of moral hazard. Dependence is meaningless in the terminal world (else hospice wouldn't have a morphine drip), and addiction is too.

It's moral hazard that scares the medical world. Tell me if I'm wrong. It's moral hazard that makes jfdwolff say "one shouldn't use opioids for that". It's moral hazard that made one doctor tell my friend "we don't want you taking them for the wrong reasons". So remember that in all the cases I am referring to, THE DOCTORS HAVE THE CT SCANS of the tumors. Don't get off the track. The moral hazard in my examples is zero. - TH


 * It is true that in patients with fully-functional CYP2D6 and related liver enzymes, most opioids offer varying degrees of dryness, constipation, euphoria, calm, patience, temperance above and beyond those patients' typical norms. Some also feel energetic.  This action is partially suggestible but mostly not so.  Benzodiazepines such as Ativan (lorazepam) are known on the street as "chill-pills" for a reason; they lower a person's level of emotional upset.  Professionally I would use alprazolam or oxazepam for a cancer patient presenting without seizures, as they are both a bit better about reducing emotional upset; lorazepam is better as an anti-convulsant.  I apologize for inserting my response here but I really can't make sense of where someone's rambling starts and stops.  Perhaps I'm getting "mentally old."  I am the lowest rung on the "doctor" ladder in my position, but I am the youngest and least experienced.  That doesn't make me more stupid than the rest of us, though; anyone worried about curing someone's opioid withdrawal shoud look into ibogaine which (has tremendous potential as a supplement to behavioral therapy and) is vehemently banned in the USA and will stay that way as long as methadone replacement clinics are available.  Why offer a fairly quick cure when you can sell a cross-tolerant and very dangerous trade-off that the ex-heroin user must buy every day?


 * You should also know that as patients age, their receptor sites become more resistant to reshaping. The implications are that the same dose of morphine every 6 hours will have a higher efficacy for a substantially longer period of time in an 86-year-old patient than in a 26-year-old patient.  Likewise dependency and addiction are harder to form, and in a 86-year-old terminal patient, your statement about their irrelevance is well-understood in the medical world.  I hope this helps clear up a few of your questions.  DrMorelos 01:29, 25 November 2006 (UTC)


 * Firstly, could you please be more concise? Secondly, NOR is one of our important policies. In the absence of a good reference, citation or other outside support, your contribution gave me the impression of advocating a treatment that is not proven for this indication, nor actually being used. That would be "original research", for which there are other outlets but not Wikipedia.


 * My rv is very common practice for material that has no outside support, and my reaction was hardly a "imperious and dismissive treatment". Please assume good faith when editing Wikipedia. It saves time. JFW | T@lk  13:24, 30 November 2005 (UTC)


 * I've done a quick Google, and this is what I learned: research indicates that stimulation of the &kappa;-opioid receptor can cause dysphoria as well as nausea. Withdrawing from opioids or antagonism with naltrexone can similarly cause dysphoria. I don't dispute the stories about your friends, but on a larger scale there is no good indication that there would be any point in using Vicodin or any other opioid for low moods. Your preaching because of my simple revert was really unwarranted. JFW | T@lk  13:33, 30 November 2005 (UTC)


 * I would think that opioids causing dysphoria (not during withdrawal) would be a rare case. Opioids are documented to block pain, both physical and emotional.  Certainly that emotional pain may come back with a vengeance as the effects of the opioids wear off, and tolerance to its effects on emotional pain may develop more quickly versus that of physical pain, I would still be as bold to say that for some people opioids provide a bonus side effect of an anti-dysphoric.  It should also be noted that opiates (including opium, laudenum, morphine, heroin) have historically been prescribed for countless things, including dysphoria up until the 1930s or later.  Tramadol is currently being prescribed as an anti-depressant despite being an opioid.  (You may want to note that valium which was prescribed as an anti-dysphoric 30 years ago, is more addictive than heroin.)  --Thoric 19:30, 30 November 2005 (UTC)


 * Thoric, just look at the evidence! It is reported all over the show that opiods may cause dysphoria. Evidence is better than theories. I'm happy for these assertions to be inserted into the article if you can provide the evidence. I'm not sure what your point is about valium; if it works, why avoid it, especially in cancer patients! JFW | T@lk  20:45, 30 November 2005 (UTC)


 * Withdrawal from opioids can cause dysphoria. Withdrawal from benzodiazepines such as valium can do the same and much worse.  Opiates have historically been prescribed for mood disorders, and tramadol is currently being prescribed as an anti-depressant.  Vicodin users have noted that it improves their mood, and none of these things is news, or rare cases.  I'm not saying that opioids are a good choice of antidepressant.  --Thoric 22:04, 30 November 2005 (UTC)


 * Okay. So mu agonists cause euphoria and kappa agonists dysphoria. Dysphoria is a side-effect of many known opiods. It follows that those opioids with more mu than kappa effect would be nice euphorics. Good. But dysphoria is certainly not limited to withdrawal, like you suggested in boldface. JFW | T@lk  22:44, 30 November 2005 (UTC)

non-pain-targeting use of opioids for physical relief
Jfdwolff at first provided nothing but a moral rationale ("should") for removing my paragraph on non-pain-targeting clinical use of opioids; that moralism kept me from assuming good faith on his or her part, which got us off the wrong foot, but I believe that is all behind us now that we are all talking facts.

The primary issue for me is physical misery -- not moods, not emotions, not physical pain.

TH 00:21, 2 December 2005 (UTC)


 * What do you mean with "physical misery"? I was not giving a moral rationale, by the way; "should" reflected clinical indication. I wish you wouldn't try to read my mind :-). JFW | T@lk  01:00, 2 December 2005 (UTC)

"Physical misery" or "physical suffering" to me is when my friend curls up in a fetal position and doesn't move for hours; finds, say, writing out a check to be an almost unbearable ordeal; finds the sound of someone crumpling a piece of paper to be a torment; says "I feel like shit"; says "I wish I could die"; says "This isn't worth it"; says "I feel a terrific fatigue, but this is far beyond anything I've ever thought of as fatigue"; says "I have no pain"; says "I often have nausea but not for the last several days but I'm still almost as miserable as when I had nausea". When asked "are you suffering from anxiety or depression?", answers "really no, and to the extent that I am, it's entirely secondary to the physical misery". This friend was well known to be emotionally healthy before the cancer diagnosis.

I know that the medical doctors have a taxonomy analogous to the social doctors' DSM-IV. Does that taxonomy contain a category for physical misery and suffering that is not pain, not nausea, not constipation, beyond fatigue, and so on?

TH 02:42, 2 December 2005 (UTC)


 * Fatigue in cancer patients is well recognised and very hard to address. I'm not sure if anyone prescribes stimulants for this indication, but opioids would simply make one drowsy and increase risk of nausea (1 in 3 for new administration). I find it plausible that people feel rotten after hearing they've got cancer, but again opioids are not the answer.
 * Again, most opioids carry a risk of dysphoria as a result of &kappa;-receptor stimulation. The best answer for fatigue is counselling, taking frequent breaks, adequate nutrition and outside stimulation. JFW | T@lk  03:07, 2 December 2005 (UTC)

My definition of "'physical misery' or 'physical suffering'" a few paragraphs up from here describes, by the way, "Patient A", whom I discussed farther above. And we're in luck, because Patient B, whom I also discussed farther above, is in the 2nd week of chemo, happens to have no pain, happens to have a prescription for Vicodin (uses four 5/500 per day, spiking just after infusion). I'll keep you posted on the results of this tiny experiment. Meantime, read about Patient B above and note that the facts of B's experience so far bode ill for jfdwolff's speculations.

Patient A, two years out of chemo, gave a look of derision (sorry, just reporting) at every one of jfdwolff's four recommendations ("frequent breaks from catatonic immobility?" she asked. "He's not even addressing chemo -- he's completely out of touch").

Patient B says the anxiolytics cause some drowsiness but the four Vicodin per day either don't or are overwhelmed by B's two cups of coffee per day.

(By the way, Patient A and Patient B are friends to each other and often discuss chemo.)

Your statements such as "most opioids carry a risk of dysphoria" always confuse me. I have not figured out an interpretation other than that you're saying "the greatest euphoric known to humankind ironically causes, in a small minority, dysphoria -- conclusion: do NOT try half-a-dozen pills one day to see whether you happen to be in the majority or in the minority". Please explain.

And about your "1 in 3 for new administration" -- then does it get worse, or do most of the new administrations get used to it and nausea settles down to 1 in 10 or 1 in 20? Again, are they all incapable of deciding for themselves whether the tradeoff is net beneficial to them?

TH 04:50, 2 December 2005 (UTC)


 * Uhh, you are putting words in my mouth. I am more than a bit worried about your insertion that medics "deny" cancer sufferers opioids when they're not in pain. What is the assumption? That a fatigued cancer patient should be on opioids? Where (apart from the small sample of your sick friends) is the evidence that this would work? What makes you think that the next patient who takes Vicodin for "non-pain cancer symptoms" does not get a dysphoric reaction? Please, please tell me why your insertions are not original research (please read this vital policy).


 * Again, I sympathise with your poor friends, and if they derive benefit from opioids - fine. But unless you cite strong evidence for your position this will have to stay out of the article. I'm sorry. Wikipedia policy. Really. Not just my "moralising" views, or whatever label you want to stick on me. Perhaps we should ask other Wikipedia editors what their views are (requests for comment). JFW | T@lk  08:47, 2 December 2005 (UTC)

Could you respond to my last two questions and my "Please explain"? TH 09:34, 3 December 2005 (UTC)


 * Please explain - there are better drugs for dysphoria than opioids, which are addictive, cause constipation, nausea, hallucination and occasional paradoxical dysphoria. I will not rehash all the stuff again.
 * Does nausea get worse? - no, the majority improves after a brief course of antiemetics. But if there are better pills then it is not very nice that your new anti-dysphoria drug makes you puke.
 * Are they all incapable of deciding for themselves - prescription drugs are prescription drugs because their only real use is as medication. Doctors are trained to assess medical problems and to decide what type of treatment would be most suitable. The government doesn't want people to decide this for themselves, no. This is especially so with opioids, which are commonly abused. There are probably a lot of people who would be very sensible and could be trusted to prescribe themselves medication, but they are in a minority.


 * If you don't mind I'm going to stop responding unless you have some very significant new information, such as a solid reference. JFW | T@lk  22:53, 3 December 2005 (UTC)

ludibund
Come on, no one really uses this term "ludibund". Someone (Jonathan Ott?) made it up by pseudo-back-translating to Latin, to avoid the word "recreational", right? But it never caught on, so why is wikipedia using an unknown dodge-word as a topic heading?

TH 00:36, 2 December 2005 (UTC)


 * It is because "abuse" is insulting to the "recreational" community, and "recreational" is an understatement to the medical community. JFW | T@lk  01:00, 2 December 2005 (UTC)

Tramadol
Tramadol, mentioned above, seems to be US FDA-approved for pain, not for depression; and it's on Public Citizen's list at WorstPills.org, so I'm not inclined to cite it.

TH 00:41, 2 December 2005 (UTC)


 * What does WorstPills base itself on? JFW | T@lk  01:00, 2 December 2005 (UTC)

I have no idea -- I did not pursue it. I hold no brief for them, but because of their listing and more importantly because of the FDA indication, I decided to spend my time on issues other than Tramadol.

nonclinical use -- major reorg
The old version was fatally flawed, I believe -- starting with the fact that the two headers "Opioid Abuse" and "Ludibund use" implied that some recreational use is not abuse -- and right there in the headers you have a POV that many would disagree with.


 * During alcohol prohibition you could say the same about alcohol — that any non-medical use of alcohol was abuse. Today, one can drink wine with dinner without being called an alcohol abuser.  Also during prohibition, a considerable number of teetotallers used opioids (opium, morphine and heroin) as an alternative to alcohol.  Now things are the opposite way around.  Does that negate opposing POV?  I think not.  --Thoric 22:20, 5 December 2005 (UTC)

Secondly, "ludibund", meaning "playful", is just an obscure synonym for "recreational", and is thus subject to all the non-neutrality of that term.
 * Obviously you don't understand how POV works. The article is a collection of information and points of view, and what makes the article have a neutral point of view, is by presenting all points of view without trying to favor one over another.  I suggest you actually read Neutral point of view.  Thanks.  --Thoric 23:40, 5 December 2005 (UTC)

I could go on.


 * WP:CITE. Please. JFW | T@lk  04:25, 4 December 2005 (UTC)

OED (uncondensed edition only). "Obsolete".

TH 19:55, 5 December 2005 (UTC)

Citation switched from Rossi to Drug Facts and Comparisons
No offense intended toward Australian readers and writers, but I clarified and added info by switching from Rossi to Drug Facts and Comparisons, widely available in the US (unlike Rossi) and therefore more meaningful to and verifiable by a larger fragment of the world population.

Drug Facts and Comparisons was indicated to me by a medical university librarian as the most authoritative and independent source of drug information. I think she said that DF&C got its information from Medex, but I'm not sure about that. DF&C is at factsandcomparisons.com.

Note added info: "sole", not "main"; anesthesia; methadone for detox; and the four "only" restrictions.

TH 17:27, 8 December 2005 (UTC)

"anxiety", "according to"
Oops -- I forgot to mention the other info change -- oxymorphone is indicted for "anxiety due to dyspnea", not "dyspnea".

I added "according to" to imply that DF&C is not the be-all-end-all -- other authorities may differ.

Why doesn't Wikipedia automatically sign my Talk for me?
TH 17:53, 8 December 2005 (UTC)


 * Put ~ after your posts. JFW | T@lk  05:29, 9 December 2005 (UTC)

Sure I do, thanks, the 70 percent of the time that I remember. What doesn't make sense to me is that Wikipedia doesn't do it AUTOMATICALLY, as a default. The could say "type '-(four tildes)' if you do NOT want to sign".

I remembered. . . TH 07:13, 9 December 2005 (UTC)


 * Hmmm. Probably because the Wiki wouldn't know where to automatically put your signature. It would have to run a diff after saving the edit, putting more strain on the server than a simple transinclusion. 07:28, 9 December 2005 (UTC)

less euphoria; unequal tolerance
The more I read, the less I see evidence that "most opioids produce euphoria in most people". For example, Reynolds et al., Morphine and Allied Drugs, says codeine does not generally produce euphoria. Lacking evidence, I think we have to go with the weaker statement.

Also, I haven't found evidence that the rate of developing tolerance is the same across all effects. I've found hints to the contrary. Lacking evidence, I think we have to go with the weaker statement. I cite Weil for the exception of constipation.

TH 07:09, 9 December 2005 (UTC)

Controlled Substances Act; British system
Controlled Substances Act:

Way, E. Leong (Department of Pharmacology, School of Medicine, Universtiy of California, San Francisco, San Francisco, California, USA), "History of Opiate Use in the Orient and the United States", in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, p. 22.

British system:

Berridge, Virginia (Institute of Historical Research, University of London, London, England), "Opiate Use in England, 1800-1926", in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, p. 9.

TH 22:08, 18 December 2005 (UTC)

The DF&C table is correct now
The table from Drug Facts and Comparisons has gotten bounced around a bit and damaged. I have just fixed it and double-checked every line against my photocopy from DF&C 4.0. The photocopy that the university medical librarian made for me after recommending DF&C as the most authoritative and impartial source.

I know nothing about indications in countries other than the US.

TH 04:22, 19 December 2005 (UTC)


 * http://www.bnf.org.uk for the British system. JFW | T@lk  08:40, 19 December 2005 (UTC)

senile dementia, geriatric depression, chemotherapy, terminal diagnosis
I added this paragraph:

"Opioids are prohibited for psychological relief (with the narrow exception of anxiety due to shortness of breath), despite their extensively reported psychological benefits. The prohibition has no therapeutic basis; its basis is fear of addiction and of diversion. The prohibition allows no exceptions, even when opioids might be especially effective and when the possibility of addiction or diversion is very low – for example, in the treatment of senile dementia, geriatric depression, and psychological distress due to chemotherapy or terminal diagnosis".

---

CITATIONS regarding the idea that opioids can relieve psychological distress and can act as antidepressants:

“In the middle nineteenth and well into the twentieth century”, morphine “was used as a tranquilizer and sedative. . . . It was used in mood disorders. . . until such applications were discouraged by enforcement” (note that Dr. Way says “discouraged by enforcement”, not "discouraged by results of clinical trials").

- Way, E. Leong (Department of Pharmacology, School of Medicine, University of California, San Francisco, San Francisco, California, USA), "History of Opiate Use in the Orient and the United States", in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York (1982), p. 18.

“From being in a state of agony and apprehension the patient is calm and at ease. . . . Closely allied to the pain-relieving effect of opiates is their ability to influence mood. This effect is again a property of great value to medicine and very much the therapeutic ally of the pain-relieving effect; even when the pain of a spreading cancer is not fully abolished by the drug injection, the mood effect can make the residual pain more tolerable and generally produce a lessening of emotional distress. The patient is in a way emotionally distanced from what is happening, and floats as it were on the surface of his experience”.

- Berridge, Virgina, Opium and the People: Opiate Use in Nineteenth-Century England, 1987, pp. xxf.

“Exogenous opiates. . . have analgesic, anxiolytic, euphoric, and calming effects”.

- Gold, Mark S., A. Carter Pottash, Donald Sweeney, David Martin, and Irl Extein (Fair Oaks Hospital, Summit, New Jersey, USA): "Antimanic, Antidepressant, and Antipanic Effects of Opiates: Clinical, Neuroanatomical, and Biochemical Evidence", in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, p. 145.

“Morphine. . . allays. . . apprehension”.

- Reynolds, A. K., PhD, and Lowell O. Randall, PhD, Morphine and Allied Drugs (1959), p. 145.

“It may be anticipated that opioids could be highly effective, therapeutically, in depressive illness".

- Emrich, H. M., P. Vogt, and A. Herz (Max-Planck Institute for Psychiatry, Munich, Germany), "Possible Antidepressive Effects of Opioids: Action of Buprenorphine", in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, p. 108.

In a study of depressed patients, buprenorphine provided “clinically striking improvement in both subjective and objective measures of depression”.

- Bodkin JA, Zornberg GL, Lukas SE, Cole JO (McLean Hospital, Consolidated Department of Psychiatry, Harvard Medical School), “Buprenorphine Treatment of Refractory Depression”, Journal of Clinical Psychopharmacology, February, 1995, 15(1):49-57.

In another study of buprenorphine in the treatment of psychiatric patients (mostly Vietnam veterans), “most [patients] commented on how much better they felt after BPN [buprenorphine], using words like ‘relaxed’, ‘peaceful’, ‘more friendly’. . . . Some went into a discussion group after BPN and for the first time spoke about painful experiences. . . . The only responder who did not like BPN was the normal subject”.

- Mongan, Lou and Enoch Callaway, Letter to the Editor, Biological Psychiatry, 1990, Volume 28, Issue 12, pp. 1078ff.

In cases of terminal disease, “the analgesia, tranquility, and even euphoria afforded by the use of opioids can make the final days far less distressing for the patient and family”.

- Gutstein, Howard B. and Huda Akil, “Opioid Analgesics: Clinical Summary”, in Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 11th Edition, 2006, edited by Brunton, Laurence L., John S. Lazo, Keith L. Parker, Iain L. O. Buxton, and Donald Blumenthal.

(The authors make no comment on the plight of those who might appreciate the “tranquility, and even euphoria” but have no need for analgesia.)

“Then Helen, daughter of Zeus, turned to new thoughts. Presently she cast a drug into the wine whereof they drank, a drug to lull all pain and anger, and bring forgetfulness of every sorrow. Whoso should drink a draught thereof, when it is mingled in the bowl, on that day he would let no tear fall down his cheeks, not though his mother and his father died, not though men slew his brother or dear son with the sword before his face, and his own eyes beheld it".

- Homer, The Odyssey, Book IV, lines 219-222, translation by Samuel Butcher & Andrew Lang. It is not certain that the drug is opium, but no other reasonable candidate has been proposed. The effect of opium may be exaggerated in this report, but the scene is a good proxy for the psychotherapeutic use of opium by early physicians such as Hippocrates, Dioscorides, and Galen.

---

CITATIONS regarding the idea that thymoleptics (SSRIs, MAOIs, etc.) are always superior to opioids as antidepressants:

Thymoleptics are unreliable and slow: “patients must be aware that antidepressants take at least four to six weeks to have a full therapeutic effect and that only about half of patients respond to the first medication prescribed”.

- Whooley, Mary A., MD and Gregory E. Simon, MD, MPH, "Managing Depression in Medical Outpatients", The New England Journal of Medicine, December 28, 2000, p. 1948.

The study called “Sequenced Treatment Alternatives to Relieve Depression” (STAR*D), sponsored by the National Institute of Mental Health, found that only half of the 1500 patients in the study “achieved remission – virtually the complete absence of symptoms. . . . About half the patients in the study who improved did not show benefits until eight to 10 weeks into the study".

- Maugh, Thomas M. II, “New Hope amid Depression”, San Francisco Chronicle, March 23, 2006, p. A3.

Opioids, on the other hand, act quickly: “We have found that most patients experience benefits of an adequate dose within three hours”.

- Callaway, Enoch, Editorial, Biological Psychiatry, June 15, 1996.

And opioids act surely: I have found no reports of opioids failing to have a positive effect, except in the case of "normal" people (see above and below) and the case of negative side effects such as nausea.

Marcia Angell, MD, former editor-in-chief of the New England Journal of Medicine, reports on a survey (enabled by the Freedom of Information Act) of FDA reviews of drug-company submissions that found placebos to differ from the six top-selling antidepressants by only two points on the sixty-two-point Hamilton Depression Scale – a difference that she says is “unlikely to be of any clinical significance”.

- Angell, Marcia, MD, The Truth About the Drug Companies: How They Deceive Us and What to Do About It (2004), p. 113.

Pharmaceutical companies can hide their failures: they are not required to make public “all clinical trials, even the ones where the drugs failed to work”.

- Lamb, Gregory M., “A New Corporate Villain – Drugmakers?”, The Christian Science Monitor, September 20, 2004, http://www.csmonitor.com/2004/0920/p11s02-ussc.html.

Pharmaceutical companies surreptitiously magnify their positive results: they “publish positive results more than once, in slightly different forms in different journals. The FDA has no control over this selected publishing. The practice leads doctors to believe that drugs are much better than they are. . . . There is a general inflation in the notion of the good that drugs can do (and a deflation in concern about side effects)”.

- Angell, The Truth About the Drug Companies, p. 112.

Pharmaceutical companies can apply suspicious selectivity when recruiting for clinical studies. A survey and a study of 803 outpatients at Brown University showed that from one-sixth to 95 percent of “depressed patients treated in an outpatient setting would be excluded from the typical study approved by the federal Food and Drug Administration to determine whether a new antidepressant medication works”. The study concludes that "subjects treated in antidepressant trials represent a minority of patients treated for major depression in routine clinical practice”.

- Zimmerman, Mark, MD, Jill I. Mattia, PhD, and Michael A. Posternak, MD, “Are Subjects in Pharmacological Treatment Trials of Depression Representative of Patients in Routine Clinical Practice?”, American Journal of Psychiatry, March, 2002, 159:469-473.

“The current practice. . . may actually skew the findings of the drug trials”, according to Zimmerman.

- Rosack, Jim, “Clinical-Trial Criteria Leave Limited Study Population”, Psychiatric News, V folume 37 Number 10, May 17, 2002, p. 28.

Opiates can be superior to thymoleptics for psychological relief: “As shown in the present investigation, the mixed opiate agonist/antagonist buprenorphine exhibits antidepressant properties in cases not responding to conventional thymoleptic therapy. This is a remarkable finding, since for this type of patient, an inevitable consequence would be the application of electroconvulsion,. . . which. . . is not a desirable choice in the treatment of psychiatric patients”.

- Emrich, H. M., "Possible Antidepressive Effects of Opioids: Action of Buprenorphine", in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, p. 111.

Opiates can be superior to thymoleptics for psychological relief: “We have personally treated five patients with BPN in whom the results were impressive. Three were more or less typical cases of depression who had failed adequate trials with various treatments, including, in one case, a thorough course of ECT [electro-convulsive therapy]. Of the two less typical patients, one was a case of panic disorder with onset in childhood and what could better be called dysthymia rather than typical depression.... All five patients were followed for several years while good results were maintained”.

- Callaway, Enoch, Editorial, Biological Psychiatry, June 15, 1996.

Opiates can be superior to thymoleptics for psychological relief: “Through advances in medicine, the human life span has lengthened with a consequent increase in the population of geriatric patients with dementia and depression. The choice of psychotropic medication for these patients poses special problems owing to their increased susceptibility to adverse drug reactions [here the authors quote three sources]. The side effects of major tranquilizers, e.g. extra-pyramidal restlessness, parkinsonism, and hypertensive episodes, may complicate the clinical picture of an elderly, agitated patient. However, the main clinical problem with these drugs is that there is often mental hebetude even though target symptoms have abated. The patients appear overdrugged, and relatives often refer to them as “zombies” and are discomforted in their presence. Many of these patients display rapid clinical improvement following discontinuation of maintenance doses of psychotropic drugs, calling in question the advisability of long-term medication for psycho-geriatric patients. . . . As for tricyclic medication for the depressed aged patient, there is a lowered threshold for toxic confusion, glaucoma, urinary retention, cardiovascular embarrassment, and parkinsonism. This may at time[s] seriously limit their use in the elderly. . . . During the past 27 years, the senior author has treated many cases of senile dementia with suitably adjusted dosage of opium-related compounds [mostly deodorized tincture of opium]. The results have often been superior to those obtained previously in the same patients with other medications, including phenothiazines and tricyclic antidepressants. Not only the target symptoms (depression, confusion, paranoid ideation, etc.) abated, but a cheerful and cooperative mood appeared, rendering the patient amenable to rehabilitative measures”.

- Abse, D. Wilfred, William J. Rheuban, and Salman Akhtar, “The Poppy: Therapeutic Potential in Cases of Dementia with Depression”, in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, pp. 79ff.

---

CITATIONS regarding the idea (voiced above, months ago, without citation) that opioids would just make a person sleepy:

Opiates may produce “excitation” and “stimulation”.

- Reynolds, A. K., PhD, and Lowell O. Randall, PhD, Morphine and Allied Drugs (1959), p. 19.

Berridge provides considerable discussion of opioids as stimulants, and shows that they were not uncommonly viewed as such.

- Berridge, Opium and the People: Opiate Use in Nineteenth-Century England, 1987.

Takano discusses farmers who take opium to help them work a long, hard day in the fields.

- Takano, Hideyuki, The Shore Beyond Good and Evil: A Report from Inside Burma's Opium Kingdom (2002).

Way discusses the use of opium as an aid to work.

- Way, E. Leong (Department of Pharmacology, School of Medicine, University of California, San Francisco, San Francisco, California, USA), "History of Opiate Use in the Orient and the United States", in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York (1982).

---

CITATIONS regarding the idea (voiced above, months ago, without citation) that constipation and nausea might be major obstacles to the use of opioids for mood therapy:

“Constipation. . . is treated [with laxatives and stool-softeners]. . . . Opium-related nausea might occur after an increase in dosage or initiation of opium therapy".

- Burton, Allen W., "Acute, Chronic, and Cancer Pain: Clinical Management", in Opioid Research: Methods and Protocols, edited by Pan, Zhizhang Z., 2004, p. 277.

(The implication is that easing in to the target dosage will greatly reduce constipation and nausea. Since opioids act so quickly, easing in is not necessarily a long process.)

"It is very important to watch out for constipation, which can be severe” and “can be a very considerable complication”.

- Abse, D. Wilfred, quoted in “Opiate Antagonists in the Treatment of Mental Diseases: General Discussion”, in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, p. 129.

“Nausea and vomiting are relatively uncommon in recumbent patients given therapeutic doses of morphine”.

- Gutstein, Howard B. and Huda Akil, “Opioid Analgesics: Effects”, in Goodman and Gilman’s.

(The implication is that nausea is manageable, given that just lying down can make it a relatively uncommon symptom.)

---

CITATIONS regarding the idea that addiction, triggered by euphoria, is a speedy and frequent result of therapeutic use of opioids:

The dosage required to produce euphoria is significantly greater than the dosage required to relieve distress, and tolerance appears to develop much more rapidly for euphoria than for other effects of opioids. For example, Hideyuki Takano says of his second use of opium: “On the one hand, the opium worked on the symptoms unbelievably well and quickly. On the other, that blissful pleasure of floating in air, experienced the first time, disappointingly never recurred. However, the milder euphoria that came instead was pleasant”.

- Takano, Hideyuki, The Shore Beyond Good and Evil: A Report from Inside Burma's Opium Kingdom (2002), pp. 188f.

While anodyne effects are common, perhaps universal, euphoria seems to be unavailable to many: “Euphoria is not a universal accompaniment of opiate administration. Indeed, to the well-adjusted individual, morphine effects may be anything but pleasant. It is in the emotionally unstable person who is liable to be abnormally excited or depressed, that is to say, the individual who is removed from normal psychological equilibrium in relation to the immediate environment and circumstances, that euphoria is most marked. . . . Opiates afford an escape mechanism from reality and the burdens and disappointments of everyday life”.

- Reynolds, A. K., PhD, and Lowell O. Randall, PhD, Morphine and Allied Drugs (1959), p. 125.

“When therapeutic doses of morphine are given to patients with pain, they report that the pain is less intense, less discomforting, or entirely gone; drowsiness commonly occurs. In addition to relief of distress, some patients experience euphoria”.

- Gutstein, Howard B. and Huda Akil, “Opioid Analgesics: Effects”, in Goodman and Gilman’s.

“Although tolerance does develop to oral opioids, many patients obtain relief from the same dosage for weeks or months”.

- Gutstein, Howard B. and Huda Akil, “Opioid Analgesics: Clinical Summary”, in Goodman and Gilman’s.

“Tolerance and dependence are physiological responses seen in all patients and are not predictors of addiction. . . . These processes appear to be quite distinct. For example, cancer pain often requires prolonged treatment with high doses of opioids, leading to tolerance and dependence. Yet abuse in this setting is very unusual (Foley, 1993)”.

- Gutstein, Howard B. and Huda Akil, “Opioid Analgesics: Effects”, in Goodman and Gilman’s.

“The importance of the issues of tolerance, dependence, and respiratory depression have been exaggerated”.

- Walsh, T. Declan, MSc, “Prevention of Opioid Side Effects”, Journal of Pain and Symptom Management, December, 1990, p. 362.

“The existence of so-called chippers, individuals who use heroin recreationally on a periodic basis, indicates that exposure to an opioid alone does not reliably lead to escalating use or addictive behaviors, even in those who consume these drugs for purposes other than pain control”.

- Portenoy, Russell K., MD, “Chronic Opioid Therapy in Nonmalignant Pain”, Journal of Pain and Symptom Management, February, 1990, p. S54.

“An early concern that self-administration of opioids would increase the probability of addiction has not materialized”.

- Gutstein, Howard B. and Huda Akil, “Opioid Analgesics: Therapeutic Use”, in Goodman and Gilman’s.

“Interestingly, according to reports of that [Kraepelin’s] time, although a standardized evaluation of the therapeutic efficacy was, and is, lacking, this treatment was effective and did not result in opiate addiction, possibly since the doses applied were comparatively low”.

- Emrich, H. M., P. Vogt, and A. Herz (Max-Plack Institute for Psychiatry, Munich, Germany, "Possible Antidepressive Effects of Opioids: Action of Buprenorphine", in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, p. 108.

“[J. H.] Jaffe many years ago [in 1968] opined that the fear of addiction is out of proportion to the actual frequency of its occurrence. In the cases of opium-treated dementias with which we are concerned, this fear seems especially misplaced. In our experience, [the patient] does not require increasing doses. . . over time”. - Abse, D. Wilfred, William J. Rheuban, and Salman Akhtar, “The Poppy: Therapeutic Potential in Cases of Dementia with Depression”, in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, pp. 79ff.

"Some 20 years ago at the University of North Carolina where I was working, people were interested in some of the opiate effects on elderly people at the psychiatric unit for whom the drug was euphoric. Also, these researchers investigated cheerful, young adults who were being given various drugs and opiates to see their reactions. Healthy, cheerful students who received opiates became depressed after they had a dose, which was the opposite of what was happening with the older people with impaired nervous systems."

- Abse, D. Wilfred, quoted in “Opiate Antagonists in the Treatment of Mental Diseases: General Discussion”, in Opioids in Mental Illness: Theories, Clinical Observations, and Treatment Possibilities, edited by Karl Verebey, The New York Academy of Sciences, New York, New York, 1982, p. 129.

TH 01:09, 18 February 2006 (UTC)

geriatric depression
Further research with respect to the last paragraph of "Clinical use" produced additional citations and the addition of "geriatric depression" to the list - formerly "senile dementia, chemotherapy, terminal diagnosis", now "senile dementia, geriatric depression, chemotherapy, terminal diagnosis".

To keep all the citations in support of the paragraph in one place, I went back up in this Discussion page and inserted them into the original list. The new citations are:

1. Regarding thymoleptics: "Through advances in medicine, . . . limit their use in the elderly".

2. Regarding constipation: "It is very important . . . considerable complication".

3. Regarding addiction: "Some 20 years ago . . . impaired nervous systems".

TH 01:25, 3 March 2006 (UTC)

Note to the person who changed Clinical Use:
If you want to alter my paragraph, you must, per Wikipedia policy, provide citations. And make sure your citations have more authority than the 38 citations that I provided, on the discussion page, in support of my paragraph.

TH 05:05, 11 March 2006 (UTC)

added citation on STAR*D and clarification on "act surely"
In support of the last paragraph of the "United States" section of the article, I added a citation regarding the STAR*D study of 1500 patients. I also added the paragraph regarding "opioids act surely".

I made these two additions above here on the Discussion page, so that all the citations would stay together.

TH 05:38, 1 April 2006 (UTC)

Etonitazene
Just started a page on Etonitazene, but don't know/can't find very much information. Anybody want to help me?

http://en.wikipedia.org/wiki/Etonitazene

Miserlou 20:09, 7 April 2006 (UTC)

Recurring Abdominal pain and nasuea
I have been to and worked in detox facilities and methadone clinics, was a junkie for over five years, my dad has been on opiates for chronic pain for half my life. I've known hundred of junkies, and never once heard of recurring abdominal pain and nasuea due to taking painkillers...that section (it's under withdrawl and dependence) is just bizarre to me...can anyone provide a source for this? —The preceding unsigned comment was added by Azrayl (talk • contribs) 21:09, May 22, 2006 (UTC)


 * Since that paragraph discusses "when the pain medication runs out," I think it's talking about nausea and abdominal pain as withdrawal symptoms. They are, of course, very common withdrawal symptoms. However, nausea is also a very common side effect of all opiate based drugs. Abdominal pain is also a common side effect and in some cases can be a manifestation of the chronic constipation (and even bowel obstructions) opiate based drugs can cause. One reference which states this is The Drug Guide by Dr Jonathan Upfall, ISBN 0957988338, p.471, which lists "constipation, dry mouth, stomach ache, nausea, vomiting" as side effects of morphine, for example. Sarah Ewart (Talk) 10:16, 2 July 2006 (UTC)


 * Okay, yeah I'm not sure why I said naseau wasn't a side-effect, because it is. and abdominal pain can present itself due to constipation or withdrawal. --Azrayl 09:11, 15 July 2006 (UTC)

Added DSM-IV terminology note
The terminology section has definitions that differ from the standard used in psychiatry. To avoid confusion by readers who may have received diagnoses from their healthcare professional, I added a note explaining the variation. With any luck, the addictive disease workgroup at the APA will address nomenclature as part of the DSM-V development. At this time, that's still in the plan. Drgitlow 02:11, 7 July 2006 (UTC)

Uncited Statements-again
Someone deleted (probably just an accident) all the explanations I gave for the changes I made, along with all of the peer reviewed professional references that I gave to substantiate them. Well, here they are again.

I took out: "it rarely develops in persons who are taking opioids under medical supervision for legitimate therapeutic purposes (such as pain management), particularly when the dosage used is too low to produce any feeling of euphoria." and also "the emerging medical consensus is that most chronic pain patients can safely use opioids for years with a minimal risk of addiction or toxicity and that the overall increase in quality of life outweighs any adverse effects of opioid use." and "Typically, persons taking opioids under medical supervision for the usual clinical purposes (such as pain management) are less likely to develop addictions or patterns of abuse than those who begin using the drug specifically for its other effects such as euphoria. However it is very likely that many addicts began using because they experienced the great relief from some types of "psychological pain" that only opiates can provide." and "Although physical dependence is nearly universal among those who use opioids regularly, true addiction is quite rare even when large amounts of opioids are used over long periods of time to treat chronic pain under the close supervision of a doctor. This is thought to be because of the rapid development of tolerance to the euphorigenic properties of opioids; without euphoria, only the unpleasant side effects (such as bowel dysfunction) remain, so there is no motivation to take more than is needed to manage pain. Because these statements are untrue and no evidence or citation is given, while evidence to the contrary is well known in the peer reviewed medical community, addictionj rates are higher among those who use opiates for medical use do to exposure. Please cite a peer reviewed source if you with to replace it. My sources are listed below thank you. 76.20.176.60 12:52, 5 October 2006 (UTC) Miller NS, Disease Orientation Taking Away Blame and Shame, Chapter 6, in Addiction Recovery Tools, pp 99-109, R. H. Coombs, ed., Sage Publications 2001. Dackis CA and Miller NS, Neurobiological Effects Determine Treatment Options for Alcohol, Cocaine and Heroin Addiction, Psychiatric Annals, 33(9): 585-592. 2003. Miller, NS, “Drug Abuse”, Rakel and Bope: Conn’s Current Therapy, W.B.Saunders Co., 2002, pp. 1117-1124 Miller NS and Goldsmith RJ, Craving for Alcohol and Drugs in Animals and Humans: Biology and Behavior, Journal of Addictive Diseases, 20(3): 87-104. 2001.

I took out "One of the advantages of opioids is that there is no upper limit to the dosage and the achievable pain relief as long as the dose is increased gradually to allow tolerance to develop to adverse effects (especially respiratory depression)." because this is untrue. There is ALWAYS a dose at which adverse effects or lethality occur for every substance man can physically intake. This includes opiates, for example, one could never titrate a dose of oxycontin up to say, 100 grams a day. 76.20.176.60 12:52, 5 October 2006 (UTC) Source: Katzung B, Basic & Clinical Pharmacology, 9th ed., McGraw Hill, 2006. Brunton L, et al, eds, Goodman and Gilman’s The Pharmacologic Basis of Therapeutics, 11th ed., McGraw Hill, 2006.


 * 76.20.etc's assertions above are false. most of the above quotes that he opposes are consistent with accepted practice in the pain-specialist community -- although it's understandable that you *CAN* find sources that are opposed, especially if you quote only from the anti-addiction literature and choose articles all from the same source.  as for his assertion about upper limits, there are documented cases of late-stage cancer patients receiving a few grams of intravenous morphine each hour without strong negative effects.  granted, this is an extreme case but it clearly shows that his assertions are untrue. Benwing 05:04, 8 January 2007 (UTC)


 * some sources:    —The preceding unsigned comment was added by Benwing (talk • contribs) 05:18, 8 January 2007 (UTC).

opioid word
i think it should be noted that Opioid is actually opi(um) + (alkal)oids

Last reversion by Daksya
This research you cite as "new developments" showing that chronic opiate users can take these drugs without dependance is flawed. It is nothing more than a case report, it does npt meet the criteria of being evidence based clinical research. RCT are the gold standard, and even a cohort study would have some credibility, but a case report is not evidence based to proove causality or lack of association. It proves nothing and is not a "development."


 * You seem to have missed the second cite which contains results of various clinical trials (including Phase III) and controlled animal studies, alongwith in vitro experiments. - daksya 06:41, 30 October 2006 (UTC)

Sorry about that, I did not see the second citation. The clinical trials you mention seem to indicate that withrawal effects can be reduced using opioid receptor antagonists. If you want to say that in the artice, ok, but to say "although recent research points the way towards chronic opioid use without tolerance or withdrawal" makes in invalid conclusion. Maybe you could say something like "recent research shows that, when used with opioid antagonists such as naltrexone, withdrawal effects can be reduced" However, the statement you made as it is written is not supported by the research you cited.

I went ahead and changed it to say "All persons receiving opioids for any reason will develop some degree of tolerance and dependence over time, although recent research suggests that these effects can be reduced by the concominant administration of opioid antagonists. [1][2]. " I think this pretty much acknowledges the research findings for what they are. It just sounded misleading the way it was written before.

Compare and Contrast
What has been bothering me is that when I read the opioid article I see a great deal of clinical information and though some is pretty biased, a lot is quite irrefutably factual and informative. Then, I read the opium article and am wildly disappointed. Is it the social-acceptance syndrome that causes this? Papaver Somniferum is one of (and perhaps the highest-importance of) the five most important plants humankind has ever discovered. The plant and its active derivatives are still the most effective and safe analgesics, cough suppressants, anti-diarrhoeals known. I wish the vast majority of you would stop bashing the plant and hypocritically lauding all its derivatives. DrMorelos 00:44, 25 November 2006 (UTC)

Categorization of synthetics
I just changed the size of the heading "Piperanilides" to match the other headings. Due to the fact that "Morphinan derivatives", "Others", etc. were subheadings of it, and they don't seem to be related to piperidines, I think it was just a mistake made by the anon who added the subhead a couple months ago. If possible, I'd like someone who knows more about the chemistry to confirm this for me, as I can't find anything on Google for "piperanilide" but WP mirrors. What relation do piperanilides have with phenylpiperidines (as fentanyl is definitely also classed as the latter... I believe)? Oy. Thanks in advance... --Galaxiaad 08:17, 19 January 2007 (UTC)


 * They are actually called "anilidopiperidines" or "anilinopiperidines". Fentanyl is no way a phenylpiperidine derivative, since it is an 4-anilidopiperidine (so N-phenylamino-piperidine) derivative.

The relation between 4-phenylpiperidines (e.g. meperidine/pethidine) and 4-anilidopiperidines (e.g. fentanyl) is that, both groups have certain structural similarity, namely the base of their molecular sceleton is the 1-alkylated, 4- substitued-piperidine. In the case of 4-phenylpiperidines, the 4-substituent is a phenyl or substitued phenyl cycle (e.g. 3-hydroxyphenyl in ketobemidone), whereas 4-anilidopiperidines have a N-phenylN-acylamido group as their 4-substituent (Ph-N(-CO-R)-), mostly N-phenyl-N-propionamido group (Ph-N(-CO-CH2-CH3)-). In general, anilidopiperidines are more potent opioids than phenylpiperidines.--84.163.87.92 21:27, 19 January 2007 (UTC)

Chemical categorisation of fully synthetic opioids.
I have removed the link to ketobemidone from the sub-category "Piperoanilidines (or anilidopiperidines), because it is chemically a phenylpiperidine derivative (4-(3-hydroxyphenyl-1-methyl-4-(1-oxopropyl)-piperidine). I further suggest to fuse the sub-categories of "Phenylheptylamines" and "Diphenylpropylamine derivatives", under "Diphenylpropylamine derivatives", since both methadone and LAAM are chemically derivatives of 3,3-dipheylpropylamine (methadone can be described as (R,S)-1-methyl-3,3-diphenyl-3-(1-oxopropyl-)propyl-N,N-dimethylamine, however it is an homologue of diphenylpropylamine, namely (R,S)-2-N,N-dimethylamino-4,4,-diphenylheptan-5-one; same can be applied for levacetylmethadol/LAAM). Discussion is wellcomed, if nobody has objections, I will do so in few days.--84.163.87.92 21:19, 19 January 2007 (UTC)

I will begin to try to improve the style of writing.
I think this article is quite good, but at present somewhat inaccessible for an untrained person. I will try to rewrite the point-wise sections as prose, and begin improving citations (as per WP:CITE and WP:CITET template). I will try not to change the content and meaning, but as always, criticism from others is important, especially as I am not a pro writer. I will post sections as I complete them. --Seejyb 23:50, 19 January 2007 (UTC)


 * Should all the long paper or book citation details within the text not be converted into footnotes ? If people agree, I can help markup as footnotes and use the relevant citation template to standardise the styling. :-) The information in the article is detailsed and good but overall it reads like lecture-notes points rather than flowing prose. David Ruben Talk 01:57, 23 January 2007 (UTC)

Summary of changes of January 24th, 2007; Section: synthetic opioids
The sub-categories "Diphenylheptylamines" (Methadone and LAAM) and "Diphenylpropylamine der." were fused under "Diphenylpropylamine derivatives"; for reason see my argumentation of January 19th. Further, "Piperoanilines" were renamed to "Anilidopiperidines", since this is the mostly used name for this subcategory of synthetic opioids in english literature (fentanyl derivatives); the opioid Etorphine was moved into subcategory "Oripavines", since it is an oripavine derivative. Opioids Loperamide and Diphenoxylate were moved into subcategory "Diphenylpropylamine derivatives", because they are both derivatives of this class (structurally akin to the opioid Piritramide). Spelling of the titles of subcategories "Benzomorphan derivatives" and "Morphinan derivatives" were corrected to "Benzomorphane" and "Morphinane" derivatives, respectivelly (see IUPAC organic nomenclature, english). For every change, a standard source cited is: ISBN 3-527-30403-7 ; Buschmann et al.: Analgesics. From Chemistry and Pharmacology to Clinical Apllication. Wiley-VCH, 2002.--84.163.91.142 03:12, 24 January 2007 (UTC)

Summary of changes to opioids Jan 2007
Over the past two months I have been working steadily to add the clinical use of opioids for people with palliative care needs. I realise that opioids are used and abused for many other reasons, but feel that some of these are subjects for other sections, particularly the recreational use of the naturally occuring agents.

There is so much misinformation about this group of chemicals that many people who need opioids for the relief of symptoms such as pain or breathlessness, are frightened by the fear of addiction, tolerance or intolerable adverse effects. Ocasionally patients will believe pain is preferable.

I realise that some will find these changes more 'clinical', but I have tried to make the academic aspects readable. As far as possible I have tried to reference the experience of palliative care and attempted to make clear the diference between safe and unsafe use of opioids.

Being relatively new to Wikipedia, I am still learning the rules, and apologise that I have not previously written a comment to explain my actions and encourage debate. I am happy to do so now.

--Claud Regnard 23:22, 4 February 2007 (UTC)

Dear Claud, I agree with you, but I think that half of this Wiki voice shoud be erased and the title changed. It's not a voice about opioids but something else, like Pain management or palliative care.

Albert0, alt.drug.hard poster, 23/07/2007

Dear Albert, I accept there is a balance to be struck between the scientific (chemical, pharmacological, medical), pragmatic (practical use and abuse) and social. However, it is not possible to isolate any one part without creating a knowledge gap in the information. Opioids bring both relief and harm to millions around the world. Understanding the aspects of both are crucial in offering a section that is useful and informative. --Claud Regnard 22:43, 21 August 2007 (UTC)

Citation needed about addiction
A citation is DEFINITELY needed for the claim that people taking opioids for medicinal purposes rarely get addicted.

-Jessica 71.246.71.26 12:30, 3 May 2007 (UTC)

Quite right, although it is true that addiction is rare. After 30 years practice using opioids in palliaitve care I have never known a patient develop a craving or drug-seeking behaviour for their opioid. There are many references for this, but currently the best text is the Oxford Textbook of Palliatve Medicine. --Claud regnard 23:34, 9 May 2007 (UTC)

Dangerous opioids
The moderator was not happy with the style of the 'dangerous opioids or dangerous prescribers section, so I have changed this into a more suitable style (I hope).

--Claud regnard 23:48, 9 May 2007 (UTC)

Harold Shipman
The mention of Harold Shipman is quite bizarre, almost suggesting that he was a victim of juducial anti-opioid prejudice. He was convicted of fifteen counts of murder, not simply of knowingly administering overdoses. It was decided by an inquest that Shipman had murdered at least two hundred and fifteen of his patients, having caused them to include him as a beneficiary in his will. There were two hundred more suspicious deaths associated with him. On that basis, I deleted it. — Preceding unsigned comment added by 86.152.5.95 (talk) 13:44, 16 May 2007 (UTC)

":You're quite right, although there have been two cases of UK doctors who were not convicted despite giving similar or higher doses. They used double-effect as their defence. --Claud regnard 00:58, 6 June 2007 (UTC)

Rarely get addicted?
There definitley needs to be something done about the article stating that people using opiates for painkillers rarely get addicted, as this is completely wrong. people taking prescription opiates are at a huge risk for addiction and many of them are addicted. by having their doctors up their dose and being on a lifelong regime, this defines addiction, particularly due to the fact that they cannot stop taking said opiates without withdrawal symptoms, and require more of said opiates for the pain relief and allevation from the withdrawal. --User:kmac20 23:34, 23 May 2007 (UTC)

kmac20, No, you are mistaken. Addiction is defined to be a "drug seeking behaviour" where an individual actively seeks a drug despite it not being therapeutic, despite any adverse criminal, social or economic circumstances, and with no regard to the consequences. What you are describing is Drug Tolerance (where the body requires a larger dose to get the same effect) and drug dependance (where a drug user's body requires the presense of a drug for "normal" function - compare to a diabetic being "dependent" on insulin). I believe the main article clearly delineates these differences, as does the article on drug addiction. For the record, I've been taking opioid based medications (Tramadol, Morphine and Oxycodone) for over a decade now on a twice daily basis, and I've never been inclined to seek any beyond the dosages prescribed by my Pain Specialist. My doses are larger than they were, and the drugs I take are stronger, but that is due to tolerance and the fact that my condition is deteriorating. Yes, if I stop taking them I have unbearable pain, but that's as much due to massive nerve damage as to dependence. Patients who are dependent on opioids will get a regime to reduce their dose when (and if) the underlying cause is cured, thus managing the withdrawal and eventual cessation of the drug. I believe that many people don't talk to their doctors about weaning off the meds once they're better due to a stigma of "addiction" caused by basic misunderstanding much like yours. Given that taking these drugs for pain doesn't seem to provide any euphoria, but does provide chronic constipation and the real risk of not noticing other injuries, most pain patients would love to be able to live without narcotics. Myself, I've only 30 or 40 years of living like this left to go ... Johnpf 09:09, 24 May 2007 (UTC)

It does seem odd to claim that addiction is rarely seen in clinical practice in patients taking opioids for pain relief. And yet, that is the reality, with extensive literature to support that observation. Johnpf gives one definition of addiction, but a more recent view is that addiction is a craving for a chemical or behaviour (relieved when the pleasure centre of the brain is stimulated by that chemical or behaviour) and that this occurs within a specific social context. For a patient in pain, the social context is to relieve the pain, and the use of opioids for pain relief does not create a craving for the opioid. Patients whose pain is relieved by other means can reduce and stop their opioid without being left with a craving. --Claud regnard 00:20, 6 June 2007 (UTC)

Johnpf, the drug users would seek the drug and attempt to obtain it illegally due to their tolerance, if their prescription was revoked. just because they are given the drug with reason does not make them any less addicted due to the addictive nature of the drug to begin with. they must be addicted, and this is why it is so dangerous to take them off of the drug, they will then just become addicts without a license. kmac20

Kmac, please take the time to check the articles on Addiction, Tolerance and Dependence. Learn a little about the difference between the terms. You are describing Addiction. Tolerance is a completely different thing, being a reduction of affects on the body. It is not usual for someone who has been using opioids appropriately to respond to medically guided cessation of these painkillers by developing an addiction. It could be the case in places where it is easy to get strong opioids (like oxycontin in the USA) that people could be self- medicating, and over-medicating, and then developing addiction. Addiction is usually (though not always) associated with abusing drugs. You also have to be aware that to people like myself, who have another 30 or so years of pain ahead of them, properly supervised medical treatment with opioids is such an important contributor to quality of life that addiction is really a non-issue - no more than a diabetic's dependence on insulin, as both are cases where medicine dramatically increases lifespan. Johnpf 11:36, 2 July 2007 (UTC)

The quality of this article is poor, because it gives some ggod datas but is heavily biased and with rhetoric argumentation

Some quotes: Contrary to popular belief, high doses.../ In the U.S., doctors virtually never prescribe opioids for psychological relief, despite their extensively reported psychological benefits/ 33% of UK doctors believe .. etc[about belief on opioid or about opioid?]/ Before the twentieth century, institutional approval was often higher, even in Europe and America [also for war was the same]] In some cultures, approval of opioids was significantly higher than approval of alcohol /  With exceptions such as Shipman, UK doctors are very cautious about shortening life (??!!)/  There is a parallel here with power tools which are inherently safe unless they are used in a negligent or malicious way. Why blame the tool—morphine—and ignore bad prescribers? [some more sermon?]/ For patients taking opioids for pain relief, this can occur in some (but not all), but it is not a clinical problem[citation needed: yes it is]/ Abuse is the misuse of opioids in the context of addiction [circolar definition, that imply no pssible problem in medical use]/ Prevention of tolerance [in the future there will be no problem, so stop worring *now*]/ Occasionally, *people who are addicted* to opioids on the street develop a painful condition which requires strong opioids. [...] they *do not run the risk of addiction*     It's enough?

Albert0 from ADH 23/07/2007

Albert, I can see why you find some parts of this article difficult, although the truth can be surprising! You are right that more statements need referencing, but it is not clear from your comments exactly what are your difficulties with the sections you quote. In relation the sections I'm most familiar with:

...UK doctors are very cautious about shortening life... This is true and comes from a recent study which is cited.

...Why blame the tool... This is a comment rather than a sermon and refers to the tendency to blame opioids for problems, when the problem is invariably incorrect, ignorant or malicious use.

...people who are addicted... There is increasing experience of patients with pain who were previously (or even currently) opioid-addicted, having no difficulties managing with opioids. In the past such patients had opioids withheld for fear this would worsen or rekindle their addiction.

Perhaps you could help us with more specific comments on the sections you quote. --Claud Regnard 22:22, 21 August 2007 (UTC)

Johnpf is correct. I am a pain patient, and I am enrolled in a pain clinic, which is ran by a local hospital. I have been without opiates for a few days due to my appointment with my physician being made a few days off. Even though I had withdrawal symptoms, I never in fact "craved" the drug, nor have I ever. I have several chronic things wrong with me that puts me above the moderate pain level, and thus am prescribed an opiate that combines Tylenol to relieve the pain. I have been taking opiates for 10 plus years, and if I did not have to take them, I would not. However, I have never "seeked" or "craved" drugs as addicts do, nor have I ever showed that type of behavior.

The National Pain Foundation is very clear in the difference, or definition, between addicts, and people who are tolerant, or physically dependant to a pain reliever. New laws are now being passed in the U.S. that shows these clear distinctions, and you can reference these at the foundations website.

Most who argue that everyone are addicts, have never been in severe pain, nor have they had to be treated for such, especially for chronic pain in a long term situation. I have found that a majority of them have some sort of religious prejudice towards the subject, similar to those involved in the temperance movement in the U.S. in the early 20th century. I actually have a few in my family, and all are religous zealots. Even though the statistics and studies are made available to them, they will still deny the truth.

Under the Addiction section, it should be noted that addicts show certain behaviors such as "drug craving, drug seeking, doctor shopping, prescription forging, and illegally obtaining the drugs". They will also try to obtain these drugs with no regard to their personal safety and health. Ones who are NOT addicts will not have this behavior, and will do as their physician orders. Physicians and pharmacies have methods to determine this difference, and they can discover who is an addict, or who actually needs the medication for a therapeutic and legal treatment. A CLEAR distinction should always be made between the two.

Ref.:

http://www.nationalpainfoundation.org/MyTreatment/News_TenMythsAboutPain.asp

http://nationalpainfoundation.org/MyTreatment/MyTreatment_Information_About_Addiction.asp

From the Mayo Clinic glossary: Addiction. An illness in which a person seeks and consumes a substance, such as alcohol, tobacco or a drug, despite the fact that it causes harm.

Opioids, Pain Management, and Addiction, Jennifer P. Schneider, M.D., Ph.D.;

http://www.jenniferschneider.com/articles/PainPractitioner_10_06.html

And;

MANAGEMENT OF CHRONIC NON-CANCER PAIN: A GUIDE TO APPROPRIATE USE OF OPIOIDS, by Jennifer P. Schneider, M.D., Ph.D.

http://www.jenniferschneider.com/articles/opioids.html

Craxd (talk) 00:54, 29 April 2009 (UTC)

Dangerous opioids (continued)
The "dangerous opioids or dangerous prescribers" section still seems biased, written inappropriately, and possibly off-topic.68.127.88.58 01:57, 10 July 2007 (UTC)

Updating references
I have added references where asked to do so by the moderator. However, in some sections (eg. adverse effects) there are so many references that could be added and I have taken the short cut of referencing to larger texts and online resources, and I'll wait to see if this is acceptable. --Claud Regnard 01:02, 6 June 2007 (UTC)