This might turn out to be more of a rant than I intend, but the SD had always been a good place to vent. As some of you know I’m a chronic pain patient. Over the last ten years I’ve been on every pain killer from Vicodin to Fentynal. The standard course for pain management is to keep a patient on extended release medication which I was on for years. The problem I had was that because of the extended release medication I constantly had Morphine flowing through me 24 hours a day. This in turn led to massive lethargy. I was literally sleeping 18 hours a day.
I talked to my doctor and tools him I had to get off the extended release medication because it was taking my life from me. I also explained that I’m in pain 24 hours a day, but there are times during the day that the pain is at a level I’m able to tolerate without drugs. So I asked him to please change my medication to immediate release and let me manage the pain as needed. He agreed and for the last two months I’ve been on Oxycodone. This has the side benefit of being without Tylenol in it, so it is much easier on my liver. The script is written as take one to two 15mg oxycodone pills every for hours. I have found that there are quite a few times I can go 8 or more hours without the medication. This regiment had completely changed my life. I now wake up at a decent hour and an not nearly as tired as I was on the extended release Morphine.
So, I went to my local Walgreens today after my doctors appointment to fill my new prescription for this month’s silly of the oxycodone and I’m told by the pharmacist (the same one who had been doing my narcotic prescriptions monthly for over 6 years) that this is the last oxycodone prescription they’ll fill for me. I’m told that my monthly allocation of 180 oils had raised red flags by the DEA and they will only fill extended release medication from now
Well crap, the last thing in the world I want to do is to go back to being drugged 24/7, but it looks life I’ll have no choice. So, the question is, why does the SEA get to question my doctor decision on what is an appropriate pain management plan for me. Shouldn’t that be something decided between a doctor and his patient? I understand that there are plenty of people playing the system to obtain narcotic needs for illegal uses. However, should the enforcement of that ironies trump the medical needs of a legitimate pain patient?
Fwiw, I do realize that protocol dictates that extended release medication is the standard for treating chronic pain. The reason I prefer immediate release is the ability to only have the pa in my system when I need them and to keep me from being so damn tired all the time.
Thanks for listening to my rant. If anyone has a clear understanding of the DEA’s policy when it chines to pain patients I would sure like some insight.
Because Drugs are Evil, and if you have to suffer because of the Holy War against drugs they don’t care. You’re lucky that they haven’t intervened to forbid you your medication entirely.
They’ve been doing things like this a long time. It must have been 10, 15 years back when I saw a *60 Minutes *episode on them doing this to people; the DEA types were quite smug and self righteous about it.
I’m a little unclear as to who the DEA actually flagged. Was it the pharmacy or was it you? If it was the pharmacy, can’t you fill the scrip somewhere else?
I’m no doctor but I believe even people with legitimate pain can STILL get hooked on their prescriptions. 180 pills a month sounds like an awful lot. I don’t live with your pain but, IMHO, it might not be the worst thing in the world to put a limit on that.
Sure, they can get hooked. But getting hooked on drugs sure beat being in pain from the moment you wake up to the moment you go to sleep (assuming you can get sleep). And so what if they’re hooked? They’ll need to keep taking the drug? Given they have chronic pain, they’ll keep taking it anyway.
And I can’t believe someone who doesn’t have to live with the pain is stating that reducing pain killers can’t be the worst thing in the world.
What makes you think that getting hooked is the worst thing in the world and avoiding this worth living in pain for the rest of your life? Would you make this choice?
Judging from Tom Tildrum’s links it’s Walgreens. They had been handing out the stuff like candy, and now they are cracking down as part of a federal settlement agreement. The DEA’s position is, ““If a pharmacy chooses not to fill a prescription for someone, that’s their decision. It’s not the DEA’s decision.”
Of course it’s in Walgreen’s interest to blame big guv. But if I were the OP, I would try a few other pharmacies.
I’m not a doctor either and I’m not going to dispense medical advice on the basis of what sounds like a lot. I understand the OP’s situation as described isn’t exactly vanishingly rare though. I also understand that fears of addiction in certain medical cases have been overblown in the past. Cite: [INDENT]Pain Medications: Addiction and Fear of Becoming Addicted Opioid pain medications are some of the most commonly abused prescription drugs. However, the risk that well-screened people will become addicted to opioid drugs when they’re taking them for chronic pain is actually low, Reisfield says.
A 2008 study that compiled previous research found that about 3% of people with chronic non-cancer pain using opioid drugs abused them or became addicted. The risk was less than 1% in people who had never abused drugs or been addicted. [/INDENT]
Keep in mind many people get scripts for both OxyCodone and OxyContin - anything you do with that many pills is going to make you look like a drug seeker. You might want to talk to your doctor about a low dose of oxycontin and a high dose of oxycodone. The number of pills is probably what is causing the flag - so for god sake don’t get a script for 180 10mg - get a script for 60 30s and split them up with a nice pill cutter (the oxycodone - not the OxyContin).
That is a huge amount of opiates a month - depending on the dosage (I assume you aren’t taking fives here). You are almost certainly dependent at this point on opiates - which also will cause some of the lethargy.
You are being smart to your health to insist on the ones without Tylenol, but keep in mind that is also a red flag - as most people aren’t aware of it - except for drug addicts who have been to the hospital once.
Oxycodone is the most abused narcotic around - OxyContin - while it has the problems you mention – has fallen in value by almost half on the street since they changed the binders to make them almost impossible to snort/inject.
I don’t remember for sure, but it think stuff like fat and what you are eating can effect the absorption - so you might be able to get the OxyContin out of your system faster by around an hour or so by changing a morning meal. Also you might want to consider setting an alarm an hour before you wake up - take the oxycontin - go back to sleep (if that is possible for you) and then it will be out of your system faster.
Of course if they literally won’t fill any more scripts for plain oxy - then you are screwed. If you want to go to a different pharmacy - make sure you transfer all your scripts to them - don’t just show up with a huge oxycodone script out of the blue.
180 just doesn’t make sense - the only reason you should be taking that many is if you need 180 mg for part of the day (which of course raises red flags as it is $5,400 worth of drugs). 180 is for someone who needs something three times a day. In their mind if you need it three times a day you need OxyContin not Oxycodone.
Can you see how this would raise red flags? I mean plenty of people take oxy for only part of the day - how you don’t feel like shit four to five hours later is beyond me - if you are taking what would be the only logical reason to write a script that large.
Oxycodone at most would be taken 3 times a day - they are available without Tylenol in 5, 10, 15, 20 & 30s.
If you are taking 10s the script should be for 90 20mg pills as no one - not even an addict needs oxycodone six times a day - and if you did you should be taking OxyContin.
Same with 5s - you should be taking that as 10mg 3x a day - why take two fives when you could take one ten? If you really need the precision - they are very easy to cut.
The ONLY reason logically to have a script for 180 pills of oxycodone is if you are taking 30s - and there is no way on earth you could take that many and not be dependent. So there is no way you would only need it for half the day - you would be sick as a dog by the next day.
So either your doctor is clueless how to write scripts for schedule II drugs - or something else is going on. I’m not trying to be a dick - I’m just telling you how it looks to anyone with knowledge of oxycodone and the way the DEA/pharmacists think.
If you are taking less than 30s than you really need him/her to write the script more carefully.
If you are taking 30s then I can’t even imagine how awful your life must be.
After reading these it is clear that I was wrong as to the actual reason you were flagged - this is an issue with Walgreens - and that should make it easier to switch pharmacies - as they will be familiar with the problem and less likely to view you as a drug seeker.
My original suggestions still stand though - it is likely other pharmacies have or will start to have similar issues as there is a lot of cracking down on the problem.
I highly recommend you read those articles and make sure you are triggering as few as those red flags as possible - as plenty of people have had similar issues at other pharmacies.
I used to use target - but their solution to Schedule II drugs seems to be not to keep that many - so it was a pain in the ass. I switched to CVS and couldn’t be happier. They never even remotely treat you like a drug addict (Target didn’t either, but they started to have constant supply issues).
The pharmacist there and I have a great relationship - she even went out of her way to try and call me to warn me there might be a problem as there was a nationwide shortage of what I usually am on and I might want to consider talking to my doctor about other similar versions of the drug that might be helpful in case they did run into a problem.
She was able to get some and I’ve never had a problem there - except there was a couple times they didn’t have enough, but they had already ordered them to replace their stock - while Target seemed to order them when I requested them - so I usually only had to wait a day or two. I think this only happens like 5% of the time while at target it was more like 30% and rising.
I know it seems like you shouldn’t have to go through this, but I think having a good relationship with your pharmacist is important. I go to her for my flu shot - I buy - and sometimes ask her opinion on all OTC medication. Once they see you as a real person they can be very helpful. They also have started some new policies - none of which have been a problem for me. They did start requiring using ID and twice I had forgotten it.
The first time I was with my girlfriend and they said - “well it doesn’t have to be you that picks it up - does she have ID?” The next time I had switched jackets and the tech that was ringing me up got to the ID part and when I realized I didn’t have my ID I was pissed off I would have to go home (pissed at me not them), but the tech helpfully asked if I happened to know the number - which I did. He said “I know who you are - so it’s no problem.” He typed it into the computer and I was on my way.
I can’t recommend them enough. Strangely enough consumer reports recently reviewed customers on pharmacies and I was shocked to find them second to last - and I know the one near where my mom lives sucked - so you might want to visit a few and ask the pharmacist about some OTC stuff and see how helpful they are before picking one.
Actually, the guidelines all generally recommend around the clock pain medications, as opposed to “prn” or “as-needed” medications, but they don’t necessarily recommend extended-release medications. There aren’t a large number of high quality studies on the matter, but the studies that exist find that, generally speaking, short acting medication dosed around the clock is not statistically significantly different from an equal dosage of long-acting medication in terms of pain relief provided. The longer acting agents are generally preferred by clinicians because, using the half-life of oxycodone (average of about 3.5 hours +/- 0.8 hours, per one pharmacokinetic analysis) as an example, the duration of effect of oral Immediate Release products ranges from around 4 hours (pretty close to the half-life) up to around 8 hours, depending on the individual (some people have even shorter or longer durations, but they tend to be the exception, rather than the rule), and we generally don’t view waking up to take a pill in the middle of the night if you’re on the 4 hour side of things to be beneficial. Further, with opioids, if we’re using the guidelines as our basis and starting low and titrating to goal effect (which is NOT complete relief of pain) slowly, sedative and cognitive impairing effects are generally short-lived and go away pretty quickly following an initiation of therapy or an increase in dosage (usually in a matter of days). If lethargy is long-lasting, it actually suggests several possible phenomena. Opioids, for example, particularly at or above doses which are equivalent to 200mg of morphine per day, are associated with worsening, and possibly even causing, central, obstructive, or mixed-type sleep apnea (according to some literature also resistant to conventional CPAP therapy), which can result in excessive daytime sedation (lethargy) due to the number of microarousal episodes resulting from hypoxic/hypercapneic (low blood oxygen, high blood CO2) conditions induced by the opioids in the brainstem. Then too, like with many CNS depressant drugs, Opioids can trigger a worsening of depression in those with a comorbid Major Depressive Disorder (not uncommon in chronic pain patients), which can also result in worsening in the duration and quality of sleep, again leading to excess daytime sleepiness (as well as poor pain control, to which more opiates will only actually make the problem worse).
Tylenol isn’t actually all that bad for your liver, in moderate doses (some of the doctors on the Pharmacy and Therapeutics committee meeting I sat in on as a Pharm Intern stated up to 2 grams per day, though the current FDA recommendation is 3 grams/day max), particularly if you’re eating a healthy diet capable of providing enough raw materials for you liver to make certain compounds (like Glutathione) to protect itself from damage.
A brief aside. Dear fellow Pharmacists, Please actually read the &!@&-ing pain guidelines (anyone reading who wants them, I can link to most of them (a few are pay-walled)), understand that the DEA (and probably State Board of Pharmacy) Red Flags are a hint to apply more stringent scrutiny, NOT an excuse to not fill a prescription without applying your FULL professional judgement, and do your utmost to NOT prematurely condemn a patient presenting with a narcotic as a drug addict when many of you probably can’t even tell me what the underlying neurologic and psychologic mechanisms of addiction actually are believed to be.
Back to the OP, your Walgreen’s pharmacist is possibly an idiot. I can understand where he or she is coming from, but he or she very clearly has not done the above.
To the best of my understanding, the DEA has no desire to question the medical validity of your pain condition. If your doctor/prescriber is following the rules of their state (and the federal rules/laws) to the T, then the DEA is supposed to do nothing (beyond the initial investigation to make sure everything is on the up and up). Your pharmacist, depending on state laws, may be required to essentially second-guess your physician due to the federal rule placing a corresponding liability on determining a legitimate medical need on the pharmacist, but that does require your pharmacist to have an actual, professionally rational reason to deny a fill. That being said, as pointed out in another recent thread, just because someone is an actual patient in pain does not mean that opioid therapy is necessarily the best or only answer for their specific concern, particularly on a chronic basis where epidimiologic data strongly suggests that chronic opioid usage isn’t nearly as beneficial as acute or subacute therapy seems to (provisionally) be.
In essence, the DEA’s policy is that if your doctor has a clear, individualized, but still based on overall standards of practice/care reason for you to be on a scheduled medication, and can demonstrate compliance with all state and federal rules touching on the prescription of scheduled medications, then the DEA is supposed to be fairly hands off. They don’t have the training/expertise to actually second guess a competent prescriber or pharmacist. Does it always work out that way in practice? I doubt it, but that’s another matter entirely.
DataX and JayRx1981, please accept my thanks as an observer for your thoughtful and informed posts. Y’all are emblematic of why I keep coming back to the SDMB.
I have severe neuropathy in my feet as a result of surgeries and am in pain pretty much all the time, and my Dr won’t give me anything stronger than Tylenol 3.
**DataX **has a good idea about switching pharmacies. Walgreens had my sister-in-law (who has diagnosed fibromyalgia) arrested because of her pain meds. She was not remotely an addict nor was she dealing, and in fact took expired meds back if she didn’t use them all.
I use CVS, my doctor contacted them and let them know that I am a patient with chronic pain, and I’ve had no issues with getting medications filled. At my highest level, I was getting 125 Percocet a month.
**JayRx1981 **also has a good point about treating the pain constantly. I like the shorter-acting meds, because you can be flexible with your treatment – half a tablet if pain is tolerable, a whole tablet if not.
I had a neurologist tell me that he “didn’t believe” in opiates for chronic pain. I suggested he let me hit him with a ball-peen hammer for 72 solid hours while he tried to go about his business, and then talk to me about how he feels about stopping that pain by any means necessary
I’ve always thought “you could get hooked!” was a stupid reason to not provide pain relief. One doctor said that about my 80-year-old stepfather toward the end of his life. He was in chronic pain from a long-mistreated back injury (his tailbone had been removed, and it gets worse from there) and from complications of diabetes. The doctor didn’t want to give him pain medication at all. My response to the doctor was, “First off, if he was going to be addicted to something, he would’ve been by now. Second, who cares if he does get ‘addicted’? He’s 85 years old! What the hell is he going to do, rob a 7-11 to get his fix?” (We then found a decent pain management doc.)
Most laypeople – and apparently a number of physicians as well – don’t understand the difference between medication tolerance, physical dependence, and actual addiction. And even when that difference is explained, their cognitive bias skips right to Oprah and Jerry Springer shows about addiction anyway.
I have chronic migraine, spinal stenosis, and a knee that needs to be replaced but can’t be for at least ten years. One of the meds in my treatment plan from the chronic pain clinic is an opioid. They help me to be an active and a useful member of society. I work a mentally demanding and interesting job. I go to social events. I do volunteer work. No one would know I take opiates. After ten years or so of their use, I am *physically *dependent – if I suddenly stopped taking them, it would be unpleasant. But I’m not addicted (I don’t get a high, I have no desire to increase the dose, I don’t think about them until it’s time to take the medication, etc.) . I treat them just like my asthma meds, parcel them out into the daily pill-boxes, take as directed, and don’t think much about it.
Yeah, a small number of people get addicted. Treat them. It’s utterly inhumane to not treat people with chronic pain because of what might happen.