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Post by doctork on Jan 19, 2018 1:16:36 GMT -5
I am feeling bombarded and the subject seems to be all over the mainstream media as well as the medical literature, 24/7/365. It is now a crime in North Carolina for a primary care physician to prescribe more than 3 days of an opiate; for a surgeon, no more than 7 days. "I think this thing's gone a little too far..."
Meanwhile, pain is considered the "fifth vital sign" and if we are not treating it, we are not taking proper care of our patients. Various entities are surveying "patient satisfaction scores" and doctors' pay is reduced if their patients are not happy with the care - how do you think the drug seekers rate the physician who will not prescribe them some Percocet?
This week our clinic received a new policy from the tribal board of directors that primary care providers may not prescribe more than 4 benzodiazepine pills (like Xanax or Valium) for a patient, and only (obviously) for a short-term use such as fear of flying, or claustrophobia with MRI. If they need more they must go to "Behavioral Health" where a Nurse Practitioner (RN with online masters program, experience not necessarily required) may prescribe as much as they wish. We happen to have good psych NP's that I trust, but that is not always the case.
Frankly, I'd rather not prescribe a lot of opiates and benzos, and do so minimally, and I do not at all care for drug-seeking patients, but it seems there are a few too many (non-physician) chiefs telling the (Board-certified and re-certified physicians, endlessly monitored) Indians what to do.
Do you folks in the "general public" have opinions about this?
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Post by liriodendron on Jan 19, 2018 6:26:59 GMT -5
I thought they sent me home with too many oxycodone after my hip surgery. Could I have been given close to 60? Whatever it was, I took three of them and moved on to Extra-Strength Tylenol and took the rest to the police station (they have a box there to dispose of medications). Then, after my gallbladder surgery, I got a bottle of 20 Percocet. Didn't take any of them, only took Extra-Strength Tylenol, so that entire bottle got taken to the police station, as well. However, I suppose I am happy to have had the option to use them in both cases, had my pain been unbearable. Still, wouldn't it have been better to have given me fewer after the hip surgery and made me ask the doctor for more?
If I could become addicted to Coke Zero (which I stopped drinking nearly two years ago), I could probably become addicted to prescription drugs. I'm sure they serve a purpose, but they shouldn't be too easy to get.
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Post by doctork on Jan 19, 2018 20:57:10 GMT -5
My doc gave me 80 tablets after the knee replacement, but then knees hurt more than hips, and I needed them. I didn't need pain meds after my gallbladder surgery either.
I think you did the right thing - take only what you really need, dispose of the rest properly. One reason I wouldn't disagree with dispensing 60 tabs to a reliable patient like you is - Percocet is Schedule II. It cannot be called in, and you or someone must come to the office and pick up the paper Rx (with at least 4 anti-tamper measures in the rx paper) and take it to the pharmacy. Honest patients don't know this since they aren't regular users/abusers, but there is not a thing your doc can do if you run out overnight, on a weekend or on a holiday. No "on-call doc" in his/her right mind would write that script to someone they don't know and see in person to evaluate the pain and need for Rx.
Better to rx the max you might need, then discuss you do NOT have to take 2 tablets every 4 hours until they are gone, just what you need when you hurt. Otherwise, the "good patients" run out on Friday night and either suffer until Monday or go to the ER - hard to tell which is worse!
However, these meds are no longer easy to get, so people are switching to heroin, often laced with fentanyl or some other "nyl" that is an elephant tranquilizer. We are now seeing lots more heroin OD deaths. It simply is not possible to treat patients until they have no pain, and have no abuse either. But we as a society have become unwilling to tolerate even a little pain.
But I also do not care for non-qualified individuals deciding that I cannot give my anxious patients 6 or 8 Xanax, not just 4 pills, when I am familiar with the patient and the long trip planned, and I know they need more than 4.
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Post by Jane on Jan 20, 2018 9:42:42 GMT -5
I have had two experiences with opioids, and I have been scared straight. The first time I took them was when I had knee surgery; I took them for about four days, and, when I stopped, was quite depressed for about a week. I didn't make the connection. The second time I took them was when I broke my leg and was misdiagnosed, and, after a time, the pain was really bad. I took them for probably two weeks, and when I stopped, plummeted into a just-short-of-suicidal depression. I am no stranger to depression, but this bout was the worst ever. I didn't have any idea that this was actually withdrawal from the medication until I heard this same response from other people. I will never, never take them again unless I am dying and can take them until I literally kick off.
If I end up having to have a knee replacement at some point, I don't know what I'm going to do.
I notice in the local paper a lot of very young deaths. My daughter has a good friend whose brother just died of long-term opioid addiction, and, of course, my son-in-law sees lots of drug seekers in the ER. He is a firm believer in "suck-it-up", but intractable pain is certainly an issue for many people.
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Post by BoatBabe on Jan 20, 2018 14:28:12 GMT -5
My Dahhlink was prescribed 240 tabs of oxycodone when he had 5-1/2 laminectomies. He took about 10 tabs over the first week of recovery. He didn't like how they made him feel. The pills didn't really get rid of his pain, which was quite severe, they just made it so he didn't care so much about the pain. Drooling and sleeping was not his idea of a good life. He couldn't read because he couldn't remember what he had read. He couldn't watch TV. He transitioned to Tylenol (which actually decreased the amount of pain he felt,) and he was back to work in 10 days.
At the hospital, the doctor had written the script, it was filled, and the bottle of 240 tabs was given to My Dahhlink with his discharge packets and papers. It's not like he had a choice. His insurance company paid the majority. He teased that the street price of $50.00/tab would easily bankroll our next cruise . . . (not that we would have a CLUE how to approach that market without risking life and limb!) Basically, the drug company got their money, and we will keep the medication until it expires (just in case we need it over some weekend,) before we take it to the drugstore for disposal.
Doc makes seriously valid points: "But I also do not care for non-qualified individuals deciding that I cannot give my anxious patients 6 or 8 Xanax, not just 4 pills, when I am familiar with the patient and the long trip planned, and I know they need more than 4."
Mom had the same situation her entire professional teaching life, only her non-qualified ruling body was the elected "School Board." In small towns, the same genre of folks ran for office and were elected: the banker, the pharmacist, the grocery store owner, the lumber mill owner, the restaurant owner, etc. Those were folks overseeing education, who knew nothing about education. If she had a strong principal, the teachers did okay. If the principal was part of the school board's social circle, it didn't usually go well for the teachers. That's when Mom bought her own classroom's paper supplies, construction paper, glue, and remember those manila-colored sheets of lined paper that we were given to learn to print and write? Solid lines on the top and bottom, and a dotted line down the center. Mom bought those for her school kids, too. One school board tried to dictate to Mom which children would be in which of her reading circles, as clearly the "Antelopes" were the best readers, compared to the "Badgers" or "Cougars," completely oblivious to the needs of the children. That matters. Mom described those kinds of people as "Small people with a little bit of power."
But every once in a while, someone was elected to the school board who listened to the needs of the teachers. This only worked well if the principal was pro-teacher also. Those were the Best-of-the-Best Times.
We are so far away from those times. I don't believe we will be so lucky as to see them again. Now, the rate of speed in which one can become suspect, be accused, and ostensibly convicted, with viable penalties, by people who have no industry education nor standard, is lightning-fast.
Mom ended up taking an early retirement, as she had been accused of "physical abuse" ("sexual abuse" wasn't a popular accusation in the late 1980s) for touching the shoulder of her seated student as she stood behind him. Mom was an educator who wandered around her class room as she taught, checking how each student was comprehending the lesson, and helping where help was needed. Knowing the story, I'll bet Mom squeezed this boy's shoulder, too. In our family it meant, "Yup. I saw that. You know better, and you better quit it. Right Now."
You've never seen the amount of "Thank You, Teacher" stories as we have seen for Mom, since Mom died.
I'll be interested to see where this story goes, Doc, this time . . .
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Post by doctork on Jan 21, 2018 2:08:57 GMT -5
You're right BoatBabe, teachers get driven out for an encouraging pat on the shoulder, a kindergardener is banned for a week because s/he drew a picture of a gun, every man in America is probably harassing his co-workers, everything is "Zero tolerance." Everything must be a disaster, perhaps to fill the 24 hour news cycle.
You're right too Jane, that there are excess youth deaths (and all ages really - see yesterday's story about Tom Petty) from drug overdoses.
Opiates and benzos are dangerous drugs, and in our nation as a whole we consume too much of them. But none of the overdose deaths are due to the medications being used as directed, by the person for whom they were prescribed (except a rare individual with anaphylaxis). And any medication that is strong enough to work is also strong enough to have side effects. Patients who have allergy, unpleasant side effects or have a history of addiction shouldn't take that medication. I have many more patients who decline to take pain meds (for, say, rib or clavicle fractures - which can really hurt) due to unwanted side effects than I have patients who request them chronically
Most people do not have serious side effects or experience addiction/withdrawal from opiates, and just use them briefly for acute pain, but you would never realize that from the headlines. The related stories often briefly mention there should be better insurance coverage for alternative pain treatment and more treatment facilities, but somehow that never happens.
As is often the case, 100% of the population is being punished for a problem of a small percentage (1%? 5%?) who have/create a problem. Many primary care docs have decided they won't prescribe any controlled substances, as it is too risky politically, so a patient with flight anxiety or broken ribs has to go to the ER for a prescription.
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Post by doctork on Jan 24, 2018 0:12:17 GMT -5
I was just reading one of my doctor blogs.
One can buy Xanax over the counter in Peru for 50 cents a pill, no prescription needed.
OTOH, Lomotil, a common treatment for travelers' diarrhea, is illegal in Dubai because it contains an infinitesimally small quantity of an opiate. UAE is not overly inclined to given tourists and international business travelers a hard time, but if they choose to, the punishments can be quite draconian. Guess I was taking a big chance when I took Lomotil to Afghanistan with me "just in case." Both times I traveled to Kabul through Dubai. Woulds been safer through Karachi, huh?
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Post by Jane on Feb 3, 2018 22:48:09 GMT -5
I just found out that my doctor son-in-law's brother was just told to get out by his wife. He has apparently become addicted to opioids after being prescribed them after a back injury. He has also started drinking heavily. He and his wife have three young children. He has always been a bit of a n'er-do-well, but this is a surprise to all of us. They live in Alabama, where his parents winter. He is now living with them, and I don't know if he is getting any help or trying to kick it on his own. Scott's mother has severe dementia, so his father is coping with all of this (plus caring for his wife full time) all on his own. Family tragedies galore.
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Post by doctork on Feb 4, 2018 16:48:07 GMT -5
Jane, I am sorry that your family is going through this.
Back pain is a tough one - I know that there are some people who have serious back pain that can respond to opiates, and that often surgery is a failure at relieving it, and that current literature says opiates are not usually helpful for back pain. A lot of contradiction.
I see a lot of patients who use "back pain" as the reason they are unable to work and must go on disability; many of those people are just lazy, some prefer unemployment & drug addiction to working for a living, but some are truly unable to work. I'd hate to see "ne'er-do-wells" preventing adequate pain control for those who need it.
Tough spot, as I said. I do not know the right solution. Tobacco and alcohol cost more in health costs and lives lost, but they do not require a prescription.
There is a substantial genetic component to addiction, and new research indicates linkage amongst the various addictions - alcohol, tobacco, opiates, benzos, cocaine, gambling and probably other addictions. I have wondered if the Darwinian solution is to let these addicts die and eliminate the genetic susceptibility. Maybe that is what is happening.
It all feels very political right now, not 100% clinically driven. Unfortunately we are seeing a lot more heroin OD deaths because prescription opiates are harder and more expensive to obtain, given the "crackdown." Drug dealers are tainting their product with fentanyl (100 X more powerful than oxycodone) and carfentanyl (elephant tranquilizer - even worse), resulting in more OD deaths.
BTW, not everyone who takes a drink or a Vicodin is an addict; some definitions I was taught:
Addiction - a disease in which a person will lie, cheat or steal to obtain the drug, and it damages their work, relationships and health. Most people who use alcohol or opiates do not become addicted, but the addicts often got their initial start legally.
Tolerance - a person needs higher and higher doses of the same substance in order to obtain the desired effect (be it pain relief or intoxication). These people will request increasing amounts of the substance. Some research suggests this reaches a stable point at some point, others say the "need" will perpetually increase.
Habituation - a person begins to need the substance in order to feel normal, and feels worse without it than they did before the whole episode began. But they will not commit a crime to obtain the substance, they stop and hopefully get back to normal.
Pseudo-addiction - a person needs higher and higher doses to control their pain, but that is because their pain is not yet adequately treated (think worsening cancer).
It's a lot easier to just say to a patient "Our policy does not allow prescription of controlled substances."
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Post by BoatBabe on Feb 4, 2018 18:57:55 GMT -5
Dang. Sorry to hear this bad news, Jane. I am astonished these days that I survived 2 years of being bed-ridden after a trucking accident. Back injuries can be painfully severe, and misdiagnosed. There is no evidence of pain (like an amputated leg, which I wished I had many times) and lots of folks, including doctors, therapists, and Labor & Industries will tell you that you are faking it. Once you've lost muscle, it is extremely difficult to come back, and a long road. Fortunately for me, my allergies didn't allow addiction to drugs because I couldn't take them. Unfortunately for me, there was no relief from the constant pain, and it was a down-hill physical spiral into a skeletal existence.
Here's hoping that the underlying problems can be corrected and a path toward physical rehabilitation can be found for the doctor's brother. We all deserve a way back.
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Post by doctork on Feb 4, 2018 22:39:10 GMT -5
You are right BoatBabe, the big problem with back pain is that, unlike blindness or an amputation or cancer, there is not necessarily any evidence on a lab test or an X-ray that something is wrong. So the conclusion is you must be faking it.
I am glad you are better now.
Jane, I hope your family member recovers. It must be especially difficult with young children at home.
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