Another issue not mentioned here is the lack of effective treatment programs to treat opiate addiction. I am speaking about people here who WANT help.

I have had more surgeries than I care to mention. This is a good thing. I got hooked on opiates and then booted them. Don’t judge something you haven’t touched!

quote:

Originally posted by Gustofer:

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Originally posted by Erick85:
Decrease the number of pills that are on the streets that have been prescribed excessively.

Even though I hate it when others do this, I'll do it to you.

Decrease the number of guns that are on the street and we'll decrease the crime.

Sure, that might help, but it won't solve the problem. What will, is changing the culture, and THAT is a much more difficult thing to do. There are no easy solutions to this problem. Stopping the means is not the most effective or even the best way, stopping the desire is. But how?

I have no doubt it won't solve the problem. But it is a piece of the overall puzzle. It also isn't just a "culture" either. Addiction has many forms and many causes. For some, it is a genetic predisposition.

I asked for a shot of Dilaudid when I had to go back to the ER and be readmitted after being discharged 5 hours earlier because the blood clot in my kidney had blocked off my urethra and I couldn't urinate. I told the doctor that this was the 5th time I was going to be catheterized in 3 days and I didn't want to feel it....at all. He agreed and that hit me like a wave, starting at my head to my toes. I did not like the feeling at all. It made me feel like I wasn't in control of my body, but also made me realize, that is the high or feeling that people search out.

You are never going to get all of the pain meds off the streets. That isn't what they are trying to accomplish. You can, however, decrease the amount that is available. If you can prescribe a 5 day supply and that is sufficient, then why wouldn't we want to see that instead of a 15 day supply?

I think the hardest thing with this all is the fact that pain is very subjective. I have a very high pain tolerance. Apparently, some opiates don't work very well on me and more is needed to achieve the desired result. I say apparently because in my screening for my second surgery, the nurse was shocked by how much fentanyl they had to give me during my surgery the previous year. Her words were something to the effect of, "Lets just say you are highly tolerant to pain meds." Prior to this I had taken maybe 4 Vicodin immediately after my wisdom teeth were removed, so it definitely wasn't a built up tolerance.

The culture you mention is multifaceted. It involves everyone including the prescriber, patient and pharmacist. The prescriber needs to truly understand what they are prescribing AND whom they are prescribing it to. The patient needs to understand that there are other effective measures to reduce pain, instead of just narcotic pain relievers. I found that I could find an almost meditative state in the hospital and not have to use my PCA. The pharmacist needs to understand these things and, while we can't always dispense everything, lay it out to the patient in a way they will understand and become an advocate for them.

I will give one more example of that last sentence. I had a patient within the last 2-3 months that was always trying to get his Norco early. It was dosed every 4 to 6 hours as needed, yet he was consistently trying to get it early. If it is dosed as needed, yet they are getting it filled again as if they are taking it on a scheduled basis, there is a problem. I spoke with him for probably 30 minutes and explained that the physician needs to be aware that he was taking it at the upper limits of what he prescribed and if that wasn't taking care of the pain, then they really needed to consider other options. This gentleman started out our conversation cussing me and ended it almost in tears thanking me for caring so much for him and he felt he was becoming more dependent on the Norco.

Again, I will say, CVS/Caremark isn't saying you can't get you medication. They are saying there will be a few more hoops for the doctor to go through. I believe their hope is it will cause more docs to think maybe just a bit longer with what they are prescribing. One bright side, they are giving plenty of notice. Express Scripts did not give any. We started processing one day and were getting rejections. Both our patients and ourselves were informed at the same time....after we called the insurance to find out what was going on.

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Originally posted by Dusty78:
This was his job. Running around getting pills was his career.

Did he have a lot of fake ID's? Where I live you need to show ID to prove you are who you say you are to receive treatment. Perhaps that is just for insurance claims, not for cash.

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Originally posted by deepocean:

quote:

Originally posted by Dusty78:
This was his job. Running around getting pills was his career.

Did he have a lot of fake ID's? Where I live you need to show ID to prove you are who you say you are to receive treatment. Perhaps that is just for insurance claims, not for cash.

Not sure if he did or didn’t. Homeless people don’t have ID and get seen and fill prescriptions all the time. Here patients have the choice to palm scan if they don’t have ID but they can refuse. Many have caught on and refuse to palm scab as it will merge all their accounts including the ones with fake names and birthdates.

quote:

Originally posted by ZSMICHAEL:
Another issue not mentioned here is the lack of effective treatment programs to treat opiate addiction. I am speaking about people here who WANT help.

Last I heard NA works if you work it ! And I hear it's free and all you have to do is "Go" to a meeting!!

There is a huge difference between an ER patient that needs pain meds and an ER patient that wants pain meds. The number of patients who want meds has increased over the last decade exponentially. Anyone with a bit of experience can see them coming a mile off. And the ones who put on a great show are going to continue to get any way they can, including violence.

What do you do about the visits that need the meds? Someone who is in obvious distress? Sure you can make the process harder and treat normal people like criminals, and yes, ER docs do not usually give out long term scrip. But there are people that need the relief. It's more often than not an on-the-spot call. "Do no harm" - and some doctors still care about their patients.

As to "no one ever died from pain" - that is not true. It can lead to many complications, including MI induced death.

As an aside, the use of pain meds over the last 2 decades in the US over foreign countries is also attributable to the US's advances in medical procedures & technologies. When gallbladder surgery is done pretty much as an outpatient procedure, pain meds are given. Some need them, some keep them on a shelf as proof of their willpower.

This is not an easy fix (yeah, not intended as a joke), nor a single answer. It's complex, and it requires a finessed answer.

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Last I heard NA works if you work it ! And I hear it's free and all you have to do is "Go" to a meeting!!

This is true to some extent. They do not however provide a complete program for most people. I have no doubt that it is a useful adjunct for many people. Recovery from any addiction is a life long process.

quote:

Originally posted by drtenb330:
There is a huge difference between an ER patient that needs pain meds and an ER patient that wants pain meds. The number of patients who want meds has increased over the last decade exponentially. Anyone with a bit of experience can see them coming a mile off. And the ones who put on a great show are going to continue to get any way they can, including violence.

What do you do about the visits that need the meds? Someone who is in obvious distress? Sure you can make the process harder and treat normal people like criminals, and yes, ER docs do not usually give out long term scrip. But there are people that need the relief. It's more often than not an on-the-spot call. "Do no harm" - and some doctors still care about their patients.

As to "no one ever died from pain" - that is not true. It can lead to many complications, including MI induced death.

As an aside, the use of pain meds over the last 2 decades in the US over foreign countries is also attributable to the US's advances in medical procedures & technologies. When gallbladder surgery is done pretty much as an outpatient procedure, pain meds are given. Some need them, some keep them on a shelf as proof of their willpower.

This is not an easy fix (yeah, not intended as a joke), nor a single answer. It's complex, and it requires a finessed answer.

If a patient is in intractable pain I will admit them. Especially if they are elderly or narcotic naive. If not they get a short prescription for 3 days and a referral. Stress induced cardiomyopathy or Takotsubo’s cardiomyopathy (which has been sometimes coined broken heart syndrome) is usually from emotional stress like losing a loved one not normally attributable from physical pain. It is also closely tied to underlying psychiatric conditions.

The reason that gallbladder surgery or cholecystectomies are so advanced now is because we do a shit ton of them needlessly. More than 50% that are done are done so needlessly. A change in diet habits would greatly help to alleviate epigastric pain. What happens is people come to the ER or to their PCP for epigastric pain after eating 3-4 times before they go see a surgeon. Each time they are told to curb their fat and friend food intake. They don’t. They get pain meds everytime which have a temporary effect. Finally the surgeon says sure conservative measures failed let’s take it out. Well the most conservative measure (no more McDonald’s was never attempted.) Now I’m not saying that this is the case in 100% of patients but it’s a high percentage. Why else are surgeons removing perfectly healthy gallbladder’s more han 50% of the time. This just goes back to the idea that things in the USA have to be taken care of immediately. I have had patients family members come into patients rooms when I’m coding someone to scream about their so-so’s kidney pain. We just live in a selfish me-me-me society. Oh and btw 2 months after their gallbladder is removed hey are back in the ER with epigastric pain.

If you walk into my ER with a broken leg you will get pain medications. I will sedate you to reduce the fracture. Admit you if needed. Setup an outpatient follow up and give you a short prescription of narcotics. If you have chronic back pain for 10 years and ran out of your pain meds because you took too many I’m sorry. That’s not the pervue of the ER. It’s not an emergency. Our facility actually had a new pain policy that advices us not to treat chronic pain. We (medical practitioners) get blamed for starting the opiate epidemic and when we try to do something about it we are heartless bastards. I treat plenty of children with bad extremity fractures with nothing more that Tylenol and Motrin. Are children just tougher then adults?

This world has 7.5 billion people in it and 350 million account for 80% of the entire worlds opiate prescriptions....let that sink in.

I don't think I'm disagreeing w/you. We've caused the problem. But there is no solution in putting up more safeguards or restrictions. It just doesn't help those he really need the help. And, you are correct; Children are a great bellwether for pain tolerance.There are children who break bones that do need pain relief stronger than NSAIDs, some don't.

I get you know what you are doing. Yes, The percentages might be off, statistics used by the big companies to their benefit. My ER is one of the largest trauma centers in the Southeast, hence the US. I don't needlessly give out anything. I'm 50+ years old, and am one of the department heads. I'm as cynical s they come. I'm also as stuck in the system as you are.

My point is the same as I wrote: more regs don't seem to be the answer, there is no universal answer. It's going to take a lot more than having pharmacists or drug stores adding more hurdles. I just have no idea what the answer is.

[quote]Why else are surgeons removing perfectly healthy gallbladder’s more han 50% of the time.

Is this confirmed by the pathology report? Seems like an issue for peer review if this is this frequent in your facility.

quote:

My point is the same as I wrote: more regs don't seem to be the answer, there is no universal answer. It's going to take a lot more than having pharmacists or drug stores adding more hurdles. I just have no idea what the answer is.

I agree completely. The government pushing more suboxone docs is a poor solution as well. Granted it is not as bad as methadone, but it is still not an effective treatment for most.

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Originally posted by ZSMICHAEL:

quote:

My point is the same as I wrote: more regs don't seem to be the answer, there is no universal answer. It's going to take a lot more than having pharmacists or drug stores adding more hurdles. I just have no idea what the answer is.

I agree completely. The government pushing more suboxone docs is a poor solution as well. Granted it is not as bad as methadone, but it is still not an effective treatment for most.

It’s a national trend. After the invention of the laparoscopic cholecystectomy the number of total cholecystectomies went up by hundreds of thousand of casss per year. The worry is that often mild to moderate biliary pain is being treated with removal of the gallbladder without cholecystitis (infection.) often surgeons will remove due to gallstones without infection as a precautionary measure. I have seen asymptotic gallstones removed. The school of thought is that since the surgery was made so much easier by laparoscopy they just do them without hard proof of actual gallbladder disease. There are entire surgical centers set up to do nothing but gallbladder removal like an assembly line.

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Originally posted by sdy:

quote:

People in America are simply pussies when it comes to pain. Anywhere else in the world after surgery you get a prescription for ibuprofen 800 and a boot in the ass at the door

Perhaps one of the dumbest comments I have read on the forum.

Why would one not relieve incapacitating severe pain during recovery from surgery ?

American doctors prescribe more opioids than any other country. Less addictive options are available.

https://www.washingtonpost.com...m_term=.e3576c7fb639

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Less addictive options are available

such as ?

Tylenol, ibuprofen etc don't touch the kind of pain I am talking about.

My wife's orthopedic surgeon does multiple major surgeries every week. While there is a difference of patient recovery timelines, he is very familiar with what typically happens and what the extremes of fast and slow recovery are.

My scenario is not an ER visit or a drug addict trying to get high. Like so many others deal with, this is a case of a medically known procedure, known range of recovery times, and a lot of experience in how much pain recovering patients have to deal with.

I am quite in disagreement that patients in recovery should suffer because someone thinks that is okay. I am also quite aware of the dangers of addiction and that was discussed with her surgeon.

quote:

Originally posted by sdy:

quote:

Less addictive options are available

such as ?

Tylenol, ibuprofen etc don't touch the kind of pain I am talking about.

My wife's orthopedic surgeon does multiple major surgeries every week. While there is a difference of patient recovery timelines, he is very familiar with what typically happens and what the extremes of fast and slow recovery are.

My scenario is not an ER visit or a drug addict trying to get high. Like so many others deal with, this is a case of a medically known procedure, known range of recovery times, and a lot of experience in how much pain recovering patients have to deal with.

I am quite in disagreement that patients in recovery should suffer because someone thinks that is okay. I am also quite aware of the dangers of addiction and that was discussed with her surgeon.

In recovery from an operation or procedure there should be SOME pain. Pain is what tells you that you are doing something wrong or putting pressure on something that isn't healed and you need to stay off of. One should not be completely 100% numb after a surgery.

There are many other options for pain reduction below Oxycontins and oxycodones. I don't know your situation and am not your doctor, so I am not speaking of your particular situation. But oxycontins were invented for terminally ill cancer patients (where addiction was not a worry), not for pain reduction for a surgery.

quote:

Originally posted by sdy:

quote:

Less addictive options are available

such as ?

Tylenol, ibuprofen etc don't touch the kind of pain I am talking about.

My wife's orthopedic surgeon does multiple major surgeries every week. While there is a difference of patient recovery timelines, he is very familiar with what typically happens and what the extremes of fast and slow recovery are.

My scenario is not an ER visit or a drug addict trying to get high. Like so many others deal with, this is a case of a medically known procedure, known range of recovery times, and a lot of experience in how much pain recovering patients have to deal with.

I am quite in disagreement that patients in recovery should suffer because someone thinks that is okay. I am also quite aware of the dangers of addiction and that was discussed with her surgeon.

The question is why can people who have the exact same surgeries in other countries tolerate the post operative pain while here we can’t? Are they inherently tougher? The best example of his is back surgery. In the US we do a lot of back surgery on people who have been on chronic opiates before the surgery. Because of this even after surgery the pain never really goes away as the patient’s pain receptors have been re-wired. It becomes an endless loop of more pain meds and more surgeries.

My mother was hit by a car when she was 19 in Chile (the country.) She had a titanium pin placed with a multilevel lumbar fusion due to spinal fractures. Never received post op narcotics. Since then she has had thoracic compression fractures that are now chronic and painful (due to the strain placed on the thoracic vertebrae from the lower fusion.) She manages the pain with Celebrex and manages it well. She never got on the narcotic train and hasn’t needed to.

CVS has for the last year or so refused to fill both opiates and benzo scripts at the same time. They’ve seen evidence that there’s a higher incidence of ODs when both are filled concurrently.
What I find disturbing is lumping all chronic pain patients into the illegal opiate problem/drug seeking population. Especially by healthcare providers. I know they mostly are referring to people that are trying to scam them by trying to get a Rx for a questionable acute injury. But there’s plenty of legit chronic pain patients who honestly need long term pain meds. They are the ones who couldn’t function at their normal activities of daily living without something to take the edge off. I’m talking barely functioning. Not getting a high, just a short respite from chronic debilitating pain. They jump through the hoops. Drug contracts, drug testing, having to immediately notify their Doc if a provider gives you an extra Percocet due to a legit reason, and being made to feel like second class citizens because someone once had surgery and roughed it out on Advil/Tylenol. If you had debilitating chronic pain, you’d do whatever you needed to do. Nerve blocks, Epidurals, Tens, Massage,PT, even long term opiates.
Healthcare providers, and I worked as an RRT for 30 years, sometime fall into the same jaded outlook as LEOs who look at everyone as a perp. When all you see are people trying to game the system, that’s all you see. Not everyone is a dirtbag. Some are,some aren’t. To only write a Rx for 3 days for a couple herniated disks,knowing it’ll take more than that to get into a pain management Doc, IF they can get off the couch, is just wrong. But hey, I once had all three lungs removed, had a 10cm kidney stone crushed by hand, and still did the Iron Man the next week.
Like a lot of things the legit patient gets thrown under the bus. The heroin/fentanyl ODs make it look like all opiate users are the same. They are not.
And I’m not talking about the chronic back pain patient who has gobbled up their Rx a week early. Or someone who has diverted their meds or sold them. There are plenty of them. Screw them. I’m talking about a legit problem/pain pt who gets lumped into the wrong crowd. It’s a very tough life for someone who has legit chronic pain. Because we once looked at the ten faces of pain and over prescribed, we are now facing under prescribing for legit pain pts. Until you have that pain, it’s all theoretical.

Because Opiates are NOT a long term pain solution, they are a narcotic. For 80% of people, the doses would go from 2 per day to 20 per day to keep the same pain relieving in 2-3 years. Opiates are highly addictive and their very nature require larger and larger doses as time goes on due to the way the body quickly builds a tolerance to them. There are other pain medications that are much better long term solutions. While not as powerful as OxyContin, they provide still provide a good amount of relief.

Benzo's are also highly addictive and after most people have been on them a year their effects are useless, and dosages need to be substantial at that point.

I think we are at the point where some of us won't be coming to an agreement.

I am quite surprised that a physician doesn't approve of relieving intense debilitating pain during recovery from surgery.

Maybe we should do away with anesthesia too and give them a stick to bite on.

I guess our orthopedic surgeon has it all wrong.