View Full Version : hydrocodone combination pills now to be Schedule II medications.
http://www.rxeconsult.com/healthcare-articles/Impact-of-Switching-Vicodin-Norco-Lortab-to-Schedule-II-270/
I just got an email. Starting October 6th, hydrocodone/aceatminophen deriviatives (Norco, Lortab, Vicodin) will become a schedule II from a schedule III mediations. The same class as oral morphine and hydromorphone. Which means they need a triplicate scripts.
Anyone bet that Tylenol #3 is going to be the new drug to kill a bunch of people?
You lost me. Abuse of Rx drugs is already a huge problem so what is new?
Most physicans I know who arent pain docs or oncologist don't routinely Rx schedule II medications.
At my place of employment, some insurance will no longer cover certain CII medications and have even dropped certain ones from formulary. These are some some of the scheduled drugs that I work with on a day-to-day basis:
http://i987.photobucket.com/albums/ae360/chc_hmc/KawecoACSportCIIs_zpsf9eb50cb.jpg
http://i987.photobucket.com/albums/ae360/chc_hmc/Cii_zps50d242bb.jpg
Well, I have my own opinions on the prescribing and [long-term] use of these drugs that I'll keep to myself (as in I'll shut up!)
TriviaMonster
08-26-14, 10:45
Methadone is the devil. What a colossal win for big pharma. Opioid dependant? Well try this other one instead! And its even harder to kick than heroine.
montanadave
08-26-14, 10:49
Methadone is the devil. What a colossal win for big pharma. Opioid dependant? Well try this other one instead! And its even harder to kick than heroine.
While methadone as a treatment for heroin addiction may be problematic, I have seen it effectively used for long-term management of chronic pain.
I ran a report on our most common Rx.. Number 1 is HC. We are currently selecting a vendor for the dual authentication so it can go e-Rx... What a pain for the docs.
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I routinely prescribe oxycodone for post-op pain control, rarely prescribe hydrocodone. Moving hydrocodone to Schedule II doesn't affect me at all except for the fact that I can no longer call in a prescription for it over the phone.
Schedule II and Schedule III drugs can be ordered through our e-prescribing system, but that program still requires that the script be printed out rather than sent electronically, even for Schedule III.
I don't even know what "triplicate scripts" are.
I routinely prescribe oxycodone for post-op pain control, rarely prescribe hydrocodone. Moving hydrocodone to Schedule II doesn't affect me at all except for the fact that I can no longer call in a prescription for it over the phone.
Schedule II and Schedule III drugs can be ordered through our e-prescribing system, but that program still requires that the script be printed out rather than sent electronically, even for Schedule III.
I don't even know what "triplicate scripts" are.
Isn't oxycodone stronger than hydrocodone?
My wife was prescribed hydro after her knee surgery last month.
Nothing like government to punish the many for the acts of a few.
Isn't oxycodone stronger than hydrocodone?
Yup.
Oxycodone has been Schedule II from the beginning, IIRC.
This is the kind of stupid shit that happens when the government tries to practice medicine. Politics and bureaucratic incompetence make for bad medicine.
This is the kind of stupid shit that happens when the government tries to practice medicine. Politics and bureaucratic incompetence make for bad medicine.
Why is this so hard for Voters to see. :(
Anyone with a problem like degenerative disc (me, due to repetitive injury) or a plethora of other disorders or diseases has been prescribed these drugs. It sucks. Pain is relative to the person who is afflicted by it.
If they choose to abuse it, than you should recieve the consequences. Life is hard enough without the douche bags messing everything up and selling, overdosing, and otherwise not taking the meds like your supposed to. Then the .gov is going to take care of it for you. And that always ends well, doesn't it?
Most physicans I know who arent pain docs or oncologist don't routinely Rx schedule II medications.
I don't agree. Surgeons often prescribe Schedule II narcotics for post-op pain control...usually oxycodone or oxycodone/acetominiphen (Percocet). Different surgeons usually have different post-op pain regimens and medication preferences and while many do use hydrocodone, many do not. Personally, I find that hydrocodone is less often effective than oxycodone. The trend these days is to limit the daily dose of acetominophen because of concerns about the potential for liver damage, so there is often less prescribing of Percocet or Vicodin, for example.
A few years ago I underwent a bilateral knee replacement. The surgeon sent me home with a prescription for 60 oxycodone tablets. I probably took about 5. I'm sure I still have 55 oxycodone tabs sitting around home somewhere. I found them effective at controlling pain and they didn't make me particularly goofy. That experience has modified my prescribing tendencies.
A friend of mine is a Hospice Care (those who are gonna die) nurse, and they use pain meds prodigiously (because the patient is dying). She says that hydro is hugely popular on the street about $2/pill. She's a big fan of marijuana (I'm not) as she believes it does a better job of relieving pain, stimulates the appetite, and for those dying it provides a modicum of comfort, with less side-effects.
As a back surgery and kidney stone 'survivor', hydro didn't do squat for me, but oxyx did. And yes, I kept what I didn't use, because when a stone is moving and the Dr is closed, it's that or the ER...
Marijuana is THE kryptonite for big Pharma. It's only a matter of time now til we see huge advancements in medical marijuana.
I've known a number of people that have had their lives completely ruined by Doctors, and opiate pain prescription medications.
Long term pain management on these types of drugs is an absolute joke. I'm all for huge restrictions on these types of medications.
wildcard600
08-26-14, 19:12
Marijuana is THE kryptonite for big Pharma. It's only a matter of time now til we see huge advancements in medical marijuana.
I've known a number of people that have had their lives completely ruined by Doctors, and opiate pain prescription medications.
Long term pain management on these types of drugs is an absolute joke. I'm all for huge restrictions on these types of medications.
marijuana should be legal period. it it were never illegal in the first place alot of the problems this country currently experiances porbably wouldnt exist.
Completely agree. It would be amazing to see how many fewer alcohol, and prescription drug related deaths would occur each year if marijuana was either completely legalized or at least available for medical purposes in all 50 states.
Just today a major study was released regarding this very topic....
"America has a major problem with prescription pain medications like Vicodin and OxyContin. Overdose deaths from these pharmaceutical opioids have approximately tripled since 1991, and every day 46 people die of such overdoses in the United States.
However, in the 13 states that passed laws allowing for the use of medical marijuana between 1999 and 2010, 25 percent fewer people die from opioid overdoses annually."
http://www.newsweek.com/states-medical-marijuana-painkiller-deaths-drop-25-266577
http://www.m.webmd.com/a-to-z-guides/news/20140825/fewer-painkiller-deaths-in-states-with-medical-marijuana-study
Yup.
Oxycodone has been Schedule II from the beginning, IIRC.
This is the kind of stupid shit that happens when the government tries to practice medicine. Politics and bureaucratic incompetence make for bad medicine.
I'm not so sure that this is a bad idea. Like you, I agree that hydrocodone is a rather crappy analgesic when you consider the rather high rate of GI side effects compared to oxycodone. However, the purpose of this move is to begin to breakdown the practice of primary care providers prescribing hydrocodone preparations over long periods of time with minimal oversight. I'm sure that you too see your fair share of patients whose PCP provides them with 120 tablets of hydrocodone every month (usually combined with 90 tablets of Xanax). This is piss poor medicine, a major source of public morbidity/mortality, and an example of the medical community failing to police itself.
Bottom line, this ruling will have no impact on our practice of providing appropriate short term analgesia to our patients with acute pain. It is however a good first step in reigning-in PCP's who think that they know how to manage chronic pain with the long-term use of short acting opiates. It will also help control diversion techniques such as calling in false prescriptions.
I'm not so sure that this is a bad idea. Like you, I agree that hydrocodone is a rather crappy analgesic when you consider the rather high rate of GI side effects compared to oxycodone. However, the purpose of this move is to begin to breakdown the practice of primary care providers prescribing hydrocodone preparations over long periods of time with minimal oversight. I'm sure that you too see your fair share of patients whose PCP provides them with 120 tablets of hydrocodone every month (usually combined with 90 tablets of Xanax). This is piss poor medicine, a major source of public morbidity/mortality, and an example of the medical community failing to police itself.
Bottom line, this ruling will have no impact on our practice of providing appropriate short term analgesia to our patients with acute pain. It is however a good first step in reigning-in PCP's who think that they know how to manage chronic pain with the long-term use of short acting opiates. It will also help control diversion techniques such as calling in false prescriptions.
I don't disagree with your points above, although this state has a very robust narcotics "oversight" program and has for years. At least a few of my primary care colleagues have been called down to appear before the Board of Medical Practice over the last several years to explain just such prescribing practices and then be sentenced to some form of rather onerous remedial action. Of course, the pendulum has since swung the other way, and I find that adequate pain control is more likely to be underprescribed these days, even for acute pain...but chronic bulk Vicodin giveaways are quite rare. So we have that going for us, which is nice.
Anyway, my quarrel is with the government, state or Federal, involving itself in the practice of medicine. One only needs to look at the Veterans Administration to see how well that works. From a practical standpoint moving hydrocodone to Schedule II will have virtually zero impact on my practice and very probably the practice of my colleagues.
Completely agree. It would be amazing to see how many fewer alcohol, and prescription drug related deaths would occur each year if marijuana was either completely legalized or at least available for medical purposes in all 50 states
Or people could quit abusing drugs and take responsibility for their actions. I know; how absurd.
In a liberal society, people either have the choice of what they put in their bodies or not. Opiates, marijuana, McDonalds, alcohol, tobacco, steroids, soda, etc.
You can't have ideological purity by recommending the legalization of marijuana and then agreeing with further restrictions on some drug used by depressed middle aged housewives.
Anyway, my quarrel is with the government, state or Federal, involving itself in the practice of medicine. One only needs to look at the Veterans Administration to see how well that works. From a practical standpoint moving hydrocodone to Schedule II will have virtually zero impact on my practice and very probably the practice of my colleagues.
I agree that the government should not provide medical care as illustrate by the experience with the VA, active duty medical centers, Indian Health Service, et al. However, .gov absolutely has a role in providing oversight - to a point. Regulating controlled substances is well within the prevue of the state, and to a lesser extent, federal government. After all, we are in the center of this epidemic, and it is our failure to regulate our ranks that has brought this unwanted attention.
For those wanting an excellent summary of where we are and how we got here, read this:
http://www.newyorker.com/business/currency/who-is-responsible-for-the-pain-pill-epidemic.
The fact that Russell Portenoy still has a license to practice is a sad commentary on the integrity of our profession.
Interesting. As a patient, I don't see the attraction.... as a surgeon I'm pretty much out of that prescribing loop. I don't know any Russel Portenoys, even among the relatively few "pain clinics" in this state. The nearest one to me is 90 miles away. I do see some patients who are on "pain contracts" with their primary care doctor, and I do get notifications from pharmacies about occasional patients who are gaming the system with multiple narcotic prescriptions from multiple doctors and ERs.
Interesting. As a patient, I don't see the attraction.... as a surgeon I'm pretty much out of that prescribing loop. I don't know any Russel Portenoys, even among the relatively few "pain clinics" in this state. The nearest one to me is 90 miles away. I do see some patients who are on "pain contracts" with their primary care doctor, and I do get notifications from pharmacies about occasional patients who are gaming the system with multiple narcotic prescriptions from multiple doctors and ERs.
There is a fair amount of population bias on both of our perspectives; patients frequently go to the emergency department for complications of their opiate/benzo dependence and rarely go to a surgeon's clinic. Thus, I tend to magnify the extent of the problem while you may minimize it.
What I can say is that about 15-20% of our ED volume is somehow tied to these medications. Some patients have acute exacerbations of chronic pain. Others might have accidentally overdosed. Lots are admitted to our trauma service due to injuries sustained while intoxicated with ETOH plus pills. Many come to us because their pain/anxiety meds are interacting with other medications or exacerbating other illnesses. A large number are psychiatric patients who have substance-induced mood disorders from these meds. The lists go on and on and I don't think that very many of us who are left picking up the pieces will say that the pill problem is being overstated.
Sensei, you come across Tripp Winslow yet??
Back to thread. Perc does not do squat for me except turn my poop into petrified stones. Roxi works, but honestly I prefer ibuprofen. I am only in the ED episodically, but when I worked there full-time I imagine 1 in 6 were on narcs of some sort, and of those 6, 2 or 3 had issues with them.
There is a fair amount of population bias on both of our perspectives; patients frequently go to the emerge
ncy department for complications of their opiate/benzo dependence and rarely go to a surgeon's clinic. Thus, I tend to magnify the extent of the problem while you may minimize it.
What I can say is that about 15-20% of our ED volume is somehow tied to these medications. Some patients have acute exacerbations of chronic pain. Others might have accidentally overdosed. Lots are admitted to our trauma service due to injuries sustained while intoxicated with ETOH plus pills. Many come to us because their pain/anxiety meds are interacting with other medications or exacerbating other illnesses. A large number are psychiatric patients who have substance-induced mood disorders from these meds. The lists go on and on and I don't think that very many of us who are left picking up the pieces will say that the pill problem is being overstated.
Nothing like government to punish the many for the acts of a few.
Welcome to my hell. My mom has had cancer since 2007 and has been on just about every effective form of chemo & radiation since. She's been stage 4 since 2011 and since she's a single mother of an only child (me) we had to move her in with us. Let me tell you how much fun it is dealing with this prescription BS on a daily basis with as many as she gets. It honestly makes me want to do it illegally just to avoid all the bureaucratic BS we deal with because a few criminals took advantage of something. Like I don't have enough going on in my life that I have to drive 30min across town four times to get a single prescription filled that was had a few words in the instructions (that we already had memorized anyway) incorrect. When will we learn as a nation that people who want to get high are going to get high and laws only punish the law abiding?
There is a fair amount of population bias on both of our perspectives; patients frequently go to the emergency department for complications of their opiate/benzo dependence and rarely go to a surgeon's clinic. Thus, I tend to magnify the extent of the problem while you may minimize it.
Yes. We deal with entirely different patient populations. My life is simpler in many ways. That's not an accident. Narcotics for acute (therefore short term) pain and PPIs represent about 90% of the prescribing that I do.
Yes. We deal with entirely different patient populations. My life is simpler in many ways. That's not an accident. Narcotics for acute (therefore short term) pain and PPIs represent about 90% of the prescribing that I do.
Sounds nice.
Most of my attendings seem to think this is a step in the right direction. Hope it curbs some of the problems. We will see. Maybe I can do a paper on it. . (got to get into fellowship somehow).
I'm not so sure that this is a bad idea. Like you, I agree that hydrocodone is a rather crappy analgesic when you consider the rather high rate of GI side effects compared to oxycodone. However, the purpose of this move is to begin to breakdown the practice of primary care providers prescribing hydrocodone preparations over long periods of time with minimal oversight. I'm sure that you too see your fair share of patients whose PCP provides them with 120 tablets of hydrocodone every month (usually combined with 90 tablets of Xanax). This is piss poor medicine, a major source of public morbidity/mortality, and an example of the medical community failing to police itself.
Bottom line, this ruling will have no impact on our practice of providing appropriate short term analgesia to our patients with acute pain. It is however a good first step in reigning-in PCP's who think that they know how to manage chronic pain with the long-term use of short acting opiates. It will also help control diversion techniques such as calling in false prescriptions.
Ironically, I see the opposite problem. People come to me as their PCM, after their surgeon gives them a minimal amount of meds after a major surgery (ortho cases, ex laps, etc) then pull the "discharged from service" routine. I rarely write more than 30 norco (our pharmacy moved away from vicoden due to acetominophen concerns) at a time, rarer to use oxycodone. I like that Tramadol went to Schedule IV... But if the patient comes to me more than two or three visits for the same pain complaint, I send them to pain management.
I agree though, lots of PCMs out there doing 90 + refills of norco or percocet vice actually putting them on a 12 hour release opiate and using the other meds for break throug. Kind of like diabetes, you have your lantus, then your meal coverage dosing...
Ironically, I see the opposite problem. People come to me as their PCM, after their surgeon gives them a minimal amount of meds after a major surgery (ortho cases, ex laps, etc) then pull the "discharged from service" routine.
After surgery, I send people home with pain meds (or my Fellow does, or the Hospitalist does if they're an inpatient). I'll see them back for a postoperative visit 1-2 weeks later and will rewrite the pain meds if they're still having pain, but yeah, I have no hesitation assigning their primary care provider the responsibility of further narcotic prescriptions after that. One person should be in charge of that patient at a time...particularly if we're talking about prescribing potentially addictive drugs for anything more than the postop period.
Ironically, I see the opposite problem. People come to me as their PCM, after their surgeon gives them a minimal amount of meds after a major surgery (ortho cases, ex laps, etc) then pull the "discharged from service" routine. I rarely write more than 30 norco (our pharmacy moved away from vicoden due to acetominophen concerns) at a time, rarer to use oxycodone. I like that Tramadol went to Schedule IV... But if the patient comes to me more than two or three visits for the same pain complaint, I send them to pain management.
I agree though, lots of PCMs out there doing 90 + refills of norco or percocet vice actually putting them on a 12 hour release opiate and using the other meds for break throug. Kind of like diabetes, you have your lantus, then your meal coverage dosing...
I'm curious, why the issue with tramadol?
Sensei, you come across Tripp Winslow yet??
PM sent.
I'm curious, why the issue with tramadol?
I'm not a big fan of tramadol due to the fact that it is a weak analgesic with some nasty side-effects, namely seizures. The seizures associated with tramadol can occur even in therapeutic doses. Most of the dogma in emergency medicine is that tramadol combined with Tylenol (Ultracet) is little better than Tylenol alone at real doses (1 gram TID).
Codeine and Demerol are other drugs that I do not use due to the side-effect profile. Codeine is weaker than hydrocodone and has a very high rate of GI upset which causes many people to claim an allergy. Demerol has a toxic metabolite, normeperidine, which accumulates in renal failure to cause seizures and is associated with serotonin syndrome in patients taking SSRI's.
I almost never prescribe oral Dilaudid or Fentanyl patches due to the overdose potential and those drugs are not in the purview of emergency medicine.
Thus, I stick with hydrocodone or oxycodone for the out-patient treatment of most painful conditions that need more than a NSAID or Tylenol. I never prescribe more than 20 tabs from the ED and I very rarely (maybe twice per year) prescribe opiates for acute back pain, migraines, or dental pain.
What Sensei said... No real issues with tramadol, I just think its too easy to over prescribe since it doesn't have a similar reputation for dependency. This may open some eyes (mine included)? I usually use tramadol more than hydrocodone, never dilaudid or fentanyl (our pharmacy doesn't carry fentanyl nor demerol, maybe dilaudulid), and I only use codeine sporadically. Which by default leaves tramadol as a step above NSAIDs for pain.
I used to use Tylenol #3 routinely, now haven't prescribed it in almost a decade. For me, oral pain meds are mostly hydrocodone or oxycodone but it reminds me that I'll have to check and see what my Fellow is ordering - he just started August 1 and I'm not sure what his personal biases are. I think he's using Tramadol occasionally. We have a post-op acute pain management protocol that involves Toradol and/or IV acetominiphen at the close of the operation, as well as a lot of wound injections with Exparel. That has been a pretty extraordinary drug relative to acute post-op pain management. In our total joint program, our length of stay is 1.4 days, even for bilaterals, and use of narcotics is minimal. No more nerve blocks or infusion catheters.
What Sensei said... No real issues with tramadol, I just think its too easy to over prescribe since it doesn't have a similar reputation for dependency. This may open some eyes (mine included)? I usually use tramadol more than hydrocodone, never dilaudid or fentanyl (our pharmacy doesn't carry fentanyl nor demerol, maybe dilaudulid), and I only use codeine sporadically. Which by default leaves tramadol as a step above NSAIDs for pain.
I was under the impression that it was the "safe" alternative to narcotic analgesics, that its action was mildly narcotic like, while not really being a narcotic...On another note I had major surgery this summer, and the doctors treated my pain with a marvelous nsaid, completely foregoing all narcotic pain management altogether! My surgeon explained that they now feel that narcotic pain killers contribute to a longer convalescence as opposed to not. The stuff they treated me with was called "Toradol" and it was amazing how effectively it neutralized pain....
toaradol is good short term but should be used for short durations only (at least the IV form, not sure about the oral route)
montanadave
08-28-14, 18:30
toaradol is good short term but should be used for short durations only (at least the IV form, not sure about the oral route)
When I had a kidney stone, a shot of Toradol in the ass was greatly appreciated.
toaradol is good short term but should be used for short durations only (at least the IV form, not sure about the oral route)
It's hard on the liver. 6 or 8 doses max if given IV. Oral form isn't very effective. Interestingly, we've found that IV acetominiphen is a little more effective than IV Toradol in the immediate postop period. Our postop pathways include giving both. Some high-risk patients, however, get higher doses of Lovenox, in which case we hold the Toradol and go just with the IV acetominophen.
Toradol is a great drug for colicky pain in patients who are vomiting because it can be given IV or IM. It is an NSAID in the same family as ibuprofen and enjoys all the same renal and GI side-effects of other drugs in its class. The oral form of Toradol is expensive and has a higher side-effect profile than ibuprofen. Thus, it is rarely prescribed because the juice is not worth the squeeze.
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