Hydrocodone to Schedule 2?

[EM Junkie]

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http://m.huffpost.com/us/entry/4159316

It sounds like this is all but a done deal. How would you change your practice if this goes into effect? I know that in Texas, schedule 2 drugs must be on triplicate prescriptions which are specifically issued to me. They also cannot be printed from my hospital's Medhost system. At the same time, for very painful conditions like fractures, I'd like to be able to offer adequate pain relief prior to follow up.

As as aside, time to buy stock in Tramadol!

 

[EM_Rebuilder]

http://m.huffpost.com/us/entry/4159316

It sounds like this is all but a done deal. How would you change your practice if this goes into effect? I know that in Texas, schedule 2 drugs must be on triplicate prescriptions which are specifically issued to me. They also cannot be printed from my hospital's Medhost system. At the same time, for very painful conditions like fractures, I'd like to be able to offer adequate pain relief prior to follow up.

As as aside, time to buy stock in Tramadol!

Pill mills, and too many PCPs have continued to write these by the tons and now everyone will have to pay for it.

I am in Texas and do not have triplicates. One question I have, in Texas, can residents even get triplicates? I have had residents from Heme/Onc and such come to be asking to write a patient a triplicate because 'they cannot get them and their attending is at home'. I don't have them so I never do it, but I have wondered if residents truly cannot get triplicates, then that will be a huge kink at teaching hospitals!

 

[EM2BE]

http://m.huffpost.com/us/entry/4159316

It sounds like this is all but a done deal. How would you change your practice if this goes into effect? I know that in Texas, schedule 2 drugs must be on triplicate prescriptions which are specifically issued to me. They also cannot be printed from my hospital's Medhost system. At the same time, for very painful conditions like fractures, I'd like to be able to offer adequate pain relief prior to follow up.

As as aside, time to buy stock in Tramadol!

Oxycodone is already a schedule 2. If it gets somehow more regulated, then we may see more of the Washington state effect - lots less of the prescription drug abuse but a ton more heroin or other drugs of abuse. If people want it, they will get it.

 

[deleted109597]

Oxycodone is already a schedule 2. If it gets somehow more regulated, then we may see more of the Washington state effect - lots less of the prescription drug abuse but a ton more heroin or other drugs of abuse. If people want it, they will get it.

Yeah, but coming to Texas from North Carolina, it's impressive how many people "get by" with Norco/Lortab. In NC, we had people with ankle sprains getting 30 Percocet/Tylox. It's just cultural.
100 years ago, people didn't have anything but opium.

Narcotics are killing somewhere on the order of 18000 people per year. I am all for making all narcotics harder to get. It will keep more people from getting hooked to begin with. Not many people I know who abuse narcotic pills are willing to go buy black tar on the street. Some might, but there's always somebody.

 

[b-real]

Pill mills, and too many PCPs have continued to write these by the tons and now everyone will have to pay for it.

I am in Texas and do not have triplicates. One question I have, in Texas, can residents even get triplicates? I have had residents from Heme/Onc and such come to be asking to write a patient a triplicate because 'they cannot get them and their attending is at home'. I don't have them so I never do it, but I have wondered if residents truly cannot get triplicates, then that will be a huge kink at teaching hospitals!

Yes, as long as they have a full medical license along w/ DPS and DEA numbers. When I got all 3, I received a letter from the TMB with instructions on how to get triplicates.

 

[JediZero]

Yeah, but coming to Texas from North Carolina, it's impressive how many people "get by" with Norco/Lortab. In NC, we had people with ankle sprains getting 30 Percocet/Tylox. It's just cultural.
100 years ago, people didn't have anything but opium.

Narcotics are killing somewhere on the order of 18000 people per year. I am all for making all narcotics harder to get. It will keep more people from getting hooked to begin with. Not many people I know who abuse narcotic pills are willing to go buy black tar on the street. Some might, but there's always somebody.

Not heroin, maybe, but most will find something. My psych rotation involved a lot of addiction medicine, including time at a methadone clinic. What I learned from my time there is that 'normal' people who become addicts after getting Percocet for a surgery or whatever are the exception rather than the rule. The vast majority who get hooked after an initial prescription are the ones who have a pre-existing pattern of addiction. I do think making these drugs harder to get can avoid exacerbating the problem, though. Just wish we could do it through physician education rather than regulation.

 

[deleted109597]

Just wish we could do it through physician education rather than regulation.

Unfortunately, that can't happen now. Not because physicians can't be educated, but because pain score is now a "vital sign" and getting pain medicine is closely related to patient satisfaction.
How many times have you had a patient who you wouldn't send home with narcotics say something like "I'm going to sue" or "I'm going to report you" or whatever. Patients have been coached to ask for them.
Making them harder to get means now we have an avenue to say "I can't give you that." Just like I use for the people who ask for Demerol by name.


My psych rotation involved a lot of addiction medicine as well. It was called the VA.

 

[Arcan57]

Unfortunately, that can't happen now. Not because physicians can't be educated, but because pain score is now a "vital sign" and getting pain medicine is closely related to patient satisfaction.
How many times have you had a patient who you wouldn't send home with narcotics say something like "I'm going to sue" or "I'm going to report you" or whatever. Patients have been coached to ask for them.
Making them harder to get means now we have an avenue to say "I can't give you that." Just like I use for the people who ask for Demerol by name.


My psych rotation involved a lot of addiction medicine as well. It was called the VA.

I think there's a role for opioid pain scripts from the ED, primarily for acute fractures and renal colic. Taking those away is going to just make repeat visits more likely since they'll have to come to the ED everyday for acute pain. I do think it's criminal that most EMRs default to 30 pills which is far to many norcos for most acutely painful conditions.

 

[deleted109597]

I think there's a role for opioid pain scripts from the ED, primarily for acute fractures and renal colic. Taking those away is going to just make repeat visits more likely since they'll have to come to the ED everyday for acute pain. I do think it's criminal that most EMRs default to 30 pills which is far to many norcos for most acutely painful conditions.

I don't disagree. And I don't want there to be a "list" that says we can only give meds for X condition, etc. However, seeing people walk out with sprains (or back pain) with narcotics? This just shouldn't be.

 

[Arcan57]

I don't disagree. And I don't want there to be a "list" that says we can only give meds for X condition, etc. However, seeing people walk out with sprains (or back pain) with narcotics? This just shouldn't be.

Agreed. Somewhere along the line we badly screwed up (and I agree it's probably the pain as a vital sign that was foisted on us), and we need to turn back. As many who moved to TX from elsewhere, I was shocked that the local populace put up with hydrocodone (which giving in other states was the equivalent of calling their mom a *****) because Schedule II's were off limits. If groups get together, they can drastically change the expectations of their population but they have to stay consistent. Having some that do give narcs and some that don't just creates a random reward (think Vegas slot machines) scenario that encourages even more frequent visits because that Rx is no longer a sure thing.

 

[GeneralVeers]

We need to use technology to figure this out. Although making things more restrictive will certainly decrease narcs to a few drug-seekers, it will make it more difficult to prescribe pain meds to people who legitimately need them.

My solution is to have a NATIONAL database run by all the states (not the Feds). I would have new rules mandating that every narcotic prescription filled by every pharmacy be put into the database within 48 hours. All EMRs that write prescriptions would be required to interface with the national database, and would alert the physician automatically as soon as they attempt to fill a script to an over-user. For EDs that don't have an EMR and still use hand-written ones, it would be the responsibility of the providing physician to check the national database beforehand. Since all access would be logged, physicians who do not check the database, or over-prescribe will be easy to track and can be punished.

Seriously, if Wall Street can design integrated computer networks and have software talk to each other, then why can't we in medicine?

I'm really sick and tired of luddites, or lazy physicians I work with complaining that they "don't have time" to check the State database. If you don't have time for something that could stop an easily preventable death, then you have no business practicing medicine.

 

[EM2BE]

We need to use technology to figure this out. Although making things more restrictive will certainly decrease narcs to a few drug-seekers, it will make it more difficult to prescribe pain meds to people who legitimately need them.

My solution is to have a NATIONAL database run by all the states (not the Feds). I would have new rules mandating that every narcotic prescription filled by every pharmacy be put into the database within 48 hours. All EMRs that write prescriptions would be required to interface with the national database, and would alert the physician automatically as soon as they attempt to fill a script to an over-user. For EDs that don't have an EMR and still use hand-written ones, it would be the responsibility of the providing physician to check the national database beforehand. Since all access would be logged, physicians who do not check the database, or over-prescribe will be easy to track and can be punished.

Seriously, if Wall Street can design integrated computer networks and have software talk to each other, then why can't we in medicine?

I'm really sick and tired of luddites, or lazy physicians I work with complaining that they "don't have time" to check the State database. If you don't have time for something that could stop an easily preventable death, then you have no business practicing medicine.

I wish we had even a state database here. I would be more than happy to look this stuff up.

 

[GeneralVeers]

I wish we had even a state database here. I would be more than happy to look this stuff up.

I'll give you a pass then. 😉

 

[deleted109597]

I wish we had even a state database here. I would be more than happy to look this stuff up.

Depends on the system.
NC had a great one. When TX first implemented it, it was terrible. Required you to input the 25 number code from your driver's license, as well as your username, and password. And it had a 5 minute auto-timeout. Thankfully, they took that away, and it's much easier to use now.

If you make it hard to do, nobody will do it. If the state forces you to do it, then say goodbye to productivity.

 

[EM_Rebuilder]

Yes, as long as they have a full medical license along w/ DPS and DEA numbers. When I got all 3, I received a letter from the TMB with instructions on how to get triplicates.

So then Interns can't, and I would assume not many programs force residents to get full licenses. You are also talking about 2K+ in costs for the license; and what if the person has no plans to stay in Texas and plan on leaving the day residency is over?

I see this as a big mess in the academic houses...

 

[EvoDevo]

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[EvoDevo]

Unfortunately, that can't happen now. Not because physicians can't be educated, but because pain score is now a "vital sign" and getting pain medicine is closely related to patient satisfaction.
How many times have you had a patient who you wouldn't send home with narcotics say something like "I'm going to sue" or "I'm going to report you" or whatever. Patients have been coached to ask for them.
Making them harder to get means now we have an avenue to say "I can't give you that." Just like I use for the people who ask for Demerol by name.


My psych rotation involved a lot of addiction medicine as well. It was called the VA.

This is so true. Most of the complaints that I've had (98%) have come from people with minor complaints who I won't write opiate scripts for. In one case, the guy sez (right after I said that the XR was negative), "Doc, I'm not asking for pain meds." What???

So ******ed

 

[EvoDevo]

One Rx loophole that I've run across is that any script filled on a military base isn't reported.

 

[EvoDevo]

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