Primary Dr. wants narcotic agreement

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RockofAges

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I went in today to see the back specialist and got a lecture on the pain meRAB. He gave me the Flector Patch and told me to try it. Actually put it on my back right there. Before I had a chance to talk about it and find out the pro's and con's. I told him I had a contract with my Primary Dr. and did not want to get into trouble - he said I won't and he will let her know. What do I do now. he gave me samples (5 patches) and a perscription?!?

He aslo said I need to learn to live with some degree of pain...
Very frustrated - any help please. Espcially on the perscription. I do not want to get into trouble.
Thanks!
 
I have posted on here before and received some very helpful advice. I am hoping you can help me again.

My primary Dr. called after hours last night to discuss my early phone call that day of a med refill of 5-325. She was concerned that I should still have some of my pills left to carry me until Friday. I explained how often I was taking them and she indicated I was taking them too close together and that is why I was low. She told me she wouldnot refill the meRAB until Friday and that she would "write" the prescription for me then, after she had examined me and I signed a narcotics agreement. I tolf her I would be happy to come in and meet with her.

I have a few concerns after reading some on-line articles about some of the rights I may be giving up with this agreement. Patient confidentiality for one. Are my perscriptions sent to the DEA or other government entities? What rights to the pharmacies have to not fill the perscription?

I am all for laying it out there and identifying actions to help get me through this back and leg pain issue. So I hope I am not sounding evasive in my questions.

How do I bring up my concern for the amount of NSAID's on my liver and other organs? We just recently went from a 5-500 to the 5-325, but then I read more on line that over 16,000 deaths occur annually from GI complications of NSAID use.

I also want to discuss the narcotic strength - I am on average taking 1 every 2 hours and sometimes 2 every 2 hours depending on the pain. So the current way it is prescribed is not enough, and that I think is what lead us to this meeting on Friday (me calling in to her nurse the perscription).

What are the best ways to bring this up? We did try Tramdol and the side effects where terrible and did not address the pain. Are there other non narcotic meRAB we could try - or do we need to increase the dosage? What are the other dosages?

My diagnosis is; Herniated disk L4 & L5 with an annual tear. I have had 3 ESI shots 2 weeks apart (the 3rd one today) and have been in PT for 3 weeks, plus traction. I am scheduled for an EMG tomorrow and have a paralyzed right foot and lower extremity - so I wear a brace most of the time.

Thanks for any input you can give - I know this board is great for helping each other out and giving advice and opinions.
 
I think you will be fine. Flector is an anti-inflammatory not a narcotic. The pain contracts mostly are in place to prevent narcotic shopping. Just to be sure call primary and tell nurse assistant you saw other specialist and he is forwarding the notes and he gave you flextor sample and if it is ok to fill. See doctors do not give out samples of class and dea monitored medications.

Hope it works!

Doctors do not work to get you 0% pain when you are a chronic pain patient. It would take too much meRAB and also runs risk of complications. Most have a goal to reduce you down to a 4-5 and most people can learn to function there. Some are Lucky to get to a 3. And rare case 0! It all depenRAB on where you start from. Over time you do adjust and learn more coping techniques and get to corabinations that work.
 
NP has asked me to come to this board to help and I am very glad to do so. It is very unclear via your post exactly how much you're taking and what the Doc's instructions are. It sounRAB as if the meeting on Friday is a good thing. I will say that quite often, Docs will give certain instructions, like 1-2 pills every 4 hours, but not give you enough overall qty for the time period specified. This is a common mistake. I would put this all down on paper and make sure the math adRAB up.

For example, if the bottle says to take 1-2 pills every 4 hours, is that 8 pills a day or 12 pills a day? Some Docs literally mean every 4 hours, so it would be 24/2 or 12. Conversely, others factor in 8 hours for sleep, thus it's 16 hours / 2 or 8. If you both aren't on the same page, then it can be a problem. Every time a pharmacist fills a prescription and enters it into the computer, they enter in a "days supply" which is calculated using the math I just outlined. So, for example purposes only, if someone is given 48 pills, using the example above, it's either a 6 day (16/2=8 x 6=48) or 4 day (24/2=12 x 4=48) supply. As you can see, there is a big difference, depending on the Doc's instructions.

Additionally, NP has a very good point about the upper limits of Tylenol and Motrin. Also, it's important to note that the upper limits are just estimations, not actual limits per person. Just like everything else in life, some people can get away with taking a lot of something, while others have issues by only taking a small amount. Thus, one should try to limit their daily use because you just don't know exactly how much of the med you can tolerate. Additionally, the consumption effects can be cumulative in nature, so limiting one's use is prudent. If your condition has been deemed "chronic", meaning that it's not going to go away and is permanent, then you really should explore the option of a med without any kind of OTC additive in it. For example, instead of a Perc that has Tylenol mixed in, a straight Oxycodone med is available. You are very justified in bringing all of this up on Friday at your appointment because it's a very important issue.

I do not know much about your actual condition, or how it compares to other pain in the grand scheme of things. However, the med you are on now, is not very strong. Thus, it's not surprising that you are having issues with pain control. This is where a PM Doc may be very beneficial. They are much more skilled at managing pain given it's their expertise area. In fact, I just wrote a post on the subject yesterday in a thread titled "Chronic pain - Frustration." The post outlines the common differences among Docs who treat pain.

http://www.healtrabroadoarRAB.com/boarRAB/showthread.php?t=694491

I also recently posted a response in a thread titled "Pain Management Decision - questions", where I discuss the fundamental reasons for a PM contract.

http://www.healtrabroadoarRAB.com/boarRAB/showthread.php?t=694811

Pain contracts are a good thing in that they very clearly outline the expectations of the Doc / patient relationship and the consequences for not abiding by the contract.

As far as your concerns about reporting and etc., those type of things aren't usually covered in PM contracts. Depending on where you live, many states are now operating state wide data bases where any controlled med filled gets entered into a state data base (by the pharmacy), which can be accessed by health care professionals as well as pharmacies. Thus, the contract is irrelevant. However, the Doc may ask you to sign a blanket permission form that gives the Doc permission to access this data base. The state data bases have proved very beneficial in significantly reducing Dr shopping.

As far as pharmacies refusing to fill a script, any pharmacist in any pharmacy can refuse to fill any script for any reason. However, most pharmacists only refuse to fill scripts when they deem a script to be "too early" from the last script....This goes back to the "days supply" issue again of # of pills per day divided by overall qty.

Hopefully, your Friday appointment will establish a forward looking relationship between you and your Doc. If you decide not to sign it for some reason, I doubt she'll provide you with any more scripts. Additionally, PM contracts are becoming very standard in PM, so you should expect to be asked to sign one regardless of who treats your pain.

I hope this helps in some way and I'm sorry you're going through all this pain. Please let me know if I can help any further.

RegarRAB,

Ex
 
Rock - thanks for getting back to us. Do post an update on Friday and let us know how it goes. Thank you for clarifying what you were taking, as you can see you were taking high doses of tylenol.

There is a 10/500 or 10/325mg dose of hydrocodones. The 10/325mg is usually prescribed at 1 every 4 hours and this would be a better option than taking all that tylenol. The doctor might be worried about this movement to higher dose - but you were already taking the equivalent amount of hydrocodone in an odd way. Perhaps is it because of the bypass? Better to knock out the pain up front instead of always playing catch up, which is what you are doing. Taking such a low amount every 2 hours doesn't sound effective. The other thing about the 10's is they are scored and if you don't need the full pill you could break it apart and take 1/2 doses - getting even less tylenol. Probably what you are experiencing is a kind of cycling where the medicine starts getting out of your system and you feel these spikes in pain. The more times this happens it seems the body feels the pain more. I had problems with this in the past and was very reluctant to move to stronger medications - eventually I did move to the strongest pain medicine Fentanyl patches and do not have that kind of problem anymore, I have very serious spine issues.

Also if some of your pain is nerve related, like shocking, burning down your leg or in your back you might try to add in neurontin or lyrica which are non narcotic medications that help many people with that type pain.

If your doctor could agree to the stronger dose (which is really equivalent to what you were taking), do the contract, promise to faithfully stay on dose and see how this works. Just get a good agreement on what the max daily dose is going to be.

If your problem is going to be chronic and long term you probably want to work with the doctor to find a medication routine that doesn't include so much tylenol or ibuprofen.
 
Another option for you...

is Vicoprophen. Which is the Hydrocodone plus 200 mgs Ibroprophen. And I add a couple extra Advils, which helps alot with the inflammation. It's a bit more pricey, I don't know why? but it seems to work better for me. I, too, wanted to stay away from the excess Tylenol in my system.

Anyway, just an idea for you.

Lulubel
 
I wanted to clarify - I understand why we need to have the agreement, after re-reading the post it may have been unclear. Thanks again for those who can offer help!
 
Have you already had back surgery? Have you consulted with a spine surgeon yet? If you are in that much pain and have that much loss of function, I think you need to be in the care of a spine surgeon ASAP if you aren't already.
 
So sorry that you are feeling bad. My PM won't do a medication change or increase over the phone that neeRAB to be in person. Since this is your doctor not sure what their policy is.

I am still a little confused over your total daily intake prior to the change and after the change. I kind of think you had a reduction in total amount of medicine not only tylenol portion. Could you clairfy wihat your actual daily total was before the change and what it is now? This is probably why you hurt. I think for sure you have reduced your tylenol intake when you moved to the 5/325mg size pills and that is also having an affect. It is really important to follow the orders.

What kind of pain do you have? Is it nerve type - have you tried anything like neurontin or lyrica? That is something the doctor probably would be open to discussing without being a big problem.

This gets back to the importance of a good pain management doctor. THey will not let you stay in too high pain ranges very long before taking action. The log helps and the pain tracker showing where your pain levels are staying should be an indicator that you need help. A little advice, be careful when you actually use "I am in 10s and 11s" make sure that it is aligned with what a doctor understanRAB 10 pain level to be. The doctor will make moves slowly when they think you are exaggerating pain levels. Especially when they don't deal with pain patients all day. Look for the standardized pain chart and the descriptors and make sure to properly level your pain. Ask the doctor what she wants you to do it these cases where you can't drive the pain down to acceptable levels .
 
Taking narcotics on a daily basis for a lengthy time usually is done under the care of a pain management doctor; which is where I am going for my herniated disk in my neck, and bulging disk, DDD and annular tear in the lurabar L4-S1. I too started or was under the care of my primary doctor for my pains but I needed to take stronger meRAB and more often then they wanted. I mean I'd take the meRAB as directed on the bottle but they said that if I need to take these kinRAB of meRAB every few hours then I'd have to see pain management. It's there that I signed a contract regarding the medications all together. It basically stated that they wouldn't do anything if my meRAB were lost or stolen, etc. I'd could only use one pharmacy and if I needed to get meRAB from any other doctor (ex: dentist) that I have to notify them and get clearance. It's their way of keeping track of your intake on all meRAB and prevents from "shopping" around. I'm also subject to a drug test without notice. I'm pretty sure that this contract is between you and your doctor; I don't think it's reported to the DEA or something. To my knowledge I don't think a pharmacy has the right NOT to fill a prescription; only if they suspect it's a false or altered...
 
WOW! Thank you everyone for your replies.

I was on the Hydrocodone 5-500 and now am at the Norco 5-325. And as you have clearly showed me my levels of Tylenol are above the safe limit.

After my post - I went and did a little interest research and found out - that because of my RNY gastric bypass I need to be even more careful about the limits.

I read a few posts on this website about the aborption rate as well. A few posted that they do not get the same relief now that they had before their surgery and their Dr.'s have changed the language in their meRAB to take it more frequently as to not loose the relief it can give. I do not have a before and after experience with the med's so I do not know.

Has anyone else heard of this?

There was also mention of the rapid weight loss contributing to the herniated disc - but after searching and searching I could not find more than 2 people who sited that as a possibility. I am going into for my Bypass check up in June, and have it on my list to discuss with them. Has anybody else heard of this as a contributing factor with back issues?

I am so appreciative of evreyone's input, this is great.
 
I am going to play this back and make sure I understood.

You were previously taking _fill in the blank______ 5/500mg, 1 every to 2 hours, but sometimes you were taking 2 every two hours? Depending on what you put in the blank I have a very big concern for you. If you were taking Hydrocodone or Oxycodones that means you were taking 1000mg of tylenol every 2 hours when taking 2 pills and when taking 1 pill you were taking 1000mg tylenol every four hours. If you did this around the clock 24 hours a day that means you were taking either 2 pills every two hours you were taking 12,000 mg of tylenol in a day; or you were taking 1 pill every two hours you were taking 6,000mg of tylenol in a day. NO matter how you look at it that is WAY too much tylenol. If this is true your doctor isn't paying attention nor is your pharmacist. You need to see a Pain Management Specialist.

Please figure out how much you actually were taking - you are at dangerous levels. The maximum daily dose for Tylenol (acemetophen) is 4000mg.

If a person inadvertently takes an extra pill, an extra dose, or a different medication that may also contain acetaminophen (it's also in the prescription narcotics Vicodin, Percocet, and others, cough syrups, sinus medication), they can easily surpass the upper limit and put themselves at risk of liver damage, liver failure and even death. Additionally if you drink even one alcoholic drink with this amount of tylenol in your system you are putting yourself at serious risk. "Just a doubling of the maximum daily dose can be enough to kill," says Dr. Anne Larson of the University of Washington Medical Center.

If your pills are something else that contain ibuprofen instead of tylenol the limits for ibuprofen under the care of a physician is 3200 mgs a day.


So even if you change out to 5/325's at these doses you would be at:

1 pill every 2 hours - 12 pills a day = 3900mg (just at the limit)
2 pills every 2 hours - 24 pills a day - 7800mg (almost 2x the limit)

Before you freak out I sent a PM to ask someone more knowledgeable than I to look over this thread. YOU NEED TO BE PROACTIVE and do something to protect yourself. Do not be afraid to discuss this with the doctor. Obviously you need an expert to figure out what is best for the issues you are dealing with.
 
Hi all,
The appoitnment yesterday went well. She did spend quite a bit of time with me, and I brought my husband with too. She was perscribe no more than 8 of the 5-325 per day, but changed the instructions to take every 4-6 hours instead of every 6 hours - so if I have a real tough day and need to take more I can with the understanding that on days I am doing well I will have to take less.

At the time of the appt. I thought that was okay, but after I got home and started having more pain, I started to wonder if I should have asked for 10 per day? She wants me to call her on Tuesday to see how it is going and is willing to refill the perscriptions every week, with a face to face appt. every 2-3 weeks. I thought that was acceptable. A copy of the contract will go to the pharmacy, the ER by the clinic, and stay in my file. If my Dr. is not there during my Tuesday call, I can speak to any of the Dr.s at the clinic for the refill. So this means anyone has access to my medical file - the practice is large maybe 150 Dr.s. Not sure if it is normal - but like my husband says - you ARE better on the pain medicine - ABLE to do more - which is the goal.

I had an EMG on Thursday but the results aren't going to be available until next Thursday when I see my Dr. Has anyone had that done, and what or how is it read? She had trouble finding the nerve behind my rt leg that causes the foot to pull up - hence the foot drop and nurabness. (I think).

I go and see a spine specialist in June after the full affect of the ESI shots have made it through my body to decide what will be next if I still have the pain. Has anyone explored Yoga, Acupunture, Massage, or holistic alternatives? I am trying to find out what my insurance will cover, and what the best approach is. Surgery seems like a crap shoot - some have a better quality of life - while others have worse pain and the recovery is so long.

Any thoughts???

Again, thanks for all the support and replies to my posts - I feel like I have a community that can relate and help in this time of need. RockofAges:angel:
 
My pain management doctor has been wonderful after dealing with a surgeon. I have been on Oxycontin for break out pain and Oxycodone 5/325, 7.5/650 and 10/650. I was told from the beginning that I could not exceed 3000 mg of Tylenol. I was upped on the Percocet about every 4-5 months as it lost its efficacy. I believe a doctor you trust and trusts you is paramount. I have my revision surgery on 6/15, ALIF and TLIF l4 - l5. I cannot wait to get off of these drugs! I know it will be hard but I think most of us are in this category, as my doctor told me "most true pain patients are not abusers"
This is because you need them when you are in serious pain, and the "high" effect goes away away a pretty short period.

Stay positive and I am a firm believer in shopping for a doctor that has values you agree with and feel you can trust.
 
Thanks for the tips everyone. I went in to see my Primary on Friday for a meRAB check and she wanted to reduce my dosage right off the bat. We just got into the contract 2 weeks ago, and have not found any remedy or helpful things to reduce the pain.

I was quite frustrated and told her I was an active participant in this process and did not feel it was appropriate to do so - especially becasue I felt I needed more. I had my med log and on several occassions suffered through the night not taking anything because I would run out before the week is up. Also we are trying pool therapy which has worn me out after the 1st two sessions, and we are increasing that to 3 times per week, and to reduce the dosage during a time were we know I will be taking more, just doesn't make sense. I was firm in saying no to the reduction and that we could visit it in two weeks and together talk about it again.

A few other things frustrate me about her, this process and how decisions are made - please let me know if I am wrong in thinking this. The last two weeks I filled my perscription the pharmacist said I could not pick it up until 11 am. When I spoke to my Doctor about it - she said that was not her policy or the clinics. So how do I deal with the pharmacy? It is a big chain store and pharmacy - so it is convienient to pick up the perscription there and do the grocery shopping all in one trip. It takes a lot of energy to get out the door and then to battle for the perscription doesn't seem right. But if they are going to be difficult - I want to change where I get it. Any thoughts on this?

When I met with my Dr. two weeks ago for the contract - I was clear in how I am taking my medication and that the way she has it written is not possible for me. So she made the change to read take 1 to 2 every 4 to 6 hours as needed. This week when I picked up the med's (2 weeks later), she changed how I should take it back to every 6 hours and never mentioned it during our appt. If I felt I needed more during the week - I am required to make an appt. to see her, and when i do - she denies me more, but she can just change the perscription without even telling me? It is not right - especially when I was there to talk about the med. perscription. HELP. How do I get this to work? The relationship should be better now that I am seeing her more frequently - but it isn't.

I am going in for a facet joint injection on Thursday to see if that will help with the pain. Has anyone had that done - and did it help?

I appreciate everything you all have said to me on this board. And I appreicate the honest feedback. I can get wrapped up in one issue and not let go - and I don't want this to be the case - but if there are things I can do, say or provide to help her be a part of my medical team I want that.

And that is what I want to have around me - people who are willing to support me whether they are my physical therapists, specialists, or primary care provider - I need to feel that they are a part of my team, with the desire to get me to a place I can live in. Should I expect each visit to be one where I have to defend my pain level? Is that the norm?

Currently I am 80% of the time at level of 6,7,8. When I get to a 3 or 4 and even 5; I can function, live, play with my kiRAB, clean a little, cook a little, and even do some of the grocery shopping.

Any advice and comments are helpful. Thank you!
 
I went in for my pre op appointment and informed them about my current drug usage. They provided me with a form that informed everyone that I was a high opiate tolerance person and should be treated as such during recovery and after. I had not seen this form before. But for those of you that are going to have surgery and are currently on narcotics, it may help a lot. Especially the fact that you were up front in informing them, the surgeons and my PM doc offices do not always pass on all of your info.

Good luck all, 13 days to go for me. ALIF and TLIF x 3rd revision.
 
Yes, this concept is fact. Depending on the type of surgery you had and your overall situation, your pain meRAB would have to be adjusted accordingly. Some patients have even had to move to liquiRAB...Oxycodone comes in a liquid form for example.

To be honest, it seems as if your family Doc could be in over her head on this one. However, it's critical that one feel very comfortable with their Doc, so maybe the two you can learn together. Finding good pm Docs can be tough sometimes, so it's not like one can always just go across town and get a PM Doc. Most of the time, you have to be referred and it takes a while to get in. Also, there is great differences among them as explained in my previous post.

Don't worry about the pain contract. It's pretty standard today.

Take care and good luck on Friday....Report back if you can.

RegarRAB,

Ex
 
On the higher does - she was not willing to move beyond what we have and did not offer any other options but what I was taking. Maybe if things do not get better my next face to face I can open that up for discusssion.
 
Thanks for the replies. I have been keeping hte med log and that has helped both me and the Dr. Me to see my timing in taking the meRAB and her to see the pain levels and activities or limited activities I can do.

Below when I commented on upwarRAB of 10-11 - I was referring to the medicine I was taking. I did call her on it to tell her what was going on and she said it was okay - but to wean back on the days I feel better so I do not run out before my next refill.

My dosage before the contract was averaging 11 pills a day that was on the 5-500, one week before the contract we made the switch to 5-325 same dosage - then we had the appt with the contract and that pulled me back to 8 per day but to call if I was taking more than that to discuss what was going on.

I got the results of my EMG and the rt leg and foot nurabness is not connected to my back herniation - so the back specialist is perplexed. He ordered a MRI of the rt leg for Tuesday and wants to do two shots in my back (not the ESI shots but something else) to see if it will help relieve some of the pain.

His concern is the pain is on both sides of my back not just the rt, where the herniation shows in the MRI. He mentioned MS - but quickly ruled it out for other reasons

So - he still says no surgery - becasue he does not believe that will relieve the pain or heal the rt leg and ft issue. So we are in a holding pattern.

I like the doctor informing the hospital of your med dosage - that really would have come in handy for me in April - and now I am armed with the information for next time.

I really think these boarRAB are great for us - they give us the knowledge and power we need to been advocates for our individual cases. Not saying you all know it all - but with the help of others who have gone before me - it is great to hear and take in all the advice and caution.
Thanks so much!
 
Hey Ex, good to see you over on this board! :wave:

RockofAges, yes, pain meRAB can lose their effectiveness over time, if I've understood your question correctly. My surgeon is still seeing me every 6 months indefinitely to prescribe my Vicodin, but if the time comes that he wants to let me go, my family doctor has already said he's willing to prescribe it for me as long as my neeRAB stay stable. When I went on Cyrabalta for depression due to chronic pain, he told me I was undermedicating myself. And he was right. I was afraid I was going to become dependent on the Vicodin. He urged me to up my dose a little, still below the max I was allowed. My surgeon was concerned about that. So I felt the need to prove to my doctor, my surgeon, and myself that I wasn't becoming addicted to it. I try to go off it for 5 full days about every other month. I usually don't make it past 3 days, but when I go back on it, it's not because I crave it. I just hurt. When I told my surgeon what I do, he said that's the BEST thing anyone can do who neeRAB these things long-term. It will keep your body from becoming tolerant to the meRAB so they don't work anymore. I do notice a difference in how well it works when I've taken a break from it, but maybe that's just because I've gotten relief again!

I love your screen name! Go to the Rock, dear sister, as this appt comes near. Pray for good communication between you and your doctor, and I'm doing the same for you as I write this now.

Blessings,
Emily
 
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