Controlled Substances and Schedule Drugs

The right to prescribe narcotics and controlled substances is regulated by the Federal Government. Physicians, dentists and health care providers apply for licensing with the Drug Enforcement Agency and request the right to prescribe medication from the different “schedules.” State legislatures and state medical boards regulate this further. Most people are unaware which medications and drugs are in which schedules or categories.

Schedule I – For the most part, these are substances which have no current accepted medical usage and are easily abused.

Examples are: Heroin, LSD, Ecstasy (methylenedioxymethamphetamine), Quaaludes          (methaqualone) and peyote.

Schedule II – These are substances with high potential for abuse with a risk of physical and psychological dependence.

Examples are: Vicodin, cocaine, methamphetamine, methadone, hydromorphone (dilaudid), meperidine (Demerol), oxycodone (OxyContin), fentanyl, Dexedrine, Adderall, Ritalin

Schedule III – these are drugs with moderate to low potential for physical and psychological dependence.

Examples are: Products with < 90 milligrams of codeine per dosage unit such as Tylenol with codeine, ketamine, anabolic steroids and testosterone.

Schedule IV – These are drugs with a lesser risk for abuse and dependence.

Examples are: – Xanax, Soma, Darvon, Darvocet, Valium, Ativan, Talwin, and AmbienTramadol.

Schedule V drugs have lower potential for abuse than Schedule IV drugs and contain limited amounts of narcotics. This would include antidiarrheal medications, antitussives, and mild analgesics. Cough medications with less than 200 milligrams of codeine per 100 milliliters such as Robitussin AC, Lomotil, Lyrica and Parapectolin.

All the medications on these schedules must be reported to E-Forcse, the Prescription Drug Monitoring Program, within 24 hours of dispensing by pharmacies. They all require the prescribing doctor to check E-FORSCE before prescribing.

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A Clinician’s View of the Opioid Crisis

“Do Not Get Caught.” seems to be the real rule of the law in S. Florida, where I live.

I was trained to limit the use of controlled substances, narcotics, hypnotics and sedatives. Their use can affect consciousness, ability to drive a car and work.  More severe consequences include respiratory depression and overdose from too high of a dosage or mixing too many medications and over the counter items.

The Joint Commission on Accreditation, medicine’s good housekeeping seal of approval authority, along with major medical organizations have accused clinicians of under treating pain. “Pain” is the fifth vital sign, they said.

This was accompanied by professional society leadership and academic researchers receiving grants from pharmaceutical companies touting the newer longer acting pain medications which “have very little addictive potential”. We were then informed we would be receiving evaluations and scores of our treatments of pain which would influence our reimbursement if we under treated pain.

In my current concierge medical practice I see 10 or fewer patients per day. In my previous general practice I saw 2- – 30 patients per day. I could go days without prescribing a narcotic pain medication. In most cases when I wrote out a script for a narcotic pain medication it was for a patient with a severe chronic pain problem, seeing a specialist for that problem, and requiring a pain pill because there were few effective alternatives. The patient visits to doctors and physical therapists and massage specialists and other alternative pain therapies were well documented in the medical record and mostly unsuccessful in attempts to relieve the pain.

This contrasts markedly with the opening of pain clinics in nearby counties with their own in-house prescribing pharmacies. One or two physicians wrote thousands of pain pill prescriptions per day. Patients lined up around the block to see these employed physicians of the pain clinic with many arriving in cars from other states. The cash flow generated was so vast that the clinics needed private security to protect the profits. Many of the security hired were off duty city and county police officers trying to supplement their income.

It’s hard to imagine that law enforcement and the DEA, were unable to recognize the difference between pill distributing centers and legitimate practices prescribing medications on a limited basis to individuals with documented needs. City, County and State governments gladly accepted the tax benefits, occupational license fees and pharmaceutical license fees from these sham clinics while drug dealers drove in and out of our state to obtain prescription pain medications for sale in their home towns. Of course the blame for this was placed on the doctors and dentists.

The State of Florida tightened up its laws and somehow law enforcement was given the tools to see and eradicate what was occurring right under their very noses. As prescription drugs dried up, the Mexican drug cartels got smart and flooded the market with cheap strong heroin. It was obviously the fault of the physicians and legitimate pharmacies that white working class people were buying plastic bags full of dope and inserting needles into their veins to avoid the pain of life.

As drug addiction soared, City and County Governments found it in their hearts to sit as zoning boards allowed drug rehabilitation centers to open up in the heart of their communities. There was little or no effective investigation of who was running these clinics and or their previous experience, methods and or success rates. If you want to read about where the soaring number of narcotic overdoses occur in our community – follow the zoning board’s placement of rehab centers and sobriety houses. What better way to increase your drug overdoses than to encourage unsuccessful addicts to come to your community and leave their money and their family’s money to improve the tax base and create new headaches for EMS and police officers?

Somewhere there should have been a higher level of thought by our elected and appointed officials about the consequences of bringing hundreds of drug dependent individuals into our area before they permitted these facilities to open.

Last week my advanced pancreatic cancer patient with severe back pain tried to purchase a controlled substance prescribed by his oncologist to relieve his suffering. Six pharmacies no longer stocked the product due to their fear of liability. It took hours to find a pharmacy that would order the medication for the patient. Physicians, pharmacists and law enforcement accessing our state narcotic registration website clearly can see that this patient only uses his medications as prescribed by one physician. This patient, and others like him, are victims of the government legitimizing of pain pill mills and drug rehabilitation centers in their communities.

As a physician we all have our failures in this area as well. I painfully recall the doctor’s wife I sent to a disciplined pain doctor to wean her off narcotics prescribed by a rheumatologist, urologist and gastroenterologist for legitimate reasons documented by tests and biopsies. I refilled the prescriptions for her convenience and ease never dreaming I was contributing to her problems.

I feel for my colleagues in the Emergency Department and in orthopedic offices having to daily differentiate acute pain requiring intervention with controlled substances as opposed to individuals with drug seeking personalities. This being said, the opioid crisis was caused by the most trusted members of the academic medical community in cooperation with the medical inspection and certifying agencies in concert with public officials and law enforcement looking the other way. They all made a great deal of money at the expense of the public. Now as they struggle to clean it up they give us medical and recreational marijuana.

How Often Do Screening Colonoscopies Result in a Complication?

Harlan Krumholz, MD is the director of the Yale Center for Outcomes Research and Evaluation (CORE). His team at Yale is being paid extraordinarily well to determine what works and what doesn’t in Medicare. Their data will theoretically allow Medicare to issue payment for services based on success rates of care without complications. His group is part of a national program promoted by the Center for Medicare Services (CMS) to spend less for more effective high quality care. This in my humble opinion is “voodoo” health care policy.

One of their areas of interest is trips to the emergency room or hospital within 7 – 14 days of a colonoscopy. They developed a formula to look at this problem and applied it to Medicare claims data in the year 2010 in NY, Nebraska, Florida and California. They found 1.6% of healthy individuals going for screening colonoscopy ended up at the hospital within seven days. They found wide variations in this rate coming from different facilities and different doctors. When the data is extrapolated to the 1.7 million Medicare beneficiaries undergoing screening colonoscopy annually it indicates there will be at least 27,000 unplanned hospital visits within seven days of the procedure.

Determining what causes complications of a screening procedure so we can determine a root cause and then prevent it is a good thing. However; the research needs to be done by independent groups not receiving funds from CMS which has a clear and strong conflict of interest!

We need to be looking at complications related to the choice of preparation, choice of colonoscopy, choice of anesthesia and whether polyps were removed and or biopsies taken. We additionally need to assess the definition of “low risk patient.”

Within the recommended age group for screening colonoscopies of 50-75 years old, very few patients are not taking prescription medications as well as supplements. The research needs to look at procedures such as CT Scan virtual colonoscopy and fecal immunochemical human occult blood testing as well for efficacy and complication rate.

There are currently DNA analysis tests of columnar epithelium colon cells sloughed during a normal bowel movement. Pre-cancerous polyps and colon cancer have distinctive DNA patterns that can be detected by looking at fecal material. There is no prep but the cost of $500 makes determining if it works and under what circumstances important. If it works then shouldn’t it be the screening test to determine who needs to have a colonoscopy? Yes, the research must be done but it must be done by agencies not affiliated with CMS with their stated goal of spending less for better service and better quality.

Computerized Prescribing and Pain Medications

As part of the government initiative to modernize health information recording and exchange , doctors and health care providers are encouraged (with financial incentives) to prescribe medications using the computer.  This “e-RX” system allows you to send prescriptions to the patients’ designated pharmacy right from your computer screen with a few clicks and turns of your computer mouse controls. The only medications you are not permitted to prescribe are narcotics, controlled substances and pain medications with narcotic contents.

At the same time this initiative is occurring, there is a massive crackdown in the State of Florida on prescribing medications for pain. Sloppy legislation in Tallahassee by the State Legislature led to the opening and growth of “pill mills.”   Drug addicts and suppliers from all over the country routinely travelled to Florida to obtain massive quantities of prescription medications from these fraudulent facilities staffed by criminal physicians. The medications ended up on the streets causing numerous drug and alcohol related deaths around the country.

The “sloppy” Florida State Legislature then attempted to rectify the problem by passing new rules and regulations that closed the “pill mills” with the help of the police and drug enforcement authorities but has frightened the legitimate physician population into not being willing to prescribe for legitimate chronic pain. Their actions included updating physicians’ online profile with the state licensing agency to declare whether you write narcotic scripts for chronic pain or not.  If you reply “yes” you are apparently placed on a list of “chronic pain” prescribing doctors that the public can access as well as the criminal elements looking for doctors to write scripts for cash.

At the same time legislation now requires doctors to take specific courses to prescribe some of the newer pain delivery products necessitating the physician to leave their practice to train on the use of the new medications. The result is that legitimate neurologists and anesthesiologists are shying away from seeing chronic pain patients less than 65 years of age even if they have been referred and have legitimate needs for pain medications.

This brings me back to computerized prescription ordering. If you are trying to track narcotic prescriptions, why prevent the doctors from using the computer to prescribe controlled substances?   What is easier to track and trace, a computerized order or a hand written prescription?   It would seem that computerized record keeping through electronic order entry would be the preferred method of tracking narcotic prescriptions.