I have experienced some headaches as a longterm user of Tramadol in regards to the transition to the new regulations. For one thing, pre-existing prescriptions were supposed to be allowed to remain valid under the new laws, assuming that they were less than 6 months old. However, one could only have a maximum of 5 refills on a prescription of Tramadol.
I had just seen my prescribing doctor before this change went into effect back in August. As I need this medicine for chronic pain issues, I was given a prescription for Tramadol with 10 refills. I assumed that I would be able to continue having my current prescription filled, with the final five refills just negated from the 'script. When I went to pick up my first refill since the change (I called in the refill over the automated phone system, with no issue), the pharmacist told me rather bluntly that I would have to have my doctor call in a whole new script, as I had too many refills on my current one.
I asked if they could just cancel my last remaining five refills so that I would be in line with the “no more than five refills” limit, and the on-duty pharmacist just shrugged and said there was nothing he could do. Well my doctor had gone on a year long personal leave shortly after my last appointment and there was no reaching him for another script. Meanwhile, I was going to begin experiencing rather severe withdrawal symptoms if I didn’t get this situation resolved, as this was a Friday and I would be without my medication for the entire weekend and I had been taking this medicine for over 9 years. I was physically dependent on it.
In a scramble to figure something out, I called my doctor’s office and explained the situation. I asked if there was a doctor that could write me a prescription in place of my regular doctor who was not there. Well, after a few hours of back and forth, they found a doctor but he wasn’t willing to prescribe me Tramadol without seeing me first. :smack: I tried explaining that I had just been seen at that very office and had a very large prescription written, and that it was just because too many refills existed that I needed a new prescription written. No luck.
What finally ended up happening is that I called back to the pharmacy to see if I could have a partial refill given to me to last until Monday, to avoid withdrawal. When I did, I was surprised to hear that my prescription was ready to be picked up. I got there and it was the regular, familiar pharmacist and he had simply changed the number of refills from 10 to five. I don’t even know if he wasn’t supposed to do that or not. But he did and it helped me out of a jam big time.
I can’t help but imagine that many, many people were left stranded in similar predicaments. How were people supposed to even know about this? There was no public awareness campaign to get people ready for this change, it just happened. Leaving people to find out the hard way. The only reason I knew ahead of time was because of the Dope and the thread about it here.
I usually buy 500 ct bottles. I’d get bigger ones if I could. I keep one giant bottle at home and one giant bottle at work. I usually replace them every month or two.
(admit it, you did the math on that and were ready to tell me I can’t take more than 4G/day. Actually, each bottle gets replaced every other year or so if I had to guess.)
Well, again in England I can only buy two 16 tab packets of paracetamol at a time, which are absurdly cheap, around 18p each packet; ( or buy many more dangerous over-the-counter medications as much as I want ) but I can cross over the road and repeat the purchase from a dozen other shops near by, or come back later and buy more in relays, so I doubt this is protecting my liver to a large extent.
On the other hand, most over-the-counter painkillers suck for anything other than the mildest headache.
Read DataX’s story. It’s not people crushing a few oxy while they watch* 2001: A Space Odyssey* on a Saturday night. It’s people like his ex girlfriend, and my cousin, who are cheating and stealing and ruining lives all around them because of their prescription painkiller addictions.
The DEA has a Manager (whatever the term for “Boss” at that place) who actually called a press conference to denounce Obama’s direction to NOT prosecute marijuana (a Federal Crime) in States which had legalized it.
That should give you an idea of the mindset at the DEA.
My doc cut my script level from 45 to 15 - because of the DEA.
This is about making sure nobody goes “Doc Hopping” and getting adequate prescription levels by getting stuff from multiple sources.
Vicodin/Hydrocodone is/was a special case - pure Hydrocodone is not commercially available in the US, and hasn’t been as far back as I know (which is about 40 years).
Hydrocodone by itself is (and has been) a Schedule II narcotic - as is Morphine, Hydromorphone, and most opiates.
It was a special case - it was a sch III (renewable, written on plain script form, phone-in, etc) until this last go-round, whereupon it became sch II even if “cut” with a NSAID.
Oh - marijuana is neither sch II nor sch III - it is on sch I - how’s that for insane?
Am I totally happy with moving hydrocodone to Schedule II? No! It makes more paperwork for me, can make it difficult to get someone an adequate dose of pain meds when they have significant acute pain, and puts up barriers for legitimate pain patients. But I expect the move will save lives; not just of addicts and abusers, but of others who are impacted by people who got their hands on opioids inappropriately or used them improperly.
My cat loves to curl up next to me in bed. Since I can do very little else (total dosage allows moderate activity for 8-12 hours), that is my prominent activity.
Adding Gabapintin simply knocks me out for 14 hrs/day - not what I would call sleep.
And - isn’t Gabapintin indicated for neuro pain? I’ve had 2 MD’s insist I use it for overnight (once the token opiate wears off) control of Osteoarthritis.
So, my bedtime cocktail is now
Opiate (MS Contin or hydromorphone - either is at a 3-4 hour dosage if asleep)
Mirtazipine
Gabapintin
My choice: lunesta 3 mg (my preference) or temazepam or clonezepam.
And 2 hypertensives.
This is a crap shoot - either close to death or awake all night.
Tell me again how a 65 year old with CKD should avoid opiates in favor unmedicated pain
I take 250mg of vicodin three times a week, when things are painful at night.
It seems I’ve been using half the tramadol dose, so I’ll double up on that those three nights a week and see how it goes.
:dubious:
In essence, this problem of increased abuse and overdoses started going up concurrently with the increase in prescriptions from the opioid class of medications, attributable in part to the liberalization of laws governing their use for the treatment of pain in the late 90s. The thinking is that by reducing the availability of hydrocodone combination products, the number of overdoses related to it will decrease as well. In truth, they probably will, though I’m of the mindset that the decrease is probably going to be modest, at best.
Pain relief can probably be argued to be a right, but I’d like to point out that said pain relief is going to generally be an ease of pain, not an outright loss of all pain. Moreover, unless we are overtreating with opioid-class medications, I’ll argue that this is supposed to be true whether we are dealing with acute (4-6 weeks), subacute (6-12 weeks), and chronic (>12 weeks) pain conditions. Unfortunately, my experience has been that most of the pain patients I get at the pharmacy end of things either have not been told what to realistically expect from a pain relief standpoint, or didn’t pay attention to it when their prescribers told them what that goal was for their treatment therapy. To put it frankly, based on the literature, we are looking for a 30% or greater improvement in function (ability to perform tasks, be they activities of daily living or recreational interests of the patient, that would otherwise be limited by the pain) and/or about 3 points improvement (using lowest or average pain rating, not highest) on a pain scale of 0-10 with the optimized use of opioid-class medications. In that order, too, mind you. Functional improvement is generally regarded as the more important of the two in most of the guidelines I’ve read (currently spanning 4 continents and 5 countries). The addition of adjuvant medication therapy (Gabapentin, Pregabalin, Duloxetine, Tricyclic antidepressants, etc), physical therapy, exercise, and for some causes of back pain and other conditions like osteoarthritis, weight loss, may get you further reduction in pain, though it is rare for pain to end up eliminated altogether without figuring out the underlying cause of pain and fixing it.
Given the number of times I’ve caught fake scripts being called in for opioids and controlled anxiolytic agents, and our current epidemic level of overdoses, as well as Federal law allowing for the physician, if in their best judgement, to issue 3 separate prescriptions in one appointment (with 2 of the 3 being required to have a next fillable date written to prevent the patient from getting all 3 at once), I’ll disagree, it’s not insane at all.
Yup, OPIAD (OPioid Induced Androgen Deficiency) is a common problem with chronic opioid therapy, particularly as doses exceed 100-200mg of Morphine Equivalence per day, as are increasing problems with new/worsening Depression, Osteoporosis, cessation of normal menstruation in women, and increased risk of obstructive, central, or mixed sleep apnea episodes, the last of which can contribute to excessive daytime sedation/lethargy by further reducing sleep quality, which, not surprisingly, can actually make good pain control with opioid therapy more difficult to achieve. Then too, there also exists the phenomenon of Opioid-Induced Hyperalgesia, where increasing doses actually worsen pain, necessitating a reduction in dosage, but which can look like tolerance if the prescriber isn’t looking carefully, resulting in dose increases instead.
At least around here, while the Federal rule allows for any Hydrodocodone combination product written prior to October 6th to have their refills honored through April 8th 2015, most chain pharmacy software cannot actually honor these refills and thus, we were told by the company I work for, and this also includes all but 1 of our major competitors, we will NOT be honoring these refills. I’ve had this past week off (moved to a new place), but I imagine my colleagues probably did not have a good week last week. However, remember, if your mom has been stable on her dosage, if her doctor desires, as I stated above and subject to state-level differences in the rules, they can issue 3 separate prescriptions at each office visit, so you are possibly looking at quarterly visits instead. Then too, if an appointment is required, under some state’s laws, prescribers can also issue an up to 3 day emergency fill by phone (they also have to write a physical copy and mail it/deliver it to the pharmacy within 72 hours, otherwise we have to report them to the State Board of Pharmacy in Ohio, so don’t expect this to happen commonly). Never hurts to check with your mom’s pharmacist about any of this stuff. As for reversing this, it’s very unlikely. The initial investigations into the “need” for the change of schedule for HCPs from Schedule III to II started back in 2006, iirc. If it took 8 years to change, I don’t think a reversal is likely to come quickly (if at all).
As was already pointed out, those abusing these drugs are also possibly going to drive while under the influence of said agent. Now, in a chronic pain patient whose prescriber is following medical standard of care and/or any of the pain guidelines issued since 2008, the effects of opioids on ability to drive seems to only be a major concern at the start of therapy or any time a dosage is changed, and then only for a few days until tolerance to the sedative/cognitive effects can develop. With an individual misusing or abusing therapy, though, I’d expect that said tolerance is probably going to be incomplete, at the very least.
Also, 60% of overdose fatalities (as of a few years ago, at least) came from prescriptions issued only by a single prescriber, with 1/3 of that number coming in as patients, as well as family members or friends who took, with or without patient permission, those opioids without themselves having a valid prescription, with daily doses of less than 100mg Morphine Equivalence, and the other 2/3 from the same groups as above on >100mg MED. While some of these patients, friends, or their family members are taking them because they “like to dissociate from reality”, most of them probably aren’t doing so for this reason.
I am not a fan of the DEA, nor of the rescheduling of HCPs into schedule II, but frankly, blaming them or the laws is probably a waste of time. Put simply, access to therapy for pain, including opioid-class medications, is only going to be as restricted as the prescribers and dispensers of these drugs choose to make them, save for an increase in the frequency at least some patients will need to see their prescriber. The DEA didn’t make HCPs illegal, they largely just increased the amount of paperwork necessary on the parts of the prescribers (as Qadgop pointed out) and on we dispensers. That might result in some prescribers no longer writing for HCPs, but frankly, given how complicated pain management can be, with at least some of them, that might not be a bad thing in the long run.
No, it’s people who decided that the arguably over-liberalization of certain laws governing the use of a habit-forming drug, which was already controlled, already in schedule II when not paired with a second or third medication, and having resulted in a massive upsurge in overdoses, including deaths now surpassing motor vehicle accident deaths in some states, along with massive increases in the necessity of additional medical services due to some expected, and some not expected long term side effects of these drugs, necessitates making their use a bit more difficult on the parts of clinicians, be they prescriber or dispenser, to attempt to limit a problem of epidemic proportions.
Unfortunately, some of the prescribers writing for these medications NEED to be second guessed. They are a small fraction of the total prescriber pool, but for all sorts of reasons, running the gamut from “pill-mill” prescribers to “road to hell is paved with good intentions” prescribers, a fraction of prescribers have been practicing outside of standard of care, evidence based medicine, and/or expert consensus recommendations, and this really probably needs to stop. Will rescheduling HCPs do that? No, I don’t think so, but the DEA and HHS are well within their legal rights to see if it does help, even a little.
Yeah, this is an area where we pharmacists, as a group, should have been far more proactive than we were in relaying this news to our patients. Granted, we only had 45 days from final rule publication to effective date, so we wouldn’t have been able to hit some of the 90 day supply patients, but with regular patients we would have probably had at least one opportunity to educate about upcoming changes–at least those who only fill their controlled substances at one specific pharmacy or chain, given most now have shared databases showing what medications the patient is on and where it was last filled nowadays. I’ll urge people to stick to one specific pharmacy for fills for a couple of different reasons, though:
If you are a regular and on good terms with your pharmacist(s), we’re far less likely to delay getting your prescription ready when you come in for your meds (we’ll still do our due diligence if we spot potential aberrant drug-related behaviors, like consistent attempts at early refills) than if you get your medications filled at multiple different pharmacies, where in many cases, due to dose amount, dose frequency, drug interactions, and the necessity (under federal law for Controlled drugs) of determining if the prescription in question is for a “legitimate medical need”, we might have to not fill the prescription in question until we can talk to your prescriber, some of whom are wickedly difficult to get on the phone.
We have a better sense of how much medication we’ll need to keep on hand in order to fill your meds to prevent out of stocks, if you don’t fill multiple places.
The better we know you, your conditions, the meds you are currently on, and what has been tried before (since we don’t have access to prescribers charts), the better we are able to make recommendations tailored to meet your specific needs and to go to bat for you when necessary.
It’s possible it could be from laziness, but it also could be from having read the various types of literature which have found little to no improvement in chronic pain rating or fuctionality with opioid-class drugs but have found an ever increasing association with some potentially nasty long term complications from chronic use.
Continuous “Doc Hopping” is a major red flag in terms of risk-assesment for development of a substance use disorder and/or other aberrant drug-related behaviors and can have an effect on the determination on whether to continue chronic opioid therapy or not. I’ll very strongly urge anyone reading this to NOT do the above, even if your current prescriber isn’t actually providing “adequate prescription levels”. “Doc Hopping” is one of those behaviors that generally is going to trigger intensive scrutiny on my part before I will fill a prescription for a controlled medication, and I know many pharmacists who view it the same.
Thank you for posting that. Seriously. Part of the problem, IMO, with our current opioid overdose epidemic is that some people tend to simultaneously attribute a great deal more benefit to opioid therapy (calling it “the good stuff”, complaining when a prescriber prescribes an NSAID instead, etc) while writing off/ignoring the significant negative effects they can have both acutely and chronically, not just on the patient themselves, but their family members and friends as well.
You’ll, I think, agree that opioids are very effective tools at times, so I don’t want to downplay or hate on the drugs themselves, but that “at times” part is crucial for us (general us including prescribers and pharmacists, not necessarily you or I specifically) to get our patients and the general public to understand.
I may not succeed, but I’m at least going to try to break people of this “good drug” nonsense. Drugs are generally useful, but neither good or bad, on their own. They are a tool, the same way a scalpel is a tool, and fire can be a tool. All of those have their strengths and their limitations with regards to their use in any relevant scenario. Opioids and Psychostimulants can make for good choices with regards to certain types of pain control and psychiatric disorders, respectively, but they can be very BAD choices in other types of pain control and psychiatric disorders.
Some are hesitant, but a small fraction of them don’t seem to be. Given that these probably contribute the most towards the overdoses we’re seeing, compared to the vast majority of their brethren, and that my experience with them is that they’ve already been relatively free with the C-II drugs (and combinations with multiple other habit-forming agents simultaneously), this scheduling change will probably not do all that much, IMO.
It might be a limitation imposed on the state level for your state, but the rule on the federal level is that prescribers cannot “post date” a prescription (ie make it so the date written is a future date on which they have not actually seen the patient that day), but can write up to 3 prescriptions at a single visit provided prescriptions 2 and 3 have something on the order of “Do not fill until XX/XX/XXXX” (not do not fill until 25 days or 50 days, either. It has to be an actual date.) written on them. Schedule III and IV can have refills, unlike schedule II, but those are limited to a maximum of 6 full fills (initial plus 5 refills) good for only 6 months from the written date on the prescription. State laws, of course, can modify those and further restrict them.
The DEA has promulgated rules allowing for e-prescribing controlled substances. In states which also don’t forbid this, the holdup is primarily the certification process for the software used by the physicians, the third-party relaying the prescription, and pharmacy software. There are very few certifiers compared to the sheer number of systems needing certified. It will come, eventually, at which point a prescriber will be able to send an e-rx in a way similar to how a Schedule III-V drug can be called in.
Both tend to produce similar “like” scores (one way of assessing for abuse potential of a drug), according to my recollection of a couple of studies and references, with the difference tending to be in what the particular individual’s exposure has been prior. Individuals on predominantly hydrocodone tend to have higher “like” scores with hydrocodone than they do when given a dose of another opioid, like oxycodone, though of course, this is more a trend than a state of absolute certainty.
Generally, the prescription drug monitoring programs only monitor scheduled medications (and prior to their rescheduling, tramadol and carisoprodol, also), not all drugs, and Ohio’s PDMP very much does list suboxone and other buprenorphine containing products in said list. If your state’s doesn’t, I’d question just how useful it’s going to be in quite a few different circumstances.
I’ll quibble on the 99.9% coming from selling scripts, as a significant portion comes from pharmacy robberies and theft from family members, friends, and strangers who are lax in their medication security, as well. As for the Urine drug testing and pain management agreements, ALL of the guidelines call for their use with at least some patients, along with regular monitoring of a state PDMP where available, with some guidelines arguing for use with ALL patients as a set of Universal Precautions (similar to how we have a set of Universal Precautions for the handling of blood and bodily fluids from a disease transmission standpoint). In those latter guidelines, everyone on chronic opioid therapy would have urine drug testing (or some other testing method) at baseline and then randomly thereafter, and a pain contract, with the difference from patient to patient being in the frequency of screening the patient’s urine/hair/blood and pulling a PDMP report, based mostly on where the prescriber has pegged the patient from a risk-assesment standpoint.
I don’t think it’s stupid at all. Proper management of a substance use disorder requires more than just therapy with a drug like methadone or suboxone. If they wish to truly quit, it is in their best interest to see a qualified addiction medicine specialist to assess what their best treatment option is, what dosage will be necessary (transitioning someone from very high dose opioid therapy to suboxone can precipitate a withdrawal effect due to buprenorphine’s partial agonist ceiling effect, thus making a taper of the primary drug of abuse necessary first), and what other supportive therapies, and lifestyle change recommendations (therapy success decreases generally with constant exposure to reinforcing drug-use conditioned cues, and increases with strong family and social support) might be of benefit. It isn’t as simple as taking someone with an Opioid Use Disorder, sticking them on Suboxone, and calling it a day. It would be great if it was, of course, but reality apparently has different ideas.
I am very sorry to read what you have been through, and you have my deepest sympathy. I cannot even begin to imagine how this must feel for you, but I am grateful you have the family support you do to help each other move forward in your lives.
This times a trillion.
While I don’t think the non-violent home delivery thing is going to occur, you’ve stated my feelings as well on what’s possibly (if not probably) going to happen, as well as why the government ultimately did what it did.
Let me be the first to give a hearty “Thank you” to **JayRx1981 **for those thorough and obviously expert posts. *This * sort of expertise freely offered is why I spend time here and support the cause through my membership.
My question is: what is the significance or difference between cancer & noncancer pain which leads to this distinction? Some people I know are dealing with cancer and opioid treatment and I’m wondering how to put the rest of the info in this thread into a context appropriate for their situation vs. someone suffering from, say, chronic back pain, amputee phantom pain, etc.
In brief, there are arguments that have been made that the distinction of cancer pain and non-cancer pain may not be quite as important as we tend to treat them. I’ve come across that argument in other review articles and op-ed style pieces in a couple of journals, but I don’t remember which ones just yet (the disorganization of my apartment following my move is messing with me). There are, of course, scientists and clinicians who would disagree. It isn’t exactly a settled matter, unfortunately.
Having said that, one of the possible differentiators of cancer pain from many forms of chronic non-cancer pain is that very generally speaking cancer pain usually has a clearly identifiable cause or active, identifiable disease process capable of triggering nociceptors in the relevant tissues, whereas with many chronic non-cancer pain conditions, particularly in the lower back, or with a pain syndrome like fibromyalgia, no amount of labs, radiologic examination, or physical examination can find any evidence of clear damage capable of causing the level of pain the patient is presenting with. Even conditions with a clearly identifiable possible cause of pain, such as severe scoliosis, syndrome of sciatica, herniated discs, and the previous mentioned ankylosing spondylitis don’t necessarily always cause pain.
Generally speaking, at least according to my understanding of several of the guidelines, textbooks, and review articles, pain with clearly identifiable nociceptive origins (bone-on-bone osteoarthritis, non-cancer tumors, many forms of cancer, to name a few) tends to respond better to opioid therapy than does pain without a clear origin, or pain arising from a process which is not necessarily painful in and of itself. This might sound surprising, but it shouldn’t be, because what we call pain isn’t just a nociceptive signal being sent to the brain, it’s our brain’s interpretation and modulation of that signal (and sometimes is thought to be generated in the absence of any signalling, like from phantom limb pain), including learned social/cultural and individual beliefs about pain, current and prior emotional responses to pain, and other memories of prior pain, etc. The same circuitry which seems to process emotions in the brain is also used to process nociception (at least partially), so the two areas can overlap in bigger ways than people might think. Chronic pain developing from sources which are less easy to identify sometimes takes on a greater affective/emotional character, which opioids will to an extent modulate, though tolerance to these effects, including the anxiolytic (anxiety relieving) effects, reward effects, and antidepressant effects tends to develop far more rapidly than to pain-relieving effects on the descending brainstem-spinal pathways capable of modulating an incoming nociceptive stimuli.
The above is somewhat of an oversimplification, of course.
As for the quote from the Annals of Family Medicine article referenced, the treatment of chronic non-cancer pain in a primary care setting is itself a contentious issue, and those arguing over whether or not it should occur regularly or not is probably better suited to a Great Debate, than General Questions.
Thanks a bunch. That clarifies the unclear waters a lot for me.
I’ve always agreed with the non-specialist reading I’ve done which suggests that a lot of chronic non-specific pain is an analog to chronic worry. The sufferer has an honest mental perception of discomfort, but it’s really a feedback loop in the psyche, rather than a nerve signal from wherever. As such, relief or cure for the pain sensation would have to come from within the psyche; no amount of manipulating peripheral nerves is gonna do much.
Late add: I’ve also suspected the cancer / non-cancer distinction is a low-key reference to the likelihood that pain management for cancer is likely to be as short-lived as the patient, whereas pain management for, say, fibromyalgia, has a much larger long-term component to be concerned about.
Crudely stated, long term addiction or side effects matter little in patients expected to die within 6 months. And if they get full or nearly full remission, the pain goes away for as long as the remission persists. Repeat as necessary until the cancer wins.
Give them a fucking legal alternative and maybe that wouldn’t happen. It’s been shown in other countries if you just give addicts free regulated doses of this stuff all the problems like this go away, and they actually function in society again.
Here in the U.S., we often force the addicts to come off, but there’s really no inherent reason to do so, and it just makes people less likely to come for help.
As for this sort of thing, the thing that pisses me off is that they affect the current users, the people most likely to be hurt. Why not grandfather people in who have been on therapy successfully without incident? Why not do everything in your power to help the actual legitimate users?
If the problem is doctors who prescribe medicines too easily, create a system to monitor that sort of thing. Don’t make it harder for the doctors doing the right thing.
Stop punishing legitimate users to get at the illegitimate ones.
I got there and it was the regular, familiar pharmacist and he had simply changed the number of refills from 10 to five. I don’t even know if he wasn’t supposed to do that or not. But he did and it helped me out of a jam big time.