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May 02, 2014

OK, That Was Strange....

So.... three weeks ago, the Blog Princess had surgery to reconstruct the ACL in her left knee. The surgeon gave us a prescription for Percocet, which is pretty normal.

The Spousal Unit takes the Rx to the local CVS and they made a really big deal out of filling it. He was pretty ticked, but finally they gave him Oxycodone, which is pretty much the same thing.

Fast forward one week. The Princess goes to her first follow up visit with the doctor and he asks her if she wants a refill. Having stopped taking the pills about 3 days after the surgery except for 1 before bedtime, she had a few left and said, "No".

One more week, another doctor's visit, another, "Do you need a refill". Again, still had a few pills, so she says "No". At which point the doctor replies, "Look, you don't have to take them all the time but if you don't have something to help with the pain you aren't going to push hard enough to get your knee moving again." So reluctantly, she said OK to the refill.

A week and a half later, she finally gets around to refilling (or trying to refill) the prescription only to be told that CVS doesn't have any Percocet and can't fill it. So she goes to a tiny little pharmacy and there seems to be a fair amount of commotion around filling it. Finally the pharmacist asks her if she had filled the same Rx previously somewhere else.

"Why yes", quoth she - I took it back to CVS (the place that originally filled it) and they said they didn't have any.

"Weird", he says. "They've probably sent 10-15 people over here today. I wonder what's going on over there?"

So La Princesse du Blog did some Googling and found this:

The L.A. Times’ David Lazarus reports that the U.S. Drug Enforcement Administration and the California Board of Pharmacy are investigating the disappearance of prescription pain meds from four stores in California.

The DEA served the stores with warrants almost a year ago after learning about prescription drugs like Vicodin that were not present and accounted for.

The company now faces up to 2,973 separate violations of the federal Controlled Substances Act because its records don’t match the actual inventory of the drugs in question. CVS could be forced to pay upwards of $29 million in penalties for these possible violations.

...and this:

When the DEA earlier this month banned a Walgreens distribution center from dispensing controlled substances to its pharmacies in Florida and on the East Coast, the measure no doubt caused more tension for some patients.

But DEA Special Agent Mia Ro said there is no oxycodone shortage in Florida.

What customers are experiencing is likely a combination of factors, industry experts say, including pharmacists simply being more cautious.

No one wants to be the next DEA target.

"What we're looking at here is a chilling effect," said Michael Jackson, chief executive officer of the Florida Pharmacy Association.

In an effort to curb Florida's prescription-drug epidemic, the DEA earlier this year blocked one wholesale-drug distributor from shipping controlled substances such as oxycodone and issued suspension orders against two CVS pharmacies in Sanford preventing them from selling controlled substances.

Many factors at play

Experts say other pharmacists and wholesale-drug suppliers who do not want to find themselves in the same position may be scaling back the oxycodone they are willing to dispense.

If a drug supplier notices a spike in orders of a particular drug from a pharmacy, the company could potentially restrict how much of that drug the pharmacy could buy or cut the store off altogether, Jackson said.

At the pharmacy counter, pharmacists can decline to fill prescriptions for a number of reasons left to the individual's judgment.

Sometimes, the store could truly be out of the drug. In some instances, experts say, the pharmacist may have caught customers lying about their medical history and other prescriptions or suspects the prescription is fraudulent or improper.

And some chains, such as CVS, have ordered their pharmacists not to fill prescriptions for certain drugs written by doctors the companies have identified as "high-prescribing." At least 22 Central Florida physicians were notified late last year they were on the CVS list.

Which explains why the second pharmacist (who DID fill the prescription) asked me what the doctor's name - which was right on the Rx - was.

The real irony here is from what we can tell, these pills really don't do much except kill pain. You don't get "high" from them, or at least we didn't experience any such jubilation and delight. Kind of a pain in the patootie for a drug we only take right before physical therapy twice a week.


Posted by Cassandra at May 2, 2014 03:57 PM

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That they don't get you high may be the problem. People in serious pain often combine Percocet with alcohol, which apparently increases pain relief and adds a sense of well-being and pleasure. Unfortunately, while the oxycodone is enhanced by the alcohol, so is the danger of severe liver damage by the acetaminophen.

There have been a number of deaths, as well as cases of brain damage. We lost an older friend to it a few years ago. His pain had become bad enough that he didn't really care if it killed him; unfortunately, his family had to deal with the consequences of the brain damage it caused for a long time before it killed him.

Posted by: Grim at May 2, 2014 06:10 PM

You weren't wearing a cheese danish bikini or anything, you know, kooky looking, were you? I mean, that could explain it, too.

Posted by: spd rdr at May 2, 2014 06:31 PM

My mother in law has been on very strong pain killers for years, so I am well aware of the risks.

But I'm not convinced the solution to some people (for whatever reason, good or bad) not taking medication as prescribed or combining it with other drugs is to make it difficult for everyone to get it. I'm also a bit confused about how it helps to punish people who aren't abusing the drug because others, are?

We're not talking about a drug that people take because it's so incredibly fun. I don't want to take it at all. And luckily, I don't really need it. I can gut it out. But there are folks who aren't so lucky.

Posted by: Cassandra at May 2, 2014 06:35 PM

You weren't wearing a cheese danish bikini or anything, you know, kooky looking, were you? I mean, that could explain it, too.

Pppppttttthhhhhhhhhhh :)

Posted by: Cassandra at May 2, 2014 06:36 PM

But I'm not convinced the solution to some people (for whatever reason, good or bad) not taking medication as prescribed or combining it with other drugs is to make it difficult for everyone to get it.

Not disputing you on this point at all. I'm just thinking that, sometimes, it might be OK if people get a little high when they're in pain. It could stop other problems.

Posted by: Grim at May 2, 2014 06:52 PM

What gets me about the articles is that we seem to have two separate problems being conflated by the companies. The DEA (with good justification) comes down on the company for allowing its pharmacists to fairly blatantly steal huge quantities of painkillers, and the company's response (instead of, say, instituting or revising a policy of reviewing the record books at a higher level) is to stop shipping those painkillers entirely?

You'd think this would be an easy enough system in which to delineate clear responsibilities. Why pharmacists would be held penalized for filling a valid prescription from a licensed physician is beyond me. If they think a doctor's overprescribing, report him/her to the DEA and the medical board, and let them figure it out.

Actually, I did just think of one reason the pharmacist might butt in -- if they suspect a patient is doubling up on prescriptions from multiple doctors at once. This might be one area where electronic health records might actually do some good, if each doctor can see what any others are doing/prescribing.

Posted by: Matt at May 2, 2014 08:03 PM

I had endless trouble with my aunt's doctors and nursing home administrators before her death. I'm sure part of the problem was that they didn't want to get into trouble, but I also picked up a strong sense that they thought there was something wrong with her wanting so much pain relief, as if they needed or wanted her to be stronger, or to complain less. She was in a huge amount of pain; I never really understood why it should be an issue for her to want heavy-duty relief from it. By the time she was bedridden and terminal, why the heck should I care if the pain meds also made her a little high? Yes, she wanted to escape from her life, which had shrunk down to almost nothing.

I do understand, of course, that any med that makes people high will create huge pressure for theft and danger of addiction. It's also true that opiates exacerbate constipation, always a horrible problem for bedridden patients. I'm sure it's no fun being in charge of meds security in a hospital.

Posted by: Texan99 at May 2, 2014 09:49 PM

Actually, a terminal patient in hospice care is supposed be able to get morphine, which is a much better pain killer than oxycodone in it's various dosage forms.
There is no addiction to pain killers as long as pain is actually being treated. It's just that people get habituated to taking pain killers for imagined pain, and then get physically addicted to the opiate or it's analogues (like oxycodone).

Some years ago, I herniated a disk in my back and was in intense pain for months. To get to sleep (while sitting up in a chair) I would drink a beer with a valium. This sometimes let me get some sleep and prevent me from becoming totally exhausted.

And yeah, people get percocets/vicodins and drink with them and smoke dope with them to enhance the high.

Posted by: Don Brouhaha at May 2, 2014 10:30 PM

So the USAian method is to painfully punish those who obey the laws for painkillers. We deserve to be doomed.

Posted by: htom at May 3, 2014 01:15 AM

My aunt had been on oxycodone or something similar for a long time before she broke her hip and experienced even more intractable pain. At the nursing home, they tried persuading her that oxycodone would still do the trick. Wrongo. After a lot of howling, and passive obstruction from my cousins, I got hospice in there, and she was able to get morphine. That went on for about eight months, during which time she was in almost constant pain. Only when she was weeks from death did they finally break down and give her the fentanyl she really needed.

Posted by: Texan99 at May 3, 2014 10:01 AM

Why pharmacists would be held penalized for filling a valid prescription from a licensed physician is beyond me. If they think a doctor's overprescribing, report him/her to the DEA and the medical board, and let them figure it out.


Posted by: Cassandra at May 3, 2014 10:25 AM

The medical profession has come a long way in the treatment of pain.

Several times during the past few weeks, I've thought how awful it would be to go through this with no recourse to pain meds. And I say that as someone who has deliberately taken as few pills as I can tolerate.

What I saw with my Dad's multiple hip surgeries is that when the body is traumatized, it becomes hyper-alert to anything that might cause more injury/pain.

This makes recovery difficult - you don't want to move because your body is shrieking, "NO! Don't do that!" even though your mind knows you have to move or your muscles will atrophy and your bones won't get a good enough blood supply to knit properly. Without your conscious mind directing it to, your body shifts weight off the injured part whenever you try to move.

I've been somewhat fascinated by physical therapy. Yesterday they added squats to my exercises - both with two legs and just using my left leg. They have a squat machine that allows the body to be positioned anywhere from horizontal to vertical - horizontal just puts you through the range of motion for a 90 degree squat and vertical has you doing squats with just your body weight for resistance.

A big part of the exercise is to train your body and mind to trust the knee again. And even though you know you can't get hurt, doing squats with only the bad leg is scarier than you might think.

They've also done a fair amount of stuff with electrodes (TENS to get my quads to fire in the first place, and another neato device that lets me see how strongly I'm contracting various muscles when I do an exercise). The feedback thing is huge - when you can see how hard you're working a muscle, it becomes almost a game to make the little digital dots go to eleventy :p

Fascinating stuff, and I've learned a ton from the young man who's doing my therapy.

Posted by: Cassandra at May 3, 2014 10:36 AM

I am allergic to most pain medications. The only thing I can handle is morphine. When I had my hip surgery it was quite amusing.

Are you in pain?
Here take this for the pain.
I can't take that, I'm allergic to it.
You must be in pain though.
Yes, but anaphylactic shock is worse.
What works for the pain?
A small dose of morphine.
Tsk, tsk, tsk, morphine can be addictive.

Just leave me the hell alone, and start working on the discharge orders.

Filling a prescription from my surgeon after that bit of theater.

Pharmacist: That's a very powerful pain medication.
Yes I know.
Does your doctor know about this?
...blink, blink...

Posted by: Allen at May 3, 2014 10:55 AM

Unfortunately, your aunt's long term use of oxycodone probably had a great deal to do with the ineffectiveness of morphine.

Morphine and the related opiates (codeine, heroine, dextromethorphan) all have a very similar structure and actually "fit" into the pain receptors. Their actual chemical morphology resembles the natural endorphin polypeptides that your body produces,and thus they fit in the same nerve receptors and block pain. And so the opiates can actually become physically addictive, if there is no pain to be treated.
Oxycodone is a synthetically made compound that has some of the same functionality or stucture as the opiates, and is not supposed to be as "addictive", but it is, to a limited extent.

Way back in my previous life when working for a pharmaceutical company, we had a long dinner presentation about the nature of pain and treatment (this was about 30 years ago now) and how morphine was NOT addictive unless it was administered or used without being needed for pain treatment.

Fentanyl is not truly an analgesic, but in your aunt's case, it was effective because of the way her chemical pain receptors had been changed by a long term usage of oxycodone. It (fentanyl) interrupts the metabolic pathway of one of the biochemical pain transmitters, in a way similar to cocaine. Fentanyl was actually created to be a diet drug, because it was supposed to suppress the hunger impulse. And it became abused because it was also similar to amphetamines, which it was created to replace as a diet drug.

Posted by: Don Brouhaha at May 3, 2014 09:57 PM

Oxycodone is the morphiate, Percocet is just the tradename of a combination of Oxycodone and acetaminophen (Tylenol). Vicodin is the tradename for hydrocodone (a less powerful morphiate) with acetaminophen. I suspect that what you got was a generic version of Percocet, not pure oxycodone.
As an aside, a "light weight" version of Vicodin is available in Canada as an OTC drug, albeit behind the counter.

Oxycontin is the version which is supposed to be hard to abuse, since it's claim to fame is that is is a time-release version; only small amounts of oxycodone are released over a long period, so that there is no "rush". Prescriptions of Oxycontin were handed out indiscriminately because of its supposed resistance to abuse. Of course, the druggies soon figured out that all you have to do is crush the pills to powder, and you get it all at once. So, full circle: Oxycontin is now actually harder to get than plain Oxycodone.

Posted by: bud at May 6, 2014 06:38 PM

Of course, the druggies soon figured out that all you have to do is crush the pills to powder, and you get it all at once.

Which, apparently, the manufacturers responded by adding something to the pills, that when crushed like that causes nausea and vomiting (but when released slowly cause no symptoms).

Posted by: Yu-Ain Gonnano at May 7, 2014 10:27 AM

I checked the label and all it says is Oxycodone (nothing about acetaminophen) but at the bottom it refers to APAP (which I Googled and that's Tylenol).

Either way, I don't want to take any more of these things than I absolutely have to :p

Posted by: Cass at May 7, 2014 10:57 AM

APAP is acetaminophen. Tylenol is one of many brand names for the stuff, but APAP is just an abbreviation for its active chemical ingredient.

Posted by: Grim at May 7, 2014 11:05 AM

Don--I'm sure you're right, but it wasn't as though there were other options. Her pain needed to be controlled one way or another, unless they were prepared to shoot her. The long-term effects stopped being the salient point, especially considering that it was fairly obvious she couldn't last long in her 90s, immobilized in bed by intractable pain. (They didn't perform surgery to repair the broken hip joint.) It wasn't as though we had to worry that she'd lose her job, or even that her recovery might be compromised. There was no possibility of recovery. The only question was how much pain she would die in.

It would be a hugely more thorny problem if we were talking about a younger person who might recover, because the opiates do present serious dangers in all kinds of ways.

Posted by: Texan99 at May 7, 2014 07:33 PM

FWIW, I took Don's comments to be more an explanation of why fentanyl worked and morphine didn't work so well than a suggestion that denying your aunt fentanyl was a sensible thing to do.

That must have been awful for your family, Tex. And of course for your aunt.

Grim, I understand that Tylenol is a brand name, but figured a lot of folks were more familiar with the brand name than the name of the chemical itself.

Posted by: Cassandra at May 7, 2014 08:10 PM


I thought you might know, but it's a dangerous chemical (especially for those of us who have been known to have a drink now and then). I just wanted to make sure you knew that Tylenol = APAP = acetaminophen, out of an abundance of regard for your health and well-being.

Posted by: Grim at May 7, 2014 08:53 PM

Well, you don't ever need to apologize for trying to educate me. Wouldn't be the first time I didn't know something :p

I guess we were just thinking the opposite way again.

I hate Tylenol with a passion - don't even keep it in the house. But there is something you can take if you need to take it to mitigate the side effects - nacetylcysteine (I probably spelled that wrong - didn't bother to look it up).

I pretty much stopped drinking except for a glass of wine very occasionally. Wine, drugs, and crutches probably not being a great combination...

Posted by: Cass at May 7, 2014 09:02 PM

Your discipline is admirable. I'd attach a whiskey IV to my crutches, if it were me.

Posted by: Grim at May 7, 2014 11:06 PM

Hey, I just want this to be over as quickly as possible. I figure anything that slows down my recovery is something I can do without.

My inclination to do a bunch of uncomfortable exercises at the end of a long day seems to be inversely related to the amount of alcohol in my bloodstream :p

Posted by: Cassandra at May 8, 2014 09:50 AM

Funny, I found them to be less of an irritation after a few beers. Although, I find pretty much everything to be less of an irritation after a few beers.....
Btw, I had a dream last night that your scar was on the back of your knee.
Weird, huh?

Posted by: DL Sly at May 8, 2014 03:30 PM

Btw, I had a dream last night that your scar was on the back of your knee.

Yep, that's weird :p

So far, I don't seem to have much of a scar. I'm hoping that doesn't change!

I have a scar on my other knee that I got when I was in 5th grade from a *major* wipeout on my bike, but other than that I usually don't scar very much. Even that one's not bad - you have to really look for it. I have another small one in the palm of my hand from putting a chisel into my hand whilst helping my oldest boy carve his Pinewood derby car.

Good times :)

Posted by: Cass at May 8, 2014 03:59 PM

Scars....oh Lordy do I have scars. I could put the battle scar scene from "Lethal Weapon III" to shame. It's a good thing skin doesn't hang around after death because people in the future would seriously wonder what kind of medical experiments they had conducted on me.
Darkness notwithstanding, of course...

Posted by: DL Sly at May 8, 2014 04:19 PM

One of my roommates at Navy was a gymnast.
Wretched scars on both knees, maybe 3 or 4 major rebuilds.

Separately, please good folks never mix acetomitophi/Tylenol (or anything that has it) w alcohol. Have observed one of those tragedies.

Posted by: CAPT Mike at May 8, 2014 10:53 PM