Tighter Control on Vicodin?

A widely prescribed painkiller


So, before reading this blog post, take a peek at this article:  http://www.latimes.com/news/local/la-me-0126-vicodin-20130126,0,4066484.story

I’m not going to comment on whether or not this is a good move because, truthfully, there’s a lot to be said for both sides of the coin. There would be patients–legitimate pain patients–who would suffer from this being approved. But, there would also be a lot less abuse (or so we would hope). Regardless, I’m not going to comment on whether this is good or bad. I can tell you one thing, though:  this would make life in a big chain retail pharmacy a nightmare. Can you imagine having to be the only one allowed to count out every hydrocodone-based prescription? I don’t know where we would store it all to be honest. But, I digress.

The real thing that should be focused on here is how we, as a health care community, look at “chronic pain”. There are so many chronic pain sufferers out there, and each is different. My thoughts are that instead of reclassifying the most commonly prescribed medication in the US, we should reclassify how it is prescribed. No primary care physician should be the main person writing for a chronic pain medication. Chronic pain patients should be going to a pain specialist. This should be required. This is not only to insure the prescribing is done correctly, but to help the patients find the best possible relief. Now, I’m not saying there aren’t pain doctors out there that give out narcs like candy, but they are better equipped to be writing for these patients. I feel like writing for chronic heavy duty narcotics is out of a primary care physician’s realm of practice. Primary doctors are too quick to write a chronic lower back pain patient a script for Percocet many times. Shouldn’t they be trying out other options, such as Cymbalta or gabapentin first before going to a potent opioid medication? I think people should exhaust all other options first before starting with meds like that, including things like acupuncture and physical therapy. It’s very difficult to get off opioids once you’ve been taking them for a while. You can always go forward if it’s not working, but it’s hard to go back.

The other thing that makes the world of opioids so tough is the lack of communication between physicians, sometimes due to the patient not telling the whole truth. We had a patient who is taking both Suboxone and Percocet on a daily basis. She stopped coming to our pharmacy because we questioned why she was on both and asked if we could contact her physicians about therapy modification. There is no reason she should be on both. I wonder if her two doctors know that she is on both medications. How it ever went through her insurance is beyond me. Usually, that kind of interaction requires a prior authorization, so either one of the doctors did the prior authorization without thinking or the insurance let a major drug interaction slip by. Whichever it is, it truly points to a problem with the way this nation treats chronic pain and opioid dependence/addiction.

It really saddens me. I wish that the FDA would focus on where pain killer abuse starts instead of where it ends. We need to be proactive about health care, not reactive. If we can prevent opioid misuse by better regulating how and by whom the medications are prescribed, then we won’t need to restrict them in the pharmacy as much. But, that’s just me, a lowly pharmacist who receives multiple 7 to 10 day early fill authorizations from the same primary doctors every few weeks. Who am I to argue?


Image courtesy of http://www.latimes.com/news/local/la-me-0126-vicodin-20130126,0,4066484.story


4 thoughts on “Tighter Control on Vicodin?

  1. Their is a school of thought – that I subscribe to.. that we have so many chronic pain pts because acute pain is not treated aggressively and the nerve path gets ingrained and altered as sensing pain and never reverts entirely to “normal”. IMO.. anything that interferes with aggressively treating acute pain.. will result in more chronic pain pts and many more people out of the workforce and collecting disability. IMO.. drugs are not addictive.. people have addictive tendencies that are triggered by certain drugs. Just like guns, cars and other dangerous things in our lives.. they don’t kill people.. people are killed because some one is irresponsible in how they are used.
    BTW.. those early requests for refills.. may be nothing more than a chronic pain pt that is getting only “token doses” in treating their pain…and their quality of life sucks.. and they are trying to regain as much quality of life as possible… not necessarily trying to get high.

    • Yes, the essential rewiring of the nerve path is a huge factor, which is why after a while the opioids stop having the effect that they do and people need more to get the same relief. That’s a reason I groan when a patient is started off on Percocet before being tried on other things. You can’t undo the nerve path alteration. Like I said, the answer isn’t to restrict the drug through the pharmacy’s end. The people abusing the drugs for the high are going to get their hands on them regardless of what class they are placed in. The answer is to focus on treating pain properly from the start so patients can have a decent quality of life.

      It’s not really the patients requesting the early refills that gets me. It’s that it’s the same primary care doctors calling in the early authorizations for many, many patients over and over every month. If they need to be calling in so many early authorizations, the patients are obviously not being treated adequately, so they either need to be more focused on the patients’ pain management or refer them to a pain specialist. I still feel that primary doctors should not be the ones treating chronic pain. In an acute situation, sure. But, as maintenance therapy for years? No. That’s why there are pain management doctors. There are specialists for a reason. Diabetes patients are referred to endocrinologists. Patients with immune disorders are referred to rheumatologists. Chronic pain patients should be referred to pain specialists. I think this would not only help with the overuse and misuse, but it would be more beneficial for the legitimate patients who are truly suffering.

      It sucks that most community pharmacists are wary of every patient that hands them a prescription for Vicodin or Percocet, when 99% of them aren’t abusing it. =(

  2. Lois1117 says:

    It is ridiculas for a disabled person to have to go to 5 pharmacies to get pain meds i think after 2 hip replacements and end stage osteoarthritis the pharmacies should be able to keep meds in stock.it is crazie to put up with this

    • I agree, though this shouldn’t affect the amount of hydrocodone products pharmacies have in stock. It would just affect the frequency with which a person can get it filled. It would also make it illegal to authorize refills, meaning you need a new script from the doctor every month. This regulation, thankfully, has only be enacted by the state of New York and not federally. It’s a hassle for both the pharmacy and, more importantly, the patient. Like I said in the post, the regulations should be stricter on the prescribing end, not the dispensing end. They need to stop it at the source and prevent “pill mill” doctors from practicing. Making things super strict in the pharmacy doesn’t help deter abuse very much; it just makes it more difficult for the legitimate patients that are already suffering. =/

      My suggestion to you, since you seem to run into trouble with things being in stock, is to talk to your local pharmacist that dispenses your pain meds and ask them to try to keep enough in stock for you. If you are a regular patient at your pharmacy, it shouldn’t be a problem. Most of my chronic pain patients are on very odd strengths and doses of their meds, so it’s easy for me to keep track and make sure we always have enough. The issue pharmacies have with keeping things in stock is when people switch pharmacies every couple of months. When that happens, pharmacists cannot foresee what people will need on a regular basis. For instance, I usually fill Exalgo (a pretty potent pain med, in case you are unfamiliar with it) for 2 people, so having 1 bottle in stock is more than enough for them for a month. But, last month, we had a person who temporarily switched to our pharmacy get twice as much as our “regulars”, so it threw things off a bit. I didn’t want to deny the new person their meds, but I was worried I wouldn’t be able to replenish my stock before one of my regular patients came in again. Like I said, have a good chat with your pharmacist and explain your frustration. Most will be willing to work with you and order it in advance, so it’s there when you need it. If they’re not willing to accommodate you, then choose another pharmacy. You don’t need to go where you are treated like a junkie.

      I hope you get things worked out and are able to get your meds.

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