Rules complicate drug prescription
Dear Dr. Roach: I recently read your comments to the patient who had taken tramadol for many years safely, but had a new physician unwilling to prescribe it. Many states have implemented new rules regarding the prescribing of any controlled substance to help with the opiate overdose epidemic.
These rules greatly reduce the number of days and number of prescriptions that can be written. Physicians are required to check databases before prescribing. There are specific rules regarding patient follow-ups and documentation. I suspect that a chronic cough is not an allowed condition to warrant long-term opiate use. A number of physicians are now nervous and afraid of board actions and losing their license if they do not comply.
P.K.
Answer: I have empathy for physicians who are genuinely worried about losing their licenses. I also understand that there have been many instances in which medical providers have been complicit in overprescribing opiates, and that has a large factor in the current epidemic of prescription drug abuse.
The rules on prescribing opiates have been put in place to reduce unnecessary overprescribing. On the other hand, I am extremely unwilling to fail to give a patient in pain appropriate treatment for their pain.
I have to follow those rules myself, but we physicians still have latitude on what we prescribe. Failing to do what we think is right due to fear about implications is a terrible situation, and one I am willing to fight.
In the case of tramadol for chronic cough, there are several published case reports providing an evidence base for this treatment. Before prescribing an opiate for any reason, a prescriber must identify people who may be at risk of substance misuse or abuse, and consider the benefits and risks of long-term opiate treatment. If their judgement is that risk of harm is low, treatment is appropriate — but so is ongoing re-evaluation.
Dear Dr. Roach: What’s the difference between a tubal pregnancy and an abortion? Are they the same thing?
J.K.S.
Answer: The term “abortion” has several meanings medically, but most people think of only one type, the elective abortion. A “spontaneous abortion” is another term for a miscarriage. A “missed abortion” is when the fetus is no longer alive, but the placenta and nonviable fetal tissue remain in the uterus.
A tubal pregnancy refers to a pregnancy outside the uterus, the vast majority of which are in the Fallopian tube, which carries the ovum (egg) from the ovary to the uterus. Rather than implanting in the uterus, occasionally the fertilized egg will implant in the tube. This is a potentially life-threatening condition for the mother, and there is virtually no chance of a successful pregnancy. In these cases, medical treatment or surgery is almost always required.
When caught early, medication treatment is as effective as surgery, but there are times when surgery is the only option. In this case, the procedure is sometimes called a “therapeutic abortion.”
The term “abortion” is vague and may refer to any of a number of very different clinical scenarios. Physicians must be careful to use the correct terms, as the implications differ greatly.