Pain Experts Predict Problems with Hydrocodone Rescheduling

Pain Experts Predict Problems with Hydrocodone Rescheduling

Pain management experts say the rescheduling of hydrocodone by the U.S. Drug Enforcement Administration could have many unintended consequences, including higher healthcare costs, as well as more suicides, addiction and abuse of opioids. Many physicians may also refuse to write prescriptions for hydrocodone products, fearing fines or prosecution.

“I predict there are going to be a lot of people who are going to find it even more difficult to get access to medication that can help them,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine.

“We may see an increase in the amount of deaths from opioids, not a decrease in the amount of harm. These are the sort things we just cannot perceive.”

Vicodin5mgcroppedThe DEA estimates that seven million Americans abuse prescription medications, including opioid painkillers like hydrocodone, and that nearly 17,000 die annually from narcotic overdoses.

The agency announced last month that it was rescheduling hydrocodone from a Schedule III medication to the more-restrictive Schedule II level because of its “high abuse potential.”

The rescheduling, which takes effect October 6th, means that pain patients taking Vicodin, Lortab, Lorcet or other hydrocodone combination painkillers will be limited to an initial 90-day supply — and then will have to see a doctor for a new prescription each time they need a refill. Prescriptions for Schedule II drugs cannot be phoned or faxed in by physicians.

“One of the unintended effects is that it’s going to raise healthcare costs tremendously. I don’t know if our healthcare system is ready to accommodate even a fraction of those additional visits,” said Steve Passik, PhD, Vice President of Research and Advocacy for Millennium Health.

“And what happens to all those people? Some of them are going to be abruptly stopped. There are going to be patients whose physiological dependence has been sort of underestimated. They’re going to turn up in emergency rooms. I think a lot of people are going to stop prescribing altogether. Some of the alternatives we know are problematic, NSAID’s, acetaminophen, Tylenol and so on.”

“Where are those patients going to go and what kinds of treatment are they going to get is the big question,” added Webster, who spoke to National Pain Report in Las Vegas during PAINWeek, a national conference of practitioners in the field of pain management.

“They’re going to look for an alternative like Tylenol with codeine — and we know that has a lot of inherent problems. And we’ll probably see a tremendous increase in Ultram. I’m not sure those are equal alternatives to hydrocodone. They’re still addictive drugs. There’s still potential harm from them.”

Patients May Turn to Black Market

Another possibility raised by Webster and others is that some patients may turn to heroin or other drugs on the black market to relieve their pain.

“To think that rescheduling of hydrocodone is going to have a huge positive in the war on drugs is really a big mistake,” said Dr. Jefferey Fudin, a pharmacist and advocate for pain patients.

“I think from a black market standpoint overall, you may see heroin use go up. We’ve already seen because of PDMPs (prescription drug monitoring programs), as we’re tracking drugs more closely, that heroin use went up because people that are trying to get these drugs can’t get it as readily as they could before. So if the same holds true and they can’t get hydrocodone, it’s one less thing that they can get their hands on. They may go to the street to get heroin because it’s relatively cheap.”

“What is it going to do to the black market? I’m not sure,” said John Burke, president of the National Association of Drug Diversion Investigators. “It’s obviously going to reduce the prescribing of it (hydrocodone). There’s some people (doctors) who are probably going to shy away from it is my guess, just because of the inherent fear of Schedule II and the fact that they can’t write for multiple refills or can’t call it in when they need to.”

For patients unwilling to use illicit drugs or turn to the black market, rescheduling could also mean more suicides, according to Webster.

“Without a doubt, in my view, if we are unable to provide adequate relief and treatment for people in pain that there will be an increase in suicides,” Webster said. “It’s an under-reported problem today. Certainly some of the opioid related deaths are people who took more medication than they should and die as a result, unintended or intended. It’s hard to know because they’re not here to tell us.”

Hydrocodonebtibu75200The rescheduling will affect dozens of pain medications that contain hydrocodone (a complete list is available here). Typically in these products, the hydrocodone is combined with either acetaminophen or aspirin. Over 130 million prescriptions are written annually in the U.S. for hydrocodone products – making it the most commonly prescribed drug in the country.

Webster says it’s a “myth” that hydrocodone is abused more often than other opioid painkillers.

“Everyone knows that it’s the most common drug prescribed (for pain management). And yet there’s a myth that it is one of the most dangerous drugs. The truth is if you take a look at the harm that is caused by hydrocodone; it is one of the lowest, if not the lowest, of the Schedule II and above, relative to the amount prescribed,” he said.

Pain Patients Worried

Many patients worried about losing their access to hydrocodone wrote to National Pain Report about their concerns.

“The DEA needs to stay out of this! It really makes me angry that they keep making it harder and harder for pain patients to be treated. Saying chronic pain patients shouldn’t be treated with opiates, and then changing hydrocodone to a higher schedule just makes me so angry,” wrote Trudy Myers.

“I am a 62 year old woman in chronic pain from my back thru my hip down my leg and into my foot. If not for Vicodin taking the edge off every few hours I would not be here anymore because I live thru such pain every single day for 3 years,” said Marty. “All these changes in chronic pain patient’s medications will no doubt increase suicide in pain patients because without small amounts of pills to at least dull the pain a little, we have no life to live.”

“I have no insurance and being in Alabama I fall in the gap, too much income for state help and not enough to enroll in the plans offered by the healthcare law,” said Deborah. “Now I’ll have to pay out of pocket to see my doctor monthly. This will mean the money for these extra visits MUST come from somewhere and it will come from the food budget which is barely sustainable now. My family would be better off if I were dead.”

Millennium’s Passik says patients in rural areas may find it particularly hard to get pain relief when hydrocodone is rescheduled.

“What are rural patients going to do in the middle of the night when they have pain and they can’t get anything?” he asked.

“I’m very worried about the public health consequences of it. It’s not that I’m in favor or not. I think some of the intended effects are needed, but I’m worried about the unintended effects.”

Authored by: Pat Anson, Editor

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Brad

My issue is, I guess, more with the issue it causes on the state level. I work for an APRN and we live in a state where schedule III is the highest an APRN can prescribe. It is hurting MANY of our patients who now have to take Tylenol w codeine instead of the hydrocodone that they have been controlling their pain with. Many people cannot metabolize codeine and in the end it leaves the APRN’s hands tied and unable to fully treat our patients. We live in a town with one medical clinic that has MD’s and their waiting list is 3 months currently. Hopefully we can get some legislation started to allow APRN’s more freedom to treat the patients they see.

it didnt work

the DEA does not care about your health. they are trying to stop people making money on the streets by sale’n meds. all people did was up the street value by 2 dollars. old people have bills to be paid and they will sale their hydros to survive. since the DEA tried to “slow down pain killer abuse” they actually made it easier to get and the ppl sale’n them are making more money……trust me

bob john

What are some of you guys even talking about? You should hear you guys trying to sound like you know what your talking about. If you are ACTUALLY living in pain & have proof, MRIs, etc. You should be able to find a doctor to help you. I live in an area where doctors avoid painkillers like the plague, but I have been on oxy for 8 years. Ive been addicted, been fired from 3 clinics for violating “pain contracts”. Im alright now with a GREAT doctor & a valid pain contract. My doctor gives me 90 days of meds at a time utilizing “post-dated” scripts which I give to Walmart all at the same time & they give 30 days at a time. I take Oxycontin CR & oxycodone ir. It has always been a problem to get ANY kind of pills this side of tylenol 3. A bunch of you that are bitching are just addicts getting one tooth pulled at a time harassing dentists because a doctor knows there isnt anything wrong with you

Mike J

While I understand the need for some kind of change, this is a horrible solution. My wife has trigeminal neuralgia (also known as the “suicide disease” due to intolerable levels of pain) and has been prescribed norco for almost 8 years. Two different procedures did not rectify the problem and, if anything, made her situation worse. Her neurologist is now considering retiring due to these new laws. He doesn’t want to deal with excessive visits from patients who are just picking up Rx’s. I hope the brainiacs in the DEA get to experience waking up in the middle of the night to their significant others / spouses reduced to tears yelling in agony…

T. Wilson

My mother was diagnosed with breast cancer and just had a double mastectomy. The doctor gave her Tylenol 3. She hurt for two weeks and it was horrible to watch. This country has lost its mind.

Edward Boss

I have full Medicare and Medicaid QMB and have took moderate pain meds for a sciatic nerve in my back for years. Now at 57 I am just going to have to see more of my doctors more and let them charge the gov more for steroid shots at the pain management clinics over pricing. I don’t care about kids overdosing because their negligent parents leave meds laying around, mine never did. I do see the new socialistic government slowly intervening into every single aspect of everyone’s life for good or bad. Just Obama waving his wand of amnesty in it self is going to cost 2 trillion in medical cost in the next 5 yrs.

I have severe cervical vertebrae issues from top to bottom all of my cervical vertebrae are out of whack. An x-ray of my neck looks like a derailed train. I have taken one or two 10/325 norcos a day for five years. I have never over done my meds.,do not consider myself an addict just a 66 year old retired construction worker that wakes up eight pin everyday not only neck spin but knee,hip arm and shoulder pain also. Am I supposed tolive in pain for the rest of my life go buy some illegal shit in Mexico. Marihuana makes my pain worse not better..otherwise I would use it. Screw the DEA….I’ll get street drugs if the pain gets bad enough…what a great country we live in.

BL

It seems like if you’re pain isn’t considered severe enough to require extended release meds, that it isn’t being considered severe. In the past few yrs the move has been towards putting patients who suffer from chronic severe pain on extended release meds. Some drs are even beginning to move away from using break through meds. Has anyone been offered a extended release med instead of the short acting hydrocodone combination meds like Norco ?

Don T

This is another example of an out of control abusive government agency. I just had an operation and could only get 30 pills. This rule is an overreaction and makes life worse for people and healthcare providers. I can see why people talk about abolishing government agencies when the have morons in them that make idiotic decisions that are draconian. I feel bad for the people with chronic pain issues the agency just sentenced to a life of agony. We all need to write to our Senators and Congressmen to have the force a correction and fire the idiots responsible for this obscene rule. The DEA should worry about doing their primary jobs properly instead of going after law abiding citizens.

Stephen S. Rodrigues, MD

Bone pain is a different problem and concept:
http://www.nlm.nih.gov/medlineplus/ency/article/003180.htm

Throughout history, it has always been assumed that long-term or everyday aches, pains and stiffness was in the flesh or muscles. This pain was treated with herds, rubs, liniments, snake oils, massage, stretching, traction and rack-like contraptions. This is probably where chiropractic or hands-on manipulative medicine got it’s start.

Things changed about a decade ago when it is easier to give out pills and more lucrative to “fix” pain with complex surgeries.

All pain has a cause.
All pain has a treatment or cure.
All pain should be treated with the appropriate matched therapy.
All acute pain should be evaluated in the hospitalization to find the cause and cure.
All long-term pain which is usually invisible to technology should be consider in the myofascial tissues.
All pain thought to be in the MF tissues should be effectively treated until resolved.

All MF pain can be treated from this list:
Beginning with simple stretching, yoga, massage, Chiro adjustments, Active Tissue Release, Myofascial Unwinding, other hands-on manipulation options, Acupuncture and all of the various types, Gunn-Intramuscular Stimulation, dry/wet needling to finally hypodermic needling, Travell/Simons injections, biopuncture, prolotherapy, neural injection therapy and platelet-rich plasma and various other hypodermic injections.

Notice that the most effective MF treatments are not covered insurance benefits so you must pay out-of-pocket.

Also notice that most of the effective treatments are disavowed by key policy makers in the medical and research communities.

Notice you are at a disadvantage. Please complain to your local Legislators to make the necessary policy changes in your favor. OR nothing will happen in your favor in our lifetime.

Rosie r

This will be an epic FAIL for the DEA. I have had multiple back surgeries and bone grafts and have been declared 54% disables for the rest of my life. I have no idea what it is to be without pain. I had a functional life before the schedule change. Neveer took more than prescribed and I dont have teens in the house to steal my “stash” so to speak. I WAS doing really well until this change. I go to a spine center. The docs and the pa’s took EVERYONE off vicodin products. Everyone. I have called twice telling them Tylenol 3 does not work and barely helps with paid. The pharmacist also says it’s only for short term use. I cant deal with this. Because of the DEA, my life and pain are now unmanageable when before, I was doing pretty well. I may have to give up my part time job now.

jose fernandez

I have cronic pain for 19 years 10 years without workin mal practice on my surgery and still have 2 more disks still broken the only pain killer i been prescrived is hidrocodone now even with prescription is imposible to buy at the farmacy may only chance to live this word with dignity is to move oregon and get my life suicide assistance hidrocodone only extended my functionality 8 more years but now i’m on bed the pain is worst every day i have 20 days without my med all dais been the worst on my life

Johnna Stahl

From Wikipedia’s “Bone pain” page:

“For many years it has been known that bones are innervated with sensory neurons. Yet their exact anatomy remained obscure due to the contrasting physical properties of bone and neural tissue. More recently, it is becoming clear what types of nerves innervated which sections of bone.”

Under “Research” heading: “Treatments focusing on biological components such as cannabinoid receptors are being tested for effectiveness. Through testing in mouse models, it has been shown that activation of the CB-1 receptor helps reduce reactions associated with acute pain, indicating that it alleviates bone pain. Thus, a new target for potential treatments is activation of the CB-1 receptor.”

HB, I have always described my pain as muscular, mainly because it hurts to move. But that doesn’t mean my bones don’t hurt, too. Specifically, TMJ causes pain in both the jaw joints and all the teeth connected to them. This bone pain is where my highest pain level can be found, which averages about a 7 — but can be much higher during episodes of increased pain.

I switched from a prescription medication regimen to medical cannabis, but it was hard to find cannabis that was strong enough for me. That’s because I’m in New Mexico, and its medical cannabis industry is small and expensive, with few options (compared to Colorado or California). There is plenty of information on the web about the 23 states that have medical cannabis programs. If you don’t live in one of these states, there are ways to obtain cannabis on the underground market — if you understand and are prepared to face the risks.

For my bone pain, I was able to obtain up to about 25% relief from the bucket full of prescriptions I used to take (including hydrocodone and oxycodone). With marijuana, it’s more about the ability to relax and distract, then about “relief,” so it’s harder to quantify with a percentage. If I had money, I would try to find a doctor that would prescribe both hydrocodone and cannabis — I think that combination would work best for me. Since the U.S. is a very big place, I’m sure with enough time, effort, and money, I could find such a doctor.

I’ve learned a lot about cannabis since I was in my state’s program, so if you want more detailed information on that treatment, you’ll have to email me (address below).

HB

I will need hydrocodone or oxycodone for the remainder of my life. The pain I have is bone pain. Is there another country where I can live, or a US state that allows hydrocodone? Although it has been recommended for me, I don’t want to take oxycodone yet because the day will come when hydrocodone probably won’t relieve my pain, and I will be forced to take oxycodone.

I would appreciate any advice about where to live the rest of my life in peace with hydrocodone available. Also, does anyone know if medical cannibis will help bone pain like hydrocodone or oxycodone? If it does help bone pain, is it as good as hydrocodone, what kind do you buy, and how do you buy it? Thank you for helping me.

Johnna Stahl

RM said: “…but more consideration across the board should have been taken into account before coming up with a draconian answer to HCP’s. This was something they had been considering for a looooong time.”

What they’ve done is to further restrict (both in supply and access) the pain medication that works for most people who take it — hydrocodone. The same can’t be said for all of the other available pain medications (and I’ve taken them all).

These agencies have undoubtedly been planning this for a long time, and I suppose almost any plan they came up with would hurt pain patients. After all, most pain patients are seen as current or potential addicts, so the rules to stop abuse would automatically hurt us.

And it’s not like politicians are hearing from pain patients, most of whom are in too much pain to fight or too afraid to rock the boat. It seems to me that, until the lawsuits begin, nothing will change. Unfortunately, not too many people can afford to hire a lawyer.

But it all makes me wonder if the cruelty shown to pain patients was purposeful… gotta be cruel to be kind, right? Once pain patients learn they can live without hydrocodone (and Big Pharma), a small percentage will turn to stronger “illegal” drugs , but most will learn other ways to adapt. So, one has to also wonder if these new ways will cause further harm (heroin) or not (medical cannabis).

Does anyone else feel like a rat in a research lab? Or a rat in a maze that has no exit?

RM

I am new to this forum, but agree with most of the individuals posting here in regards to the hardships this new ruling is going to cause. My opinion is shaped from being a nurse for nearly 20 years. The FDA has been talking about rescheduling, or worse, banning most all narcotics from the scheduling system, for several years. When I first caught wind of this “ugly aroma” about rescheduling HCP’s I began to fear the worst, and the worst is now here. I can predict that people will turn to other forms of pain relief for their actual somatic issues: MJ, heroin, illegal acquisition, overseas supply, etc., etc., etc. The ramifications and fall out will be discussed for years to come. Any ruling like the one that came down from DEA/FDA collaboration will take and act of God, or the Supreme Court, to overturn. BL stated that public hearings were held while the FDA, DEA, and DHH, collaborated on this issue. That is true, but more consideration across the board should have been taken into account before coming up with a draconian answer to HCP’s. This was something they had been considering for a looooong time. In other words, they wanted to do this a long time ago. This was not recent careful consideration of scientific studies, or careful debate with experts on the real issues involved.
This new ruling has very real ramifications and most of them are negative in nature. From a realistic standpoint will this stop the real problem of diversion and drug abuse? No, probably not. Will this increase prosecution, incarceration, and bloating of the FDA and DEA budgets? Maybe and probably. The ruling does not touch the real issues of diversion and abuse. that is the sad part of it. When a loved one has to be treated with Tramadol for long term pain and gets no relief, the issue will start to hit home. Already I have seen the increase in use of Tylenol #3 for treatment of pain and for sending home with patients. This drug is less effective on treating pain than Vicodin/Norco. So, this is what we are left with. Very sad.

Jason

It’s a crying shame when the government gets involved where they don’t belong, when will we as the people stand up for our rights before there isn’t any left to stand for? I also had a choice to live off of the government on disability and I’ll be damned if I want them in my business more so than what they already are!!! The only way I can work is with my meds and it’s not just opioids it’s also a medication to stop the bone breaking cramps caused from my spine. Obama and his servants of satan can blow me! DEA , you are nothing but as* kissers and we all know how much you care about all of us addicts right? Because we all fit in the same category right? And because of a few we all have to suffer? And you wonder why people want to blow up your offices and kill your families? Self righteous pri***!! And that goes for all you self righteous sob’s who think your better than others because you’ve got your health and you can walk without reeling in pain!! WHAT HAPPENS WHEN YOUR ON MY SIDE OF THE FIGHT? What then? Will you still say it’s great laws you helped create and supported? Hey DEA, what happens when that crackhead you should’ve been after shoots you in the spine and you need some painless nights and days? What if it was your son or daughter crying daddy mommy it hurts, help me please! THINK!! Quit being so quick to judge all others for a few!!

Johnna Stahl

Chuck: When I couldn’t find any pain doctors in my state willing to continue my 8-year treatment program, I traveled by plane to a different state — but all it did was cost a lot of money and prolong the inevitable.

If it hadn’t been for medical cannabis, I don’t know what I would have done.

Chuck

I was on my way home from work minding my own business when I was hit by a drunk driver. Since then I had to have back fusion in my lower back. I got staph infection while in the hospital spending almost 30 days there recuperating. I don’t want to go on disability and the medications allow me to work as I don’t abuse them. I, like others, never wanted this, who does? It is hard to get out of bed in the morning. I get up early to take the meds then lie back down until they start working. But over the years the DEA keeps making them harder and harder to get. You are made to feel like an addict. You already feel bad enough without all the problems just to get the meds. Then working overseas doubles the trouble to get the meds. It is very hard to get them in some countries so you have to get a supply to last you. Then your doctor stops writing prescriptions for the meds because of the DEA. So now you have to hunt for another doctor which is getting harder and harder. Even the pain management docs don’t want to give you any or give you enough. Again you are made to feel like an abuser. So now not only do you have the stress of the pain but the stress of finding a doctor to help you. The DEA needs to stay out of it as they are making things worse. It doesn’t matter what they do there will always be people who abuse the system. So what do we do now. It just gets worse and worse and now I see why people commit suicide. If it weren’t for the Lord I don’t know what I would do.

Johnna Stahl

Amy, I also think hydrocodone is one of the best medications for chronic pain. Unfortunately, codeine is probably the strongest prescription pain medication you can get at this time. You know, unless you’re on your death bed. (And just feeling like you’re on your death bed doesn’t count, according to the DEA and doctors.)

I’m also in New Mexico, one of over 20 states that has a medical cannabis program. If you can’t access hydrocodone, maybe you could at least try to access medical cannabis?

I created a list of pain doctors in New Mexico for my own use, so maybe I could give you some more names to call? If you need help, I would be happy to lend whatever assistance I can. I’m at painkills2@aol.com.

Amy Frank

I understand what the doctors are saying. I’ve read many articles about doctors going bankrupt. Already in New Mexico I can not get hydrocodone prescribed. The PCPs hang up signs saying we do not treat chronic pain patients. I’ve also contacted the pain clinics here in New Mexico. They are telling me to be large minded and not to expect to use hydrocodone ever again. I had one PCP tell me that opiods create pain and if I just walked I never would have had chronic pain. I know now that I will have to live with level 10 pain on a constant basis. I had tried all other treatments as I had had chronic pain for 20 years. Hydrocodone was the only medication that helped me.

Crongy

f**k the DEA bastards. Just another of our freedoms being taken away by the Feds. It makes me sick, literally SICK inside to see this happening in a country that has our constitution. Shame on our government for letting this happen. Our forefathers are turning over in their graves. Goodbye America!

Indrid Cold

As of 10-21-2014 there were zero hydrocodone/acetaminophen tablets to be had at ANY Las Vegas NV pharmacies. None at Wallgreens, None at CVS, None at Costco pharmacies. Additionally, none of these chains could offer an estimate of when the medications would be available. As I suspected, legitimate pain sufferers, with legitimate prescriptions are unable to obtain the medication they depend on.

BL

DS, the part of the law about the refills on rxs written before Oct 6 says the pharmacist “may” refill. I guess they put that in the law as a “cover their a** clause, so to speak.

DS

A lot of the chain pharmacies got together and decided not to fill ANY hydrocodone products even if they were written before October 6th. They decided it was too much trouble and would rather not deal with it. Since they’re now C2’s, they can’t be transferred to a pharmacy that would fill them. So the pharmacy cartel decided it was afraid of the DEA nazis and that patients aren’t that important. Everyone is so afraid of the DEA it’s sad…I have no respect for them or their employees. The war on drugs is a failure and the government keeps deciding it’s job is to protect me from myself more and more. Many for the rescheduling say 60% of hydrocodone products go unused which is where addiction can begin as teens will find these unused pills and experiment, yet they also use the high amount of prescriptions to show how how of control the issue is. So we have a problem because we have 175,000,000 prescriptions written which are all being abused and then we also have a problem because teens get a hold of the 60% of unused hydrocodone and their addiction starts there. Then we have 44,000 deaths from opiates(yea, I’m sure it has nothing to do with the alcohol they used to wash down the Norco or the 5 grams of Tylenol the abuser took…). These statistics are manipulated and twisted to such a point it’s a joke. Maybe, roads, sidewalks and homes should be built from rubber so no one hurts themselves and needs an Rx in the first place. How about we shitdown the DEA and use the funding for cancer research. I know for a fact if we cured cancer less opiates would be prescribed than what this rescheduling will do. In a year, I guarantee they’ll say deaths are on a huge decline because then they WILL factor in what ACTUALLY caused the overdose. Like how if you’re a tobacco company you say people die from lung cancer, but if you’re anti-tobacco people die from smoking. This whole prohibition/rescheduling thing is a joke and it all needs to go back to the way it was.

Stephen

Hell, the government should be hand delivering my damn medication instead of making it harder for me to obtain. I was robbed and shot two times in the head with a bolt-action rifle by an “American soldier”, and a cocaine buddy of his a little over 6 years ago. I am now permanently disabled, in constant pain, and will have to risk being ran into by the idiots on the road in my town, and possibly killed by the rifle round in my brain just to get my damn medicine! This country truly is going down the drains.

BL

Johnna Stahl, personally, I don’t believe any of the federal agancies will do anything adverse to the pharmacies that refuse to do these refills. I understand that it is Federal Law, but it is still up to each pharmacist to decide if they will fill or refill a rx. It isn’t right, but I’m not surprised. It is possible that the pharmacys can claim it is due to cost. When the med was a Schedule III, it was cheaper to dispense that it will be when it is a Schedule II. Whatever the reason(s), you can bet that once again, the drs won’t be the ones that decided how to prescribe for patients. For example, a dr may have written the refills because for some reason the patient can’t get back to the office for several months, or perhaps the patient doesn’t take the med every day but does take it several days a week, etc. It will be interesting to see how this plays out.

Johnna Stahl

BL writes: Insert from a local pharmacy: “Unfortunately, any refills remaining on Hydrocodone prescriptions will not be available as of October 6, 2014.” (Even though the federal deadline is in 2015.)

I am not surprised that the pharmacies are creating their own rules and deadlines. If they’re not ultra-compliant, the DEA will have their heads (and their licenses). And the DEA controls the supply and distribution of many (or all?) of the products that pharmacies sell. (Can anyone say “cartel”?)

The biggest provider of prescription drug insurance has already taken Zohydro off its formulary, regardless of whether the FDA approved it for use.

The CDC is advising doctors to only prescribe pain medication for cancer pain and end-of-life care.

The pharmacies, doctors, insurance companies, DEA, FDA, CDC — heck, let’s throw in the NSA, FBI, and the ACA while we’re at it — where will the next threat to pain patients come from?

Seriously, our fight is starting to look rather sad.

BL

The confusion has already started. Federal Law states if a rx is written before Oct 6 and has refills that the refills can be filled until April 8, 2015. “Prescriptions. All prescriptions for HCPs must comply with 21 U.S.C. 829(a) and must be issued in accordance with 21 CFR part 1306 and subpart C of 21 CFR part 1311 as of October 6, 2014. No prescription for HCPs issued on or after October 6, 2014 shall authorize any refills. Any prescriptions for HCPs that are issued before October 6, 2014, and authorized for refilling, may be dispensed in accordance with 21 CFR 1306.22-1306.23, 1306.25, and 1306.27, if such dispensing occurs before April 8, 2015.”

But, I saw a infomation insert from a local pharmacy today that states “What if my prescription has refills remaining as of October 6, 2014 ? Unfortunately, any refills remaining on Hydrocodone prescriptions will not be available as of October 6, 2014.”

Go to VII. Requirements for Handling HCPs, then to Prescriptions-
http://www.deadiversion.usdoj.gov/fed_regs/rules/2014/fr0822.htm

Norco has kept me working full-time for the last 8 years. I have very few side effects and it is the only med to have a lasting impact on my chronic digestive pain. I am heart broken to see this crack-down and worried it will only get worse for people with chronic pain. We don’t seem to have any impact or receive any empathy as a disease. Can’t imagine making treatments for cancer or diabetes harder to obtain without a national outcry.

Johnna Stahl

Deborah, thanks so much for keeping us updated, and letting other patients know what they can expect (or ask for, if not offered this choice).

I also think there is a big difference between the effectiveness of codeine over hydrocodone — but then, I think there’s a difference between generic and brand, too.

Take it easy with your new regimen, and give yourself time to adjust to your new pain levels. You might also want to add “legal” drugs like caffeine and sugar, which can sometimes boost the effectiveness of pain meds.

Deborah

I am the Deborah quoted above. I am happy to report that I will still be able to see my doctor every three months instead of monthly. I’m sad to report that my medication has been dropped down from Norco to Tylenol 4 a much weaker medication.

It is an understatement to say I am terrified. Norco allowed me to remain somewhat active. I know that this change will put me straight into the wheelchair I’m prescribed.

I pray that I’m not allergic to the codeine and that my stomach tolerates it. If not I don’t know what I will do.

BL

Aaron M. Levine MD, The general public doesn’t realize the cost of having a medical practice, sadly. Thank You for putting it in plain words. Your operating expenses are conservtative. It is obvious from what you’ve said that you care more about your patients than the money they bring in. Your retirement will be a great loss to your patients.

Johnna Stahl

“The perfect storm is coming. I suspect the plan is to make it hard to get the pills to avoid treatment and thereby avoid abuse.”

I appreciate the information provided by Dr. Levine — it is good to be reminded how hard the DEA has made life for doctors. And since I am familiar with the amazingly powerful Texas State Medical Board, including their collusion with the DEA, I am surprised there are any pain specialists left in that state.

But the perfect storm is already here. The plan to make it hard to get pain medication has forced patients to seek other avenues of treatment, and ipso facto, we now have patients dying from illegal and unregulated heroin. (Not to mention the amount of suffering by patients unable to access adequate treatment.)

Thanks DEA! No matter what, we can always depend on ya’ll to make everything worse, especially for pain patients (most of whom are also disabled and poor). I bet there are no pain patients working for the DEA who are denied medication.

Bullies get a kick out of making life miserable for those unable to fight for themselves.

Aaron M. Levine MD

I am board certified in pain and general rehab medicine. The latter is my bread and butter. The increased time spent in the hospitals and paper work in the hospitals has cut back my office time so I see fewer patients with pain. Texas workers comp cut the pain medications I could presecribe. Now insurance companies are asking for more precertifications. Each takes 20 min or more on the phone, etc. When I am down to 2 -3 hours a day in the office, and 10 hours in the hospital, I either can not do preauthroizations for the medication or cut office hours and see fewer patients as such, or close up altogether. The DEA allows up to 3 months of prescriptions, but only 1 month at a time. This can be misleading as the state narcotic units will monitor anyone writing more than a month at a time. The Medical Board went through my records recently to see that I document what I write for, what I test for to avoid diversion, and that I see patients on a reasonable frequency the 90 days sounds good, but they want more frequent visits for people at higher risks. We are counseled to see patients more often to avoid being prosecuted as drug dealers. Hence, frequent visits. The cost of the EHR that was required by the Federal government adds to the time consumed in treating patients. A study this week said it takes an hour a day out of patient care or an hour a day out of rest time. The perfect storm is coming. I suspect the plan is to make it hard to get the pills to avoid treatment and thereby avoid abuse. While there are different treatments for pain, some insurance companies and Medicare place limits on therapies and other medications, so cheap pain medications may be the only option. In short, the problem is multifactorial, and I can not see any solution except retirement. Mine is coming.

Now, without trying to sound “cheap.” The costs for operating my office including malpractice, rent, salaries, health care, electronic records, license fees, etc comes out to just over $100 an hour. Medicaid pays $45 and hour and Medicare $80. I used to see people and ate the costs. I found I attracted people that others would not see, but whom I could not afford to follow me. I even paid for some medications for some people, I was behind in bills and loans, and then got told to expect costs cuts and pick up more expenses. Simple economics requires treating the patients from whom we can cover costs. Before any one jumps on me, my last vacation was nearly 20 years ago. My car is a domestic model compact with 60K miles on it, and my wife’s car has 130K on it.

I am a 6’5″ male…taller (and heavier) now because my lumbar was in such bad shape I had a major rebuild from the S1 thru the L3. Titanium discs, laminectomy, fusions etc… I now have a new knee and a new hip. I have constant pain from arthritis, too! So after over a decade of doctors ignoring my back, hip and “don’t worry about your knee” and constant years of misdiagnoses, I end up with a body so screwed up now even the pain management doctor I was referred to does not want to see me. The spine doc does not want to prescribe because of the new laws. I have a very physical job and the only thing that helps is simple NORCO 10/325 daily. So for all of you that failed to keep your teens out of grandpa and grandma’s medicine cabinet, the soccer moms that did not monitor the kids, you head off to Washington and cry fowl so now those of us in need get tossed to the curb. Guess what? When you turn 60 and have a body that’s been rebuilt you will want pain meds. l wake up in the AM not even wanting to get out of bed. You take the basic low level stuff away and smile while we suffer. Yes your little ones will be safer, except that the ones that are abusing it will just go to the black market to get it. So they won’t really be safer. Oh I forgot to mention…I have more spine surgery pending in November and already they don’t want me to have pain meds. So now it is supposed to be better for everyone with this new law?! I predicted everything I have read recently and can see that, between Obamacare and this new law, the drug dealers and Cartels will be the real winners. Is anyone aware that the Cartels have been stock pilling loads of the real brand name pain med drugs and buying in bulk from the drug manufactures around the world? They saw it coming so they can sell the pills and make more money. Did we forget to monitor the fake pharmacy build up in Mexico and other countries and the massive amounts of these low level drugs being produced and sold in huge quantities only to be sold back to folks on the street starting this fall? No! We let mommy and daddy cry wolf to the FDA and Dems in Washington. So now those of us growing old with chronic moderate to severe pain get to suffer more. These one sided addiction arguments are for the birds. What about all the TV adds that show so many new drugs to help anything that ails you but side effects and problems far beyond what NORCO or VICODIN can do to hurt someone. We pass a law now for every aspect of human life that people fail in…from medicine to getting a haircut we regulate who, what, when,… Read more »

Stephen S. Rodrigues, MD

@BL, Good insight! I have to say you are correct. I will rethink the petition.

BL

Rebecca Gavin, I said it is much harder to find a dr who accepts Medicaid, especially specialists. Few drs accept Medicaid due to the amount they are paid. Medicare pays much more so more drs accept Medicare and the quality of care in far better.

Regarding Louisiana Medicaid not paying for the management of chronic pain that is non cancer related. You cannot find a Pain Management Dr that will accept Louisiana Medicaid because it will not pay for it. The PCP’s and other specialists tell patients they need Pain Management. So it is up tp them to come up with app $300 every month to see a Pain Management Dr if they receive Medicaid. Many on Medicaid also receive SSI due to disabilities that cause chronic severe pain. Without pain meds, they aren’t able to do activities of daily living like take a shower, get dressed. prepare a quick meal, go grocery shopping, etc. The max federal amount for SSI in 2014 is $721 a month.

For those who receive Medicare and are low income, they should qualify for help with their Medicare Premium, co/pay and deductible through Medicare Savings Program. They should also qualify for Extra Help that helps with the cost of Medicare Prescription Part D costs.

Rebecca Gavin

@BL – You do realize that Medicare only pays 20% of medical bills, right? You obviously don’t have a clue what life is like for people who are both disabled and poor. With my Medicare Advantage plan, it’s the difference between $40/month for a specialist, and $10/ every 3 months for a primary care visit. I already do see a specialist every month, but I am fortunate that having worked for 40 years, my SSDI is higher than some people’s. It’s still a burden, and unnecessary. And, if you think that it’s not harder to find a specialist who takes Medicaid, you have never been involved with helping people on Medicaid. In my area, no general practitioner will even consider prescribing pain meds. I have to drive 1 1/2 hours each way every month. Gas costs money too. I agree you need to keep your comments to yourself.

Rebecca Gavin

ER, Dan…this was not a Senate action. It was an FDA action. Save your bombastic opinions about Democrats and West Virginia for situations in which they actually apply (if there are any.) I live in West Virginia, and it is a beautiful state with a very reasonable cost of living. It is rural, and rural areas require that people be able to amuse themselves because there are not the cultural amenities that you might find in more urban areas. It also has fewer of the problems associated with the urban areas. Poverty is certainly a problem here, that much is true. I am also resentful of those people who abuse the medications that I need to have a decent life. But you can’t blame Manchin for trying to do something for the people of West Virginia, even if you think it is misguided. There is a lot of suffering around here from the aftermath of drug abuse, such as the death of loved ones. So go stick your insensitive, ill-informed comments in your ear.

Rebecca Gavin

Another consideration is that many people who are getting by on Hydrocodone now, because it is easier to get, and is more readily prescribed by primary practice physicians, will be referred to pain clinics where their pain will be re-evaluated and they may be put on a stronger medication. It’s all schedule II so if someone would do better on Oxycodone or Hydromorphone or Morphine…they will get it. This might be better for those patients in terms of pain management. But the added cost of seeing a specialist and having to go monthly, may not be worth it to the patient. At this point, however, the choice has been taken away.

BL

Stephen S. Rodrigues, MD, I have lost count of the petitions from chronic pain patients asking for easier access to pain medications, over the past 7 yrs. But, none of them have had more than a very small number of signatures. I don’t know if people are afraid to sign something like a petition on the internet for privacy reasons or if maybe there aren’t as many being negatively impacted by more restrictions as some would have us believe.

Stephen S. Rodrigues, MD

There are many of CAM providers under the radar who have taken on this task, I’m just the one who uses this type of social media. This type actually seems a bit nonproductive so I may try a different venue.

“different invasive treatments”
This is an important concept related to the names given to all the different pain syndromes and the improper category idea. You can alter someone’s imagination by how you describe a problems. These terms used today are causing confusion leading to deceptions. I got the “Pain Cancer” idea when a breast cancer survivor was exasperated with her pain crying saying, “I’m all alone now no one is listening or want to help … when I had cancer they helped me.”

Based on what I now know I can make this statement, “All pain is valid, has a pathological cause, must be treated with the proper therapy based on it’s category of structural pain which requires with medications or surgery and nonstructural which requires Myofasical Release Therapy.

So this invisible “Pain Cancer” is a valid pain that requires the proper ongoing therapy until the “Pain Cancer” is gone! How do we know it’s gone??? When the Patients tell us it is gone! The power has to be placed in the hands of the patients, not the AMA, DEA, FDA, codes, insurance co, naysayers, policy makers or a cookbook.

The proper myofasical therapies are all basically old-school, safe, nontoxic, holistic and follows the laws of Mother Nature:
http://nationalpainreport.com/chronic-pain-is-manageable-with-the-right-therapy-8819887.html

None of these ideas are new or mine, I was fortunate to find the ideas in a few old textbooks. These books have been buried under technology, ideology, expediency, deceptors and profiteer who are now policy makers. Policy makers listen to those with the most influence and gifts, so we have work to do.

This pain care environment is actually getting worse so nothing will happen until you all rally around a single cause, the Change.org idea is falling flat :(. You may notice that each and every one of us is a tiny point of light on a separate path searching for a way — not working. I will draft another petitions based on “Pain Cancer”, present it, wait and see.

Johnna Stahl

Dr. Rodrigues said: “This pain progress and can act like a ‘cancer’ because it can spread deeper…”

Although I have never heard of the term “Pain Cancer” before, I find it hauntingly accurate.

Over 25 years ago, my pain started as a headache… just a simple headache. But as the pain progressed, it spread — from my head to my face, to my neck and shoulders, and on down to my toes. It wasn’t the same kind of pain in every area, and the level of pain varied, but most of the pain eventually became constant.

This progression didn’t happen overnight, and part of it is due to degeneration and referred pain. But…

Perhaps under-treatment contributed to the intractable levels of my pain (or maybe I would have ended up here anyway). And there’s always the chance that some of the pain and damage was caused by all of the different invasive treatments I suffered through before ending up on a drug regimen.

Most likely, it is some combination of all of these. But the pain does seem like an unstoppable invasion of something like cancer cells.

Thank you, Dr. Rodrigues, I really appreciate your input. In time, I’m sure the “powers that be” will appreciate it also.

Unfortunately, for pain patients, time moves so very, very (very) slowly. In fact, I’ve estimated that I’m already 100 years old — in pain years. So, I have to put my hope in making things better for future patients. And Dr. Rodrigues, some of that hope lies with doctors like you.

I hope that’s not too much pressure 🙂

Johnna Stahl

A doctor first prescribed medication for my pain because of the ridiculous amounts of Advil and aspirin that I was taking at the time. But I did not become addicted to the prescription drugs, I became addicted to the RELIEF they provided.

Can you become addicted to Advil or Tylenol? Not to the drugs, but to any relief derived therefrom? And isn’t overuse of OTC drugs also a big problem? Or are opioids only restricted and shunned because they are psychoactive (where the relief is found), while OTC drugs are not?

Because now that I don’t have access to pain medication (or, at this time, medical cannabis), I am back to the OTC drugs, which will no doubt do more long-term damage to my internal organs than narcotics.

And while the way that statistics are gathered for drug deaths is haphazard and not very accurate (especially when there is more than one drug in the system), ProPublica found:

“According to yet another database, the CDC’s National Hospital Discharge Survey, about 33,000 people are hospitalized annually due to acetaminophen poisoning, with about 75 percent of them having intentionally overdosed, the study found.”

Chronic/intractable pain is a disease of the nervous system and the brain. Treatment is not about a cure, it is about relief. And guess what? Compared to all other options for the treatment of pain, drugs are the most effective. So until all the stakeholders can agree on the reality of the situation, we will continue to move backwards instead of forward.

Stephen S. Rodrigues, MD

A clue to why we are in this situation,
“Medicaid doesn’t pay for the management of Chronic Non Cancer Pain”

I have found that this term, “non cancer pain” used to describe long-term pain is categorically and scientifically incorrect. IMO, this is fueling confusion and deceptions of what pain is and how best it needs to be treated. I have witness the most astute, learned, educated academic use it and unfortunately they are in positions of power who write the rules and regs we have to live with and abide by.

I see pain through a different lens and a more accurate term would be nonstructural pain. This pain is embedded in the flesh of the muscles, tendons, ligaments, fascia and bursae which makes it invisible, has no structure (like cancer) and cannot be detected by modern scientific technology(MRIs).

Pain can be grouped into 3 categories of problems, ALL require some help from us, a lot or almost none:
Structural; cancer, aneurysms, infections tumors and malfunctions. These need us the most.
Injury type: Twisted knees and ankles, rips, and broken bones. These should automatically repair by nature with little help from us.
Nonstructural: Medium or long-term invisible pain in the flesh needs therapy too!!! Most of us are experiencing long-term pain or chronic pain in our a daily battle with aches, pains and stiffness.

Nonstructural pain has a dark and sinister side:
This pain can masquerade as many types of structural pain so delays in the proper treatments are common.

This pain progress and can act like a “cancer” because it can spread deeper into the flesh, spread broadly across muscles and it can even metastasize to distant areas of the body. Today we call this kind of pain neuralgias, CRPS/RSD, chronic back pain etc..

Prolong untreated or undertreated progressive chronic myofascial pain can also start to alter and disrupt the molecular structure of the cells like a cancer. In this state all human-like cell activity becomes deranged. The muscles start to function poorly, lose their ability as in movement disorders and stress joint cartilage The chemical reactions of the cells falter leading to immune and regulator problems. The programs from the chromosomes get rewritten leading altered tissue construction and function. I call this devolving of human flesh “Pain Cancer.” This is the pain that wreaks havoc on people’s souls.
Sorry for the long wind, but when I see the term noncancer pain, I feel it is necessary to clarify the terms.

John Buck

I was in a automobile accident 10 years ago and have significant pain. Because of all the restrictions my doctor is telling me I must reduce my medication intake as he fears DEA problems. I absolutley hate that because some people make choices to abuse meds I am penalized.

Kris Wieland

Thank you for the petition information, Dr. Rodrigues. I will definitely use the information you provided to make my voice heard and I will share the contact info with others.

BL

Nancy Sterner, someone who receives SSDI also receives Medicare, 29 months after their Established Onset Date. Those who receive SSI also receive Medicaid. I know of only 1 state where Medicaid doesn’t pay for the management of Chronic Non Cancer Pain, Louisiana. Medicare is much better than Medicaid. More drs accept Medicare and there are more treatment and prescription options.