grrr arrgh pain meds
So. The CDC, in its infinite wisdom, is working on creating new guidelines for prescribing pain meds. Explanation and description over here.
Okay, so, here's the thing. I read over the guidelines, and the only thing that really stands out is the dosage restriction. The suggested guidelines--and keep in mind, these haven't been adopted yet, although the CDC is being really horrible about letting people comment on them--say that doctors should do their best to keep prescriptions below 50mg/day in morphine equivalents and should try not to prescribe more than 90mg/day in morphine equivalents.
Everything else basically says that doctors should prescribe opiates as a last resort, that they should work with patients to find other methods of treatment, that doctors should review the prescription monitoring database to make sure patients are only taking what they're supposed to, that opiates should only be given for a few days for acute pain.
Maybe it's because I live in Washington, a state that has implemented some pretty tough restrictions on opiate medication, but none of this except the dosage restriction seems all that new or outrageous to me. A hassle, absolutely, and it's absolutely difficult to find a doctor who will prescribe opiates if you need more than like one or two Vicodin a day (and even that's hard sometimes), but what I'm reading on that page doesn't strike me as all that different than what I go through now to get my meds.
In my particular situation, I'm already going against established medical guidelines. Most national doctors' associations, including whatever the neurologists' one is called, say that opiate medication for chronic migraines is a really bad idea. Chronic migraineurs should try other methods of pain management including Botox therapy, triptans, lifestyle changes, etc. but should not take opiates because long-term they just don't work. Hell, I've had ER doctors tell me I shouldn't be taking what I do.
On the other hand, I have yet to find a triptan that works reliably and effectively; I've tried four or five, and either they don't work at all or they're wholly unreliable and I never know what result I'm going to get. I've taken Zomig about four times in the last two weeks and I did not have the same reaction once. As well, my insurance will only pay for about 6 pills every two weeks (it might actually be 6 pills a month, I'm not sure). It takes at least one, maybe two pills to kill a migraine, and that's assuming it works at all. I get more than three migraines a month most of the time, and if I can't count on it to work every time, you can see where I'm going with this. The oxycodone actually works, and is reliable, and I can depend on it.
I am incredibly fortunate that I have finally found a doctor who is willing to set aside the guidelines for chronic migraineurs and write me prescriptions for oxycodone. I am also aware that my tolerance has really increased since I started taking it, and that most people would have really bad reactions to the amount of it I take at one time. I try to be careful; if I've taken oxy once or twice in a day, I try to avoid taking it again for a while. If I've had to take it for a couple days running, I stop taking it for a few days because if I continue taking it I'll give myself a rebound migraine, and those are the worst.
But the hoops I have to jump through to get my piece of paper every month keep growing, and every doctor I've ever had who will give me said piece of paper has been very clear that this should not be a first resort, that I should try everything else first. Most of them will make me try everything else first. With Dr. Z they made me get nerve blocks and see a pain psychologist as a condition of continuing to get my scrip, and every time I see them they encourage me to try things like acupuncture or chiropractic or whatever else they think might help me. Dr. Z's office will write me the oxy scrip but I get anxious every month before my appointment, wondering if this is the time they'll tell me they can't prescribe me narcotics anymore. Every time the clinic calls me and I'm not expecting it I almost have an anxiety attack wondering if they're telling me I can't be a patient anymore. Granted, I have anxiety issues, but I'm far from the only chronic pain patient in this boat.
I don't know what the dosage restrictions will do to other patients because I don't know what other people normally take. When I was on ER morphine I think I was at 60mg/day, which is a bit higher than their suggested dosage but lower than what they say the upper limit should be. Now my oxycodone dosage is at max 30mg/day, which is lower.
On the other hand the new guidelines also recommend prescribing IR (immediate-release) meds rather than ER (extended-release) meds, and a lot of chronic pain patients rely on ER meds. I understand where the CDC is coming from on this, but it doesn't make it easier to hear if you depend on ER morphine or OxyContin and suddenly you're being told you might not be able to get that.
What I don't know, and would like to know, is whether the CDC rules are actually binding rules or if they're more guidelines, in which case individual doctors can exercise discretion for individual patients. I'm pretty certain that oversight of prescriptions is going to get more stringent, so a lot of doctors may not want to write them anymore or will only write for small amounts. But I hope that there will be leeway for doctors to prescribe opiates based on the needs of the patient and not "One Size Fits Few" guidelines.
I keep being torn between some of the data that's out there and my own personal experience as a chronic pain patient. The US has more prescriptions for narcotic pain medication than any other country in the world. There are, undoubtedly, a lot of people taking pain meds long-term that maybe should be on something else, or trying other treatments for their pain. And to be completely honest, opiates aren't a really good solution for chronic pain.
The problem is that they're a crappy solution but the others are worse. Taking opiates long-term will fuck you up, undoubtedly. Your tolerance increases, the risk of psychological addiction gets higher, the risk of physical dependence rises, and the drugs have lots of side effects that aren't really fun to deal with. Oxy and dilaudid make me itch like a motherfucker--this isn't an allergic reaction, it's a histamine side effect. If I take enough to kill my pain I'm usually scratching my skin off for a few hours.
But there's only so many other solutions, and none of them are all that effective. As well, a lot of people don't have insurance that will pay for things like chiropractic or acupuncture or steroid injections. Even if they have the insurance they may not be able to afford it, and even if they can afford it they may not have the time. There are some medications like Cymbalta and gabapentin and things for neuropathic pain, but that's only applicable in some conditions. I've said before: If you want a medication for pain relief, and you're not looking at a Cymbalta-like drug, your options are NSAIDs, opiates, or Tylenol. I have yet to find an actual pain medication that's none of the three.
So while I understand that people are dying from pill overdoses, it's also worth remembering that when states crack down on prescribing pills people turn to heroin and die from that, or lose their whole lives because of it. Rather than enact burdensome laws and make doctors afraid to write prescriptions, how about we work more effectively to treat addiction? Let's step away from 12-step and move to a philosophy of harm reduction instead.
Pain contracts are inherently demeaning and treat the signer as though they're either an addict or someone who will be addicted eventually. While I understand where some of the clauses come from--most of them, really--it's still humiliating to have to pee in a cup randomly every few months to prove I'm being compliant. It's frustrating and a bit difficult to go only to one or two pharmacies to fill prescriptions. I end up having to arrange things like vacations around my refill days, because I can't get an early refill on anything unless I ask my clinic about it months in advance and even then it's hard. When I went to KY and then NJ in August, my refill date was supposed to be the day after I flew out to KY. I had to confirm with them I could move it up by two days to that Monday, and that required them checking with the doctor because they couldn't just let me move the fill date. I had to move my appointment from Tues to Thurs this week because of work stuff so I don't know what that will do to my fill date next month.
None of this benefits me, and none of it really benefits my doctor except that it might get the DEA and the FDA off his back for a few more months. And yet it's what I do.
And speaking of, I need to post this so I can start shutting down and get out of here to see said pain clinic and get my new scrip. There's amusing timing in this...
This entry was originally posted at http://blueraccoon.dreamwidth.org/1355221.html. Please comment there. |
comments
Okay, so, here's the thing. I read over the guidelines, and the only thing that really stands out is the dosage restriction. The suggested guidelines--and keep in mind, these haven't been adopted yet, although the CDC is being really horrible about letting people comment on them--say that doctors should do their best to keep prescriptions below 50mg/day in morphine equivalents and should try not to prescribe more than 90mg/day in morphine equivalents.
Everything else basically says that doctors should prescribe opiates as a last resort, that they should work with patients to find other methods of treatment, that doctors should review the prescription monitoring database to make sure patients are only taking what they're supposed to, that opiates should only be given for a few days for acute pain.
Maybe it's because I live in Washington, a state that has implemented some pretty tough restrictions on opiate medication, but none of this except the dosage restriction seems all that new or outrageous to me. A hassle, absolutely, and it's absolutely difficult to find a doctor who will prescribe opiates if you need more than like one or two Vicodin a day (and even that's hard sometimes), but what I'm reading on that page doesn't strike me as all that different than what I go through now to get my meds.
In my particular situation, I'm already going against established medical guidelines. Most national doctors' associations, including whatever the neurologists' one is called, say that opiate medication for chronic migraines is a really bad idea. Chronic migraineurs should try other methods of pain management including Botox therapy, triptans, lifestyle changes, etc. but should not take opiates because long-term they just don't work. Hell, I've had ER doctors tell me I shouldn't be taking what I do.
On the other hand, I have yet to find a triptan that works reliably and effectively; I've tried four or five, and either they don't work at all or they're wholly unreliable and I never know what result I'm going to get. I've taken Zomig about four times in the last two weeks and I did not have the same reaction once. As well, my insurance will only pay for about 6 pills every two weeks (it might actually be 6 pills a month, I'm not sure). It takes at least one, maybe two pills to kill a migraine, and that's assuming it works at all. I get more than three migraines a month most of the time, and if I can't count on it to work every time, you can see where I'm going with this. The oxycodone actually works, and is reliable, and I can depend on it.
I am incredibly fortunate that I have finally found a doctor who is willing to set aside the guidelines for chronic migraineurs and write me prescriptions for oxycodone. I am also aware that my tolerance has really increased since I started taking it, and that most people would have really bad reactions to the amount of it I take at one time. I try to be careful; if I've taken oxy once or twice in a day, I try to avoid taking it again for a while. If I've had to take it for a couple days running, I stop taking it for a few days because if I continue taking it I'll give myself a rebound migraine, and those are the worst.
But the hoops I have to jump through to get my piece of paper every month keep growing, and every doctor I've ever had who will give me said piece of paper has been very clear that this should not be a first resort, that I should try everything else first. Most of them will make me try everything else first. With Dr. Z they made me get nerve blocks and see a pain psychologist as a condition of continuing to get my scrip, and every time I see them they encourage me to try things like acupuncture or chiropractic or whatever else they think might help me. Dr. Z's office will write me the oxy scrip but I get anxious every month before my appointment, wondering if this is the time they'll tell me they can't prescribe me narcotics anymore. Every time the clinic calls me and I'm not expecting it I almost have an anxiety attack wondering if they're telling me I can't be a patient anymore. Granted, I have anxiety issues, but I'm far from the only chronic pain patient in this boat.
I don't know what the dosage restrictions will do to other patients because I don't know what other people normally take. When I was on ER morphine I think I was at 60mg/day, which is a bit higher than their suggested dosage but lower than what they say the upper limit should be. Now my oxycodone dosage is at max 30mg/day, which is lower.
On the other hand the new guidelines also recommend prescribing IR (immediate-release) meds rather than ER (extended-release) meds, and a lot of chronic pain patients rely on ER meds. I understand where the CDC is coming from on this, but it doesn't make it easier to hear if you depend on ER morphine or OxyContin and suddenly you're being told you might not be able to get that.
What I don't know, and would like to know, is whether the CDC rules are actually binding rules or if they're more guidelines, in which case individual doctors can exercise discretion for individual patients. I'm pretty certain that oversight of prescriptions is going to get more stringent, so a lot of doctors may not want to write them anymore or will only write for small amounts. But I hope that there will be leeway for doctors to prescribe opiates based on the needs of the patient and not "One Size Fits Few" guidelines.
I keep being torn between some of the data that's out there and my own personal experience as a chronic pain patient. The US has more prescriptions for narcotic pain medication than any other country in the world. There are, undoubtedly, a lot of people taking pain meds long-term that maybe should be on something else, or trying other treatments for their pain. And to be completely honest, opiates aren't a really good solution for chronic pain.
The problem is that they're a crappy solution but the others are worse. Taking opiates long-term will fuck you up, undoubtedly. Your tolerance increases, the risk of psychological addiction gets higher, the risk of physical dependence rises, and the drugs have lots of side effects that aren't really fun to deal with. Oxy and dilaudid make me itch like a motherfucker--this isn't an allergic reaction, it's a histamine side effect. If I take enough to kill my pain I'm usually scratching my skin off for a few hours.
But there's only so many other solutions, and none of them are all that effective. As well, a lot of people don't have insurance that will pay for things like chiropractic or acupuncture or steroid injections. Even if they have the insurance they may not be able to afford it, and even if they can afford it they may not have the time. There are some medications like Cymbalta and gabapentin and things for neuropathic pain, but that's only applicable in some conditions. I've said before: If you want a medication for pain relief, and you're not looking at a Cymbalta-like drug, your options are NSAIDs, opiates, or Tylenol. I have yet to find an actual pain medication that's none of the three.
So while I understand that people are dying from pill overdoses, it's also worth remembering that when states crack down on prescribing pills people turn to heroin and die from that, or lose their whole lives because of it. Rather than enact burdensome laws and make doctors afraid to write prescriptions, how about we work more effectively to treat addiction? Let's step away from 12-step and move to a philosophy of harm reduction instead.
Pain contracts are inherently demeaning and treat the signer as though they're either an addict or someone who will be addicted eventually. While I understand where some of the clauses come from--most of them, really--it's still humiliating to have to pee in a cup randomly every few months to prove I'm being compliant. It's frustrating and a bit difficult to go only to one or two pharmacies to fill prescriptions. I end up having to arrange things like vacations around my refill days, because I can't get an early refill on anything unless I ask my clinic about it months in advance and even then it's hard. When I went to KY and then NJ in August, my refill date was supposed to be the day after I flew out to KY. I had to confirm with them I could move it up by two days to that Monday, and that required them checking with the doctor because they couldn't just let me move the fill date. I had to move my appointment from Tues to Thurs this week because of work stuff so I don't know what that will do to my fill date next month.
None of this benefits me, and none of it really benefits my doctor except that it might get the DEA and the FDA off his back for a few more months. And yet it's what I do.
And speaking of, I need to post this so I can start shutting down and get out of here to see said pain clinic and get my new scrip. There's amusing timing in this...
This entry was originally posted at http://blueraccoon.dreamwidth.org/1355221.html. Please comment there. |
comments