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Old 03-10-16, 02:58 AM
Honeybadger Honeybadger is offline
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Changing physicians - how to broach the off label, controlled substance topic?

So my psychiatrist is ramping down his practice as he approaches retirement and in order to maintain good standing he's not going to prescribe any more controlled substances that are not on-label for ADD. For the past five years I've been on the exact same dose of clonidine, aprazolam (both on label) and for my focus and motivation, I've been taking 5mg hydrocodone TID/QID. My dosage has remained absolutely constant and the overall results have been phenomenal, with no withdrawls or tolerance buildup. But the problem is that the drug is off-label and particularly in WA, the laws around painkillers are nothing short of insane. My psychiatrist has been prescribing it on-label for "post injury knee pain" for these years to keep my insurance happy, and they've never raised an eyebrow.

Overall, my current situation with medication is perfect. All upsides, no side effects. I sleep, I work, I can manage life like a normal person. But now I need to convince a new doctor that my medication situation is worth continuing, and the stress is killing me. I'm basically having to act like a common drug addict going doctor shopping, but I don't want to waste anyone's time, and particularly, I don't want to get stuck with doctor's bills from seeing a new GP, potentially having him say "no, I will not prescribe you hydrocodone" and then having to move on to another doctor.

Has anyone had success dealing with a situation like mine? I have a letter of referral from my psychiatrist detailing my situation and history, but even if I convince a doctor, he may not be willing to write it in such a way that keeps it on-label, and the off label cost would raise my prescription costs astronomically each month, basically to the point where I couldn't afford it. Any advice would be greatly appreciated. It's unbelievably irritating that the only medication I've found that provides me ANY relief whatsoever, let alone gives me everything I could ask for (of the dozens I've tried, on and off label) is the medication that the state has determined is basically only used by addicts and they've made obtaining it into a social stigma.
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Old 03-10-16, 03:37 AM
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Re: Changing physicians - how to broach the off label, controlled substance topic?

If you have a referral maybe ask the doctor whom he would recommend.

I've never heard of hydrocodone being used off label for add. I have chronic pain issues and proven physical diagnosis. Even then never have I heard of this being perscribed for such things. Maybe try to find research that backs the doctors claim. But for a psychiatrist to be perscribing you thee seems like a pharmacy would be flagging this anyways.

Pain medication sadly has such a negative stigma, that even chronic pain patients have problems obtaining these medication in proper dosage. It's sad how a few cause such problems for the majority
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Old 03-11-16, 03:18 AM
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Re: Changing physicians - how to broach the off label, controlled substance topic?

Quote:
Originally Posted by Honeybadger View Post
So my psychiatrist is ramping down his practice as he approaches retirement and in order to maintain good standing he's not going to prescribe any more controlled substances that are not on-label for ADD.
I am confused by this? What do you mean by good standing and why does this only matter to him because of retirement? Can you elaborate?



Quote:
Has anyone had success dealing with a situation like mine? I have a letter of referral from my psychiatrist detailing my situation and history, but even if I convince a doctor, he may not be willing to write it in such a way that keeps it on-label, and the off label cost would raise my prescription costs
astronomically each month, basically to the point where I couldn't afford it.
Well, since your knee injury, have you had any chronic pain or flare ups or is that situation perfect? If you have, then its not necessarily off label that he would need to prescribe it. It would be on label with the bonus that it treats your adhd. For me, opiates have never been sedating and have always boosted my mood and I can see how it could give certain people focus. My issue is I probably would have an issue not misusing the medication. I am am alcoholic in recovery and never had had issues with stimulants but I know I could have an issue with long term use of an optiate.

Quote:
Any advice would be greatly appreciated. It's unbelievably irritating that the only medication I've found that provides me ANY relief whatsoever, let alone gives me everything I could ask for (of the dozens I've tried, on and off label) is the medication that the state has determined is basically only used by addicts and they've made obtaining it into a social stigma.
I hear you on this. its amazing that instead of combating the opiate drug problems like heroin with better access to treatment the solution has been to make everyone suffer and jump through hoops to have access to what works. But thats off topic and a debate for another day.
I wish I had a solution. I can totally see your predicament. The only thing that comes to mind is to find a doctor with good reviews or a referral from your current one, make the appointment and in the mean time get all the records from the current doc, including notes and send them ahead of time to the new doctor. This way at least they have had time on their own to become familiar with your case rather than you walking in and just telling the doctor what to do in one visit.
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Old 03-15-16, 02:49 PM
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Re: Changing physicians - how to broach the off label, controlled substance topic?

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Originally Posted by Socaljaxs View Post
If you have a referral maybe ask the doctor whom he would recommend.
He is a private practice physician, so he doesn't really do referral contacts. he mentioned one physician that another patient had switched to, but that doctor has been exceedingly difficult to contact, so in the meantime I'm looking into other options.

Quote:
I've never heard of hydrocodone being used off label for add. I have chronic pain issues and proven physical diagnosis. Even then never have I heard of this being perscribed for such things. Maybe try to find research that backs the doctors claim. But for a psychiatrist to be perscribing you thee seems like a pharmacy would be flagging this anyways.
Five years, not a single issue. A physician is permitted to prescribe any non-special circumstance medications (such as merlsasoprol for african trypanosomiasis, which has a 10% chance of killing you outright) so there's no reason it should get flagged by a pharmacist. A review board upon recertification, maybe, which is why he is winding down his prescribing of non-ADD controlled substances to the small number of patients he has. He doesn't want to get into a headache battle with the washington DOH due to their fairly draconian new laws regarding all controlled substances as he is getting ready to retire. I also know my pharmacist well, and she has no reason to think that my doctor is prescribing inappropriate painkillers when 3/4 of the time I pick up my meds in full, pressed uniform complete with stethoscope around the neck

Quote:
Pain medication sadly has such a negative stigma, that even chronic pain patients have problems obtaining these medication in proper dosage. It's sad how a few cause such problems for the majority
Agreed. I'm a medic, and I see addiction and abuse every day. In my four years in the field, I've never actually had a patient who abused painkillers. But i've lost count of the number of people having "marijuana overdoses" let alone all the meth, heroin, and above all, alcohol (not that marijuana is bad in any way, it's just a point that the painkiller drug "fad" is nowhere as large as one would think based on how it's portrayed)

Quote:
Originally Posted by sarahsweets View Post
I am confused by this? What do you mean by good standing and why does this only matter to him because of retirement? Can you elaborate?
it's not exactly pertinent, but washington's DOH has new, obnoxious laws for prescribers regarding controlled substances. they have begun randomly auditing physician prescribing habits and will open inquiries that can be nightmares for doctors that prescribe controlled substances more than a single time, and this can even include psychiatrists prescribing ADD meds such as methyphenidate, though those inquiries are much easier to close. As my doctor is retiring soon, he wants to renew his license before he retires and doesn't want to get into a six month-two year fight with the DOH regarding his patient care.

Quote:
Well, since your knee injury, have you had any chronic pain or flare ups or is that situation perfect? If you have, then its not necessarily off label that he would need to prescribe it. It would be on label with the bonus that it treats your adhd. For me, opiates have never been sedating and have always boosted my mood and I can see how it could give certain people focus. My issue is I probably would have an issue not misusing the medication. I am am alcoholic in recovery and never had had issues with stimulants but I know I could have an issue with long term use of an optiate.
You're on the ball here. I pass my regular drug screenings, even if I take my meds 40 minutes before said screening (my fiance fails hers, and she only takes a low dose of adderall) I drive an ambulance, I am never sedated by a 5mg dose of hydrocodone. I have no drug abuse history, and just as many, if not more, people abuse stimulants as abuse painkillers, including methadone. It's entirely dependant on the person. More people abuse alcohol than any hard drug, alcohol and prescription benzodiazepines are the only two drugs that can literally kill you with withdrawals, and alcohol is available to anyone with an I.D. and benzos aren't even covered under the controlled substances laws. I do RARELY get a pain flare up in my knee, but only when I've been hiking for 8-10 hours on hard terrain, and ibuprofen has always been fairly effective at that. So I could "polish a turd", as we say in the EMS business, and mention that the pain is also still pertinent, but I am as a general rule very opposed to misconstruing information. That said, once I've established a relationship with my new doctor (I am looking at trying to get it done through a general practitioner this time, as I do need a new GP and I feel like my current medication situation is perfect) it would matter less, and going with the knee pain on occasion argument would give him plausible deniability (the knee injury as an initial reason for prescribing them is mentioned in my continuation of care letter my doctor wrote)

My letter of referral from my current psych is pretty glowing on my current situation, so that's about as good as it'll get. I made an appointment with a well reviewed GP through a small clinic, and we'll see how things go. This is just such a disgusting way to FORCE a person to act, like any other drug addict, going "doctor shopping" until I find a physician that isn't terrified of the asinine laws in place and is comfortable taking me on as a long term patient.

Our drug laws are famously insane, and the more you see the drug problem in this country up close, the more jaded against it you get. I've seen people who abuse benzos by getting them prescribed to their cat in order to up their dose. Those people are just considered criminals, ignoring the fact that they're nonviolent and not a threat to society, instead of that they're people who just need help. Thankfully the police up here are finally catching wind of that and for a kid who uses heroin and meth sitting at the bus stop off his face on both, they'll call an ambulance and put him into involuntary treatment for 24-72 hours, rather than just hauling him off to jail for paraphernalia.

Last edited by Honeybadger; 03-15-16 at 03:09 PM..
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Old 03-15-16, 09:22 PM
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Re: Changing physicians - how to broach the off label, controlled substance topic?

With the new cdc guidelines that came out today. It's going to be even more difficult now for anyone seeking, new doctors and new perceptions. Still not sure how/if affects current real chronic pain patients but I'm sure everyone gets affected
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Old 03-16-16, 01:44 AM
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Re: Changing physicians - how to broach the off label, controlled substance topic?

I just saw those guidelines in my news feed. I understand the thought process of the guidelines, but they are truly asinine for people and punish people that have found that happy medium that provides them with the level of function they need to function normally. The vast majority of people out there are not taking dangerous doses of prescription painkillers. if you're titrating your dose with your doctor's supervision, overdose is nearly impossible. But thankfully the guidelines are not laws, just suggestions. Though I am worried that they will work laws into place around it.
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