The overconservative approach to prescribing pain meds

[bubotzu]

I actually had a physican who prescribed t3 for constant migranes along with another med. Was on it for appx. 15 mo., all the time seeing doc on every 4-5 months for check up. Was on vacation, ran out of the meds, and doc would not refill rx. Thought I may be overusing..... I took the meds as prescribed on each migraine occurance - as was prescribed by doc! How absurd...

[stampino]

The doc probably attended some sort of physician conference where he proceeded to hear a lecture on the dangers of pain meds. Then, along comes your innocent request and you got caught in the cross hairs. Dolt!

[pucci]

OxyContin: Purdue Pharma's painful medicine - Fortune Features

As someone with a DEA number and the ability to write narcotic prescriptions, I understand being a bit standoffish with writing narcotics. I work in oncology and see patients whose medications are "stolen" "lost" "dropped" and when we drug test they have no detectable levels. Several rotten apples in the basket have ruined it for everyone. Don't take the prescription that I write you and sell in on the street. Every Oxycontin sold on the street is an inappropriately written narcotic given by some provider. I also see where people overdose on grandma's medications, teenagers die from putting on granny's duragesic patches. I check online and see where patients get prescriptions from 3 different providers. I also see patients that are given oxycontin for migraines when that is not an indication for it. I do the paper work for Medicaid/Medicare prior authorizations that are denied for people with metastatic cancer because these drugs have been used and prescribed inappropriately. I am one of those guys that if you are suspect to me I will not write a prescription for a narcotic.

[eke]

OxyContin: Purdue Pharma's painful medicine - Fortune Features

As someone with a DEA number and the ability to write narcotic prescriptions, I understand being a bit standoffish with writing narcotics. I work in oncology and see patients whose medications are "stolen" "lost" "dropped" and when we drug test they have no detectable levels. Several rotten apples in the basket have ruined it for everyone. Don't take the prescription that I write you and sell in on the street. Every Oxycontin sold on the street is an inappropriately written narcotic given by some provider. I also see where people overdose on grandma's medications, teenagers die from putting on granny's duragesic patches. I check online and see where patients get prescriptions from 3 different providers. I also see patients that are given oxycontin for migraines when that is not an indication for it. I do the paper work for Medicaid/Medicare prior authorizations that are denied for people with metastatic cancer because these drugs have been used and prescribed inappropriately. I am one of those guys that if you are suspect to me I will not write a prescription for a narcotic.

How are people in your profession defining "narcotic"? That is not rhetorical question. It seems to have different meanings depending on the context.

[pucci]

Schedule II - IV drug abuse has made it very difficult to manage cancer pain all the way from getting the meds paid for by insurance to putting the people you write the drugs for at risk for being robbed. Seems like a couple of times a month you see where a drug store has been robbed.

*This post was auto-merged. The following text was added 5 minutes after the last post:*

and to answer the question what I mean by narcotics (in the context above) are sedating pain and anxiety medications.

[eke]

It's not every day I have a candid conversation with someone in your field so your input is greatly appreciated! Am I correct though that the word narcotic has a negative connotation? What I mean by this is that "sedating pain and anxiety medications" are only considered narcotics due to their addiction potential and over use/abuse potential, correct? Do you actually use the word when discussing these meds with peers? I'm not trying to lure you into an argument. If I look for answers to these questions online I'll waste an hour and only find arguments and heavens knows what. It's nice to hear from somebody in the biz! Sincere thanks!!

[magchik]

But if REMS is implemented appropriately, it "may be an important component for addressing the opioid epidemic in the U.S."

So true.
Just like BOOZE AND CIGARETTES.

And Twinkies!


Happy Trails to...
magchik

[Art Vandelay]

OxyContin: Purdue Pharma's painful medicine - Fortune Features

As someone with a DEA number and the ability to write narcotic prescriptions, I understand being a bit standoffish with writing narcotics. I work in oncology and see patients whose medications are "stolen" "lost" "dropped" and when we drug test they have no detectable levels. Several rotten apples in the basket have ruined it for everyone. Don't take the prescription that I write you and sell in on the street. Every Oxycontin sold on the street is an inappropriately written narcotic given by some provider. I also see where people overdose on grandma's medications, teenagers die from putting on granny's duragesic patches. I check online and see where patients get prescriptions from 3 different providers. I also see patients that are given oxycontin for migraines when that is not an indication for it. I do the paper work for Medicaid/Medicare prior authorizations that are denied for people with metastatic cancer because these drugs have been used and prescribed inappropriately. I am one of those guys that if you are suspect to me I will not write a prescription for a narcotic.

By one of those guys I assume you mean just about every doctor in the country now. Cause what you just stated is the status quo right now. You say several rotten bad apples but out of all the people who have severe pain the percentage of teenagers who die from grannies fentanyl patches is really low. Same as the percentage of pain sufferers who would rob a pharmacy. I despise doctors because of times in the past when I was in severe pain and could not receive treatment. Just take ibuprofen. Ibuprofen destroys your stomach and doesn't do jack for pain. If a legitimate pain sufferer is robbing a pharmacy what does that tell you. I know not all drugstore cowboys are legitimate pain sufferers but I betcha some of them are.

You spout the same rhetoric that seems to be so common now with doctors. The number of people who are in constant pain and unable to find relief is probably in the hundreds of thousands in this country. I'll never understand it. There will always be the 1 percent of people who use guns to butcher people in a movie theater and the same is true for drug abuse. To take guns away from the responsible gun owners for that massacre is foolish. To punish the 99 percent of people who are in pain but don't abuse pain meds in this Country is ludicrous. I didn't know until recently doctors now require drug testing to be prescribed pain meds. That just seems way too invasive to me.

It reminds me of the war on drugs, MADD, gun control. So nowadays if you drink more than 1 beer you can potentially get pulled over for drunk driving. How are bars even legal with the drunk driving laws. It's the one percent of people who drink way too much who have no business driving that cause this.

So I think Americans are way too reactive to things that aren't major problems. Shit happens sometimes and drug testing elderly people to make sure they didn't smoke weed in addition to taking they're pain meds is ridiculous to me. Most doctors I know are egomaniacs. It will be nice to see them brought down to earth once our country socializes medicine and pays them way less than they are making now.

[pucci]

One child that dies is one too many! It is not an acceptable risk. I work oncology and what I mainly write are pain medications. You seem defensive in your stance when what I am saying is that it is more and more difficult to prescribe these drugs due to the inappropriate use and abuse of them. How in the world did we manage people with bad back pain/ chronic pain before 1996? (oxycontin became available) Was the pain managed that much better? I don't think so. I firmly believe that every oxycontin bought on the street was an inappropriately prescribed medication. This is not a prn use it when you hurt medication it is a long acting daily time released drug. If you are able to sell it then you evidently don't need it.

[eke]

One child that dies is one too many! It is not an acceptable risk. I work oncology and what I mainly write are pain medications. You seem defensive in your stance when what I am saying is that it is more and more difficult to prescribe these drugs due to the inappropriate use and abuse of them. How in the world did we manage people with bad back pain/ chronic pain before 1996? (oxycontin became available) Was the pain managed that much better? I don't think so. I firmly believe that every oxycontin bought on the street was an inappropriately prescribed medication. This is not a prn use it when you hurt medication it is a long acting daily time released drug. If you are able to sell it then you evidently don't need it.

I think you are speeking to Art as I asked a sincere question. All the best!

[Oxidize]

Ugh. I both hate and relish this topic. But it is a good one, no question.

Look, they isolated the alkaloids codeine and morphine from opium a long time ago. During the American civil war, they were still 75 years away from antibiotics, but thank god they had morphine. It is a more humanitarian way to die from an infection that was going to kill you anyway, maybe even with an amputation.

But since then... they have used both codeine and morphine to synthesize many other opioids of different strengths and effectiveness. Dihydrocodeine was one easy step away from codeine, then oxidation from there and you get hydrocodone. Diacetyl morphine was synthesized in the 19th century for heaven's sake. There are others... oxycodone is more difficult to synth but not with modern equipment, then you have hydromorphone, oxymorphone, fentanyl, and on and on we go.

And try as they might, no one can come up with anything even NEARLY as effective for pain. How many non-narcotic pain relievers have they tried for moderate to severe pain that ended in disaster? How about Celebrex, eh?

Opiates and derivatives work best, and always will. But they are addictive. So what do you do? What I never understood was... why does every country seem to have just a few drugs of choice? Why give someone percocet for pain that T3's would control? Why in the world don't we prescribe DHC in the USA? It lasts longer than hydro/oxy and in my opinion the abuse potential is certainly present, but far less than the stronger pain meds. So if codeine doesn't do it, move up to DHC. Try different dosages. try it with APAP, or perhaps with NSAIDS if you don't have bleeding issues because of post-op or something. You know, they make vicoprofen. They just never ****ing prescribe it. Why?

There are so many ways to move up the ladder and find a balance for people where pain is controlled, but you don't have to hit a tack with a sledgehammer. If someone needs Opanas or oxycodone, so be it. It is ethical and right to prescribe it, along with stern warnings about misuse.

Why is it that every pain management situation is either that SHIT tramadol, OTC products, or we jump up to hydrocodone or oxycodone? I think Vicodin was one of the (if not the) most prescribed drug in the USA over the last few years. In the top 10 for sure. Address the NEED. Why is that so difficult? I would like to add that I have gone through cycles where I purposely reduce my opiate intake, sometimes even quitting entirely so that my tolerance goes back down. 2 months and I can often start back on something much less powerful and don't have to move back up for at least a few months. What about resetting tolerance? Ibogaine and such? Why aren't modern practitioners at least looking at those possibilities so that long term pain management is actually possible without getting to fentanyl in 6 weeks?

Further, if you restrict these meds enough, people will find ways to get them or to get relief from something else, probably black market. Is that really the way we want to go?

I don't think most doctors, other then true pain management specialists, know jack shit about what they are prescribing. I have found that mixes of opioids can provide enduring pain relief that ends up better than either of the two when taken separately, even at higher doses. I am not suggesting someone take 5 different pain meds at once. I am saying that if you actually experimented with any of this, you would know that some things work better than others, and may NOT require stepping up dosage or strength of meds if used in combination properly. But nobody seems to do this, or know anything about it. Why?

If you address the need appropriately, then if the patient does get to a point of not needing the meds anymore, the route to being drug free is much easier. Also, as a consequence of appropriate pain relief prescribing, people who need the stronger stuff will get it. As they should.

My grandma had terrible joint pain, hip pain, back pain, just about every pain you could imagine the 2 years before she died. Her doctor prescribed her ONE vicodin 5/500 per day. OK, first, why the **** does someone who is 90 need 500mg of APAP to wreck their liver every day when the 5mg hydrocodone is 100 times more effective anyway? Next, since these pills did not deal with the pain properly, my grandma was always uncomfortable, but was afraid to ever take more then she was prescribed. She told her doctor, but her doc refused to up her script.

So a few years of pain go by, and then she is in palliative care with so much morphine she can't tell if she is on foot or horseback. What the hell? What is the point of all that? Why not give her the meds she needed to control pain WHILE she was alive, mobile, and needed it. What, were they afraid a 90 year old would get "hooked"? And do what? Turn to prostitution to buy drugs? For ****'s sake.

Give people the pain meds they need. Cheaply. Do it right, be smart, look at it like any other part of medicine - it takes some thought and a little bit of effort. Keep offering rehab for people who develop addictions. And on we go. Having the DEA literally in an adversarial relationship with the medical community is ridiculous, and I fear most doctors know almost nothing about what they are prescribing for pain anyway.

I personally would rather see us err on the side of true pain patients getting the meds they need even if it means abusers have easier access to the drugs, as opposed to "clamping down" on supposed abusers and consequentially forcing people in serious pain situations to just keep suffering. Sorry, but that seems more civil and ethical to me.

[GoingBananas]

This is a sore issue for me as well.
My mother died slowly of cancer for 4 years.
Up until the last month guess what her ONLY pain medication was?
DARVACET

I remember when the hospice nurse came out and chided her for taking too many one night in the last couple months. She was concerned about her liver.

I took all this in.
I could have got her much stronger pain meds and offered many times but my mother was always one that would follow rules to the letter and thought she had to deal with it.

It changed me.

War on drugs.
Not really.
It is a war on the poor, the middle class too, maybe the upper middle class to some degree.

It takes money to have an unlimited supply of pain killers.

All the rest of it, if you keep asking the question why? You will get to the root eventually. MONEY.

As long as the world is distracted and in pain then people can't get their shit together enough to rise up. It has always been this way. Not with medications of course. I am talking about fear.

People are scared they will suffer and no one will help. Why?

[dingleberry]

By one of those guys I assume you mean just about every doctor in the country now. Cause what you just stated is the status quo right now. You say several rotten bad apples but out of all the people who have severe pain the percentage of teenagers who die from grannies fentanyl patches is really low. Same as the percentage of pain sufferers who would rob a pharmacy. I despise doctors because of times in the past when I was in severe pain and could not receive treatment. Just take ibuprofen. Ibuprofen destroys your stomach and doesn't do jack for pain. If a legitimate pain sufferer is robbing a pharmacy what does that tell you. I know not all drugstore cowboys are legitimate pain sufferers but I betcha some of them are.

You spout the same rhetoric that seems to be so common now with doctors. The number of people who are in constant pain and unable to find relief is probably in the hundreds of thousands in this country. I'll never understand it. There will always be the 1 percent of people who use guns to butcher people in a movie theater and the same is true for drug abuse. To take guns away from the responsible gun owners for that massacre is foolish. To punish the 99 percent of people who are in pain but don't abuse pain meds in this Country is ludicrous. I didn't know until recently doctors now require drug testing to be prescribed pain meds. That just seems way too invasive to me.

It reminds me of the war on drugs, MADD, gun control. So nowadays if you drink more than 1 beer you can potentially get pulled over for drunk driving. How are bars even legal with the drunk driving laws. It's the one percent of people who drink way too much who have no business driving that cause this.

So I think Americans are way too reactive to things that aren't major problems. Shit happens sometimes and drug testing elderly people to make sure they didn't smoke weed in addition to taking they're pain meds is ridiculous to me. Most doctors I know are egomaniacs. It will be nice to see them brought down to earth once our country socializes medicine and pays them way less than they are making now.

Well said man. I would love to see the doctors who don't write or help legit patients taken down a notch too but my real problem is with the DEA not so much the doctors whom they intimidate, still, docs need to grow a pair and help people in pain!

*This post was auto-merged. The following text was added 9 minutes after the last post:*

One child that dies is one too many! It is not an acceptable risk. I work oncology and what I mainly write are pain medications. You seem defensive in your stance when what I am saying is that it is more and more difficult to prescribe these drugs due to the inappropriate use and abuse of them. How in the world did we manage people with bad back pain/ chronic pain before 1996? (oxycontin became available) Was the pain managed that much better? I don't think so. I firmly believe that every oxycontin bought on the street was an inappropriately prescribed medication. This is not a prn use it when you hurt medication it is a long acting daily time released drug. If you are able to sell it then you evidently don't need it.

First off I do understand your sentiments and thank you very much sir for contributing to the forum with your knowledge and experience in the field of medicine.

I do not believe one child who dies is too many (I understand it in the sense you meant it though) there are so many ways to die parents and people in general need to take personal responsibility, lock up your meds or store them safely. Far more people die from illicit drugs flooding into the country then from controlled pharmaceuticals anyway. Why don't we stop the heroin flooding in killing our kids first before taking out our grief on legit patients over some who misuse. lets just ban everything wherein some irresponsible people die, makes no sense, harm so many legitimate and responsible people because by human nature a few will be irresponsible. The math just does not add up.

And by the way, every time we as a nation crack down on pain medication the market compensates and heroin dealers make more money. Its a lose lose, just like any prohibition has ever been. Our priorities should be with defending the legitimate patients and their best interest first and foremost.

[Harry Irene]

Common Sense...What in the name of God happened to Common-Sense and Compassion? I'm in my early forties and almost every day in the last 3 years it feels like somebody has whacked me in the knees with a 2" X 4" (h) and went on their merry way.

First year... nobody knew what it was, all kinds of "specialists"...my knees and ankles were swollen Big-Time throbbing..Awful pain..my knees and ankles just by looking at them you would go "Oh My God".In this duration..it was Tylenol, Advil or Aleve....Wha'??????

Occasionally you get 30 T3's thrown at ya'...Absolutley nothing to help me...Friggin' joke...The stuff that's given to kids for tooth aches. I truly needed heavy duty Oxycodone and or Hydrocodone for the miserable Flare-Ups that come and go - Nothing

Now this new rheumatologist said it is psoriatic arthritis....which me and my sister who is an RN have thought for sometime..PAIN..He gave me a low-dosage of 'Mobic' and told me to take 2,000 mg's of Tylenol a day (Gee Thanks Doc)....absolutely absurd..In the meantime I am Destitute...I had to quit my job (Good job) and I am trying to move closer to my family and friends out east, I can't function on my own right now, it's very hard...Basically it's "Just get used to the Pain"..It's awful instead of giving somebody a narcotic that will help them and they can get somewhat on with their life and be productive..Even with the meds I speak of the pain will still be there...but I will be "Comfortable..The Doc knows the pain I'm in....I don't get it.

I was also was diagnosed with a "Severe Anxiety Disorder" last October...Panic, Big-Time anxiety..Klonopin, Xanax, Valium?? NOPE - Lexapro and Trazadone"..HAHAHAHAHAHA..I said to the prescriber...Wha?? I'm not depressed and WTH is this Trazadone stuff?? (By the way it's absolutely awful awful stuff) She said her "Boss" HATES' Xanax or Valium..He likes to jam Lexaporo and Trazadone down peoples throat...How is that better then Xanax, Klomopin or Valium?????...I just hope and pray I find a compassionate, Common-Sense doctor when I finally do head back Home - East Coast..It's been a painful, tension-filled, Anxiety-Filled 3 years...Why? It didn't and doesn't have to be this way..You bet your sweet bibby my medical bills are up the WAZOO, insane bills for nothing...It's just nuts...I'm tired and broken.

[alumni]

Far more people die from illicit drugs flooding into the country then from controlled pharmaceuticals anyway. Why don't we stop the heroin flooding in killing our kids first before taking out our grief on legit patients over some who misuse. The math just does not add up.

You might want to check those statistics again. ER visits and overdose deaths involving "controlled pharmaceuticals" have now overtaken those from heroin and cocaine combined.
That's the unfortunate "math" that exists in the US today.

[cherrybomb]

I was also was diagnosed with a "Severe Anxiety Disorder" last October...Panic, Big-Time anxiety..Klonopin, Xanax, Valium?? NOPE - Lexapro and Trazadone"..HAHAHAHAHAHA..I said to the prescriber...Wha?? I'm not depressed and WTH is this Trazadone stuff?? (By the way it's absolutely awful awful stuff) She said her "Boss" HATES' Xanax or Valium..He likes to jam Lexaporo and Trazadone down peoples throat...How is that better then Xanax, Klomopin or Valium?????...I just hope and pray I find a compassionate, Common-Sense doctor when I finally do head back Home - East Coast..It's been a painful, tension-filled, Anxiety-Filled 3 years...Why? It didn't and doesn't have to be this way..You bet your sweet bibby my medical bills are up the WAZOO, insane bills for nothing...It's just nuts...I'm tired and broken.

hey @Harry Irene --your story is so awful geez! The reason i quoted this specific part is because OF COURSE a person is going to wind up with anxiety and panic if the pain isn't treated! The pain itself and lack of RELIEF is going to eventually take down the strongest of us all--it's so sad. They don't want to treat the pain and THEN don't want to treat the anxiety issues that crop up.

Sorry to rant but i had similar issues when my back pain wasn't addressed--led to horrific (which i'm still dealing with) anxiety disorders.

What a world

[Bradlaugh]

Same here. I just had a panic attack ending in an embarrassing and expensive trip to ER. Followed up with my doctor the next day and he gives me... Zoloft. A drug that hasn't worked for me before and takes 2 weeks to take effect. I suppose many doctors are essentially refusing to treat anxiety. It makes me furious. My doctor is an impediment between me and healthcare and it's pushing me into low-level criminality just to get treatment for a legitimate illness.

[Harry Irene]

@cherrybomb

Thank You...How true indeed.
@Bradlaugh

Same here.

"Pushing me into low-level criminality just to get treatment for a legitimate illness." - BINGO.

Mine was Lexapro and Trazadone for my anxiety and panic attacks which was a horrid experience to be on either drug...I personally had awful side effects and black-outs from something that was supposed to help me..especially the withdrawals from the Lexapro - Be careful with that stuff if you are on it...Very strong and fuc** with your head. If they work for some folks - God Bless Ya'...I was diagnosed with a Severe Anxiety Disorder, not Depression at all and they still gave me Anti-Depressants instead of something to take 'AS NEEDED' for my anxiety and stress??!! It's insane.

[Divinity]

So, I've had two back surgeries. Have yet another herniated disc (caused by a car accident), degenerative disc disease, arthritis and scoliosis. So, let's just say I'm in chronic pain pretty much all the time. I had a good doctor where I was living who was compassionate and really thorough. Moved here to this tiny town where they have only two medical clinics. The doc told me that he agreed that I am definitely in need of oxy and soma (as I was receiving in WA), BUT their pain management program was full. So, I'm like "so what happens, I just get to suffer?". His response was "yes...until someone leaves the program". JUST RIDICULOUS! Why is there a maximum? You are there to treat patients not maintain some kind of quota, right? I get that there are abusers. But no where in my medical history does it indicate I've over used and everywhere in my medical history it indicates that I'm in chronic pain and thus need those meds. And so I suffer on.