17 February 2009

I must have missed this

Joe Paduda reports that last week, the FDA announced that they are "considering" a requirement for additional training for physicians to prescribe certain "high risk" opioid medications.  The list is pretty much exclusively the long-acting narcotics like oxycontin and fentanyl patches.


I don't know quite what to think about this.   On the one hand, my "Physician Deity Syndrome" instinct is to bristle at the suggestion that I need more training, some sort of merit badge, in order to continue doing what I already do.   On the other hand, I know a number of doctors who merit the appellation "candyman" and a little refresher (and reminder of stricter oversight) might not be a bad thing.   It's challenging when you see their patients come to the ER over and over with their chronic fibromyalgia and they are already stoned on narcotics and insisting they need more.

From my very provincial perspective, it has the potential to make life easier.  I pretty much never prescribe long-acting narcotics from the ER, of course, so I would likely not seek out the merit badge.   We get a number of patients who present seeking prescriptions for these meds -- "I lost them," "Doctor out of town," and similar tales of woe.   Solution!   "I'm sorry, but I'm not licensed to prescribe that."   The only problem is on those rare occasions when I do have a legitimate indication to prescribe it, say a cancer patient with uncontrolled pain, or a new pathologic fracture, then my hands are tied.

It will be interesting to see if this goes through.  It's not unprecendented -- Suboxone was released with a restriction on the providers who could prescribe it.   I am not sure if Suboxone is still subject to that restriction, but it's another drug that I'm just as happy not to prescribe through the ER.   But that's a small niche drug, whereas the long-acting narcotics have a much larger market presence.

(As an aside, given the presence of certain key words in this post, I fully expect this post to have ten times the traffic of a usual post, and some annoying spam in the comments.  We'll see if that turns out to be the case.)


  1. I must say I think the downside would be worse than the upside. I usually use the line "our policy is that we cannot prescribe those medications" (fentanyl, methadone, etc). However, it is frequent enough (1x/month) that I do write for the heavy hitting opiods, I would hate to have that taken away from me.

    I am not sure that this has much upside. Do you really think a little extra training would put the candyman out of business?

  2. Surely the drug companies will howl at this idea, and lobby like hell to make sure it never happens.

  3. I would love to tell drug seekers "sorry, I can't write for that stuff!!!!" Go see Shadowfax! LOL

  4. I have a solution for the cancer patients -- page the on-call medical oncologist and make them write the script. Maybe the same could happen with ortho for the fractures?

  5. I don't see the benefit to this idea - sorry. If the DEA or the BOM doesn't think we're prescribing appropriately, then why not remove the CII qualification for those who aren't capable of setting appropriate limits?

    The DEA application lists each level individually.
    Creating tiers of DEA qualification is silly. Requiring an X-license equivalent for all CII drugs is just goofy. The next level is saying that you can have only so many patients on CII drugs, requiring a registry for audit, etc., and making the CIIs akin to Suboxone or methadone...

    As far as an ER policy, that's a separate issue, but I agree, the X-type license won't work there. I am a big fan of the 3 day fill, then the 2 day fill, then the 1 day fill, though.

    I'd love to see something that pushes use of the heavy-hitters for non-cancer pain out of the FP offices and into the physiatry clinics / genuine pain specialists. On the other hand, the reality: those offices aren't going to absorb every single "pain patient" in the world. So, what, we're gonna say that FP is going to give 'em all Vicodin/Percocet? Quick, someone, buy all the Mucomyst futures...

    This is like saying that all antidepressants must be prescribed by psychiatry. It's a great idea, in theory. Psych would, in theory, rule out bipolar disorder, and screen for comorbidities and suicidality, and link the patients to therapy - but there aren't that many psychiatrists out there, and not everyone is insured, so we have a lot of people who see their GP and do OK, and a few people who see their GP and do quite poorly on ADs, and a fair number of people who are referred out to psychiatry with varying degrees of success. But no one says, "Hey, we need a special P-license to prescribe psychiatric drugs." Not even Xanax.

    And anyone who's worked an ER can tell you how fun Xanax abusers or overusers are when they are in search of an early fill.

    Maybe requiring the patient to sign an informed consent for a CII, such as is done with Suboxone/methadone, acknowledging abuse potential, the need for monthly fills, etc., wouldn't be a bad idea instead. The good pain clinics around here do this for CIIs (and I think they do it for all chronic controlled substances, although I'm not certain.) It puts some of the responsibility back on the patient, and I've heard ER patients say, "Yeah, Dr. X told me I'd have to be seen, and I messed up, I was out of town, I didn't realize." At least it was a refreshing change.

  6. There is no way we could call onc/ortho (assuming the ortho docs learn how to rx the big meds) and say: "uh....I have this patient here you have never seen, how about you call in some Fentanyl for them?" Of course, if you work at a teaching hospital, just wait 6 hours for the resident to come down....

  7. As a patient with fibromyalgia, I view managing my pain levels as being part of what I just have to do. If I were diabetic, I'd have to keep an eye on my sugars and how many syringes I had, etc. Now I journal three times a day for pain levels, food eaten, meds taken, where I am in my menstrual cycle, what the weather was doing (weather triggered migraines and joint pain), and I keep an eye on my amounts of medication. I deliberately use non-drug methods, as far as I can, to manage the pain and stiffness that comes with this.

    Funny thing is, the one that really sucks to run out of isn't the tramadol. I primarily was moved to that to avoid the effects with long-term NSAID use. It's the Ambien, since my deep sleep is borked and the Ambien gives me normal sleep.

    I hate it that others with this condition have made fibromyalgia a word that equals drug seeker. After my diagnosis, I've delayed care visits to anyone but my normal provider out of fear that the ER people, specifically, would say, "You're just a drug seeker, there's nothing wrong with you." But I keep such close tabs on myself, I know when something is. (sigh)

  8. I never go to my doctor anymore asking for pain killers prescription and then be turned down at the end, all I do is order online from www.medsheaven.com hassle free and low cost, they have three pain killers listed on their website which are ultram tramadol celebrex that you buy, and the best part is no prescription required!!!

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