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    Need advice
    Anon_3225 posted:
    I have been getting injection therapy for pain management out of state from where I live and see my regular pain physician. I was offered additional pain medications from the out-of-state doctor but I told him I was not allowed to get controlled substances from another doctor because I signed a pain contract. He offered muscle relaxants (soma) and Tramadol (non-narcotic) because these injections cause additional pain. My question is, will I get into trouble with my pain physician for doing this? I can't find a copy of my pain contract and went ahead and filled the prescriptions thinking the 2nd doctor surely wouldn't prescribe something controlled right after our talk. I'm confused and need to find out what to do. I don't want to get dismissed. I thought I was doing the right thing but these drugs are schedule 4 in my state but not at the federal level. Any input? Thanks!
    TDXSP08 responded:
    Tramadol is considered an opiate it is schedule II and Soma the muscle relaxant i believe breaks down in the body to a small dose of a barbiturate which if your Pain Management Doctor Does a Urine GCMS on you you will FAIL with flying colors if you have taken any because Soma is on the standard Pain Medicine UA and depending on your doctor just the act of filling those scripts was reason to drop you as a patient, i think what you need to do is pick one doctor and get all your services from that one Doctor.
    i have no small step for man, but i have 6 tires for mankind,Watch your Toes!
    An_245956 responded:
    From what I understand Tramadol is a schedule IV and is opiate like-binds to the opiate receptors. Soma has a higher "abuse potential" and is also a schedule IV in my state. If you told the physician that does the procedures that you cannot take "controlled substances" from anyone other than your pain physician then he could have gone by his state guidelines, either way, they may be scheduled in your state which may be reason enough for dismissal. If you're concerned about a UA as the other poster mentioned, the Soma won't be detected if ceased 3 or more days prior to the sample-depending on the amount in your system. I'm not certain if Tramadol is standard for those tests or not.
    77grace responded:
    I tried replying to you yesterday and for some reason it did not go through,Sorry about that!
    Anyway,I had a few thoughts on your problem!First I thought I should tell you what I learned about concerning the 2 mediactions you indacated!Tramadol is a type of narcotic and it may show up that waymI'm not sure.It is addicting if taken on a regular baisis .Please be advised that Soma can be dangerous,alot of Drs. won't even prescribe it!
    As far as your contract with your pain Dr.,they are usually very strict!I'm pretty sure they will show up in your test!How do you know when they are goiing to test you??I never knew ahead of time!That would defeat the reason,one anyway.
    Why do you go out of state for injection threapy???I'm confused about some of your post!But I wish you well and hope it al works out for the best!
    Anon_3225 replied to 77grace's response:
    Thanks everyone for your advice. I live on the boarder of 2 states so it's not that uncommon to go from state to state. My regular doctor prescribes medication and the other doctor performs procedures. They are aware of each other. I'm not running back and forth trying to get pills. There is a system that doctors can look into to see what patients are prescribed and my urine screens are random. I havent had one in a while so I was expecting it soon. I was just confused about why the out of state doctor would give me controlled medication right after I said that I can't accept narcotics from other doctors because my regular doctor prescribes schedule II drugs. I don't know what to say when they run the report at my next visit! Or if I should just come clean with it all!?! The info online says Tramadol is not usually addictive and I can't see how it would be. Anyways thanks for the responses.
    bren_bren responded:
    Anon, I understand the necessity of acquiring different docs who offer distinct modalities thus you cannot just choose one. But why not explain to your PM that the "procedures" cause additional pain and have him adjust your med's appropriately? I guess it may be too late in your case, as you have filled the scripts, and to ponder why the 2nd doc would give you a controlled substance when you asked him not to, is pointless at this stage of the game.

    Take all of your med's w/ you to your next appt, be forthcoming and hope for the best. Tramadol is controlled (schedule IV) in some states, but there is debate of whether or not it is an opioid since it does bind to the receptors. Soma is a C IV in some states, but not at the federal level.

    What it comes down to: do federal categories override state? Or vice-versa? I, myself, would like to know the answer to that. I'm thinking that docs should adhere to state 1st because their licensing is at stake. Best of luck. Let us know how it turns out. Take care, B
    cweinbl replied to 77grace's response:

    Whoa! Hold on there! No medication is "addicting." Addiction is a PHYCHOLOGICAL DISORDER, in this case characterized by using too much medication, running out too soon, stealing it, purchasing it illegally, obtaining it concurrently with several different physicians and using it to obtain a state of euphoria, rather than to manage pain.

    The rate of addiction among all patients using opioids for pain management is less than 3%. I say again, it's less than three percent! Here are two recent comprehensive research studies that reveal the addiction rate to be much closer to 1% ( and ).

    One of the reasons why so many of us with chronic pain are denied the medication we require is from the public-induced hysteria about "narcotic addiction." You are (I suppose innocently) perpetuating this proclivity of nonsense. Tramadol is not a "narcotic." It is a quasi-opioid, far less powerful than Hydrocodone, hydromorphone, Oxycodone and Fentanyl. It is NOT "addicting." Addiction (again) is a PSYCHOLOGICAL condition, not a physical reaction to a pain medication. Please take advantage of the wealth of data available via Internet search that explains the difference between addiction, dependence and withdrawal.

    77grace, I know that you mean well. But please refrain from using terms like "addicting" in reference to medications. No medication is "addicting." Addiction refers to a set of behaviors characterized by psychological choices. You are throwing gasoline upon the fire in which chronic pain patients burn. Such terminology is far more incendiary than factual or useful.

    Finally, "injection" therapy typically refers to the injection of steroids, anesthetics or both into the thecal space, between the spinal cord and the spinal nerve roots. Research clearly shows that if these injections do not work well initially, then future iterations are also likely to fail. Since there is risk of spinal nerve root impingement with each injection, the patient should be certain that the benefit of the injection far outweighs the risk of permanent nerve root damage. Frankly, if those injections were working, why would one require additional medication (Tramadol)?

    When injections are not helping enough, most patients turn to more powerful therapy, which typically includes long-acting opioids, short-acting opioids for breakthrough pain and off-label drugs, such as Lyrica or Neurontin for neuropathic pain and an anti-depressant to inhibit the reuptake of plasma Seratonin. It thus occurs to me that you could gain greater pain management by using a combination of medications (more powerful than Tramadol), rather than injections, if those injections are impotent to the extent that additional (oral) medication is required. If the combination of those opioids frightens you, just click on the links I supplied above. If you have no history of addiction disorder, there is no reason for fear. And when the pain medication is no longer required, withdrawal is typically well-managed with gradual diminished schedule/dosage and use of opiate antagonists.
    annette030 replied to Anon_3225's response:
    Write to the doctor that you have the contract with, and ask the office staff to send you a copy of the contract for your files. Be sure to include your date of birth, name, and address. If you have an account number, include that. If it is easier go to the office and request this, and sign for it. They need to have written authorization to be in compliance with the HIPAA laws.

    Also make an appt. to see this doctor right away, and tell him in person what happened with the doc that did the injections. Ask him exactly what you can take from other doctors and what you need to do in the future.

    I had a contract with my pcp as she manages my pain meds, and also had surgery. The surgeon offered me a RX for pain meds for the initial two weeks after surgery, I declined to take them, I did fill other RXs she gave me before surgery. When I mentioned all this to my own pcp at my pre-op exam, she didn't care at all, she didn't care if the surgeon wrote for pain meds for two weeks after surgery or not. She said she didn't worry about me, because I had never given her reason to.

    This does not mean you should take whatever they offer you, I think you have done things correctly so far as you know how to do. It just means don't freak out about it, just ask the doc what to do next time.

    Take care, Annette
    Anon_3225 responded:
    Thank you for all the suggestions to help ease
    Anon_3225 replied to Anon_3225's response:
    To help ease my mind. (messed up my post, it's been a while). The botox into my piriformous muscle is a technique to help freeze the muscle to eliminate spasm. They are painful for me and everything gets so tight that the doctor offered the muscle relaxant, Tramadol combo. I was correct about the test. I told the nurse about everything I was prescribed by both doctors so there's no surprises. When I saw the doctor face to face I mentioned the Tramadol after he asked about the injection therapy and he asked who was giving me that. I told him who he said "oh, okay. It's not a very powerful medication". I guess he didn't object but we will see. The soma would be in my urine but I didn't realize it's metabolizing into a barbiturate? That's odd. Well I hope he isn't upset with me over the whole thing. They even had a new contract that was updated and many of the statements just mentioned the term "Narcotic" rather than "controlled substance". I don't even drink alcohol and obviously don't need to worry about illegal drugs showing up in my urine, but no matter how many "good" test results I have, there is always rules in pain management so complete trust is not something this guy has in patients.
    annette030 replied to Anon_3225's response:
    Narcotic is an old fashioned word, more often used by lay people. Personally, I would ask the doctor to be more specific about what kinds of meds are included. Medically the word narcotic can mean drugs that make you tend to be sleepy as a direct effect, or a side effect. It is derived from the word "narcosis". Many people use the words opiates and narcotics interchangably nowadays though. Hard to say what his intent is.

    Take care, Annette
    Anon_179676 replied to Anon_3225's response:
    I have a pain contract also and was prescribed tramadol by my rheumatologist. My contract at that time was with my orthopedic doctor. I called the ortho clinic and they said it was fine to take and did not have a problem with it.
    My question is this, did you actually fill and take the medication, and did you fill them (if done) at your usual pharmacy??
    My contract says that I must fill ALL my medicines, narcotic or not at one pharmacy only.
    To protect your pain contract I would make sure I clarified with my pain medicine prescribing doctor and take it from there.
    Also make sure both doctors receive chart notes from the other.
    Hope this helps and btw, I live in Oregon.
    DancnDar replied to annette030's response:
    I also have a pain contract with my pain management doctor. Last year when I went for hip surgery, he told me that I can take whatever the surgeron prescribed for pain after the surgery. At the time I was on 10mg of oxycodone and the surgeon prescribed Percocet 5mg up to 2 pills every 4 hours. It was suggested that for the first 3 days at least I take it every 4 hours around the clock. He also prescribed a muscle relaxer and an anti-inflamatory. All of these were taken anywhere from 2 to 6 weeks after surgery.
    I think if you are open with your pain management doctor then things should be ok. In the future, before filling an RX call the pain doctor and ask him.
    HurtingInMN replied to DancnDar's response:
    Two comments about your situation. First, I agree wholeheartedly with DancnDar, be open and honest with your pain management doctor and tell him or her exactly what happened, maybe even offer to bring any unused portions of those meds into them. I am quite sure your dr will understand. I have one of these contracts as well, and the main point of them is to prevent you from getting schedule II or schedule III meds from other doctors other than your PM doctor. Second of all, do your research, or better yet call your PHARMACIST. I have some Tramadol as well that I just take occasionally when I want to cut back on the Lortab, and I just called my pharmacist out of curiosity and asked about Tramadol. While it is a derivative of an opiate, it is NOT considered a true opiate like Vicadin or Percocet, and it is NOT a schedule II or schedule III drug. My PM doctor knows I have some Tramadol and she doesn't have a problem with it, as long as I'm not taking it daily, especially in combination with the Lortab/Vicodin. Hope it all works out, good luck!
    annette030 replied to DancnDar's response:
    Yeah, as long as your pain management doctor and your surgeon are on the same page, everything should be fine.

    When I had surgery, my surgeon asked me to go see a pain management specialist as a consult since my internist prescribes my pain meds. I saw a guy who I had seen once before, and he suggested I take up to 20 mg. of oxycodone every 4-6 hours as needed for pain, along with my regular methadone dose. Since my internist already had ordered that much for BT pain, I did not need to get any additional meds from the surgeon.

    I agree with you, just call your doctor prior to filling any RXs and ask what to do. Better safe than sorry.

    Take care, Annette

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