Tramadol

[jj337]

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Our clinic was told today by a Walmart Pharmacy that Tramadol is now either a schedule II (or classified as something else) and we cannot send prescriptions using our EMR. Has anyone else heard this? Frankly, I think I would of heard about it prior to today if it was true.

 

[facets]

I believe it varies by state. In AZ it is still not controlled. I have a hard time believing it is a schedule 2. I think it is a #4 in some states

 

[emd123]

Our clinic was told today by a Walmart Pharmacy that Tramadol is now either a schedule II (or classified as something else) and we cannot send prescriptions using our EMR. Has anyone else heard this? Frankly, I think I would of heard about it prior to today if it was true.

Are you in Kentucky by chance (schedule IV)? Still not scheduled at the Federal level (last time I checked) and like stated above, schedule IV in some states with others considering. Haven't heard of any putting it on schedule II. That would be overkill, to say the least. Schedule IV seems very reasonable, but its a rare patient that makes unreasonable demands for Tramadol, in my experience.

 

[PMR 4 MSK]

I sent 3 scripts for it by EMR today, no problem.

 

[lobelsteve]

Mu opiate binding affinity for tramadol is 1:6000 to 1:8000 that of morphine.

This makes tramadol as much an opiate as dihydrogen oxide.

Putative mechanism is more likely serotoninergic/norepinephrine like Cymbalta and Savella.

 

[jj337]

New Mexico

 

[specepic]

I love this med. Patients with pain tend to respond (assuming they tolerate), and seekers hate it. If the FDA ever takes it away I will cry.

 

[emd123]

I've had one patient, and I'll never forget this guy or his name, would come in over, and over, and over again, wanting tramadol. He'd ask for it by name and would turn down anything else, even "real" narcs. It was so weird, I actually remember the guys name, to this day. He wanted tramadol all the time. I made the assumption that there was no way he could be a seeker since he never wanted anything stronger than tramadol. Well...he disappears and I don't seem him for a long time. Fast forward 2 or 3 years, he shows up again and it turns out he's a heroin addict now on methadone. Whether or not he started on tramadol and worked his way up the ladder or was always a heroin addict and it staved off withdrawal somewhat for him I don't know. Bizarre. Other than this one guy, I've never had anyone else show an inappropriate desire for tramadol (sorry, drug company)

 

[knoxdoc]

Tramadol undoubtedly has some mu binding affinity. It is the medication most commonly abused by physicians in the state of Tennessee (in terms of disciplinary action from the medical board).

 

[deleted6669]

not a big tramadol fan...we have folks here on suboxone to get off tramadol...and then there are the drug interactions with many psych drugs causing seizures...

 

[lobelsteve]

Tramadol undoubtedly has some mu binding affinity. It is the medication most commonly abused by physicians in the state of Tennessee (in terms of disciplinary action from the medical board).

They chose this med for ease of access, low visibility from enforcement, and possibly for false belief in addiction potential.


It is the patient and not the drug.

 

[lobelsteve]

not a big tramadol fan...we have folks here on suboxone to get off tramadol...and then there are the drug interactions with many psych drugs causing seizures...

WTF? Go schedule 3 for non schedule drug addiction? No plausible rationale for swapping out this addiction. Oi get the concept of mmt or suboxone for heroin, but swapping rx drugs for rx drug addiction does not seem logical.

 

[jj337]

Found out NM Board of Pharmacy now classifies it as a schedule IV drug and a (likely) overzealous pharmacist wouldn't let me send it electronically but obviously that is not the rule. I think this drug is great for neuropathic pain and would hate to lose it. Lonelobo might 😀

 

[lonelobo]

Tramdol is a powerful pain killer
which can be used in accute pain emergency with the patients.

Better get back to your nap time before the teacher realizes your missing.

 

[knoxdoc]

Tramdol is a powerful pain killer
which can be used in accute pain emergency with the patients.

Better not use it with the patients, that can get you into trouble.

 

[Jcm800]

Found out NM Board of Pharmacy now classifies it as a schedule IV drug and a (likely) overzealous pharmacist wouldn't let me send it electronically but obviously that is not the rule. I think this drug is great for neuropathic pain and would hate to lose it. Lonelobo might 😀

i too think its great for patients...

 

[bananaface]

Found out NM Board of Pharmacy now classifies it as a schedule IV drug and a (likely) overzealous pharmacist wouldn't let me send it electronically but obviously that is not the rule. I think this drug is great for neuropathic pain and would hate to lose it. Lonelobo might 😀

Schedule III, IV, and V controlled substances can be faxed or printed out and signed but not e-prescribed.

If you go to the AZ Board of Pharmacy site's FAQs at http://www.azpharmacy.gov/faqs.asp you will find a document specifically addressing the topic:
http://www.azpharmacy.gov/UPDATE ON ELECTRONIC CONTROLLED SUBSTANCE PRESCRIPTIONS.doc

It is just one state's site, but the factual content of the document applies nation wide. When we get to the point that programs can be certified as secure e-prescribing should expand to include those schedules.

 

[lobelsteve]

Schedule III, IV, and V controlled substances can be faxed or printed out and signed but not e-prescribed.

If you go to the AZ Board of Pharmacy site's FAQs at http://www.azpharmacy.gov/faqs.asp you will find a document specifically addressing the topic:
http://www.azpharmacy.gov/UPDATE ON ELECTRONIC CONTROLLED SUBSTANCE PRESCRIPTIONS.doc

It is just one state's site, but the factual content of the document applies nation wide. When we get to the point that programs can be certified as secure e-prescribing should expand to include those schedules.

OR:

http://edocket.access.gpo.gov/2010/pdf/2010-6687.pdf

It has been legal since June 1 2010. But I am unaware of any software at the practice level or pharmacy level that currently supports the new rule.

 

[lobelsteve]

From MagMutual:

E-Prescribing Controlled Substances

In an effort to encourage the utilization of e-prescriptions, the DEA approved an interim final rule in June 2010 to allow e-prescribing of narcotics and other controlled substances. Having to keep a separate paper-based prescription trail for these drugs has been a major obstacle in the adoption of e-prescription technology. With this obstacle removed, it is much easier for physicians to use a single, electronic prescription system. Several requirements must be met, however, in order to prescribe these controlled substances electronically:
Only DEA registrants may sign controlled substance e-prescriptions;
The authentication method must ensure that the practitioner cannot repudiate the prescription;
The prescription records must be reliable enough to be used in legal actions;
The security systems used must prevent the possibility of insider creation or alteration of prescriptions, to the greatest extent possible.
A full copy of the ruling is available in the Federal Register, online at: http://www.deadiversion.usdoj.gov/ecomm/e_rx/index.html.

 

[J ROD]

Tramadol is not a CII in any state.....that person was an idiot or lazy.

 

[CrazyJake]

When I was a practicing pharmacist (for about 5 yrs total) I probably had 3-4 prescriptions that were Percocet forgeries...probably 7-8 Lortab forgeries, and easily greater than 20 Tramadol forgeries.

Don't let it's former C6 schedule (vs C3 or C4 in some states now) fool you. 1 or 2 Tramadol q 6 hours - not addictive. A handful every hour or so is highly addictive - as I've been told from addicts.

Red flags for me - anyone that ask outright for Tramadol.

Hope this helps.
CJ

 

[jettavr6]

There are some patients, either desperate or bored, who crush tramadol tablets and snort them for the high.

 

[J ROD]

When I was a practicing pharmacist (for about 5 yrs total) I probably had 3-4 prescriptions that were Percocet forgeries...probably 7-8 Lortab forgeries, and easily greater than 20 Tramadol forgeries.

Don't let it's former C6 schedule (vs C3 or C4 in some states now) fool you. 1 or 2 Tramadol q 6 hours - not addictive. A handful every hour or so is highly addictive - as I've been told from addicts.

Red flags for me - anyone that ask outright for Tramadol.

Hope this helps.
CJ

I question it when anyone asks for any drug over and over....and seem like they have an "itch" for it.....

Yeah, it can be addictive but it is not one that I see abused alot like benzos, anything hydrocodone, oxycodone, and Darvocet.....(I thought some were going to died when they took it off the market!)

 

[clubdeac]

Got a 34 y/o with a seemingly benign exam and unremarkable imaging who I can't seem to get off tramadol. He swears it is the only thing that seems to help his back pain. I know he has some underlying PTSD, anxiety and anger issues and suspect he may be self medicating. He does follow through with non opioid recommendations such as acupuncture and PT and has no aberrant behaviors. Would you guys continue prescribing or wean completely off. I've successfully weaned him down from #180/month when I got him to #60/month. While we're at it I've got a similar girl with mid back pain and benign exam and unremarkable imaging on #45 Nucynta 50mg per month. Every time I try and decrease them she starts crying....ughhhh

 

[DubVille]

Got a 34 y/o with a seemingly benign exam and unremarkable imaging who I can't seem to get off tramadol. He swears it is the only thing that seems to help his back pain. I know he has some underlying PTSD, anxiety and anger issues and suspect he may be self medicating. He does follow through with non opioid recommendations such as acupuncture and PT and has no aberrant behaviors. Would you guys continue prescribing or wean completely off. I've successfully weaned him down from #180/month when I got him to #60/month. While we're at it I've got a similar girl with mid back pain and benign exam and unremarkable imaging on #45 Nucynta 50mg per month. Every time I try and decrease them she starts crying....ughhhh

Does he work full time?

 

[Timeoutofmind]

Got a 34 y/o with a seemingly benign exam and unremarkable imaging who I can't seem to get off tramadol. He swears it is the only thing that seems to help his back pain. I know he has some underlying PTSD, anxiety and anger issues and suspect he may be self medicating. He does follow through with non opioid recommendations such as acupuncture and PT and has no aberrant behaviors. Would you guys continue prescribing or wean completely off. I've successfully weaned him down from #180/month when I got him to #60/month. While we're at it I've got a similar girl with mid back pain and benign exam and unremarkable imaging on #45 Nucynta 50mg per month. Every time I try and decrease them she starts crying....ughhhh

I have had very many young people missuse tramadol and become addicted as opioid of choice

 

[NJPAIN]

We toss this concept around frequently - " COT only for those who are working age and working". What is the origin of this? Is the concept simply if you don't get meds you will detach from the workforce and become a burden on society? Will that hold water as a justification if one has to defend the decision to prescribe COT??


Sent from my iPhone using SDN mobile app

 

[lobelsteve]

Got a 34 y/o with a seemingly benign exam and unremarkable imaging who I can't seem to get off tramadol. He swears it is the only thing that seems to help his back pain. I know he has some underlying PTSD, anxiety and anger issues and suspect he may be self medicating. He does follow through with non opioid recommendations such as acupuncture and PT and has no aberrant behaviors. Would you guys continue prescribing or wean completely off. I've successfully weaned him down from #180/month when I got him to #60/month. While we're at it I've got a similar girl with mid back pain and benign exam and unremarkable imaging on #45 Nucynta 50mg per month. Every time I try and decrease them she starts crying....ughhhh

Functional benefit documented? No aberrant behaviors or side effects limiting care?

Would Rx without hesitation. But the girl of Nucynta (C2) needs to have objective evidence of a problem before she should have gotten Rx #1.

 

[bedrock]

Got a 34 y/o with a seemingly benign exam and unremarkable imaging who I can't seem to get off tramadol. He swears it is the only thing that seems to help his back pain. I know he has some underlying PTSD, anxiety and anger issues and suspect he may be self medicating. He does follow through with non opioid recommendations such as acupuncture and PT and has no aberrant behaviors. Would you guys continue prescribing or wean completely off. I've successfully weaned him down from #180/month when I got him to #60/month. While we're at it I've got a similar girl with mid back pain and benign exam and unremarkable imaging on #45 Nucynta 50mg per month. Every time I try and decrease them she starts crying....ughhhh

There are worse problems to have.

If the patients are working and following the rules, then what is the harm in continuing to prescribe tramadol and nucynta? Neither drug has street value, major risk to internal organs, or risk of fatal OD, and both patients report improved pain, so why are you so dead set on taking these meds away from them?

 

[PapaDosh]

Functional benefit documented? No aberrant behaviors or side effects limiting care?

Would Rx without hesitation. But the girl of Nucynta (C2) needs to have objective evidence of a problem before she should have gotten Rx #1.

Is the girl on Nucynta on any other psychiatric medications? My guess is that the SNRI effects has significantly helped underlying depression.

 

[Ducttape]

the essence of employment is that it is concrete corroboration that the patient is demonstrating a certain level of functioning - from not just a physical but a social and psychological standpoint.

its no wonder that the most common reasons for SSD is bipolar disorder and chronic low back pain.

if you have no functionality to maintain (ie on SSD, or just not working), why prescribe to maintain a minimally existent level of functioning? (and opioids dont improve functionality...)

 

[clubdeac]

They both are employed at least I think so. The kid is a firefighter 3 days a week. The girl I can't remember but I'm pretty sure she's working. I'll double check at her 4 month f/u. I have both of them come in every 4 months for surveillance. Neither causes much of a problem but insists on their med. Just thought it'd be good to get some additional perspectives. Thanks guys

 

[lobelsteve]

They both are employed at least I think so. The kid is a firefighter 3 days a week. The girl I can't remember but I'm pretty sure she's working. I'll double check at her 4 month f/u. I have both of them come in every 4 months for surveillance. Neither causes much of a problem but insists on their med. Just thought it'd be good to get some additional perspectives. Thanks guys

4 mo for schedule 2 is a nono.

 

[bedrock]

4 mo for schedule 2 is a nono.

agree. 4 month is fine for tramadol, but nucynta, as a schedule 2, (even a very safe schedule 2, that should be a schedule 3) requires more follow-up than every 4 months.

 

[clubdeac]

agree. 4 month is fine for tramadol, but nucynta, as a schedule 2, (even a very safe schedule 2, that should be a schedule 3) requires more follow-up than every 4 months.

Is that in the new CDC guidelines? I guess I thought it was more just the standard of care. I'll get them in sooner. Thanks

 

[lobelsteve]

Is that in the new CDC guidelines? I guess I thought it was more just the standard of care. I'll get them in sooner. Thanks

DEA regs. Not more than 90 days.