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The Pain of Painkillers

October 25, 2013

The DEA and the FDA have a funny relationship.  The DEA deals with drug overdoses, both illegal and legal.  The FDA deals with drugs, legal only.  The DEA can tell the FDA what it thinks but the FDA doesn’t have to listen when it comes to legal drugs.  The DEA has been recommending for a long time that the FDA put Hydrocodone on the same list as morphine, that is, a Schedule II narcotic, subject to restrictions on prescription and use that other drugs are not.  The DEA says this because it sees the data on prescription drug overdoses.  The FDA, subject to the lobbying efforts of doctors and physician organizations, has been reluctant to do this.  I actually thought Hydrocodone (Vicodin for the average joe) already was Schedule II.  It’s by far the most common post-operative pill prescribed by surgeons (anesthesiologists don’t usually give prescriptions for post-op pain after the patient leaves the recovery room, that is usually the surgeons purview).

Ordering practices, or prescription-writing practices, have a habitual component.  Doctors prescribe a certain number of pills based on their experience with how painful the surgery is, how much manipulation they had to do, how many of these procedures they have done, etc.  Ideally the decision about what and how much to prescribe is also based in part on knowledge of the patient.  Some people, in all honesty, need more pain meds than others for the same surgery, and this is based on personality, anxiety, pain tolerance, other prescription drugs they may be taking, etc.  In this age of fragmented care the surgeon may not know the patient that well, hence the resort to habitual prescribing practices.  The decision about what and how much to prescribe also tends to have a component of doctor convenience.  Nobody likes to get called in the middle of the night for pain prescription refills, so it’s easier just to write for a whole bunch of pills just in case.  This presumes that the patient will only take what they need and throw out the rest.  The FDA is going to require that prescriptions be filled for only 90 days, then if you want more you have to go see the doctor again.  In acute pain, like surgical pain, in which the duration and degree of pain can be anticipated to some degree, this is more than reasonable.  If you are given Vicodin for, say, knee surgery, if you still need narcotic pain relief after 3 months you really should see the doctor because something might be wrong.  Normal surgical healing time implies that you really shouldn’t need the pills anymore.  If I were a surgeon and my patient were still having that much pain, I’d want to see him or her.  So on the acute pain side, I think the requirement is reasonable, and most patients won’t be inconvenienced.

Chronic pain, pain that lasts more than three months or is related to some other long-term condition, is a little different but in the case of Vicodin the new regulation still makes sense.  Chronic pain often doesn’t respond to narcotics, or may respond only in combination with other drugs or procedures.  Chronic pain has a significant psychological component as well as poorly-understood cellular and neurological mechanisms.  Vicodin is one of only a dozen drugs that pain specialists use.  If you have a long-term relationship with Vicodin, you should be seeing a chronic pain specialist.  Some chronic care specialists suggest that the new rules might cause people to have trouble getting access to care.  Poppycock.  Chronic pain patients see their pain doctors frequently, as they should.  If you need narcotics for more than three months for any reason, you should see a doctor, inconvenient or no.  If the doctor thinks you need more, he’ll write a new prescription, and the pharmacy will fill it.  That’s not an access to care problem.  That’s good medicine.

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From → Healthcare

2 Comments
  1. eqvet2015 permalink

    Good post. I would also add that there is an amazing diversity of neurobiological factors due to genetics, epigenetics, non-neuronal factors affecting PK/PD, and prior experiences rewiring that amazingly plastic organ system that the “etc” in your sentence about individual variation does not do justice to.

    Unfortunately, there is a different access of care issue in some (many? I don’t know) areas of the country. I.e., trained pain doctors who are good at pharmacological management may have waiting lists of weeks to months, so patients who inhabit the grey zone – of the transition from acute pain to chronic pain, of surgical complications or surgical pain that should have gone away but never did, of pain that doesn’t respond to “take two Vicodin and don’t call back if it doesn’t work” – end up suffering because no one is both willing and able to help them get back to normal function. However, that doesn’t mean that letting non-pain docs throw more opioids at the problem without monitoring the patient is going to improve anything.

    • Good point about the access to care. I live and work in Boston where there are 100 doctors per square mile. I can see how the regulations could be tough on someone without this level of availability of pain management doctors.

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