Narcotics

\"drug_addict\"If you do much reading of medical blogs, you will come across the word narcotics a lot.  Much of the lives of physicians (including myself) deal with medications, and a good portion of these drugs are controlled substances. It occurred to me that many readers might not know what narcotics and controlled substances are.  The term narcotic for many people brings to mind the image of a junkie on the street or someone who is addicted to prescription drugs.  So I thought it would be helpful to many for me to give an overview of narcotic drugs, as well as other controlled substances – discussing their appropriate and inappropriate use.  I will also touch on the concepts of addiction and chemical dependency – as they are obviously closely related to these drugs.
Narcotics

Wikipedia defines narcotic as follows:

The term narcotic is believed to have been coined by the Greek physician Galen to refer to agents that benumb or deaden, causing loss of feeling or paralysis. It is based on the Greek word narcosis, the term used by Hippocrates for the process of benumbing or the benumbed state. Galen listed mandrake root, altercus (eclata) seeds, and poppy juice (opium) as the chief examples.

In U.S. legal context, narcotic refers to opium, opium derivatives, and their semi-synthetic or fully synthetic substitutes \”as well as cocaine and coca leaves,\” which although classified as \”narcotics\” in the U.S. Controlled Substances Act (CSA), are chemically not narcotics. Contrary to popular belief, marijuana is not a narcotic, nor are LSD and other psychedelic drugs.

\"\"So basically a narcotic is a medication which alters the consciousness of the person taking it.  The term is used by many medical professionals synonymously with the term controlled substance.  When I use the word narcotic, I generally include the following classes of medications:

  • Opioids – Potent pain medications, drugs in this class include Morphine, Dilaudid, Fentanyl (Duragesic), Oxycodone (Percocet, Oxycontin), Meperidine (Demerol), Hydrocodone (Lortab, Vicodin), Codeine, and Propoxyphene (Darvocet).
  • Benzodiazapenes – \”Tranquilizer\” medications, generally used to treat anxiety.  Common drugs in this group include Diazepam (Valium), Lorazepam (Ativan), Clonazepam (Klonapin), Alprazolam (Xanax).
  • Barbiturates – These are prescribed infrequently – used to treat epilepsy and are also somewhat sedating.  The main drug still used in this class is Phenobarbital
  • Amphetamines – These are stimulant drugs, generally used for attention deficit disorder, although they have been used to help weight loss in the past.  Drugs in this class include Methylphenidate (Ritalin, Concerta, Focalin), Dexamphetamine (Dexadrin), and Amphetamine Salts (Adderal, Vyvanse).

This list is not meant to be exhaustive; I just put what I encounter most commonly.

Controlled Substances

So what about controlled substances?  The term comes from the Controlled Substances Act (a US law passed in 1969) in which potentially abused drugs were controlled to varying degrees.  These levels are called schedules, and each schedule carries its own set of rules as to how these medications can be prescribed.  The schedules are as follows:

  • Schedule 1 – These drugs are illegal to prescribe (except with DEA permission) because, in large part, of their high addiction potential and low medicinal benefit.  Drugs such as Heroin, LSD, and (to some people\’s consternation) Marijuana.
  • Schedule 2 – These drugs can be prescribed by professionals approved by the FDA to do so.  They carry significant abuse potential, and so have significant restrictions on how they can be prescribed.  For instance, they cannot be called in or sent electronically and cannot have refills.  Recently they have required the use of special (expensive) paper with these prescriptions, and many states require the use of a \”triplicate\” form for prescriptions.  The main Schedule 2 drugs I prescribe are ADD meds (Ritalin, Aderall, etc.), and pain medications (Duragesic, Oxycodone).
  • Schedule 3  – These drugs are \”weaker\” and overall have a somewhat lower abuse potential (although I am not sure how they made that decision).  We can call in and fax these drugs (but for some reason e-prescribing isn\’t allowed), and they can be given with refills up to 6 months.  Drugs on this list include anabolic steroids (testosterone preparations), as well as pain medications (Lortab).
  • Schedule 4 – Supposedly lower abuse potential than schedule 3, but the medications of this class are some of the more commonly abused prescription drugs (such as Xanax, Valium, Ativan).  Sleep medications (Ambien) and weaker pain medications (Darvocet) are also in this class.  The rules for prescription are the same as schedule 3 (generally).
  • Schedule 5 – Lowest abuse potential – includes cough medications with codeine, and (for some reason), Lyrica – the seizure medication used for fibromyalgia.

The significance of this drug schedule lies in the legal repercussions if they are distributed in an illegal manner.   Prescribing them in a way that does not adhere to the Controlled Substances Act or giving them in an irresponsible manner can result in significant negative repercussions.  If a patient begs me for an antibiotic when not indicated (they do sometimes) or for Viagra (ditto) and I give in to their begging, I am simply practicing bad medicine.  However, if a patient begs me for a narcotic when they don\’t actually need it and I give in, I am committing a crime.  Physicians with \”suspicious prescribing behaviors\” can come under review by the DEA.  If guilty, they may get their DEA license revoked or even possibly be prosecuted for a felony.

This is why patients with legitimate need for these medications end up feeling like they are \”getting the third degree\” from their doctor\’s office when requesting them.  No physician wants to come near \”suspicious prescribing behaviors\” and risk an investigation by the DEA.  Even being investigated and acquitted can end up on your record.

The Good and Bad

Narcotic medications are often the best drug for the job.  Morphine and its derivatives are some of the most effective pain medications, and so people with painful conditions may be best treated with these medications.  Similarly, Valium and other benzodiazepines are very good at helping with anxiety.  A person having a panic attack is often best treated with something like Xanax.

These medications work – and therein lies the problem.  Repeated use of these medications can result in two serious problems: chemical dependency and addiction.

Chemical dependency is a physical phenomenon described by two criteria:

  1. Withdrawal – the presence of physical symptoms and clinical signs with the abrupt cessation of the substance.
  2. Tolerance (also called Tachyphylaxis) – decreasing effectiveness of the drug over time, requiring higher doses for the same benefit.

\"628\"Most of the scheduled drugs can create chemical dependency (the biggest exception being amphetamines), but other substances can also do this.  Alcohol and caffeine are two of the best examples of things that are not (generally) prescription drugs but can create chemical dependence.  I personally get a bad headache if I don\’t have my coffee in the morning.

Addiction is different (although the term is sometimes used in place of chemical dependency); it is the development of compulsive behaviors associated with the substance or action.  I think of addiction as being mainly a psychological phenomenon, as a person can become addicted to things they aren\’t chemically dependent on (such as gambling, shopping, and checking the traffic meter for your blog – heh).  A person can become addicted to anything that offers significant intense pleasure.  In general, the quicker the onset of the pleasure, the more the addiction.

So how does this relate to narcotics?  In a huge way.

The Right Way and the Wrong Way

There are two factors to consider when approaching someone in pain:

  1. How much it hurts.
  2. How long it has gone on.

Patients with acute severe pain are unlikely to abuse pain medications, while those with chronic lower-level pain are at very high risk.  So if someone comes in with a fractured arm, pain medication is fairly safe to use.  Some physicians are still reluctant to prescribe narcotics even in this situation (being jaded by people who exaggerate or lie to get pain medications), leaving many patients to suffer needlessly.  Having broken many bones (as a consequence of distractibility), I can say that pain medications make life much better when your pain is severe.  So, for acute severe pain, short-acting medications are appropriate and low-risk.

Chronic pain is different.  Some people have longstanding pain that is fairly severe – compression fractures in the back, chronic severe degenerative arthritis, and cancer pain can be relentless.  It is very difficult for these patients to gauge the severity of the pain, as it becomes hard to remember what being pain-free feels like.  It is very hard for the physician to determine the severity as well, as there is no pain-o-meter to stick on someone and measure how much they hurt.  You have to take the patient\’s word for it – which can be hard if the stated pain is inconsistent with physical findings.  The result is that some patients suffer silently, while those who report severe pain are held in suspicion by the physician.

The best approach to treating someone who is in significant chronic pain is to use long-acting medications as much as possible and short-acting ones as little as possible.  The reasons for this are:

  • It is easier to keep pain away than it is to intermittently get rid of it.  Patients on long-acting pain medications end up using less medication than those who use only short-acting medications.
  • The nature of short-acting medications is to relieve the pain quickly, but for a short period of time.  This creates a repeated decision the patient has to make: \”do I hurt enough to take a pain medication?\”  Since these medications  have a euphoric effect along with the pain-relief (longer-acting medications with a slower onset don\’t have as much of a euphoric effect), the decision becomes even harder.  This is what drives many people to addiction – they start taking the medication as much for emotional reasons as for pain relief.  It is a very hard situation for the patient with true chronic pain.  Long-acting pain medications on a schedule take away this decision and make the risk of addiction much lower while doing a better job on the pain.

Long-term use of any narcotic will result in chemical dependency, but that is not nearly as big of a problem as addiction.

This approach actually works for anxiety as well – with antidepressant/anti-anxiety medications like Zoloft or Paxil being used to minimize the need for benzodiazepines.

Bad Actors

\"sammy_davis\"There are some people, however, who are simply addicted to the euphoric effect (translation: buzz) they get from these medications.  Since we still haven\’t invented the Pain-O-Meter, they can claim they have significant pain and take advantage of compassionate (or just careless) physicians.  Emergency physicians see a disproportionate amount of these \”drug-seekers\” and so tend to be very jaded toward anyone using narcotics.  As a primary care physician, I am constantly measuring the likelihood that a patient is a drug-seeker.  It is often very difficult.

This makes many people with legitimate pain get labeled as drug-seekers and/or not get adequate treatment for their pain.

There are also some physicians who play the role of \”candy-man,\” handing out short-acting narcotics recklessly.  This feeds the hunger the drug-seekers have for their substance of choice and make life much harder for the rest of physicians.  In every town I have worked in, I have known who these physicians are – and cringe when one of their patients comes through my door.

Narcotics are a victim of their own success.  They should simply be highly effective drugs for people with significant problems; instead, they are under-used in people with real need and abused by those who shouldn\’t get them.

44 thoughts on “Narcotics”

  1. Still confused about the classification..how can cocaine, a stimulant, be characterised as a narcotic? The only medications I consider narcotics are opioids and barbiturates.
    It is certainly an interesting point to be aware of; that different health providers and patients may have different definitions of what constitutes a narcotic.

  2. Still confused about the classification..how can cocaine, a stimulant, be characterised as a narcotic? The only medications I consider narcotics are opioids and barbiturates.
    It is certainly an interesting point to be aware of; that different health providers and patients may have different definitions of what constitutes a narcotic.

  3. Thank you google reader for finding me this blog:) This is a great post! As a pharmacist I feel many of the same frustrations with the candy man / emergency room extremes…maybe both should use lie detector tests to find a balance!?

  4. Thank you google reader for finding me this blog:) This is a great post! As a pharmacist I feel many of the same frustrations with the candy man / emergency room extremes…maybe both should use lie detector tests to find a balance!?

  5. Your comment about meds for acute severe pain reminded me of the reaction I encountered with a nurse, shortly after my broken hip was diagnosed. She asked if I wanted any pain meds, and, when I said no, it didn’t hurt all that much, replied that I could pretty much have asked for anything they had, because that kind of injury is supposed to hurt quite a lot. She almost seemed disappointed.

  6. Your comment about meds for acute severe pain reminded me of the reaction I encountered with a nurse, shortly after my broken hip was diagnosed. She asked if I wanted any pain meds, and, when I said no, it didn’t hurt all that much, replied that I could pretty much have asked for anything they had, because that kind of injury is supposed to hurt quite a lot. She almost seemed disappointed.

  7. I enjoyed this article. I am on a small dosage of Morphine CR and Lortab for “break thru” in case I over-do it.
    I also understand these types of meds can make my depression worse?

    I also have to have drug testing done once a year – very expensive too! I understand he has to CYA like everyone else, but my last urine drug test was $392.

    They claim they cannot write either of these meds with any refills. I have to go every single month to get new Rx’s. Unless I read your article wrong, that’s not true…?

  8. I enjoyed this article. I am on a small dosage of Morphine CR and Lortab for “break thru” in case I over-do it.
    I also understand these types of meds can make my depression worse?

    I also have to have drug testing done once a year – very expensive too! I understand he has to CYA like everyone else, but my last urine drug test was $392.

    They claim they cannot write either of these meds with any refills. I have to go every single month to get new Rx’s. Unless I read your article wrong, that’s not true…?

  9. ToLazyToThinkOfOne

    Some states have more restrictive rules and the DEA has a bad habit of changing its mind sometimes about its interpretation of the unchanged law. This relates more to the Schedule 2s but some doctors may legitmately decide to stay on the safe side and be more restrictive than the law allows for fear of the DEA not really caring what the law actually says.
    It is also quite possible, and perfectly legitimate, that the doctor is very aware that it is legal to give refills but it is his policy to monitor his patients on narcotics monthly all the same as these are drugs have an enormous dosage range and potential for abuse. Be glad you are only drug tested oncea year. I know some local docs who test every quarter on some patients. I actually perform one rather randomly once a year or so and anytime I have any suspicion.

  10. ToLazyToThinkOfOne

    Some states have more restrictive rules and the DEA has a bad habit of changing its mind sometimes about its interpretation of the unchanged law. This relates more to the Schedule 2s but some doctors may legitmately decide to stay on the safe side and be more restrictive than the law allows for fear of the DEA not really caring what the law actually says.
    It is also quite possible, and perfectly legitimate, that the doctor is very aware that it is legal to give refills but it is his policy to monitor his patients on narcotics monthly all the same as these are drugs have an enormous dosage range and potential for abuse. Be glad you are only drug tested oncea year. I know some local docs who test every quarter on some patients. I actually perform one rather randomly once a year or so and anytime I have any suspicion.

  11. ToLazyToThinkOfOne said:I know some local docs who test every quarter on some patients. I actually perform one rather randomly once a year or so and anytime I have any suspicion.

    Man, I wish! I am in pain management and I get tested every visit. I have no history of abuse, have never failed a urine test and take my meds in each monthly visit for my doc to count my meds. I have signed a “pain contract” with my doc stipulating what meds I am allowed, the frequency of dosing, exactly which pharmacy I am allowed to purchase my meds at, etc. etc. etc., and yet the doc hands me a cup at each visit. If I’m not mistaken, this doc has the most restrictive medical practice in the Indianapolis, Indiana area.

    Don’t get me wrong – I am not complaining. I knew the doc’s policy when I was referred by my Neurologist’s office and accepted it without reserve. He, the pain doc, has saved my life several times over by limiting my crippling pain. It makes me proud personally to know that I can and do follow the rules of the clinic and continue to see the look of amazement on the doc’s face with each visit because I know that he has been “burned” so many times with patients diverting or abusing.

    Here’s my quandry:

    Why aren’t doctors trained better in UNDERSTANDING pain management? I do not mean, “Why don’t they prescribe more meds?”, but rather why docs constantly imply or overtly state that I get “buzzed” or “high” from my meds when I feel that that simply isn’t true.

    I am on low-dose Duragesic patches that I get no more “high” from than I do from taking an aspirin for a headache. If my doctor makes a comment like that (getting high or buzzed) during my visit I promptly stop them and remind them that I do not get a high on my current med levels and their reply is that I have built a tolerance to the med.

    The only med that HAS given me a high (other than anesthesia for surgery) was the Actiq suckers that my Neurologist prescribed previous sending me to pain management, and that side effect was immediately reported to him prompting the referral to the pain management clinic where I was prescribed the Duragesic to better control pain over the long-term and not the short-term, up-and-down that the suckers provided.

    Is that the way it is for most others that get treated with narcotics? That the smallest ingestion or injection of a narcotic and they are flying high?

    As an aside, I have “successfully failed” all other treatment modalities that the clinic has tried such as Cognitive Behavioural Therapy, massage, Physical Therapy, water therapy, TENS unit, Chiropractic, Botox shots in the Cervical and Thoracic spine, Botox shots in the pectoral muscles. I did not recover any mobility nor did I have a reduction in pain levels.

  12. ToLazyToThinkOfOne said:
    I know some local docs who test every quarter on some patients. I actually perform one rather randomly once a year or so and anytime I have any suspicion.

    Man, I wish! I am in pain management and I get tested every visit. I have no history of abuse, have never failed a urine test and take my meds in each monthly visit for my doc to count my meds. I have signed a “pain contract” with my doc stipulating what meds I am allowed, the frequency of dosing, exactly which pharmacy I am allowed to purchase my meds at, etc. etc. etc., and yet the doc hands me a cup at each visit. If I’m not mistaken, this doc has the most restrictive medical practice in the Indianapolis, Indiana area.

    Don’t get me wrong – I am not complaining. I knew the doc’s policy when I was referred by my Neurologist’s office and accepted it without reserve. He, the pain doc, has saved my life several times over by limiting my crippling pain. It makes me proud personally to know that I can and do follow the rules of the clinic and continue to see the look of amazement on the doc’s face with each visit because I know that he has been “burned” so many times with patients diverting or abusing.

    Here’s my quandry:

    Why aren’t doctors trained better in UNDERSTANDING pain management? I do not mean, “Why don’t they prescribe more meds?”, but rather why docs constantly imply or overtly state that I get “buzzed” or “high” from my meds when I feel that that simply isn’t true.

    I am on low-dose Duragesic patches that I get no more “high” from than I do from taking an aspirin for a headache. If my doctor makes a comment like that (getting high or buzzed) during my visit I promptly stop them and remind them that I do not get a high on my current med levels and their reply is that I have built a tolerance to the med.

    The only med that HAS given me a high (other than anesthesia for surgery) was the Actiq suckers that my Neurologist prescribed previous sending me to pain management, and that side effect was immediately reported to him prompting the referral to the pain management clinic where I was prescribed the Duragesic to better control pain over the long-term and not the short-term, up-and-down that the suckers provided.

    Is that the way it is for most others that get treated with narcotics? That the smallest ingestion or injection of a narcotic and they are flying high?

    As an aside, I have “successfully failed” all other treatment modalities that the clinic has tried such as Cognitive Behavioural Therapy, massage, Physical Therapy, water therapy, TENS unit, Chiropractic, Botox shots in the Cervical and Thoracic spine, Botox shots in the pectoral muscles. I did not recover any mobility nor did I have a reduction in pain levels.

  13. Uh, around here, the long-acting stuff is just crushed up and turned into a short-acting drug. Oxycontin comes to mind… Fentanyl patches are licked, etc. I get your point though.

  14. Uh, around here, the long-acting stuff is just crushed up and turned into a short-acting drug. Oxycontin comes to mind… Fentanyl patches are licked, etc. I get your point though.

  15. Thanks for the comprehensive overview Dr. Rob. I agree these classifications can be confusing for the public & even health care professionals. In hospice & palliative medicine (my field), we are frequently working with medications listed as controlled substances by the DEA. What I have found to be important when discussing these medications it is important to realize how broad or narrow of a term one should use.
    Frustratingly, ‘narcotics’ is frequently used when a medical professional means ‘opioids’ as a class of medications. In my experience ‘narcotic’ is often used with a pejorative connotation, especially given the association with law enforcement activities searching out illegal drugs (both street and medical drugs used/sold illicitly). If you ask a sheriff, they will tell you the narcotics division doesn’t ignore marijuana if they find it just because it is not technically a narcotic. Consciously or subconsciously I think many people (including health care professionals) associate the following quite freely:
    narcotics, morphine, dope, addiction, illegal, bad, police, junkie

    So for my patient population they have frequently been the receivers of subtle messages (i.e. ‘narcotics’) that opioids are bad, and there is a lot of education with patients and families about the potential benefits and the ways to minimize risks from opioids.

    I find that my non-palliative medicine peers will write/talk about ‘narcotics’ when alluding to perceived or real addiction, overdose, or diversion in a medical situation, but will use the brand/generic names in communications for what is perceived to be real pain.

    I cannot recall observing any physician or nurse write/speak of ‘narcotics’ in reference to benzodiazepines, barbiturates, or amphetamines, although that does not mean there are those who lump those altogether.

    On the same topic, Thomas Quinn, my co-blogger at Pallimed wrote about a study of patient knowledge of the terms opioid and narcotic.

    Thanks for featuring the differences among tolerance, dependence, and addiction. This is a common education topic for med students, residents, patients, and families for me.

    So to conclude I wish the following terms were primarily used by the following: narcotics for law enforcement, controlled substances to medical administrators, and opioids for point of care clinical staff. But I know that will not happen anytime soon.

    Thanks for bringing this subject up!

  16. Thanks for the comprehensive overview Dr. Rob. I agree these classifications can be confusing for the public & even health care professionals. In hospice & palliative medicine (my field), we are frequently working with medications listed as controlled substances by the DEA. What I have found to be important when discussing these medications it is important to realize how broad or narrow of a term one should use.
    Frustratingly, ‘narcotics’ is frequently used when a medical professional means ‘opioids’ as a class of medications. In my experience ‘narcotic’ is often used with a pejorative connotation, especially given the association with law enforcement activities searching out illegal drugs (both street and medical drugs used/sold illicitly). If you ask a sheriff, they will tell you the narcotics division doesn’t ignore marijuana if they find it just because it is not technically a narcotic. Consciously or subconsciously I think many people (including health care professionals) associate the following quite freely:
    narcotics, morphine, dope, addiction, illegal, bad, police, junkie

    So for my patient population they have frequently been the receivers of subtle messages (i.e. ‘narcotics’) that opioids are bad, and there is a lot of education with patients and families about the potential benefits and the ways to minimize risks from opioids.

    I find that my non-palliative medicine peers will write/talk about ‘narcotics’ when alluding to perceived or real addiction, overdose, or diversion in a medical situation, but will use the brand/generic names in communications for what is perceived to be real pain.

    I cannot recall observing any physician or nurse write/speak of ‘narcotics’ in reference to benzodiazepines, barbiturates, or amphetamines, although that does not mean there are those who lump those altogether.

    On the same topic, Thomas Quinn, my co-blogger at Pallimed wrote about a study of patient knowledge of the terms opioid and narcotic.

    Thanks for featuring the differences among tolerance, dependence, and addiction. This is a common education topic for med students, residents, patients, and families for me.

    So to conclude I wish the following terms were primarily used by the following: narcotics for law enforcement, controlled substances to medical administrators, and opioids for point of care clinical staff. But I know that will not happen anytime soon.

    Thanks for bringing this subject up!

  17. As a chronic pain patient and a former medical professional (RPh), I thank you for this article from the personal and professional standpoints. I have known tight-fisted prescribers, and “candy-men”…most of the latter do seem to eventually get caught by the state board.
    And although more physicians are becoming trained in pain management, many of the other allied fields are not. I’ve come across nurses like Bill encountered, and pharmacy techs who assume everyone who takes OxyContin snd Oxycodone or MSContin and Morphine IR every month is an addict.

    As far as refills go, per FEDERAL law, prescriptions CII substances (Oxycodone, Morphine, Fentanyl, Methadone, plain Codeine) can NOT be refilled.
    Prescriptions for CIII-CV may be refilled for a maximum of 5 times within 6 months under FEDERAL law, but states may have different laws. If the STATE statute is stricter, it supercedes the Federal law. And, of course, some physicians prefer NOT to refill any controlled substance.

  18. As a chronic pain patient and a former medical professional (RPh), I thank you for this article from the personal and professional standpoints. I have known tight-fisted prescribers, and “candy-men”…most of the latter do seem to eventually get caught by the state board.
    And although more physicians are becoming trained in pain management, many of the other allied fields are not. I’ve come across nurses like Bill encountered, and pharmacy techs who assume everyone who takes OxyContin snd Oxycodone or MSContin and Morphine IR every month is an addict.

    As far as refills go, per FEDERAL law, prescriptions CII substances (Oxycodone, Morphine, Fentanyl, Methadone, plain Codeine) can NOT be refilled.
    Prescriptions for CIII-CV may be refilled for a maximum of 5 times within 6 months under FEDERAL law, but states may have different laws. If the STATE statute is stricter, it supercedes the Federal law. And, of course, some physicians prefer NOT to refill any controlled substance.

  19. I have a pretty disadvantaged patient population, and plenty of drug-seekers of the bad variety come my way (or more often, to the residents in my clinic…especially just after July 1). It’s a nightmare, figuring out who’s getting high, who’s selling their prescription opiates, and which poor souls are just undermedicated for their pain.
    I think the fundamental issue is this: doctors are being asked to perform law enforcement functions. This is bullshit. I didn’t go into medicine to become a DEA agent, and I have no expertise in detective work.

    Here’s an idea for fundamental reform. Let doctors just manage pain and take patients at their word regarding drug diversion. We can also manage drug dependency. But let the fucking DEA (or whatever law enforcement officers are handy) deal with the criminal aspect…when patients sell their oxy, etc, this is a _criminal law_ problem. Not a medical problem.

    Doctors should be held harmless for patient criminal activity, unless there is hard evidence of actual criminal behavior by the _doctor_ (i.e., kickbacks for scripts).

  20. I have a pretty disadvantaged patient population, and plenty of drug-seekers of the bad variety come my way (or more often, to the residents in my clinic…especially just after July 1). It’s a nightmare, figuring out who’s getting high, who’s selling their prescription opiates, and which poor souls are just undermedicated for their pain.
    I think the fundamental issue is this: doctors are being asked to perform law enforcement functions. This is bullshit. I didn’t go into medicine to become a DEA agent, and I have no expertise in detective work.

    Here’s an idea for fundamental reform. Let doctors just manage pain and take patients at their word regarding drug diversion. We can also manage drug dependency. But let the fucking DEA (or whatever law enforcement officers are handy) deal with the criminal aspect…when patients sell their oxy, etc, this is a _criminal law_ problem. Not a medical problem.

    Doctors should be held harmless for patient criminal activity, unless there is hard evidence of actual criminal behavior by the _doctor_ (i.e., kickbacks for scripts).

  21. Excellent explanation.I need to print it out and give it to all pain patients.

    Most are so confused, some deathly afraid they might get addicted to short-term therapy and others who just want to feel good, no matter what.

    We all know chronic pain is real and narcotics, by themselves, are not the long-term answer.

    Thanks

  22. James Hubbard, M.D., M.P.H.

    Excellent explanation.I need to print it out and give it to all pain patients.

    Most are so confused, some deathly afraid they might get addicted to short-term therapy and others who just want to feel good, no matter what.

    We all know chronic pain is real and narcotics, by themselves, are not the long-term answer.

    Thanks

  23. Stiff man: Docs are afraid of narcotics because they can lose their ability to practice medicine (or they think they can) with these drugs. Nobody wants to get the DEA on their case. Used right, however, the abuse potential is not high.
    Nurse K: Patients’ abuse will get them kicked out of my office. They won’t get kicked out of coming to various ER’s or searching for a candy-man. I thought that oxycontin was reformulated to make it much harder to crush and inject. Plus, most of my pain patients are people I have cared for over a long time.

    Christian. Thanks much – the palliative medicine folks know the most about this stuff, no doubt. I learned it best when I did oncology at Indiana University in Residency. They taught me well the concept of long/short acting meds.

    Docanon: I don’t think removing liability is likely, and I absolutely thing the candy men in our community should be stopped and not allowed to prescribe without worry. Yes, the abusers are clever, but you don’t have to make it easy for them.

    My real grief is that legitimate pain-sufferers are tagged with suspicion and worse.

  24. Stiff man: Docs are afraid of narcotics because they can lose their ability to practice medicine (or they think they can) with these drugs. Nobody wants to get the DEA on their case. Used right, however, the abuse potential is not high.
    Nurse K: Patients’ abuse will get them kicked out of my office. They won’t get kicked out of coming to various ER’s or searching for a candy-man. I thought that oxycontin was reformulated to make it much harder to crush and inject. Plus, most of my pain patients are people I have cared for over a long time.

    Christian. Thanks much – the palliative medicine folks know the most about this stuff, no doubt. I learned it best when I did oncology at Indiana University in Residency. They taught me well the concept of long/short acting meds.

    Docanon: I don’t think removing liability is likely, and I absolutely thing the candy men in our community should be stopped and not allowed to prescribe without worry. Yes, the abusers are clever, but you don’t have to make it easy for them.

    My real grief is that legitimate pain-sufferers are tagged with suspicion and worse.

  25. Most of the comments seem to be from pain patients or pain docs—I admit to be ing a puzzled PCP. Like docanon I wonder how exctly what my law enforcement responsibilities are. I live in a small town and I have seen diversion as well as the more common overuse . I have seen patients go to the ICU in the hosptal with Co2 retention (not breathing enough) because they were given their “usual” opioid dose and thought it was a great opportunity to get a buzz. I have caught 3 patients pretty much red-handed in 20 years , only because I pursued it to the end, in two cases to the grand jury, with no support at all from the DA. End result of all this effort each time : Patient finds new doc, suspicion falls on me that I am getting a kickback and turning in my partner in crime, and one patient wrote a letter to me that he was going to turn me in to the board, because here in Oregon the perception is “its illegal to undertreat pain” . I guess it did not happen, I haven’t seen my name in the board report. I am probably still stupid but I hate diversion, its a crime, diverts money and food stamps , tears up communities with loaded driving and parenting and I think overuse is a danger to the patient. I think if you use resaonable care you should be held harmless. I also think the DEA and local police need to help us when we say” I am concerned that Ms. X may be selling prescriptions” rather than turn their attention to real drugs. For Gods sake these are the real-est.

  26. Most of the comments seem to be from pain patients or pain docs—I admit to be ing a puzzled PCP. Like docanon I wonder how exctly what my law enforcement responsibilities are. I live in a small town and I have seen diversion as well as the more common overuse . I have seen patients go to the ICU in the hosptal with Co2 retention (not breathing enough) because they were given their “usual” opioid dose and thought it was a great opportunity to get a buzz. I have caught 3 patients pretty much red-handed in 20 years , only because I pursued it to the end, in two cases to the grand jury, with no support at all from the DA. End result of all this effort each time : Patient finds new doc, suspicion falls on me that I am getting a kickback and turning in my partner in crime, and one patient wrote a letter to me that he was going to turn me in to the board, because here in Oregon the perception is “its illegal to undertreat pain” . I guess it did not happen, I haven’t seen my name in the board report. I am probably still stupid but I hate diversion, its a crime, diverts money and food stamps , tears up communities with loaded driving and parenting and I think overuse is a danger to the patient. I think if you use resaonable care you should be held harmless. I also think the DEA and local police need to help us when we say” I am concerned that Ms. X may be selling prescriptions” rather than turn their attention to real drugs. For Gods sake these are the real-est.

  27. “My real grief is that legitimate pain-sufferers are tagged with suspicion and worse.”
    Thank you for this excellent informative post. I’m a patient who suffers from chronic and at times excruciating pain, and have experienced some frustration in this area. I have a question for you: do you think these problems may be alleviated somewhat if more patients and doctors both made it a priority to stick together long enough to build up a trust? It seems to me that a large part of the problem is when doctors play “hot potato” with a patient and patients go “shopping” for which doctor suits their fancy. Of course, this is oversimplifying the matter considerably, as there are certainly times referrals are needed and switching doctors can be beneficial, but it seems to me that if more patients and doctors stayed together it would be a bit easier for the doctors to make judgment calls on prescribing narcotics.

    I’ve experienced this with the difference between my regular doctor and an ER doctor. Due to adverse reactions from lesser pain meds, we had started me on a very low dose of morphine. I was half afraid of getting addicted, but then I educated myself on its proper use and was determined to under-dose when in doubt. In any case, I began having very severe gut pain, for which my caretaker gave me more doses of morphine to no avail–in fact, my pain increased (screaming in pain, eventually ending with violent vomiting). I ended up in an ambulance ride the ER, where the doctor said nonchalantly, “Oh, you’re probably addicted.” This happened twice before we figured out that it was the morphine causing this reaction. Nevertheless I was upset that the ER doctor automatically assumed I was addicted, when I had worked very hard to make sure I took the medication responsibly as I certainly did not want an addiction on top of the pain.

    It’s hard for both sides. I really appreciate the doctors like you who are willing to wrestle with this issue in order to bring a bit of comfort to those in pain who truly need it. Thank you.

  28. “My real grief is that legitimate pain-sufferers are tagged with suspicion and worse.”
    Thank you for this excellent informative post. I’m a patient who suffers from chronic and at times excruciating pain, and have experienced some frustration in this area. I have a question for you: do you think these problems may be alleviated somewhat if more patients and doctors both made it a priority to stick together long enough to build up a trust? It seems to me that a large part of the problem is when doctors play “hot potato” with a patient and patients go “shopping” for which doctor suits their fancy. Of course, this is oversimplifying the matter considerably, as there are certainly times referrals are needed and switching doctors can be beneficial, but it seems to me that if more patients and doctors stayed together it would be a bit easier for the doctors to make judgment calls on prescribing narcotics.

    I’ve experienced this with the difference between my regular doctor and an ER doctor. Due to adverse reactions from lesser pain meds, we had started me on a very low dose of morphine. I was half afraid of getting addicted, but then I educated myself on its proper use and was determined to under-dose when in doubt. In any case, I began having very severe gut pain, for which my caretaker gave me more doses of morphine to no avail–in fact, my pain increased (screaming in pain, eventually ending with violent vomiting). I ended up in an ambulance ride the ER, where the doctor said nonchalantly, “Oh, you’re probably addicted.” This happened twice before we figured out that it was the morphine causing this reaction. Nevertheless I was upset that the ER doctor automatically assumed I was addicted, when I had worked very hard to make sure I took the medication responsibly as I certainly did not want an addiction on top of the pain.

    It’s hard for both sides. I really appreciate the doctors like you who are willing to wrestle with this issue in order to bring a bit of comfort to those in pain who truly need it. Thank you.

  29. A Euphoric Violet Delight
    Often, medications for severe pain are made from opoid plants. These purple-flowered plants produce opium poppies, which are used in the production of opium. Opium is what we in the U.S. call narcotics, and they dull and numb one who ingests what may be made by these opium poppies, as there are several drugs that have been developed from what these plants provide that are these prevalent narcotics.
    Some medications are from natural opium, such as cocaine, or the opiates from the poppy seeds can be used to create semi-synthetic medications, such as Heroin. Heroin was marketed by Bayer Pharmaceuticals for 12 years by telling others that it was a non-addicting form of morphine (pure opiate drug), since there were many soldiers addicted to morphine after the civil war. During that same period of time, Bayer marketed heroin for children who coughed. Of course, Heroin is very addictive, and is no longer available.
    While Poppy plants exist and are grown in areas of IndoChina, Afghanistan is the number one producer of poppy plants. The United States is the number one country that consumes what is derived from these plants. Opium-derived medicines once could be bought freely in the U.S. by anyone less than 100 years ago. Yet now, they are classified by the Drug Enforcement Agency as narcotics, and are scheduled by them, according to the danger they potentially could cause another who takes them.
    While prescribed to patients for such issues aside from pain on occasion, such as chronic coughing and diarrhea, their greatest benefit is for the relief of pain experienced often by patients is the primary reason doctors prescribe opoid drugs, and they do so often. Vicodin, a mild narcotic, is the most frequently prescribed medication in the U.S. presently.
    If patients take opium-derived drugs for long periods of time, tolerance may develop, and the patient may need to take more of the drug to acquire an effect of relief. In addition, the patient may develop a dependence on these types of drugs, which can lead to addiction and possible abuse. This is why overdose of these types of medicine occur- as the reasons for taking these drugs initially become replaced with relief due to addiction in some who take narcotics for a long period of time.

    Dan Abshear

  30. A Euphoric Violet Delight
    Often, medications for severe pain are made from opoid plants. These purple-flowered plants produce opium poppies, which are used in the production of opium. Opium is what we in the U.S. call narcotics, and they dull and numb one who ingests what may be made by these opium poppies, as there are several drugs that have been developed from what these plants provide that are these prevalent narcotics.
    Some medications are from natural opium, such as cocaine, or the opiates from the poppy seeds can be used to create semi-synthetic medications, such as Heroin. Heroin was marketed by Bayer Pharmaceuticals for 12 years by telling others that it was a non-addicting form of morphine (pure opiate drug), since there were many soldiers addicted to morphine after the civil war. During that same period of time, Bayer marketed heroin for children who coughed. Of course, Heroin is very addictive, and is no longer available.
    While Poppy plants exist and are grown in areas of IndoChina, Afghanistan is the number one producer of poppy plants. The United States is the number one country that consumes what is derived from these plants. Opium-derived medicines once could be bought freely in the U.S. by anyone less than 100 years ago. Yet now, they are classified by the Drug Enforcement Agency as narcotics, and are scheduled by them, according to the danger they potentially could cause another who takes them.
    While prescribed to patients for such issues aside from pain on occasion, such as chronic coughing and diarrhea, their greatest benefit is for the relief of pain experienced often by patients is the primary reason doctors prescribe opoid drugs, and they do so often. Vicodin, a mild narcotic, is the most frequently prescribed medication in the U.S. presently.
    If patients take opium-derived drugs for long periods of time, tolerance may develop, and the patient may need to take more of the drug to acquire an effect of relief. In addition, the patient may develop a dependence on these types of drugs, which can lead to addiction and possible abuse. This is why overdose of these types of medicine occur- as the reasons for taking these drugs initially become replaced with relief due to addiction in some who take narcotics for a long period of time.

    Dan Abshear

  31. This is my problem with most of the comments made by the doctors on this page. I am very educated when it comes to the real world and its “stereotypes”. I’m a student at the University of Cincinnati and I am just scared to even go in to the doctors office and say anything is wrong with me because I am a student it instantly has to be DSB. I have two herneated discs in my spine from a football injury and I fell off a ladder at work. My back was black and blue from the fall I was in agony and they prescribed me IBP 800. I mean i’m not an addict an abuser and have only read up on the success stories that opiates have done to people. I’m not trying to say I need to be prescribed Oxycontin or anything of that nature but every single morning my back hurts. Every single morning the back of my legs and the bottom of my feet hurt. I don’t know why I can’t get a doctor to believe me I almost want to give up hope on everything. I don’t go out anymore I am not active anymore, all I do is go to school and come home. I have no life I can’t even do my co-op right now because I just don’t feel up to it. I tried going to a methadone clinic because i wanted to get any pain medication but got refused because I wasn’t going through a state of withdrawl and had no opiate dependancy issues. I’m just a student sick of every person being labeled and “stereotyped” over the same BS because doctors want to make sure they are doing the right thing. Well in my experiences when it comes to practically all of you, you are more worried about losing your liscense and not being frowned upon than listening to the actual patients!!! It is 2 in the morning and I’m writing on this blog when I have a midterm in 7 hours because I can’t sleep because my spine is killing me and this insomnia/depression/feeling of hopelessness never ends…
    Thats all I have to say

  32. This is my problem with most of the comments made by the doctors on this page. I am very educated when it comes to the real world and its “stereotypes”. I’m a student at the University of Cincinnati and I am just scared to even go in to the doctors office and say anything is wrong with me because I am a student it instantly has to be DSB. I have two herneated discs in my spine from a football injury and I fell off a ladder at work. My back was black and blue from the fall I was in agony and they prescribed me IBP 800. I mean i’m not an addict an abuser and have only read up on the success stories that opiates have done to people. I’m not trying to say I need to be prescribed Oxycontin or anything of that nature but every single morning my back hurts. Every single morning the back of my legs and the bottom of my feet hurt. I don’t know why I can’t get a doctor to believe me I almost want to give up hope on everything. I don’t go out anymore I am not active anymore, all I do is go to school and come home. I have no life I can’t even do my co-op right now because I just don’t feel up to it. I tried going to a methadone clinic because i wanted to get any pain medication but got refused because I wasn’t going through a state of withdrawl and had no opiate dependancy issues. I’m just a student sick of every person being labeled and “stereotyped” over the same BS because doctors want to make sure they are doing the right thing. Well in my experiences when it comes to practically all of you, you are more worried about losing your liscense and not being frowned upon than listening to the actual patients!!! It is 2 in the morning and I’m writing on this blog when I have a midterm in 7 hours because I can’t sleep because my spine is killing me and this insomnia/depression/feeling of hopelessness never ends…
    Thats all I have to say

  33. Oh and the worst part is all the aleve, aspirin, and tylenol I take is killing my liver and kidneys so bad I’ll probably end up having some kind of issues with that because it seems to be the only pain medicine I can find. Don’t get me wrong I have tried everything especially the Chiropractor and TENS and massages practically everything up to the point of Acupuncture and nothing. For awhile I could deal with it and just go on but over this last 8-12 months it has taken a hold of me and I really don’t know what to do anymore. Any advice with someone in the medical field would be greatly appreciative. Also something I have noticed is that with the OTC medicine I take if I don’t have Pepto Bismol with me 24/7 there is no eating anymore because my stomach probably looks like swiss cheese with all the ulcers or that is atleast what it feels like.

  34. Oh and the worst part is all the aleve, aspirin, and tylenol I take is killing my liver and kidneys so bad I’ll probably end up having some kind of issues with that because it seems to be the only pain medicine I can find. Don’t get me wrong I have tried everything especially the Chiropractor and TENS and massages practically everything up to the point of Acupuncture and nothing. For awhile I could deal with it and just go on but over this last 8-12 months it has taken a hold of me and I really don’t know what to do anymore. Any advice with someone in the medical field would be greatly appreciative. Also something I have noticed is that with the OTC medicine I take if I don’t have Pepto Bismol with me 24/7 there is no eating anymore because my stomach probably looks like swiss cheese with all the ulcers or that is atleast what it feels like.

  35. I have had lower back problems since 1986 and I was diagnosed with severe degenerative disc disease in 2003; all 5 of my lumbar vertebrae are affected. Two neurologists told me there was nothing they could do for me and my experience with a pain management clinic was a complete joke. I have always been extremely careful about the use of opioid pain meds (I refused prescriptions for Oxycontin) but hydrocodone is the best way for me to control pain that I can’t control with Alleve and Tylenol.
    I had a fantastic MD in Georgia but, after having to leave a great job because of the increasing severity of my back problems, I came to the Arkansas/Tennessee area. Since arriving here 2 years ago, I have consistantly been treated like a leper by MDs. I’ve heard that the state medical boards of these states have been rabid in their pursuit of MDs who treat chronic pain. The only time I go near a physician for my back is if it has gone completely out on me. What happens everytime is that I’m given a prescription for lortab (say 30 pills). When I show up in that same MD’s office 2-4 months later with the same complaint, I am practically shown the door! It’s criminal that responsible patients are treated in this way. Also, as Marcelian points out, I have taken so much Alleve that I now have severe acid reflux that even 2 Prilosec/day can’t take care of. It’s no telling what all of the acetaminophen (Tylenol) has done to my liver!

    Where is all of this scrutiny leading to? Do people have to endanger their cardiovascular, hepatic and renal health because MDs have to be scared to death of their state boards and the DEA?

  36. I have had lower back problems since 1986 and I was diagnosed with severe degenerative disc disease in 2003; all 5 of my lumbar vertebrae are affected. Two neurologists told me there was nothing they could do for me and my experience with a pain management clinic was a complete joke. I have always been extremely careful about the use of opioid pain meds (I refused prescriptions for Oxycontin) but hydrocodone is the best way for me to control pain that I can’t control with Alleve and Tylenol.
    I had a fantastic MD in Georgia but, after having to leave a great job because of the increasing severity of my back problems, I came to the Arkansas/Tennessee area. Since arriving here 2 years ago, I have consistantly been treated like a leper by MDs. I’ve heard that the state medical boards of these states have been rabid in their pursuit of MDs who treat chronic pain. The only time I go near a physician for my back is if it has gone completely out on me. What happens everytime is that I’m given a prescription for lortab (say 30 pills). When I show up in that same MD’s office 2-4 months later with the same complaint, I am practically shown the door! It’s criminal that responsible patients are treated in this way. Also, as Marcelian points out, I have taken so much Alleve that I now have severe acid reflux that even 2 Prilosec/day can’t take care of. It’s no telling what all of the acetaminophen (Tylenol) has done to my liver!

    Where is all of this scrutiny leading to? Do people have to endanger their cardiovascular, hepatic and renal health because MDs have to be scared to death of their state boards and the DEA?

  37. Michael: The point of writing this was to educate about the short/long acting meds. You are staying away from oxycontin, but taking hydrocodone. To me, this is a bad choice because the actual addictive nature of the shorter acting drugs is more than the longer ones. Very few drug-seekers (the bad ones) come asking for long-acting drugs. Oxycontin got its rap because folks could grind it up and inject huge amounts. The drug itself is not as likely to cause addiction as the hydrocodone.
    I feel your grief, though.

    Oh yes, also watch the Aleve. It’s not refulx that you worsen, it’s the risk of having an ulcer (which is far worse). That’s why I actively push long-acting narcotics.

  38. Michael: The point of writing this was to educate about the short/long acting meds. You are staying away from oxycontin, but taking hydrocodone. To me, this is a bad choice because the actual addictive nature of the shorter acting drugs is more than the longer ones. Very few drug-seekers (the bad ones) come asking for long-acting drugs. Oxycontin got its rap because folks could grind it up and inject huge amounts. The drug itself is not as likely to cause addiction as the hydrocodone.
    I feel your grief, though.

    Oh yes, also watch the Aleve. It’s not refulx that you worsen, it’s the risk of having an ulcer (which is far worse). That’s why I actively push long-acting narcotics.

  39. Hi Rob. Physicians in this area have notices posted next to the stations where patients check in stating, “We do NOT treat long-term pain. Do not ask for narcotic pain medications.” In some cases, these notices are also posted on the front door. Dealing with that kind of attitude, how does a pain patient go about requesting anything, let alone a drug like Oxycontin, which around here, seems to be viewed as “the Devil’s plaything”?
    btw – Thanks for writing this; it’s great to have education and on-going dialogue. One certainly doesn’t see that around this part of the country!

  40. Hi Rob. Physicians in this area have notices posted next to the stations where patients check in stating, “We do NOT treat long-term pain. Do not ask for narcotic pain medications.” In some cases, these notices are also posted on the front door. Dealing with that kind of attitude, how does a pain patient go about requesting anything, let alone a drug like Oxycontin, which around here, seems to be viewed as “the Devil’s plaything”?
    btw – Thanks for writing this; it’s great to have education and on-going dialogue. One certainly doesn’t see that around this part of the country!

  41. MichaelI understand every last statement you say. I mean what are the ones who are really hurt supposed to do. I was waiting for a response on this blog and never received one but its understandable they have there own reasoning. Atleast you can know that you are by far not the only one out there dealing with the B.S.

  42. MichaelI understand every last statement you say. I mean what are the ones who are really hurt supposed to do. I was waiting for a response on this blog and never received one but its understandable they have there own reasoning. Atleast you can know that you are by far not the only one out there dealing with the B.S.

  43. Marcellian:Sorry I didn’t respond. I thought it was more of a statement than a question. I agree 100% that most doctors are far too quick to label someone as a drug seeker. To make matters worse, they don’t do things they should to prevent addiction as a whole (use of longer acting narcotics and other modalities outlined in this post). It’s far worse to mistakenly label someone who is not a drug seeker than to be fooled.

    Both of you seem to be stuck, in that if you “doctor shop,” it will look like you are a drug-seeker. If you don’t, you are stuck with either short-acting meds for a little while, or nothing. Here is what I would suggest: 1. Find a pain management clinic that takes pain seriously. They can do many things to help and are more willing to look at more aggressive treatments. 2. If you find a new doctor, don’t start out asking for narcotics. Let them get to know you as reasonable people and not unstable ones. 3. If you have clear evidence of your pain (i.e. x-rays showing significant problems), find a doctor that specializes in that sort of problem. 4. Saying something like “I don’t like being on these short-acting drugs because they can be addictive” is always reassuring to the physician. 5. Even doctors misunderstand the Oxycontin deal. I prefer the Duragesic patch because it is much harder to abuse. Say something like “I hear the pain patch is less addictive. What do you think about that treatment?”

    Hopefully this helps and you can find someone who approaches it reasonably.

  44. Marcellian:Sorry I didn’t respond. I thought it was more of a statement than a question. I agree 100% that most doctors are far too quick to label someone as a drug seeker. To make matters worse, they don’t do things they should to prevent addiction as a whole (use of longer acting narcotics and other modalities outlined in this post). It’s far worse to mistakenly label someone who is not a drug seeker than to be fooled.

    Both of you seem to be stuck, in that if you “doctor shop,” it will look like you are a drug-seeker. If you don’t, you are stuck with either short-acting meds for a little while, or nothing. Here is what I would suggest: 1. Find a pain management clinic that takes pain seriously. They can do many things to help and are more willing to look at more aggressive treatments. 2. If you find a new doctor, don’t start out asking for narcotics. Let them get to know you as reasonable people and not unstable ones. 3. If you have clear evidence of your pain (i.e. x-rays showing significant problems), find a doctor that specializes in that sort of problem. 4. Saying something like “I don’t like being on these short-acting drugs because they can be addictive” is always reassuring to the physician. 5. Even doctors misunderstand the Oxycontin deal. I prefer the Duragesic patch because it is much harder to abuse. Say something like “I hear the pain patch is less addictive. What do you think about that treatment?”

    Hopefully this helps and you can find someone who approaches it reasonably.

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