Totally. Agreed. Fucking epidemic. What I don’t get is how this…
…does anything to solve the problem. More than half of the deaths are coming from people who are already doing everything right for those legitimate pain patients. They don’t need more hoops when they’re running the correct track voluntarily - and that track is still killing people.
What have they been doing since 2010, and how great of an impact has it had? You mention 2007 was the peak - what brought us off that peak? Greater physician education, I suspect, but I don’t know. Whatever it was, we should do that.
Or we should figure out how unsafe these things actually are, when taken at “reasonable” doses (or what we currently believe to be reasonable. If that many legitimate pain patients on 100mg/day are ODing, I think maybe we need to go refigure our LD50, no?) Figure out how to make them safer, or remove them from market.
Or figure out which subpopulations are at greatest risk (teens and young adults, perhaps?) and change the recommended dosing accordingly
Or legalize marijuana, which may or may not provide decent pain relief, but people *believe *it to be good pain relief, and may be satisfied with that safer addiction.
Or accept that people in pain would often rather risk death than remain in pain and don’t fight it; do we truly support informed consent or only when we agree with the decision?
If crooked doctors and doctor-shopping drug dealers are *not *the biggest problem here, and I believe you that they aren’t - then why use the solution that will slow *them *down, but not the majority of opioid related deaths - the legitimate pain patients?
Remember, I work with mostly elderly, *homebound *patients. This is going to hit them (and therefore me) really hard. Mobile doctors are the worst to get written prescriptions from (for a number of reasons, including that they’re hardly ever “in the office”, so when I call their secretary, we get to play phone tag for two days) and for every extra phone call to the doctor or to the pharmacy to get these things straightened out, there’s an extra day at least of delay where my patient is in severe pain. Those are the legitimate pain patients who are still apparently at some sort of increased risk at <100mg/daily from a single prescriber. So they will still have that risk, and now they will have increased days of pain, confusion and frustration.
Meanwhile, the local drug lord will keep buying bulk cartons from Mexican pharmacies. And probably making more money selling to the few people who are using recreationally who no longer care to go through the additional hoops - and quite possibly also selling a few pills to sweet old Mrs. Jones, because she really needs her pain pills before the pharmacy can get them to her!
Still not buying it. Maybe some people are dying from pain pill overdoses, all I know is, doctors won’t prescribe effective pain pills any more. Hell my wife went to the dentist a couple of months ago for an infected tooth that had her in great pain, he gave her a prescription for an antibiotic and tylenol-3s after fixing the tooth. Tylenol 3s have codiene but so little of it that they are sold OVER THE FUCKING COUNTER in Canada. She spent two days in some fairly intense pain DESPITE the meds, thank you very much. Hell when I had a similar dental issue 15-20 years ago, the doctor prescribed fricking LORTABS. They fricking did the job, too, and I am pretty sure they did not kill me, or even come close.
I went to my primary care physician with back pain a week ago. I had pulled my back out and going from a lying down position to a sitting position was agonizing and going from sitting to standing was painful as hell too, and for a couple of days, sitting involved a certain amount of gritting my teeth and use of an ice pack. My doctor refused to prescribe ANY pain medication for me, gave me a muscle relaxant and told me to take OTC tylenol for the pain, which I did, and which for the first couple of days had NO noticeable effect.
My doc told me if I had chronic pain I needed to go to a pain management clinic, but hell, I didn’t have chronic pain, my back goes out every year or two, I have a couple of days of intense pain, a week or two of mild pain, and then no pain. I just wanted something to help me past the intense pain. I used to get some pretty good stuff for it … hydrocodone, IIRC. Did the trick, and when the pain was gone I’d stop taking it, and that would be that for a year or two.
Nowadays doctors won’t give you effective meds for dealing with pain, they just let you suffer, because the DEA is on their backs. The DEA even hassles hospice care doctors who are treating patients with pain associated with terminal diseases. That’s wrong. Doctors are supposed to relieve human suffering, not ignore it. You can spill as many acronyms and studies as you like … doctors are being forced to let their patients suffer, rather than treat them for pain, by the DEA.
If true I am curious how these people are overdosing on such low doses
This says the oral lethal dose of morphine for someone with no tolerance is 120-250mg, and I would assume any patient taking that high a dose would have a tolerance so the lethal dose would be higher.
Something isn’t making sense, I wonder if these deaths are due to people taking more than they are RXed trying to get high or possibly suicides being hushed up? Is death by seeking a high less stigmatizing than suicide?
As for Mrs.Jones I have heard there are sort of freelance street pharmacists that sell painkillers, even heroin without a prescription. And they don’t follow any DEA rulings, so that is one option. <sarcasm;)
I just finished night 6 of 7 on, this one a 12 hour shift, having only slept 4.5 hours the “night” (which for most of y’all is actually daytime) prior, so apologies for not getting to your other questions, grude’s, Evil’s, and statements by Inna and Ambivalid right away. I have to hit the sack here very shortly for my final work shift on tonight, but I did want to promise to try to respond when I’m…slightly more coherent than I feel at this particular moment.
You are welcome for providing them, though honestly, I wish the statistics were trending in the opposite direction. Evil’s most recent post establishes a pretty good example of how current responses to this epidemic are still failing our patients, even if in a different way from a “liberal” approach to pain management. I’ll further add that my intent was not to necessarily personally agree with the DEA/FDA/HHS action in rescheduling Hydrocodone products (I actually have mixed feelings, but overall lean against the rescheduling, but as soon as the FDA advisory panel made it’s decision early this year, I knew the writing was on the wall whatever I might think), but to try to explain that their reasoning didn’t have to come from a perspective of “keeping people from getting high”, as if their sole mission is to be a buzzkill to people wanting to have fun. I don’t think I phrased my statements sufficiently to establish that perspective.
Exactly. That “freelancer” is someone’s grandson, and I don’t find it at all outlandish to imagine him visiting his grandmother in Mrs. Jones’ building, and hearing that she can’t get her medicine. “Oh, no problem,” he says, “Here, take these. Just a few, until everything is figured out.”
And then he hands her some Norco 10/325 instead of her normal 2.5/325…
JayRx1981, ugh, man, go get some sleep! This can wait.
And I’m sorry I got a bit ranty there last night. I’m the first to admit, I’m not dispassionate here. This is a really emotional issue for me. I’ll try to reign it in.
One slight ray of sunshine that I missed earlier (stupid DEA publishing this in the middle of my workweek when I had little time to read the entirety of the publication) is that it appears any prescription for Hydrocodone products issued prior to October 6th will have their refills considered valid until 6 months after written or 5 refills pursuant to 21 CFR 1306.22, .23, .25, and .27, though this practice would of necessity end on April 8, 2015 (which is 6 months and 3 days after October 5th, 2014, the last date a prescription could be written with refills).
…does anything to solve the problem.
[/quote]
IMO, It won’t solve the problem. Slightly decrease some of the symptoms of the problem, sure, but the problem(s) causing this will remain. This is the DEA we’re talking about (and the FDA, and HHS, and the State Boards of Medicine and Boards of Pharmacy), though. These are government bodies, imbued by law with specific functions and specific powers. They can’t actually extend beyond their legislatively defined roles. The DEA has the power to determine if a drug is scheduled or not. They have the power to determine if a reschedule is in order. They have the power to go after those who violate federal law with regards to scheduled drugs. Only by an act of Congress can that power be changed. The DEA decided, using powers legislatively granted, at the behest of the Obama Administration, the FDA, and HHS, to move hydrocodone into schedule II. They justify it using their 8-factor analysis, required by the Controlled Substances Act.
The link to their actual analysis can be found here. This a link to their page to download a pdf, not a direct link to the pdf itself.
On technical grounds, I can’t fault them. Hydrocodone alone has always been a schedule II drug (until Zohydro, there just wasn’t an approved standalone hydrocodone product available in the US). It is considered, as a general rule, 1:1 equivalent orally, on a milligram basis, with Morphine, another schedule II drug. Hydrocodone is active at mu-opioid receptors to an appreciable degree in it’s own right (as compared to codeine, of which the conversion to morphine is believed to be required for most of it’s pain relieving effect), and is also metabolized to Hydromorphone (Dilaudid) via Cytochrome P450 (CYP) 2D6, believed to add clinically significant additional mu-opioid activity over hydrocodone alone.
The problem, for me, is that while the DEA may have all the justification in the world for this change, legislatively and scientifically, I don’t believe it will do anything more than mildly blunt the problem we’re dealing with. I suspect it’ll make state and federal prosecutions of prescribers and pharmacists and pharmacies a bit easier due to the additional documention associated with ordering, prescribing, and dispensing Schedule II drugs versus Schedule III-V drugs. I suspect it’ll stop some of the arguably unnecessary prescriptions for Hydrocodone combo products currently being filled by simply making it a nuisance to write for them now that they can’t be called in. I just don’t think it’ll do much more than that.
I’m honestly afraid it will result in an increase in pharmacy robberies in the short term (I’ve been unlucky enough to be present for two so far in my career, though thankfully no one got hurt and both perpetrators were caught later). I’m honestly afraid that we’re going to see a resurgence of heroin abuse when otherwise law abiding users choose to turn to the streets (heroin, from my understanding, is currently less expensive on the street than pharmaceutical grade opioids). I’m honestly afraid that some of those whose current treatment with certain opioid therapies are about to be thrown out of what may very well be a delicate balance between just enough relief to function and unnecessary pain and suffering in response to a “few” bad apples. I really do hope I’m wrong, but I don’t honestly think I am.
Having said all of the above, I have to follow the rest of your quote with, well…no, they have not necessarily been doing everything right. Clearly if these patients are dying from circumstances involving overdose, something is going wrong somewhere in the process of pain treatment. Though, to be fair, in looking at the stats a little more closely, some of these overdose deaths are actually occurring in friends and family members who are receiving some of these drugs from the actual patient, rather than directly from that single prescriber (put another way, the single prescriber is providing the medication to the patient, who then either gives the drugs to someone else like a family member, or that family member/friend takes the drugs from the patient without their consent, and ends up being the person who OD’s). Still, making the hoops harder to jump through might just limit the total supply available enough to lessen the chance of the patient themselves OD-ing, or being willing to share with family members/friends, or take more serious the security of the drugs in their homes to prevent theft given that lost meds would require re-issuance of a written prescription (and probably a police report to get a pharmacy to dispense early) as opposed to being able to call the doctor and have them just phone one in. It is going to cause access problems for many patients, and I lament that fact, but I also know I can do nothing about it, so instead I’m trying to educate ahead of time to blunt the worst of it.
I actually said 2010 was reaching peak levels, not 2007, though in truth, I’m not actually sure even that’s accurate. It may be even more recent (2011-2013) given how long it’s taken to get some of the counter-initiatives off the ground (Ohio’s “Press Pause” initiative, coupled with increasingly stringent requirements for reporting to and use of our prescription drug monitoring program, OARRS, were only published back near the beginning of 2013, and our PDMP is actually serving as the model example for states currently implementing or who have yet to implement their own, according to one source). Greater physician education, pharmacist education/involvement, patient education, and education of the general public on the risks versus benefits of opioid therapy, realistic expectations of results from the treatments (despite what some may think, complete elimination of pain is not the goal of successful pain management in a chronic context and I can quote from 6 separate guidelines to back me up on that one), and on a better understanding of what pain and addiction actually are is going to be necessary to turn things around.
Efforts have been made to define those things, and they usually end up coming to the same conclusions–what is both reasonable and safe in terms of dose is going to differ across a very wide range depending on the individual patient, though the vast majority do end up settling on a dose below 100mg MED. The problem isn’t actually so much the drugs themselves. They are tools to be used. Tools with strengths and limitations to be appreciated. Opioids need to be considered in the same context as the archetypal tool, Fire. Both can be used judiciously to accomplish beneficial ends (opioids: improvement in patient function, fire: cooking of food), and both can be used recklessly resulting in intentional harm (opioids: poisoning, fire: arson) and/or unintentional harm (opioids: increased overdose deaths from too free of access, fire: wildfires started by poorly tended campfires). The current problem doesn’t stem from opioids being “bad” drugs or “unsafe” drugs. It instead stems from how we’re using them, and how we’re viewing them (they are too readily viewed, in my view, simplistically as “pain pills” when given the ubiquity of the mu-opioid G-protein-coupled receptor complex in the brain, let alone where it is found in the rest of the body, it is doing far more than just relieving pain, and are too often associated with statements like “the good stuff”, particularly in relation to scientifically slightly better supported drug classes like the NSAIDs or acetaminophen in long term use), and won’t change until we start to fix those.
While we can always refine and search for better risk assessment criteria, we already have a fair idea of what those risk factors are: Personal history of current or past Substance Use Disorder, Family history of either, Young age (teens to mid-20s in particular), White, Male (particularly when those 3 are put together), Untreated/unstable co-morbid Psychiatric disorder (Depression, AD(H)D, Bipolar Disorder, Schizophrenia, Anxiety/Panic disorder), and to a lesser extent stable/treated versions of those disorders, instability in living environment (homelessness, direct or familial abuse), and past/current aberrant drug related behaviors (sharing drugs with/taking from friends/family, consistently early refill attempts, unsupervised dose escalation, to name a few). Not all of those are equally weighted, of course, as some are relatively weak correlations and others very strong, but even if someone happens to meet every single one of those, that fact would still not be an absolute contraindication to use, if necessary, provided more stringent monitoring/followup/quantity/day supply limits were used.
Interestingly enough, this is one proposal starting to garner some tentative scientific support. The support is still a correlation, not a proven causation, but see this abstract from JAMA published yesterday.
If more practitioners were following any of the published since 2008 pain management guidelines (though admittedly, I prefer the more recently published ones over the older ones) more faithfully than they seem to be, we likely wouldn’t have near the problems we currently do and wouldn’t have to view it as a binary “pain or risk death” choice. I can rely on my own anecdotal experience with the actual prescriptions being presented for we pharmacists to fill, answers to various questions we ask of patients, and answers we (sometimes don’t/can’t) get from the prescribers to claim this, but the truth is, both the DEA and HHS also made comments about this in the final rule publication (see subsection (f) under Section 11 - Proposed Alternatives). Among other issues, what we’re dealing with right now is a LACK of truely informed consent in a lot of these cases, not the other way around.
As you now know, I don’t fully support the use of this solution. I understand why they are implementing it, but it will, quite frankly, IMO, do little good. I suspect even they know that. Unfortunately, we’re dealing with Washington DC here. Cynical though it may be, exactly how things have been timed leaves me strongly suspicious of politics being played here. Looking at the timing of the publication of the Opioid overprescription reporting in the earlier linked CDC’s MMWR (early online posting July 1st, official publication July 4), the timing of the final rule publication in the Federal Register for Tramadol’s rescheduling (Filed July 1, published July 2), and the timing of the final rule publication for Hydrocodone Combo product rescheduling (Filed August 21, published August 22, mere days after the tramadol rule went into effect), as well as the comments in the tramadol rule about the 45 day window being argued as too short, and I’m at least suspicious that the DEA held off on publishing the tramadol rule until the MMWR was early published, and then used the tramadol rule to gauge the feasibility of the 45-day compliance window on the Hydrocodone rule. Given that this is a heavily contested Congressional election year, one can cynically make an argument that the Administration might try to use this to score political points. I don’t think they deliberately made these specific decisions for political points, mind you, but instead possibly saw a value in the timing of how they announced and implemented them, though since I hate politics, I could be very much wrong/biased here.
Well, thankfully as I noted at the start of the post, you might have a several month window to work with instead of a 45 day window, if you can get the prescribers in question to write for, call in, or fax in a prescription with whatever amount of refills (up to 5) they deem appropriate for any given patient prior to 10-6-2014. As to their pain, confusion, and frustration, that is precisely why I’m trying to make people aware of these facts ahead of time.
Now this and some of my previous posts might heavily be focused on prescribers, suggesting I’m biasing responsibility for this situation towards them, so I’m going to follow up with this:
We pharmacists share a very large portion of the blame leveled at prescribers in this issue. We are, per our state boards of pharmacy, supposed to be the last line of healthcare defense before medications get into the hands of the patients. It is our duty, no matter how annoying it might seem at times, no matter how offended some prescribers might get, to question if a prescription is for a legitimate medical need, and to refuse to fill if we aren’t provided sufficient justification, in our professional judgement. We are, per my state’s laws at least, supposed to perform our due diligence in assuring any Drug Utilization Review concerns we have are sufficiently satisfied. We have very clearly failed in that regard, though some of us have at least realized that and are trying to change it. But we absolutely bear a generous portion of the responsibility for our opioid epidemic.
Now that I’ve probably offended prescribers and pharmacists both, off to the rest of my response…
Many drug overdose deaths are, at least based on what I’ve read so far, the result of poly-drug cocktails. Some of them occur because, yes, the person is attempting suicide. Others occur because of a lack of education about the dangers of mixing certain drugs, like opioids, with other agents like ethanol, or failure of that education to impress into the mind of the person who OD’s. Still, others occur because of drug-drug interactions, like combination of Methadone (and to a lesser extent the other opioid agents) with a benzodiazepine like Alprazolam or Diazepam. Then too, they can occur when someone non-tolerant takes a dose that works for a tolerant individual but is far too much as an initial dose in a drug-naive individual, particularly if the non-tolerant person is a child or elderly or has kidney or liver disease, or even when a tolerant individual does something to alter/increase the absorption of a dose they’d otherwise be tolerant to, like crushing a high dose tablet and snorting/injecting, or taking a really hot shower or trip to a sauna while wearing a fentanyl patch (seriously, be careful of various heat sources with the patch technology in a fentanyl patch–it’s incredibly unpredictable and has resulted in death very rapidly).
Originally, the reasoning behind Hydrocodone alone being schedule II, but Hydrocodone combination products being schedule III was precisely because it was thought that people would know or be told that exceeding the max recommended dose would put you at risk for liver problems and therefore avoid using too much. We now know that this thinking was naive, because people did end up doing exactly that, prompting the FDA to remove APAP-combo products with more than 325mg per dose from the market earlier this year.
Having said all of that, tolerance is not, strictly speaking, a purely “physical” phenomenon. To quote from this article on Heroin overdose and Pavlovian conditioning, “drug tolerance depends not only on experience with the drug but also experience with drug-paired cues.” The article then later goes on to describe an experiment performed 60 some odd years ago on a dog by placing it in a specific location (an injection stand) and giving it a shot of epinephrine. After doing this enough times for tolerance to the effects of epinephrine to have occured, the researchers then dutifully put the dog in the injection stand and gave it a shot of something inert. Result? The dog went bradycardic. Epinephrine, when injected, has numerous effects, one of which is an increase of heart-rate–a tachycardia. The tolerance that developed to this was, by proxy of the conditioned cue of being placed in the injection stand and injected, a drop in heart rate to counter the expected effects of the epinephrine. That the dog developed bradycardia, even in the absence of the drug which originally prompted the conditioned effect, showed that once a cue is in place, it doesn’t necessarily have to rely on the presence of the drug to occur. This contribution of Pavlovian (Classical) conditioning in drug tolerance is termed the “Situation-specificity of Tolerance”. Later, they tell the story of a reported case where a man with pancreatic cancer would always receive morphine injections for the pain in the confines of his poorly lit bedroom. After about a month, he decided to go into the more brightly lit living room and since he was in pain and it was time for his next dose, he administered his usual tolerated dose. He died a few hours later, after initially displaying the telltale signs of opioid overdose (pinpoint pupils, respiratory depression). They also tell of a man who had been treated for several months with oral morphine for pain. Tolerance had developed to it, so, he decided to change to transdermal fentanyl (a different structural class opioid). In calculating the conversion dose, the doctor made an error and actually dosed the man at a dose 4 times LOWER than the manufacturer recommended. The man quickly displayed signs of toxicity after the patch was applied, indicating no cross-tolerance, where it would have otherwise been expected. Had they applied the correct dose, he might very well have died. It is believed that the changing of the drug-paired administration behaviors, as well as differences in detected interoceptive stimuli, resulted in the person in question not getting the cues his brain normally associated with his morphine and therefore didn’t trigger any of the tolerance countermeasures it otherwise would have, and therefore demonstrated that same “situational-specificity of tolerance” observed in the dog-epinephrine experiment. This same phenomenon is believed to account for at least some of the overdose deaths involved in long-time heroin users.
As I’ve said before, tolerance is a fascinating, if sometimes scary as hell phenomenon.
By and large, you are correct, though while Serotonin Syndrome CAN occur if you combine Tramadol and SSRI’s and no other interacting drugs, it is unusual. The biggest offender class of drugs involved in Serotonin Syndrome are the MAO-Inhibitors (you know, that warning on a huge chunk of OTC and prescription meds). Otherwise, it more often involves quite a few different drugs having an effect on serotonin levels being administered together (Fentanyl or Methadone on top of an SSRI on top of Tramadol for breakthrough pain, etc).
Indeed, call your pharmacy first and have them check for a valid script. Only if they find no valid prescription would a follow-up with the physician’s office be needed (whether by pharmacy phone call or fax, or patient phone call).
First of all, I’m sorry your wife suffered the pain she did. Did she call the dentist back to indicate she wasn’t getting much of a relief from the Tylenol #3? My experience with many dentists is they prefer to use a combination of an NSAID and Tylenol #3 for pain relief until the treatment for the infection can arrest the worst of the underlying causative portion of the pain, unless the patient indicates to them ahead of time, or after having tried the prescribed regimen, that they aren’t responding.
As for being sold OTC in Canada, as they were just barely behind the USA in terms of the Morphine Equivalents in mg/capita in 2007, according to one literature source, they might not exactly be a shining beacon to reference in this regard.
Unfortunately, many primary care physicians are undereducated as to how and when to prescribe narcotic agents, as well as the risks of using that type of therapy. This results in some of them utilizing in ways, doses, and medication combinations that have contributed extensively to the current epidemic health problem, but it also results in many of them refusing to use them altogether, even if a particular patient’s situation might benefit from judicious use of opioid therapy. Like a certain GNC Fish Oil consuming poster’s doctor, however, your doctor’s choice isn’t necessarily unreasonable for the treatment of a temporary back pain issue. Conservative, yes, but not unreasonable.
Likewise, while you might not be experiencing chronic, intractable pain, if your back does what you’re describing on even an every couple of years basis, your doctor isn’t unreasonable in treating as a chronic condition which might benefit from specialist evaluation. Even if you don’t currently need more potent treatment, a specialist may just be able to indentify based on history, your description of what occurs in these circumstances, and his/her physical evaluation the presence of an underlying condition which might at the very least benefit from specific physical therapies or exercises, or other non-pharmacologic modalities. The ligaments and intervertebral discs supporting the spine generally have an increasingly difficult time doing so as we age, and so we have to rely more on supporting musculature to keep things from slipping or stenosing, particularly in the lower back. Potentially catching this early enough could lessen a possible future need for more intensive spinal therapies.
I read the linked dailykos article, as well as some expanded information on the Dr Hurwitz mentioned in the article, and while certainly the result of his trials (he was found guilty in the second trial after the first trial’s results were overturned on appeal) is that some of his pain patients were made to suffer, he himself admitted to deceiving himself about obviously criminal activity from some of his patients prior to the sentencing portion of his second trial. To call him a hospice care doctor (two of the months spent on rotations in my final year of pharmacy school were with a Hospice care consulting pharmacist group, so I got quite a bit of experience in understanding end of life palliative care), however, at least based on the information presented in the article you linked, as well as his wikipedia entry, at least, is…a reach, IMO.
You can brush aside the statistics I’ve quoted, the Acronymed groups providing them, and the studies they are based upon if you wish, but I have yet to run across a case where a physician, following any one of several chronic pain/opioid guidelines and relevant state and federal practice laws having any problem with the DEA, other than perhaps brief investigation to ensure that the physician was performing his due diligence in the use of chronic and/or high dose opioid therapy. And given my practice experience in my specific geographic area, I can tell you that quite a few doctors have no problems putting their patients on either acute or chronic opioid therapy.
I’m surprised this hasn’t happened long before now.
I had a horrible, potentially life-threatening experience with Ultram (Tramadol) back in 2001. I can’t blame it on the drug, it was actually due to my (former) Primary Care Physician combined with my own irresponsibility.
My PCP had me taking double the recommended maximum dose (450mg daily) of Effexor (Venlafaxine) for Anxiety. My dentist prescribed Ultram (along with an antibiotic) for a dental abscess. The Ultram didn’t do much for my pain at the prescribed dosage, so I decided to double and eventually triple it. Two days into taking the triple dose of Ultram and the mega-dose of Effexor, I was feeling better and went out to dinner with friends. Foolishly, I drank several beers shortly after taking the meds…
Several hours later, I woke up in the E/R very confused and aching from head to toe. I had suffered a seizure as a result of mixing the high doses of both drugs and the alcohol was just icing on the cake!
As I understand it, Effexor (and similar SNRIs) lower the seizure threshold. Tramadol can cause seizures and the higher the dosage, the greater the risk. It was sort of a ‘perfect storm’ situation and probably wouldn’t have happened if I had taken the prescribed dose of Ultram and NOT drank alcohol. But I was a dumbass and I learned my lesson the hard (and very SCARY) way…and I’ve avoided Tramadol since then. I also got off of Effexor and found safer ways to cope with my anxiety…Valium works quite well.
I am an expat living in Tbilisi, Georgia and its hard to find english language work here, anyway I saw a job posting on jobs.ge for British/American English speaking staff to work for this company. The website showed IT based equipment and so we assumed this is what we are going to sell.
First we attend an interview - no problem then invited to attend a training program starting the week after.
At the first day of training we are handed a list of medication to learn, Tramadol, Soma, Xanex, Ambien, Ativan and such. Medication i thought you required a prescription for.
1 week later and i am live on phones calling past customers who have ordered from one of 250+ websites selling prescription medication.
My question not only about their tactics of “keep calling the customer until they answer”, and “upsell upsell upsell” but is it actually illegal to sell pills from India to USA without going through a medical professional first?
I know in the Republic of Georgia I can purchase medication over the counter without question for my diabetes, but I would have thought in the US its the same as the UK.
After a few weeks my “sales skills” weren’t good enough and they asked me to leave.
Also if somebody spends lets say $15,000 on Tramadol in one month how would you get that through customs? That’s no longer personal use and as such you would think it would be seized?
