hydrocodone combination pills now to be Schedule II medications.

[Trajan]

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.

[Sensei]

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/cu...-pill-epidemic.

The fact that Russell Portenoy still has a license to practice is a sad commentary on the integrity of our profession.

[Hmac]

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.

[Sensei]

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.

[chuckman]

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.

[Jer]

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?

[Hmac]

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.

[Texas42]

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).

[Caduceus]

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...

[Hmac]

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.