The opioid crisis

Politics and religion
81

Well sure, man. But here we’re talking about whether it reduces pain, and they present studies which support exactly that. Hell, even if you want to skip all of the other stuff and just go to the summary:

Both HF and LF TENS been shown to provide analgesia specifically when applied at a strong, non-painful intensity and HF TENS may be more effective for people taking opioids.

There’s no suggestion that it’s some kind of magic or something. It’s merely a technology that has effects that can help reduce the need for pharmaceutical analgesics. As you say, it’s not new at all. The only thing that’s new is that it’s now much more widely available to consumers.

If the argument is merely that it’s not magic, ok. That’s totally cool.

All I said is that I have not seen any research that suggests its impact is greater than that of a placebo for things like pain relief. Maybe such studies exist, I have no idea.

82

As always the issue is money. TENS units are one of the areas of medicine where providers can easily work around insurance company and government fee schedules and charge ludicrous prices. This is similar to the compound pharmacy problem. In compounding pharmacy situations, you can have an insurance fee schedule that pays say $50 for a bottle of 50 mg pills or $200 for a bottle of 200 mg pills. If the doctor wants something other than 50 or 200, as long as they work with increments of 50 mg, it’s pretty straightforward. However, if a doctor gives a prescription for say 75 mg, then the compounding pharmacy is often not bound by the fee schedule and can charge a much higher price. I’ve seen situations where compound creams that were made of ingredients that would cost $50 if purchased individually per fee schedule be charged at $4,000 (not kidding) when compounded. And yes, for those counting at home that’s an 8,000% markup.

TENS units are similar: they are semi-complicated electronic devices and the providers can always slap on an extra circuit board or some minor widget and say the product is not covered by the fee schedule, and then proceed to charge a massive markup. For cheap individual TENS units, the prices are typically in the low hundreds and for heavy-use capable, multi-setting machines (often for clinical use, or use by patients with severe chronic pain) prices are typically in the low thousands (as someone said up-thread). However, in my CA workers’ comp practice, I’ve seen bills as high as $50,000 (again, not fucking kidding) for a TENS unit with some minor tweaks (“this one goes to 11!”).

Yet another example of the reality that coverage is only half of the problem with US health care. The other half is prices.

83

One more thing in response to the recent posts, in my experience in CA workers’ comp (representing the black hat side, employers and insurers) TENS units are actually a fairly effective method of pain mitigation for some patients. And what I would consider the “legitimate” cost of a TENS unit ranges from low hundreds for a light use / home use unit to low thousands for a heavy use / clinical use unit. As an alternative to say, opioids, it can be both very cost effective and have much fewer side effects and problems.

The problem is not usage of TENS units per se but rather the ease with which this type of product can be used to evade fee schedules and charge ridiculous prices.

Again, it’s similar to compounding pharmacies: there are some legitimate uses of non-standard dose and compound medications but the kind of crazed markup I described above makes the area something that insurers hate with a great and mighty hate.

84

Is there, or is there not, research showing TENS as more effective than placebo?

Because placebos are cheaper. I’m just sayin’.

85

Yes, quite a lot at this point.

86

This is the wrong question to ask. Chronic pain is extremely complex and different people respond differently to different modalities.

Just the issue of “placebo” is complex. A simplistic conception of placebo is that a doctor hands you a sugar pill, tells you it will make you all better, and it does, b/c you believe it does. Notice a key word there? Believe. For a sugar pill to generate a placebo effect, it requires the patient buy into the effect with belief. But in our modern society, sugar pills only go so far. Sometimes a placebo effect can be generated by a modality that does not provide any actual anatomical benefit but caused the patient to believe / buy into the effect. IMO, acupuncture falls into this category. Some people do in fact experience meaningful pain relief from acupuncture, with very little empirical evidence for a true anatomic improvement. But the experience of being worked on, touched, poked etc. helps the patient buy in and generate a placebo benefit.

As to TENS units, my understanding is that

“Both HF and LF TENS been shown to provide analgesia specifically when applied at a strong, non-painful intensity and HF TENS may be more effective for people taking opioids.”

That article discusses the fact that there may be some neurological thing going on, but IMO there may also be a placebo element. WHICH DOES NOT MATTER. If the placebo works, great. If a modality helps people buy into the placebo and that works, great.

Chronic pain is insanely complex and the anatomic, neurological, and mental components are inextricably interlinked.

87

If you look through some of the other studies on tens effectiveness, even some of the ones cited in that review, you see studies where they found that tens therapy provided greater analgesic effect than placebo.

88

The Thermacare people make a cheap, battery-operated TENS unit for about $30. I use one when I have back pain flair ups; the effect is essentially identical to what I got when I was having TENS at a physical therapists’ office.

89

The placebo effect is a lot stronger then you think.

Heck, even if you it’s fake, it can still have a strong positive effect. Belief isn’t strictly necessary for it to have an impact.

http://www.npr.org/sections/health-shots/2016/10/27/499475288/is-it-still-a-placebo-when-it-works-and-you-know-its-a-placebo

90

According to the Centers for Disease Control, fifty-three thousand Americans died from opioid overdoses in 2016, more than the thirty-six thousand who died in car crashes in 2015 or the thirty-five thousand who died from gun violence that year. This past July, Donald Trump’s Commission on Combating Drug Addiction and the Opioid Crisis, led by New Jersey governor Chris Christie, declared that opioids were killing roughly 142 Americans each day, a tally vividly described as “September 11th every three weeks.” The epidemic has also exacted a crushing financial toll: According to a study published by the American Public Health Association, using data from 2013—before the epidemic entered its current, more virulent phase—the total economic burden from opioid use stood at about $80 billion, adding together health costs, criminal-justice costs, and GDP loss from drug-dependent Americans leaving the workforce. Tobacco remains, by a significant multiple, the country’s most lethal product, responsible for some 480,000 deaths per year. But although billions have been made from tobacco, cars, and firearms, it’s not clear that any of those enterprises has generated a family fortune from a single product that approaches the Sacklers’ haul from OxyContin.

Even so, hardly anyone associates the Sackler name with their company’s lone blockbuster drug. “The Fords, Hewletts, Packards, Johnsons—all those families put their name on their product because they were proud,” said Keith Humphreys, a professor of psychiatry at Stanford University School of Medicine who has written extensively about the opioid crisis. “The Sacklers have hidden their connection to their product. They don’t call it ‘Sackler Pharma.’ They don’t call their pills ‘Sackler pills.’ And when they’re questioned, they say, ‘Well, it’s a privately held firm, we’re a family, we like to keep our privacy, you understand.’ ”

91

The mark ups are what they are going from home to professional. Just how it is in all industries - you pay for the duty.

I would go so far as to say it’s effects are relatively straightforward, simple, and depending upon the intensity, devastating.

The complexity that lies underneath, well, we just don’t have the science to understand it. The causes of disease prior to the advent of microbiology were mystifying, and science resorted to speculative theories like miasma, which were nonetheless widely accepted. You can’t not have an answer. When the plague runs through, there has to be meaning, from God or whomever.

Dirac summed it up well for the hard sciences, to which the scientific method is best suited, ‘The aim of science is to make difficult things understandable in a simpler way’

But can we understand pain, which is an expression of consciousness, through science? Anymore than we can understand happy, scientifically? That is light years beyond our capability, so we fill the vacuum with our modern day equivalence of miasma as we plod away at it. We can make some correlations and make a few statements, but we don’t understand it.

You’ve put a lot of thought into it. You’ve even stumbled upon the role of ministration in the art of medicine. You’d be surprised how few are aware of it.

I think if you give it considered thought, you can’t dismiss something like acupuncture, precisely because you’ve admitted whatever it is treating is poorly understood. I’m not too fussed either way, but I see no basis to dismiss it anymore than any of these weak modalities - all the hot\cold presses, massages, trigger points, chiro, Bowen therapy, TENS, shiatsu etc. They all have physiological effects. Heck, even placebo will have a physiological effect. All emotions do. A lot of these things probably work in ways we don’t understand.

You’ve appreciated the subtlety that placebo is real, but you must believe. I like it.

92

To clarify I don’t “dismiss” acupuncture. It is an effective pain mitigation / pain relief method for quite a few people from what I’ve seen. My view is that it operates on the placebo effect rather than a purely clinical/anatomical benefit, but it still works, for many people. I guess my broader point is that since the placebo effect is both real and powerful in pain management, placebo-based modalities can be quite effective.

As to markups on TENS units, the “home to professional” range that NotTooFussed mentions is basically “per fee schedule” which IMO are reasonably sane prices. However, b/c TENS units are semi-complex devices that can be easily modified by adding additional circuits/settings/etc. it’s easy for unscrupulous manufacturers to make devices that don’t fall under the fee schedule and thus allow the manufacture to exploit the inherent inelasticy of demand in health care to charge truly ridiculous prices (tens of thousands instead of hundreds or thousands.) The money issue is why TENS units are sometimes more controversial than some other modalities, with some insurance companies.

93

President Donald Trump overrode his own advisers when he promised to deliver an emergency declaration next week to combat the nation’s worsening opioid crisis.

“That is a very, very big statement,” he said Monday. “It’s a very important step. … We’re going to be doing it in the next week.”

Blindsided officials are now scrambling to develop such a plan, but it is unclear when it will be announced, how or if it will be done, and whether the administration has the permanent leadership to execute it, said two administration officials.

“They are not ready for this,” a public health advocate said of an emergency declaration after talking to Health and Human Services officials enlisted in the effort.

Trump’s off-script statement stunned top agency officials, who said there is no consensus on how to implement an emergency declaration for the drug epidemic, according to interviews with officials from the White House, a half dozen federal agencies, state health directors and lobbyists.

94

This is definitely the correct way to run the country.

95

No one knew that _____ could be so hard.

96

This is like when he said they were gonna release a tax plan, and it ended up being, literally a single sheet of bullet points. Looked like something you got from a student who had forgotten he had an assignment until the night before it was due.

97
98

Wow what an amazing article.

I knew about Purdue pharmaceuticals as the company of oxycontin infamy, and I was vaguely aware of the Slacker family as big in philanthropy. But there very good marketing strategy of keeping Oxy and Slacker complete separate worked on me.

Whatever, “evils” the tech billionaires have done they really pale in comparison to old money folks.

99

“We can be the generation that ends the opioid epidemic,” Trump said at a White House ceremony

Thank you Donald, I am sure your decisive action will soon make this true.

100

So no funds for it. We’re just wishing it away at this point?

WTF, Trump.