# Why is the DEA trying to override my doctor? **URL:** \ **Category:** Great Debates\ **Created:** [October 16, 2014, 1:16am UTC](https://boards.straightdope.com/t/why-is-the-dea-trying-to-override-my-doctor/701459 "2014-10-16T01:16:31Z")\ **Posts on this page:** 3\ **Page:** 2
**Author:** ![obbn](https://avatars.discourse-cdn.com/v4/letter/o/d6d6ee/32.png) [@obbn](https://boards.straightdope.com/u/obbn)\ **Post date:** [October 16, 2014, 6:04pm UTC](https://boards.straightdope.com/t/why-is-the-dea-trying-to-override-my-doctor/701459/21 "2014-10-16T18:04:38Z")
Thanks for all the replies, they were very informative and appreciated. Please understand that I’m taking these pills because I have to, not because I want to. I’ve investigated every form of treatment to help with my pain but there just aren’t any. I use a TENs unit, but the effects are limited and only work while the unit is on. The only option I’ve been given is for a surgeon to go in and “have a look around”. Thanks, but no thanks. Three back surgeries is enough in one lifetime. As far as my doctor, he is very dedicated and truly wants to help. The move to immediate release was requested by me as I pleaded to be off the extended release pills because I was sleeping so much and tired when awake. Today for instance I finally took my first dose at 1:30pm. My last dose was at 12:30am last night. Over twelve hours between doses! On an extended release is be getting the drug even though I didn’t need it. With the immediate release I can be “drug free” when possible. I realize that 180 pills seems like a massive amount, but it really isn’t much for a chronic user. That’s 6 pills per day. Yes, 30mg of oxycodone is a high dose, but remember I’ve been taking opiods for more than ten years now. Tolerance has made lower does ineffective. I also have nothing against the DEA and is fight against illegal prescription drug use. But the paranoia that I see in the doctors, pharmacist and others really unfairly points a finger at those of us who haven’t any other options to deal with crippling pain. I wish there was another way to fix my pain. Both I and my doctor read all we can about promising treatments, but truthfully there really isn’t much or there. If anyone has a suggestion, I’m all ears. I more than anyone would be happy to never have to put another oil in my mouth ever again. ---
**Author:** ![JayRx1981](https://avatars.discourse-cdn.com/v4/letter/j/71e660/32.png) [@JayRx1981](https://boards.straightdope.com/u/JayRx1981)\ **Post date:** [October 17, 2014, 1:20pm UTC](https://boards.straightdope.com/t/why-is-the-dea-trying-to-override-my-doctor/701459/22 "2014-10-17T13:20:33Z")
> [@DataX](#): > > 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. Not necessarily. Being dependent on a drug and lethargy are two separate side effects. Dependence is basically determined by the presence of one or more symptoms usually characterizing a withdrawal syndrome, while lethargy, as I stated earlier, can come from direct sedative effects of the drug, or can arise as a manifestation of worsened depression or the development/worsening of apnea. > [@](#): > > 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. Given that Acetaminophen can have a positive effect on pain control by serving as an additional modulation of pain signaling in brain-spinal nerve pathways, I won’t agree that eliminating it altogether (if that is indeed what the OP has done) is necessarily good for the OP’s health or pain control. Absent poor nutrition or use of other hepatotoxic agents, acetaminophen can be used safely and effectively and can act as an opioid sparing therapy (meaning less of the opioid is necessary to achieve the same level of pain control, which in turn will lessen opioid side effects). > [@](#): > > 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. Taking an opioid with food will generally delay the time to onset and time to maximum plasma concentration, though to the best of my recollection, it doesn’t effect overall exposure/duration of effect. > [@](#): > > 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. You might be surprised to learn that there is technically no ceiling on the dose of opioids you can work up to. The only limitations are the rates you develop tolerance to various side effects (tolerance from a pain standpoint develops at a different, generally faster, rate than tolerance to the respiratory depressant effects, to name an important example), the presence of side effects making a given dose intolerable, and the absorption kinetics of the specific dosage form. While 90mg of oxycodone per day isn’t low by newer guideline standards (it’s roughly the equivalent of 135mg of morphine), older guidelines allow for up to 200mg of morphine equivalence, and most of the more serious/difficult to treat side effects are generally, but not absolutely, more prevalent above 200mg of morphine. > [@DataX](#): > > 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. Having a good relationship with your pharmacist(s) is incredibly important, in cases like chronic opioid therapy, though I’m of course biased. I might not even bat an eye at a prescription for high dose in one patient, whom I know, know their medical history, know they aren’t attempting early refills, while an equivalent dose in an unknown patient is going to get quite a bit of initial scrutiny, because I’m required under the law (with every fill) to determine if a prescription is for a “legitimate medical purpose” and to perform Drug Utilization Review (DUR) to check for things like drug interactions, duplications, over/under-dose, over/under-utilization, etc, and that is harder to do without asking lots of questions of a patient and their doctor if I don’t know them. > [@hotflungwok](#): > > 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. While opiates provide some pain relief in neuropathic conditions, the evidence so far suggests they don’t provide much, if any, functional improvement in performing activities of daily living and activities a patient enjoys but can’t perform due to pain, and that it takes higher doses than for somatic pain conditions to achieve the same reduction in pain, which puts one at greater risk for side effects and actually impairing functionality further. Antidepressant agents, be they tricyclics (like amitriptyline, desipramine, nortriptyline) or SNRI (evidence is best for Duloxetine, known commercially as Cymbalta, though Venlafaxine is also an option), tend to do a better (if still imperfect) job at neuropathic pain relief. > [@GrumpyBunny](#): > > \*\*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’d be intrigued to know what exactly she was arrested for. We usually only involve the police if we know or very strongly suspect a prescription is fake, someone trying to fill scheduled drugs under multiple fake identities (had it actually happen), are dealing with a patient who is making overt threats, or are involved in theft/robberies. Otherwise, forceful negative confrontation tends to work opposite the way we want it to, in my experience, leaving a patient less likely to trust me, instead of more likely to do so. Fibromyalgia, though, tends to function like the above mentioned neuropathic pain. You can get a pain relief response with opioids, but generally they impair or fail to improve function in the process, and most guidelines (that I’ve read, at least) recommend non-pharmacologic therapies (and/or neuropathic pain therapies) as being more effective than opioid therapy. > [@](#): > > 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. To put things into perspective, if we assume the above Percocets were the 10/325 form, 125 per month is roughly 4/day per 30 day period with 5 extra for breakthrough and/or volitional pain, which works out to 40mg of oxycodone, and 60mg of morphine equivalents. Ohio’s “push pause” initiative sets 80mg of morphine equivalents as the “re-evaluate if this is the right therapy, that you are doing everything correctly, etc” point, so this dose falls under that. If Grumpy were elderly, some literature suggests a lowering of said point to 50mg of morphine equivalents, but Ohio just sticks with 80mg across the board. Not too long ago, we filled a prescription for a patient with cancer for up to 10 oxycodone 30mg/day (450mg morphine equivalents), and while I’m not exactly thrilled with this prescription from a pharmacokinetic standpoint, that’s not a dose that’s all that hard to work up to when we’re talking cancer. > [@](#): > > \*\*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. A study published not all that long ago in _Pain_ found that generally this seems to hold true for many of the patients involved (it involved dihydrocodeine, which isn’t used here in the USA, to my knowledge). The potential problem with regards to more frequent IR dosing is again, duration of effect can have an impact on the amount and quality of sleep, which can worsen pain, and that the more frequent (and rapid) the rise in drug levels, the more likely we are to see a shift towards problematic drug-use behaviors (called aberrant drug-related behaviors in some literature), which can be a sign we’re moving towards, or have ventured into, substance use disorder (addiction) territory, which is why we hoped the introduction of long-acting forms would curtail some of the addictive risk. > [@](#): > > 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. To be fair to the neurologist, we have practically no good evidence of efficacy for opioid therapy beyond the subacute range (6-12 weeks), and an ever increasing body of epidimiological literature strongly suggesting that at best, we’re not reducing the overall reported pain levels, and at worst, we’re actually making them worse, with chronic opioid therapy. Provided he wasn’t opposed to intermittent use on a chronic basis, I can see his point. Moreover, to go pedantic, hitting him with a ball-peen hammer for 72 hours would be an example of an acute pain scenario, for which the evidence of benefits for opioids is much greater than with chronic treatment. Instead, you should have asked him to go old school, like Head who in 1905 purposefully divided the cutaneous branch of his radial nerve in his OWN arm. Doctors these days, pansies, the lot of them. 😉 > [@GrumpyBunny](#): > > Agreed. > > 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.) A few months ago, we had a late 60’s patient who, despite receiving opiate therapy from a pain doctor (who eventually “fired” her from his practice for constant uncorrected aberrant drug-related behaviors), then opiate therapy from family pratice doctors who had her sign a pain contract including random urine drug testing, who still ended up getting “fired” a second time because she was using heroin on the side. The elderly are not immune to addiction, and are even more likely to experience some of the more problematic side effects than younger, usually healthier, individuals are. If we were dealing with a 100% all risks explained, informed consent scenario, where the patient and family waive the right to sue if the patient experiences those effects, because they were warned in advance that up to and including death from cardiac arrest secondary to respiratory arrest were possible with this therapy, or we had _ **GOOD** _ evidence that chronic opioid therapy was actually beneficial for pain, then I might agree. > [@](#): > > 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. Hey, don’t forget pharmacists! Wait, no, that’s not a good thing to be proud of. Forget Pharmacists! 😉 Seriously, though, you aren’t wrong. I’ve got colleagues whom I’ve explained the difference to who still state stupid stuff like, “well yeah, but they’re an addict so I don’t care if they’re actually in pain”. Not very many, but a few. A most epic [face palm](http://images.t-nation.com/forum_images/auto/r/786x0/a/9/a9779_ORIG-JesusFacepalm.jpg) was experienced on THAT day. > [@](#): > > 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. Except that, as I’ve stated, as Qadgop the Mercotan (sorry to name drop, but dude, you’re like legendary) has stated, as countless other healthcare practitioners have stated, Opioids are NOT the panacea the general public and the media like to portray them as. They are a messy, hitting the entirety of the brain in ways we’re still trying to work out, may render you less functional, more prone to excessive healthcare utilisation compared to other pharmacologic and non-pharmacologic strategies, but still SOME of the time useful tool. They are not “good drugs”, the “good stuff”, “the shit” (in a positive sense), and any other terms patients have used to describe them. They aren’t just analogous to fire, they ARE fucking fire in the damage they can wreak, and until people understand that, I’m gonna be a Debbie Downer (while still trying to provide as accurate of information as I can) with regard to their long term usage. ---
**Author:** ![clairobscur](https://avatars.discourse-cdn.com/v4/letter/c/839c29/32.png) [@clairobscur](https://boards.straightdope.com/u/clairobscur)\ **Post date:** [October 17, 2014, 2:58pm UTC](https://boards.straightdope.com/t/why-is-the-dea-trying-to-override-my-doctor/701459/23 "2014-10-17T14:58:41Z")
> [@JayRx1981](#): > > 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, Do phamarcies make significant money from Schedule II drugs? If not could this policy by the company be intended to actually discourage patients from ever buying them in their chain, hence getting rid entirely of the problem? [Previous page](https://boards.straightdope.com/t/why-is-the-dea-trying-to-override-my-doctor/701459.md?page=1)