Update: From the comments:
Hello,
I am a internal medicine resident in my second year. I read this post on Yglesias' blog and I think that it is somewhat factually flawed. While the opiate/acetaminophen combination pills you cite (percoset and vicodin, are the two most popular) are unconscionably stupid, I think it is for other reasons. I really do think initial reasoning of pharma/docs was not "poison the addicts." There is a fashion I don't understand that stresses "synergy" in various medications (blood pressure, cholesterol, etc.) and the thought in this particular case was probably to reduce the quantity of opiates used, most likely due to fear of side effects. While arguments about intents are somewhat difficult to make, I just don't think you are correct in the assertion that acetaminophen was added as a "poison." You don't ever see the industry/public health/DEA making arguments about the "poison" in Percoset, for example. For good reason! Lots of people without addiction (or with addiction) take these medications every day without any problems. Acetaminophen is really are only toxic when one gets to 7-10g (and probably higher than that), so as a "poison" it simply is not very effective. If you do the math, it is something like 20 or more percoset (depending on the formulation) in one ingestion. For an opiate naive person, the respiratory depression would get you before the liver failure. There are lots of "pharmie" addicts who populate clinics who are just fine; percoset/vicodin are readily available on the street (shocking!). As a poison, it simply isn't especially effective as a deterrent. Furthermore, toxicity of liver failure simply doesn't manifest acutely and it would be difficult to relate cognitively to the addiction. Most patients and addicts I have met have no idea acetaminophen is in the compound. Therein lies the problem. Patients who are in pain take both acetaminophen and these preparations together and, voila, you have the number one cause of acute liver failure. Booze, of course, is the king gorilla of chronic liver failure. I actually counsel addicts (when no one is watching) to switch to oxycodone, as there are less end organ toxicities. While I agree with the general thrust that the state regulation of opiates is incredibly counterproductive and misguided, in this specific case it is more incompetence than conspiracy.
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2 comments:
Hello,
I am a internal medicine resident in my second year. I read this post on Yglesias' blog and I think that it is somewhat factually flawed. While the opiate/acetaminophen combination pills you cite (percoset and vicodin, are the two most popular) are unconscionably stupid, I think it is for other reasons. I really do think initial reasoning of pharma/docs was not "poison the addicts." There is a fashion I don't understand that stresses "synergy" in various medications (blood pressure, cholesterol, etc.) and the thought in this particular case was probably to reduce the quantity of opiates used, most likely due to fear of side effects. While arguments about intents are somewhat difficult to make, I just don't think you are correct in the assertion that acetaminophen was added as a "poison." You don't ever see the industry/public health/DEA making arguments about the "poison" in Percoset, for example. For good reason! Lots of people without addiction (or with addiction) take these medications every day without any problems. Acetaminophen is really are only toxic when one gets to 7-10g (and probably higher than that), so as a "poison" it simply is not very effective. If you do the math, it is something like 20 or more percoset (depending on the formulation) in one ingestion. For an opiate naive person, the respiratory depression would get you before the liver failure. There are lots of "pharmie" addicts who populate clinics who are just fine; percoset/vicodin are readily available on the street (shocking!). As a poison, it simply isn't especially effective as a deterrent. Furthermore, toxicity of liver failure simply doesn't manifest acutely and it would be difficult to relate cognitively to the addiction. Most patients and addicts I have met have no idea acetaminophen is in the compound. Therein lies the problem. Patients who are in pain take both acetaminophen and these preparations together and, voila, you have the number one cause of acute liver failure. Booze, of course, is the king gorilla of chronic liver failure. I actually counsel addicts (when no one is watching) to switch to oxycodone, as there are less end organ toxicities. While I agree with the general thrust that the state regulation of opiates is incredibly counterproductive and misguided, in this specific case it is more incompetence than conspiracy.
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