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State of Controlled Substance Prescribing

edited 01/29/2016 - 9:55 PM in Pain Medications
In the mid 00's I had a back issue. I tried PT, NSAIDS etc and after nothing worked I was given low dose opioids and muscle relaxers without any hassling of my Dr at all, in fact, I didn't even ask for them he just prescribed them matter-of-factly as the next course of action to my problem. After a year or so I stopped the meds after exercises helped the problem to the point of not needing meds anymore.

Fast forward to 2011 and I incurred a bad shoulder injury but this time Dr.'s were extremely reluctant to prescribe narcotics while I suffered for months.

It wasn't until I was in the ER for the 4th time that I finally got an adequate dosage with more than a few day supply(still a low dosage but I don't need much) . Still, over the course of care, for my condition and others, I was told by about 60% of Dr.'s (out of a large sample size I might add - I have multiple health problems) about how I should get off the pain meds because they weren't helping me, even though they were... Recently I just went to a pain clinic at a world renowned hospital and even there I was told I should get off pain meds because they were bad for me and don't work well when previously I read so much about how the clinic pride themselves on exploring every option available. Also, I've yet to be prescribed a controlled muscle relaxer when muscle spasms has constantly been my biggest pain issue. I have finally been diagnosed with a nerve condition that has been causing muscle wasting/atrophy/contracture/spasms and more in my shoulder for the past 4 years, yet Dr.'s avoided prescribing these meds for me even when I was in a completely disabled/bedridden state for months. This type of behavior denies important medicine to the chronic pain patient and facilitates an air of distrust between both the Dr and the patient - the Dr. not trusting the patient to use meds responsibly and the patient not trusting the Dr. to adequately treat their medical condition. Not only this but the avoidance of narcotic med prescribing has turned from 'I don't want to prescribe this b/c abuse potential' to 'I don't want to prescribe this b/c I believe it doesn't even work for chronic pain' maybe I'm missing something but where is the research that says it doesn't work for a significant portion of CP population?

The anti-narcotic agenda has no doubt come in response of painkillers widespread abuse and the public/gov't backlash to the epidemic. However, just because people abuse these drugs doesn't mean they don't work for Chronic Pain patients, one doesn't negate the other. It seems that we are going from a Dr. culture where these meds were once over-prescribed and now, with people overcompensating/over-reacting, we are in the early stages of a culture where they are being under-prescribed for chronic pain.

Instead of vehemently denying access to these meds, why can't we find the happy medium?

What are your thoughts on this? And proposed solutions to the problem? Have you found it harder to get a prescription for these type of meds now compared to some years ago?

Personally, I think, pain contracts work well, so why not implement something like a government standard pain contract across the country(USA)? So every Dr. that prescribes these meds to CP patients has a protocol to follow and gov't/people can feel better about controlling the issue. This way, Dr.'s that don't use contracts would be forced to use a system to weed out the abusers, Dr.'s that don't prescribe these meds at all can have a system where they can feel comfortable doing so, the government/people pressuring gov't feel satisfied they are curbing the issue and the responsible chronic pain patient can have access to vital meds. We should regulate the meds use not deny it altogether. It's a win-win-win-win.

Unfortunately, with the way things are going it seems that we will probably go further down the fearmongering path before things balance out, which is extremely unfortunate. Thankfully, I'm only on a couple Norco a day now and not completely dependent on pain meds anymore so I don't worry about this as much anymore but I still feel the need to stand up for those in chronic pain dealing with this issue.


  • Max_LeeMax_Lee New York, United StatesPosts: 88
    This under-treatment problem is something that I saw a lot of before moving back home (booted out of the military after getting injured in BCT). We would have massive (800mg/3x day) doses of ibuprofen thrown at us and told to suck it up! After they figured out what was actually wrong with me, they continued to treat it with high doses of NSAIDs and weak muscle relaxers (may as well have been taking M&Ms) and that was it. They still treated me like a liar, even though my MRI said otherwise. I spent the entire four months there in agony.

    Fast-forward to the other day, and new primary doctor is floored by the military records. He doesn't even consider any of them valid except the radiology reports, and insisted in seeing the actual images as well. He and my pain management doctor are now working together to try and fix my mess. I'm in my early 20s, and nobody has accused me of drug seeking yet (I hope it never happens), and both doctors are okay with narcotics if it has to come down to it. A couple pharmacists have looked at me funny when I pick up my meds (I'm on muscle relaxers, gabapentin, tylenol, and antidepressants thus far - my doctors are still figuring out what works - still may as well be taking M&Ms), but so far that's the worst I've seen in the civilian sector, and I live in an area near the Canadian/US border where heroin and other opioid abuse is a huge problem. New York also has some pretty tough laws surrounding narcotic prescriptions, which makes the heroin problem worse. So far I've gotten lucky, I've only run into one not so great doctor who thought I was on too much medication (really?) and denied that I had anything wrong with me. I ended up switching, and my PM told me I was very justified to do so.

    As far as change to the system, I do agree that some form of a contract would be a good idea. A change in the attitude towards narcotics is also in order. I do realize they can be quite dangerous if used incorrectly and hold a high potential for addiction, but they are very effective if used appropriately under a doctor's direction and monitoring. I do see it getting worse before it gets better, and those with chronic pain are going to suffer because of it and not have their pain appropriately managed; and that's not something I want to see. I believe that a medium does exist, we just have yet to find it.
    Kieran Lee
     "The loneliest people are the kindest. The saddest people smile the
    brightest. The most damaged people are the wisest. All because they do
    not wish to see anyone else suffer the way they do.''-Anonymous

  • Hey Max, I am in my 20's as well and it sucks dealing with issues like this so young, it definitely makes you feel jaded at times.

    I'm sorry you had to go through that. I was actually going to bring up Military/Vet Hospitals because a couple years ago they implemented guidelines that their Dr.'s should no longer prescribe opioids to patients after the 3 month mark of pain and there are organizations that are pressuring civilian medicine to follow suit and implement the same stringent guidelines. If that did ever happen, hopefully organizations like WHO and others would fight back for CP patients.

    I feel the same about the muscle relaxers and nerve meds I take at the moment - might as well be sugar pills. The norco I have does help but I can only take it a couple times a day otherwise they slow down my digestion(one of those .1% chance side effects of opioids, lucky me lol).
  • If these suggestions get approved every chronic pain patient who takes opiates medications at risk of losing them. The CDC in trying to selling these suggestions by saying that they will only apply to primary doctors and that they are only suggestions. However we know fear will make it as if it is law by not only primary care doctors but by pain clinic and surgeons. The one thing that is very upsetting is the thought that opiates should not be used longer then 3 months unless you have cancer or at the end of life. I guess you only deserve to get pain relief the last 6 months of your life. According to the CDC studies after that time they should be stopped since opiate medications are no longer effective in dealing with pain. Well how many people on just this site alone have been on opiate medication for more then 3 months ( if not years ) and know from their own chronic pain experience that this is just not true. There is no doubt that the CDC have forgotten to talk to the chronic pain patient on what is helping them and what is not. I have been on morphine for about 14 years. While my back has gotten so much worse I have not increased my dose. In fact in the past 6 month I have cut it down by a third. My pain is very well controlled. Of course I do other things like exercise, stretch, use heat and other medications but what gets me to be able to exercise is the opiate medication. My medication allows me to go to the grocery store, visit family, and to live on my own. My primary told me 2 months ago that she no longer wanted to prescribe opiate medications to her chronic pain patient because of these suggestions and they have not even been approved yet. So for 2 months I have been filling out pages of intake forms and making calls trying to find a pain clinic. The problem is that they do not want to take patient unless they can do expensive and without risk procudures. In fact it has gotten so bad that patient are afaird to say no to these procudures even though they do not work and cause them more pain because they are afraid they will be dropped and thus lose there pain medications. Another un-informed suggestion is that the chronic pain patient be limited to 50 mg - 100mg of morphine per day or equivalent no matter what ithe problem is. These decisions should be made by the doctor who is treating the patient and not by someone who has never meant the patient.
    If you suffer from chronic pain you need to check the CDC website and read what your future will be. If you are as angry as I am about this then you need to write your local, state representatives and tell them your concerns. Even if your Chronic pain is not so bad now that you do not need opiate medication (or need just a little) that can easily change down the road. We all should have the right to be treated for are pain and should have the right to get the best pain relief we have today. Until scientist find something different opiate medications is still the best and safest choice.
  • edited 01/30/2016 - 11:53 PM
    That is terrible to hear your Dr. failed to treat you... I looked into what you mentioned about the CDC. Here is a good article on what happened [edited to removed link,] the article is shown on post below this one #6

    Here are the actual guidelines that have been implemented (as of 1/25/16 - 6 days ago): http://www.cdc.gov/drugoverdose/pdf/common_elements_in_guidelines_for_prescribing_opioids-20160125-a.pdf

    And a statement on the published guidelines which reads,

    "We recognize that the Guidelines are just that. The Guidelines provide a foundation for practice, recognizing that doctors will need to adapt them to meet the individual needs of their patients. But the core message — that many patients can be treated with lower doses or alternative
    treatment methods, provides much-needed direction to doctors. It gives doctors the knowledge
    and confidence to prescribe opioids when appropriate, and to more safely manage patients on
    opioids. The Guidelines also recognize that opioids remain an important tool for responding to
    extreme or intractable pain."

    There is nothing all that scary in the guidelines if you read them. In fact, they are quite in line with what I proposed as a hypothetical solution to the opioid problem, except they are only guidelines and not law. However, despite this, you are right in that the CDC mentioned in conferences that there is no substantial evidence of benefit in prescribing opioids to CP patients after 3 months. And many Dr.'s are buying into these statements. Being afraid of the abuse potential is one thing but to wholly negate the medicinal value of these meds seems like a huge over-reaction to this problem and simply ignorant.

    We need Dr.'s/pharma companies, at this point, to do 6mo-1 year+ studies with opioids to prove these people wrong, why isn't such a study in the works?
  • LizLiz Posts: 7,832
    edited 01/31/2016 - 7:45 PM
    Here the article without the link, the link is not permitted on the forum Liz, Spine-health Moderator

    ORLANDO, Fla. —Controversial guidelines that advise doctors to stop prescribing certain pain medications are continuing to raise questions from medical professionals and patients.

    CDC guidelines for prescribing opiates

    The Centers for Disease Control and Prevention is evaluating its recommendations to doctors to avoid using opioid drugs to treat chronic pain, but they could easily become a reality.

    The CDC said the new guidelines would reduce the amount of opioid drugs in circulation and heard testimony today from those who have lost loved ones to overdose and addiction.

    But people who use the drugs legitimately to ease pain said the guidelines will prevent them from getting the medicines they need to simply function.

    Dr. Julie Fernandez has been treating patients in Central Florida for more than 15 years and has seen firsthand the benefits of the powerful pain medications. She said they are helpful to those with long-term chronic pain.

    But the CDC isn't so sure. Earlier in January, the director of the CDC said the benefits of opioids for treating chronic pain are "unproven and uncertain."

    The statement angered many pain patients and confused others.

    "I can't say that it's unproven, because, obviously, I see the outcome of the relief of the pain," Fernandez said.

    Fernandez said she's seen patients benefit from medication when other forms of treatment, such as injections and surgery, didn't work.

    In a conference call Thursday, officials with the CDC said again that there is insufficient evidence that opioids are effective in treating chronic pain.

    Those who suffer from chronic pain and are prescribed opioids for treatment disagreed.

    "If it comes to a point where they take away my pain meds, I won't be here no more. I will be one of the suicides," patient Diane Gracely said.

    The CDC has drafted 12 guidelines that encourage doctors to prescribe less pain medication, citing a nationwide overdose and abuse epidemic.

    Fernandez said she supports the guidelines, and so do 36 attorneys general, including Pam Bondi.

    In a letter to the CDC, Bondi said, "To reduce these deaths, we must provide clear guidance for prescribers to assess the appropriate balance between the potential harms and benefits of opioid use."

    Bondi said she believes the guidelines will actually improve access to pain medications for those who need it.
    By Matt Grant

    Liz, Spine-health Moderator

    Spinal stenosis since 1995
    Lumber decompression surgery S1 L5-L3[1996]
    Cervical stenosis, so far avoided surgery
  • itsautonomicitsautonomic LouisianaPosts: 1,806
    The undertreatment and under diagnosed chronic pain conditions are an epidemic currently and I will say that until I die with no hesitation. Many many people who need pain medication are not getting the help needed. I fully agree it's all part of the blend , but I think if you take pain medication from people who need it and their ability to maintain the blend crumbles.
    Do your due dilegence, trust you know your body and question everything if it does not fit. Advocate for yourself and you will be suprised what will be revealed trusting your body and instinct.
  • itsautonomicitsautonomic LouisianaPosts: 1,806
    edited 01/31/2016 - 8:16 AM
    As quoted by one of the best PM in country for his stance:

    We have a long-standing standard knowns the World Health Organization 3 Step Analgesic Ladder which was developed in 1982. Only when non-opioid treatments fail are opioids used because about everyone knows they have complications.
    There cannot be a cap on dosages as patients vary. The government should certify and recognize the MDs who will prescribe high dose opioids so patients who need high dosages can get the help they need.
    Patients who are currently on opioids and doing well should be left on them.

    Do your due dilegence, trust you know your body and question everything if it does not fit. Advocate for yourself and you will be suprised what will be revealed trusting your body and instinct.
  • itsautonomicitsautonomic LouisianaPosts: 1,806
    If you think normal pain management is tough their is a smaller subset that has it worse than the majority, this is some writing on the subject where the PM I quoted above, who is also editor for largest PM publication, talks about treating the outliers:

    There are some forms of pain—just as there are forms of conditions such as hypertension, diabetes, and schizophrenia—that are appropriately called malignant or catastrophic.6 These are the outliers from the norm. Patients with these tragic conditions, just as some pain patients, cannot survive and function without competent, caring help, and high dosages of medication. If left untreated, severe centralized intractable pain not only causes a total bed-bound suffering state, but may contribute to early death. The mechanisms of death in severe pain patients are known to include cardiac arrhythmia, malnutrition, adrenal failure, and sepsis.7 Sometimes pain patients are found dead in bed or on the toilet and are falsely diagnosed as an overdose death.

    Unfortunately, patients who require ultra-high dose opioid therapy often have seen too many practitioners who have attempted too many treatments that have failed to help. Practitioners often are afraid of ultra-high dose opioid therapy, so they try all kinds of treatments that may be detrimental and brutal to the patient. For example, I have been referred patients with spine conditions who have received between 25 and 50 interventional corticoid procedures of which none provided more than a few hours or days of relief. Multiple spinal surgeries are sometimes attempted because practitioners don’t want to embark on ultra-high dose opioid therapy. A review of my last 15 referrals in preparation for this paper revealed that the number of prescription medicines taken by each patient ranged from 6 to 15. Polypharmacy is not a substitute for directed opioid therapy. A delay of ultra-high dose opioid therapy may result in a patient’s pain becoming uncontrolled, resulting in detrimental immunologic, hormonal, and neurologic damage.6

    Each community, therefore, needs a subspecialist or a referral and evaluation mechanism to get these patients the help they need. For example, a primary care physician or interventionalist pain practitioner may wish to help follow an ultra-high dose opioid patient if there is a physician they can consult with who is familiar with ultra-high dose opioid care. The important point is not to ignore these patients just because they are complicated and need extraordinary long-term treatment.

    Long-term Care And Monitoring
    It is doubtful that ultra-high dose opioid patients can ever be opioid-free, unless cures are found for centralized pain. They can, however, develop a quality of life and function quite well. These patients will need to be seen and monitored regularly to determine that opioids are not impairing their quality of life. Simple tests to measure blood pressure, pulse rate, and observation of ambulation and alertness usually are sufficient at each visit. Too high of an opioid dosage lowers blood pressure and pulse rate and too low of a dose allows pain to raise the blood pressure and pulse rate.7

    Families must be aware of treatment goals and expectations. Many of these patients have shortened life spans. Patients will also need to be in a health care network that includes other health care providers, such as a primary care or specialist physician. It is quite helpful to have a psychologist, social worker, or minister counsel these patients to help them accept their “fate” and to develop skills to enable them to live a happy and fulfilling life.
    I find that opioid dosages can almost always be reduced once a patient is stabilized, has good pain control, and has achieved homeostasis of adrenal-gonadal hormones. Abrupt discontinuation, rotation, or forced reduction in opioid dosage will almost always result in failure in that the patient will resort to benzodiazepines, carisoprodol, antidepressants, and even street drugs to compensate. Hence, the risk of overdose goes up. Opioid reduction, in my experience, is almost universal when it is done slowly and progressively with a treatment plan that patient, family, and practitioner agree to. Urine testing will need to be done periodically to ensure compliance with a high-dose regimen as well as eliminate any use of abusable drugs.

    Do your due dilegence, trust you know your body and question everything if it does not fit. Advocate for yourself and you will be suprised what will be revealed trusting your body and instinct.
  • itsautonomic said:
    The undertreatment and under diagnosed chronic pain conditions are an epidemic currently and I will say that until I die with no hesitation. Many many people who need pain medication are not getting the help needed. I fully agree it's all part of the blend , but I think if you take pain medication from people who need it and their ability to maintain the blend crumbles.
    I could not agree more with what you have said in all your posts.
  • itsautonomicitsautonomic LouisianaPosts: 1,806
    JAMM661, When a director of one of the most prestigious medical places ( it's being echo'd across the large teaching hospitals) says they can't measure it so they can't truly understand it, I don't see how anyone could argue otherwise that people are suffering from untreated pain............

    It’s a national disaster,” said Dr. X director of pain management at Harvard
    ( children/adults)

    Dr. X is recognized as a leader in the fight to understand the origins of pain to find better treatment.

    “Chronic pain is a complex experience that integrates emotional and sensory experience and demands multiple treatments, but right now we still don’t have an objective way to measure it and because we can’t measure it, we don’t understand it,” he said.

    Do your due dilegence, trust you know your body and question everything if it does not fit. Advocate for yourself and you will be suprised what will be revealed trusting your body and instinct.
  • itsautonomicitsautonomic LouisianaPosts: 1,806
    In any industry to truly improve the process you have to be able to measure it, if you used a 1-10 scale for how your process is doing in manufacturing you would go bankrupt . You could make some improvements , but true improvement is based off measured, recorded, precise , undeniable data. When your key performance indicator or how you are doing for a patient is a 1-10 ranking with smily faces to sad faces and faulty in nature due to human nature and interpretation , you will never be an efficient , truly improved , fully functioning practice helping people. Right now it's a do the best we can with limited resources , limited med school training, limited ability and limited freedom to treat in the pain management world.
    Do your due dilegence, trust you know your body and question everything if it does not fit. Advocate for yourself and you will be suprised what will be revealed trusting your body and instinct.
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