Breakthrough pain

[Starpower]

Looking for thoughts on this ... would you ever concurrently prescribe Tylenol #3 and Norco 5/325, with instructions to use one or the other for breakthrough pain? I've rotated in PM clinics where much stronger opiates were combined for regular w/breakthrough (such as Oxycontin with Percocet), so I saw no problem in writing for the T3 and Norco, but our county pharmacy protested. Thoughts?

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[lobelsteve]

Writing 2 short acting opiates is not logical on the face of it. If qty is low for each, and your note supports a valid reason- it can be fine.

Example: codeine is less sedating for a patient and they take it bid, but need Norco for night pain. Tyl3#60 and Norco#30 will not get you in trouble.

But #120 of each is stupid.

 

[Aether2000]

Using two short actings is attempting to achieve the same drug stability as a long acting medicine. The drug levels are much more variable than with a long acting such as butrans. Also it is outside the practice of most pain physicians and non-pain physicians, therefore I understand the reluctance of the pharmacist.

 

[powermd]

Using two short actings is attempting to achieve the same drug stability as a long acting medicine. The drug levels are much more variable than with a long acting such as butrans. Also it is outside the practice of most pain physicians and non-pain physicians, therefore I understand the reluctance of the pharmacist.

I see this going on all the time when I do peer reviews. Plenty of doctors think it's okay to prescribe both Vicodin and Percocet for "moderate" and "severe" pain. They play similar games with benzos. All for non-malignant pain cases, of course.

 

[Aether2000]

It used to be more common, but with long acting meds having some statistical evidence of having less substance abuse issues, it makes little sense to prescribe truck loads of short acting medications. Sometimes, due to insurance restrictions (eg. will cover MS Contin at BID dosing only or restrict fentanyl patches to 10/month even though some patients are in full withdrawal every third day, or won't cover any long actings at all), then ya do what ya gotta do...
But for the most part, using multiple short acting drugs is not indicated. If patients have variable pain, then they need lattitude in how the medications are taken or half the tablets routinely, etc, rather than more than one short acting med. It gets very confusing to the patients to have multiple short acting meds and also sends a message that there are virtually no limits on what they can take when they want to take them...

 

[Starpower]

Thank you much.

 

[mille125]

It used to be more common, but with long acting meds having some statistical evidence of having less substance abuse issues, it makes little sense to prescribe truck loads of short acting medications. Sometimes, due to insurance restrictions (eg. will cover MS Contin at BID dosing only or restrict fentanyl patches to 10/month even though some patients are in full withdrawal every third day, or won't cover any long actings at all), then ya do what ya gotta do...
But for the most part, using multiple short acting drugs is not indicated. If patients have variable pain, then they need lattitude in how the medications are taken or half the tablets routinely, etc, rather than more than one short acting med. It gets very confusing to the patients to have multiple short acting meds and also sends a message that there are virtually no limits on what they can take when they want to take them...

agreed..

 

[PMR 4 MSK]

The problem with this approach is twofold:

1) you are asking the patient to constantly judge his/her pain and what level of medication it will take for them to reach their own definition of an acceptable level of pain." It would be the same as writing "Vicodin 5-500, 1-4 PO q 4 hours prn." The pt gets to judge how much pain they are in at any given moment and self-regulate their meds. It won't be long before 4 q4H becomes their norm.

2) The physician is no longer prescribing the meds, so much as merely placing limitations on how much the pt gets per month. "You can have 30 of these and 75 of those." It becomes a negotiation every month, because the entire focus of therapy is how many of each pill the pt gets. Way too much focus on pills as the therapy.

Pick one drug, and if you don't need as much at any given time, cut it in half and save the other half for later, when it's worse.

Better yet, find something besides short-acting opioids for the patient to focus on as their main therapy. I know, that's heresy, pain pills help chronic pain, sometimes there's no other options, blah, blah blah. But if someone is appropriate for chronic opioid therapy, I can't see much a reason for 2 SAOs to be repeatedly prescribed regularly. Too high of a chance of diversion and abuse.