Hydrocodone Now Schedule II

[Yangkower]

So hydrocodone is now schedule II. In my opinion this is a good move not because it will change abuse of the drug but because it gives physicians additional ammunition to deny patients prescriptions of these drugs for chronic pain. While I agree with its use in patients with cancer pain and rheumatoid arthritis I disagree with its use for almost any other chronic pain.

I would even go so far as to say prescribing narcotics for chronic pain is becoming malpractice. When patients tell me that nothing else works I suggest that they are taking the medication to prevent withdrawal and it is doing nothing for their pain and probably making it worse. Of course this will reduce my patient satisfaction and hurt my Press Ganey Score so I am conflicted...ha

Any thoughts?

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[BLADEMDA]

I disagree here. Prescribing large doses of narcotics for chronic pain should be the last resort but it isn't malpractice.

Some chronic pain patients get by on NSAIDs, tramadol and other drugs like elavil or lyrica, etc. Still, they may have severe pain at times requiring a boost from a narcotic. These patients should not be denied narcotics.

Other patients may have tried everything including stimulator implants but still need some narcotics to get through the day.

I'm all for restricting the use of these drugs to the right patients. But let's not throw the baby out with the bath water. I agree there is a lot of overprescribing of narcotics in the USA.

Limiting the use and amount of narcotics to patients make sense. Eliminating the use of narcotics is best left up to the patient and his/her physician.

 

[Yangkower]

Some people cant get through the day without alcohol. I don't buy that as an argument for their use. It just means they are dependent on Narcotics. Again I don't disagree with their use in cancer patients or patients with conditions such as rheumatoid arthritis for example.

This is a society created problem that has been exacerbated by well intentioned physicians. Maybe malpractice is a harsh term but there needs to be a paradigm shift in out treatment of chronic pain.

 

[AlmostAnMD]

Slightly related topic:

Not sure how common this is, but my friend just started attending in an ER that doesn't carry Dilaudid. Completely unavailable (one of the reasons he's working there since no one can seek it out there).

 

[jwk]

So hydrocodone is now schedule II. In my opinion this is a good move not because it will change abuse of the drug but because it gives physicians additional ammunition to deny patients prescriptions of these drugs for chronic pain. While I agree with its use in patients with cancer pain and rheumatoid arthritis I disagree with its use for almost any other chronic pain.

I would even go so far as to say prescribing narcotics for chronic pain is becoming malpractice. When patients tell me that nothing else works I suggest that they are taking the medication to prevent withdrawal and it is doing nothing for their pain and probably making it worse. Of course this will reduce my patient satisfaction and hurt my Press Ganey Score so I am conflicted...ha

Any thoughts?

I'm with Blade - there are certainly chronic pain patients, besides those with cancer pain and rheumatoid, that will benefit from narcotics. Just making a blanket statement that any use outside that represents malpractice is overly simplistic.

 

[Ronin2258]

I agree with Blade and others. Narcotics aren't the first choice, but they shouldn't be off the table.

I wonder if the issue is primary care doctors adhering to the WHO pain ladder, which is only pharmacologic. All that is available to them is to medicate, medicate, medicate until a modicum of pain control is achieved. Some do it because they aren't aware of other choices, some do it because they want to keep the patient to themselves. I have, unfortunately, seen patients come in with Dilaudid and Opana for simple low back pain as a first choice medication from their primary providers. I regrettably suspect that they use the addictive properties to keep them coming back.

The basic ladder illustration doesn't broach the topic of procedures or other interventions to help. This is understandable in underdeveloped countries, where procedural pain treatment is rare to nonexistent, and narcotics are the only method available.

However, in a developed country where access to procedures, stimulators, and corrective surgery, and other options are available like the US, perhaps it would be beneficial to point out where on the pain ladder consideration for surgery or procedures would come into play. A consensus of where one should consider procedural/specialists as an alternative to taking a step up the ladder.

 

[deleted171991]

Pain is not the "5th vital sign" - Skeptical Scalpel

No, contrary to what you may have heard, pain is not the 5th vital sign. It's not a sign at all.

Vital signs are the following: heart rate; blood pressure; respiratory rate; temperature.

What do those four signs have in common?

They can be measured.

A sign is defined as something that can be measured. On the other hand, pain is subjective. It can be felt by a patient. Despite efforts to quantify it with numbers and scales using smiley and frown faces, it is highly subjective. Pain is a symptom. Pain is not a vital sign, nor is it a disease.

How did pain come to be known as the 5th vital sign?

The concept originated in the VA hospital system in the late 1990s and became a Joint Commission standard in 2001 because pain was allegedly being undertreated. Hospitals were forced to emphasize the assessment of pain for all patients on every shift with the (mistaken) idea that all pain must be closely monitored and treated .

 

[BuzzPhreed]

Yes, FFP. This is exactly right. And it is one of my hugest pet peeves. Especially when the nurse awakens a sleeping patient only to page me (yes, even as an attending anesthesiologist) in the middle of the night to tell me they are 6-7/10 pain and "what should I do?" despite the fact that they were sonorous with perfect vitals not 5 minutes before.

You want to get real? The fifth vital sign should be BMI. That should be the focus of the Joke... ahem... Joint Commission.

 

[BLADEMDA]

the use of narcotics should be left up to the patient and the physician. I do agree narcotics can be over-prescribed for a variety of reasons. But, the answer is not the elimination of the drugs. Instead, a thorough discussion should be had with the patient about benefits/risks etc.

I've met Professors, Anesthesiologists, Surgeons, etc on CHRONIC pain meds who are functional because of them. Some of these individuals even use Narcotics on a regular basis. All of them understood about the addiction risk, the limitations of increasing dosage and the need to find other agents/adjuncts to deal with their pain.

 

[BuzzPhreed]

Oh, no doubt Blade. But then there's Opana. Talk about complete disregard for good pharmaceutical stewardship.

 

[Ronin2258]

Oh, no doubt Blade. But then there's Opana. Talk about complete disregard for good pharmaceutical stewardship.

Totally. The number of people I saw on Opana when I was a GP was ridiculous. Rules with the group is that we had to turn them away from the clinic if they couldn't go with a Schedule III narcotic. I swear that some of the PCPs were using it to keep their patients faithful.