Home Forums Discussions General Discussion narcotics

Everyone needs to be careful with narcotics. Please don't flirt with disaster. Pt. demands and urgency should not over-ride proper prescription habits and laws. Class II narcotics should never be prescribed without physically seeing the pt. Not only is it good practice, it's the law. Review your state and federal regulations. Post-dated scrips are not a good idea either, whether legal or not depending on your locale.
Review your state and federal narcotic license. Not only do they allow you prescribe certain narcotics, BUT YOU ARE REQUIRED TO SUSPECT, INVESTIGATE, AVOID, AND NOTIFY AUTHORITIES of atypical narcotic prescription events.
Please also remember, not only do you have a duty to do the best for your pts, you also have a duty to protect your local population from diverted narcotics. Kids dead with a narcotic prescription bottle with your name on it in their pocket isn't good. Many a doctor have lost their prescription license b/c they didn't pay attention or didn't act when the saw a problem.
For those of you not in the southeast, look what happened in Florida and North Carolina.
As a pain doc, I try to educate my follow docs so they don't get fitted with an government orange suit.
Nate

Make sure you have all taken the REMS online for opioids. We were all 'strongly advised' to take this some time back. It did take me a few hours. I can imagine one of the first things an attorney will ask is what special training you have for prescribing opioids. If you say, well I'm a doctor aren't I? they will then pull out the letter on REMS training and ask if you have seen it.

Our state does not allow post-dating, but you can prescribe up to 90 days at a time for a schedule 2, is my understanding.

I would like to invite you to join me at University of Washington in Seattle Nov 1 and 2 for an excellent Chronic Pain CME.

(There is also an oyster, seafood, wine, and beer festival Saturday night!)

I did see the course Chris is talking about and the link for registration is as follows:

http://depts.washington.edu/cme/live/pdf/MJ1407.pdf

Oregon doctors and Medical Examiners veer from excessively permissive to excessively restrictive and back in about 20- year cycles.

Currently, we are just a little behind Washington in reining in the rather sloppy habits that prescribers have developed over the past 15 years -- abetted by "pain clinics" and pharmaceutical companies who have been pushing narcotics as more or less thesolution to chronic pain.

Years ago, UW medical school had a superb behavioral pain management program -- but in the early 90's it was eclipsed by narcotics pushers (starting in the Oregon Legislature), and because that sort of thing is expensive and labor intensive -- and requires some buy-in and personal work by patients -- it fell away.

Then the "pain clinics" stopped prescribing the narcotics they recommended, and pushed that task downhill on the "PCP" -- while they confined themselves to lucrative injection techniques and implants (for well-insured patients only, of course).

I'm pretty fed up with the whole thing.

I don't see that "modern" medicine is a great deal better at dealing with chronic pain (say from MVA or logging accidents or neurosurgical back surgery disasters) than we dinosaurs were in the 1970's

I need to come to Astoria and get some clam chowder and some pyramid ale....you are exactly correct...had a hand surgeon just dump his chronic screwed up surgical patient on me and it cannot be helped as the patient wont partake in the behavioral therapy needed to overcome her problem...all she wants is a pill....

I recently had an encounter with a "chronic painer" who just completed treatment and post treatment described his addiction as a beast that needed to be fed at all costs, lying to not only his physician, wife, family, but himself. This gives one great pause about how any one can treat such a patient.

When the patient doctor relationship is inherently based on trust and the beast within cannot play by those rules, how can we treat such a patient?

I do my best, follow the guidelines, and do not have much advice and this component of medicine is the least gratifying for me personally.

The DEA changed the rule in 2007, here it is and the link:
Issuance of Multiple Prescriptions for Schedule II Controlled Substances

The DEA has revised its regulations regarding the issuance of multiple prescriptions for schedule II controlled substances. Under the new regulation, which became effective December 19, 2007, an individual practitioner may issue multiple prescriptions authorizing the patient to receive a total of up to a 90-day supply of a schedule II controlled substance provided the following conditions are met:

Each prescription must be issued on a separate prescription blank.
Each separate prescription must be issued for a legitimate medical purpose by an individual practitioner acting in the usual course of professional practice.
The individual practitioner must provide written instructions on each prescription (other than the first prescription, if the prescribing practitioner intends for that prescription to be filled immediately) indicating the earliest date on which a pharmacy may fill each prescription.
The individual practitioner concludes that providing the patient with multiple prescriptions in this manner does not create an undue risk of diversion or abuse.
The issuance of multiple prescriptions is permissible under applicable state laws.
The individual practitioner complies fully with all other applicable requirements under the CSA and C.F.R., as well as any additional requirements under state law.

It should be noted that the implementation of this change in the regulation should not be construed as encouraging individual practitioners to issue multiple prescriptions or to see their patients only once every 90 days when prescribing schedule II controlled substances. Rather, individual practitioners must determine on their own, based on sound medical judgment, and in accordance with established medical standards, whether it is appropriate to issue multiple prescriptions and how often to see their patients when doing so.
http://www.deadiversion.usdoj.gov/pubs/manuals/pharm2/pharm_content.htm
So post-dating is not ok but issuing a current and 2 future C-II Rx'es with "fill after x/x/xx" dates are ok.

Todd --
Chowder good at Charlies Chowder House.

I blame the media and the drug companies for our current narcotics mess -- they play on suffering (and therefore, gullible) patients desires for relief beyond what is possible to provide.

I have essentially been forced on some occasions to prescribe and "manage" megadoses of narcotics by pain specialists who wouldn't consult unless I agreed to continue prescribing after they were done sucking as much money as they could from insurance with their "procedures", then dropping them like hot potatoes.

At least there is beginning to be an intelligent conversation about this in our Coordinated Care Organization (the Oregon version of the Federal "Accountable Care Organization"

The government via the auspices of Medicare is partially responsible for this growing problem. The have labeled PAIN another vital sign, and the ER docs are 'dinged' if they do not get good survey results. Thus the ERs are getting everyone started on the Percocet and quickly hand them over to use for continued management. By then, the addiction is often set in.

On a personal note, my brother told me he was given a couple Percocet for a legitimate injury, and 5 months later he was still feeling a powerful craving for it!

Tom:

That gives me a craving to head down to Newport, OR and have some Mo's clam chowder, followed by beer battered fish and chips at Rogue Brewing.

Once upon a time, I was poor and dating a girl in high school. We went to Newport and I think we had spent all our money on gas, so we each got a cup of chowder at Mo's and put copious amounts of crackers in it to make it last! Good times: poor, but young and full of life.

Years ago, I attended a course at the University of Oregon that was supposed to address pain management. Instead, it turned into a diatribe on why not to prescribe controlled substances. It included a director from one of their local emergency rooms who flatly said he did not allow any of his staff to prescribe a controlled substance for pain, ever. I found the presentations very unrealistic and frustrating. Maybe Dr. "X"'s ER did not prescribe Tylenol #3 for a broken ankle, but you can rest assured the next ER down the road did, thereby doubling the healthcare costs. What I need are real guidelines for pain management, not blanket lectures against their use. I did not find the REMS course helpful. All I got out of it was to be extra careful with methadone due to its long half life, and don't start opiate naive patients on long acting opiates.

I don't know how many ER's there are like that any more -- most of them seem to be responding more to administrative edicts to keep the customers happy, rather than evidence based medical guidelines.

Our ER is likely to give you a blast of IV dilaudid the minute you hit the door. They have very happy customers.

Years ago (say 1960-1975) Oregon was notorious for the number of Percocets prescribed (mind you, these were Percocet-5!) and there was a Draconian crackdown about 1975. For the next 20 years it was pretty much risking your license to prescribe a Tylenol-3 once a day for an arthritis flare if you prescribed for more than 30 days.

That all changed about 1995-2000 with Pain the Fifth Vital Sign, and a rather problematic distinction being made between dependency and addiction. "People in chronic pain don't become addicted to drugs even if they are dependent on them". Pain clinics erupted, and pharmaceutical houses made mountains of cash on narcotic pain relievers.

Now, we're in another backlash.

I have a few patients who genuinely benefit from chronic high dose narcotics for intractable, non-malignant pain.

I have difficulty with a larger group who really shouldn't be taking them, but got started on them, and now don't believe they can stop.

Let me make a couple suggestions:
#1 Remember federal and state Narcotics laws and regulations are not always the same. The more stringent law trumps the other. Just because federal may say you can do something, your state may disagree.
#2 Don't think of narcotics as a uniquely separate type of medicical practice. If a patient demands a higher dose of Coumadin Just because they want it, You would not give it to them unless it was clinically indicated. If you think narcotics are not medically indicated, don't prescribe. Are you ever bullied to prescribe antibiotics?
#3 legal or not depending on your locale, post-dating narcotic prescriptions is not a good idea.
#4 physician's disagree with other physicians all the time about patient care.That's normal. Why should controlled drugs be any different? Always do what is clinically indicated. What others think of your practice habits is not important, as long as you stay above the law and provide appropriate medical care.
#5 It's perfectly okay to show some patients the front door to your office, Particularly the part that allows them to leave.

Nate

I haven't been in this game long enough to see the pendulum swing so many times. But what seems different about the Fifth Vital Sign is that CMS and Joint Commission are looking at patient satisfaction, both in the ER with pain and on the floor. Statistics for hospitals are now published on the CMS web site. Pain addicts will not be satisfied unless you feed the addiction.

The odd thing, is that the government is working against itself. CMS is mandating treatment that floods the market with opioids, while another branch of the fed, the DEA, is arresting doctors.

I'm a hard core, born again Christian, but after dealing with opiates as a physician I say legalize drugs. If that were to happen we would only be seeing people who wanted real pain relief. We wouldn't have to do all these screening tests and have all of this mistrust in patients.

This really hit home during the last republican primary presidential debates. Ron Paul was asked about legalization and he responded to the tune of(paraphrasing) "How many in the audience use heroin please raise your hand? Ok no one raised their hand. Now how many do not use it because the government tells you not to? Still no one. Now who would start using it tomorrow if was not illegal? Still no one raised their hand.

Bottom line, we don't do these things for other reasons than because the government says it is a bad thing.

I love Scott's answer.

In so many areas of medicine, there has been this great pushback against paternalism. My Dad was a doctor in the 1950's. Back then he was "The Doctor", explained nothing, told patients what to take and when, and would have been affronted beyond belief if anyone asked a question about his decision. He also felt that women were temperamentally unsuited to be doctors or operate machinery. He was not stupid or evil; he was the product of his time.
Now my wife is my medical partner, hunts big game and pilots aircraft, and my patients get reprints from UpToDate and we discuss treatment options.
It seems the next logical step is to begin to eliminate the need for prescriptions altogether. Patients would come in for consultation and education ("Doctor" means "Teacher" as was pointed out in another thread), then simply go buy whatever medication was decided upon. Or, skip the physician entirely and go buy whatever medication struck their fancy.
Personally, I'd be happy to be out of the prescribing loop. No more being sniped at by everyone from the DEA to the insurance companies. And the laws of natural selection would leave me with a patient population who appreciated what I have to offer and would value my advice.

Right on dgrauman!
There may be some voluntary component to addiction, but I do not believe it is large.
For sure, treating addiction as a crime has had severely deleterious social results.
Time to start thinking of it as a public health problem, use a medical approach.
That might not work, either, but it hasn't been seriously attempted -- at least, not in the US.

The audience Scott describes may be different from the general population. It is young people who are apt to experiment with anything available. Those kids out back who are smoking cigarettes and look guilty when I walk up to see what they are doing, snuffing it out under a foot to hide it. They sneak shots from dad's whiskey bottle and try their friend's MJ. If heroin, bath salts, crack, or other drugs were readily available, they would be trying them, overdosing, and you would have a lot more dead kids on your hands. One of my patients took some plant like product, probably laced with bath salts, and ate it just because a friend told him to. Some of the bath salt chemicals have 800x the potency of regular THC. Other kids have walked out onto the freeway like zombies and been hit by traffic under their influence. Do you really want the DEA to give up fighting this stuff? Can you imagine the misuse of Percocet if it was on the store shelves? You think drunk driving is a problem? Granted, this is an expanding problem and overdoses from narcotics have gone from 4 million a year in the 90's to 12 million. Survival of the fittest is right!

Well, I don't have a simple answer.
However, the plant world is just full of poisons, and seems like mostly human beings are getting poisoned -- you don't see bears getting off on opium and marijuana -- but even people didn't used to have such a drug problem.

Something about human culture is seriously haywire.

All I am saying is that treating drug use as a criminal offense hasn't helped a whole lot, and has contributed to other social problems.

Time for a new paradigm.

http://us.yhs4.search.yahoo.com/r/_ylt=A0oG7qPJTk1SNDYA6eoPxQt.;_ylu=X3oDMTBybnZlZnRlBHNlYwNzcgRwb3MDMQRjb2xvA2FjMgR2dGlkAw--/SIG=120uuti6c/EXP=1380826953/**http%3a//www.youtube.com/watch%3fv=VMJqIyW849s

http://us.yhs4.search.yahoo.com/r/_ylt=A0oG7qZjU01Sr1UAXq8PxQt.;_ylu=X3oDMTByZmU2MmgwBHNlYwNzcgRwb3MDOARjb2xvA2FjMgR2dGlkAw--/SIG=12d7t5hbm/EXP=1380828131/**http%3a//www.break.com/video/drunk-animals-in-nature-754682

This second one is a bit longer but try to watch it all the way through, it is worth it!

Not to belittle any one's perspective but found these two links funny.

Well, yes.
Birds get drunk on rotting berries around here.

Doesn't change my perspective, however. Substance abuse is a medical disorder -- saying that doesn't relieve anyone of responsibility in my mind; we are still supposed to be responsible for the consequences of our behavior.

It's just that turning to the criminal justice system instead of the medical system isn't doing anyone any good except for those who have a vested interested in that particular enterprise.

How do you know that it 'isn't doing any good?"

Great thread!

Narcotics is a problem for all of us, especially in primary care. That's because pain is a problem--not just physical pain.

I don't think putting addicts in jail is the answer, but legalization won't help either. A legal deterrent is needed. Treatment or medical solutions (methadone, suboxone, etc) can help to some extent, but doctors can't really fix what ails the addict. Look at all the money spent on drug/alcohol rehab. How much good does it do?

I have come to have tremendous respect for the benefits of 12 Step groups for helping addicts. It's not an answer for everyone, but when you've hit bottom, AA/NA/OA, etc can be life-saving and life-transforming.

John

We had a provider meeting this morning. I'm thinking this:

I'll talk to one of the pain specialists, and see if they would be willing to do a consult 4 times a year. I'm willing to write and monitor narcotics, just not make decisions on if and how much. I'll ask them to be hard nosed, and say "no" if they think narcotics are not the answer. Then they will not have their precious procedure schedule clogged, and I won't be left being manipulated. We will see if that works.

Pain docs that only want to do procedures are just needle jockeys. Their day is valued based on the number of procedures they do not pt. outcome. How do I know? I use to be one until I grew up and realized I was a physician that is supposed to take care of patients.
Nate

Wow, Nate. What I wouldn't give to have you in my town.

Well, I may have been somewhat hyperbolic, and stated as a fact an opinion which I can't support with peer-reviewed articles.

But the bottom line is that USA has more drug addicts per capita and more people in prison per capita than just about any other place on the planet, and we are still arguing about whether the criminal justice system is any good for dealing with drug abuse.

There is the whole separate issue of whether chronic narcotic administration is of any use in dealing with chronic non-malignant pain. I tend to believe it is, much like meds are useful to control, but never cure other chronic diseases -- but it is much harder for me to determine who benefits from chronic narcotics than it is to determine who benefits from chronic lisinopril or metformin.

It is hard to say how well the current legal system is working in regards to this. It is also hard to quantify how bad things would be with no legal controls. Most young people today do not seem to have the moral standards or inclination to say no to dangerous substances. I can only imagine how much dependence there would be if these were even more readily available. Legalization would certainly not stop people from exploiting others for their own profit.

Maybe I can help yall. Don't put narcotics In a separate category different than other medications that we prescribe for Our patient's. Medications we prescribed all have a goal with a desired measurable outcome. Beta blockers don't work for Everybody for blood pressure control, and you may switch to a calcium channel blocker because you're following serial blood pressure readings looking to see if your medication is getting to the desired blood pressure control measure. Is the medication getting you to the goal of blood pressure control? Are there any negative side effects from this medication? If so you will have to change drugs again.
Narcotics and analgesics are no different. However, their desired treatment endpoints take a little more effort to evaluate, BUT can be done. Is their daily function better? Are they more active? Are they loosing wt.? Are they missing less work or school? Are they compliant? Is their life better b/c of narcotics than not on narcotics? If the answer to alot of these questions is NO then DON'T PRESCRIBE NARCOTICS.
Don't let pts bully you to prescribe. If a guy comes in saying he wants a script for estrogen, you would tell him no after you stop laughing. Narcotics are no different.
Lastly, if your follow area pain docs are idiots, don't send them pts and keep on practicing good pt. care.
I gotta go see clinic and RX proper narcotics. Later.
Nate

Thanks Nate.
Somehow my world seems more complex that that -- Perhaps, it is just a problem of my own attitude

However, I see a qualitative difference with narcotics: You can't take your beta blocker and sell it for more than you (or your insurance company) paid for it.

Nate, I really appreciate your comments, but it seems more complex to me as well. Leaving aside the diversion issue, there is no objective way to gauge another person's discomfort or function, whereas I can measure a blood pressure or a sedimentation rate or range of motion. I can ask "How much more do you get done with the medicine than without?", and I'll get an answer "without it I hurt too much to do anything" about 100% of the time. Granted, a lot of the time it seems that the patient is mostly frightened that they will have some pain, when in fact they are so tolerant that they are just treading water. But the fear is also real.
In one of the pain management classes I took, they said that it should be considered a success to reduce pain by two units, say from a 6 to a 4. When I had an epidural for back issues done, the clinic gave me a pain questionnaire, starting with the level of pain. I had no idea if it was a 3 or a 9. I mean, compared to what? Having my skin peeled off with hot irons? No one had done that to me. Maybe it was only a 2 if compared to that. Maybe it was a 9 if compared with pain I had experienced previously. Then it finished with " What level of discomfort do you hope to achieve after this treatment?" Now, of course, I knew they expected me as a good patient to say a 2 or 3 level of reduction. But, what a stupid question. I hope for the pain to bleeding go away, all of it, forever. So, if a patient just were to come in and say that "the pain used to be a 9 and now is a 6, please give me my Percodan", all is right with the world? The more educated I get about this, the more confusing it becomes.
Today I got a prescription back from a mail-order pharmacy that I had written for 60 Vicodin saying I now had to write "take so and so many tablets every so and so many hours for not more than so and so many days, not to exceed X tablets in 24 hours." And, by the way, did I want to write for 360 tablets like his last prescription? Wow. I'm sure that is really going to solve the overdose issue.

Crystal clear, lucid moments of truth are few and far between, and not unlike listening to beautiful music, and universally recognizable, if we stop to listen.

The "chronic painer" I referenced earlier was such an encounter when he conveyed his beast within.

This extremely articulate, successful, highly intelligent gentleman was able to paint this beast in such a way during his recovery phase, it has given me great pause.

I think we all have this beast within, but most of us can keep it tempered. But the raging beast within such a gifted individual makes this area of chronic pain management extremely difficult and challenging.

Whether this beast is driven by financial gain and/or personal gratification, makes little difference, either way affects many lives negatively.

I think the best we can do is be cognizant of this beast within, and always remember this from the Hippocratic Oath "I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone."

David,
You bring up some interesting points. Assessment of pain and function are not easy compared to temperature, heart rate, or blood pressure. One objective measure I use is the patient's weight. The pain medication allows them to improve their daily function and activity and this should work towards being able to have some weight loss and conditioning.
Ask this,"How is the patient's life better on narcotics than not?"Feeling better just doesn't cut it. Example, 2 obese people are are sitting on a couch watching Opera, One has been prescribed narcotics and the other has not. What's the difference? Answer-One is taking narcotics and the other one and is not.
Maybe all the needle jockey's don't prescribe narcotics because it's too difficult.
The numeric pain score is unique to reach patient. I don't use it to compare 1 patient to another. Everybody's pain response depends on multiple variables such as age, race, sex, ethnicity,
family and social upbringing, and prior pain experiences.
Some patients present with pain complaints and on exam there are no abnormalities. That's why I also like getting plain old x-rays sometimes. When you see the railroad spike in their chest, you can understand why they might have some pain.Some endocrine and metabolic abnormalities can cause diffuse pain and boy are they hard to pick up.
Also if the pain seeking behaviors improved with treatment or disappear altogether, then you must be on the RIGHT track.
Again, treating pain is not easy.
Nate

Nate,

I appreciate you bringing up this topic for discussion, and respect your perspective.

One additional thought that keeps rattling around in my brain, and is a bit random and quite unrelated but has merit, I think.

I am not a hunter, but when my son showed interest, I took the 2 week hunter education course with him. One of the rules taught in the course is always be sure of your target and beyond.

If you apply this particular rule to the treatment of pain, hopefully, will reduce unintended consequences with the treatment plan.

Great point, Jimmie

When hunting, however, there is always time to get into "the zone"; where all factors can be weighed and a decision made. Pain management is more like combat. A patient arrives in the office, you have limited time, pressure to make a decision, and limited information. It is the essence of Von Clausewiz's "fog of war". And, as he also said, "the first casualty of any battle is the plan".

It is easy to criticize the decisions that are made in these conditions. It is quite another to be the one forced to make them.

David,

This is the essence of the topic at hand I needed to hear. Thanks.

Wow! Yall are DEEP.
Good points.

Nate