cbd oil to replace norco for chronic pain

Previous Research

Objective: To determine if a 2-day protocol measuring pharmacokinetic and pharmacodynamic characteristics can demonstrate drug-drug interactions when smoked cannabis is added to orally administered hydrocodone/acetaminophen combination products. Case Summary: A 51-year-old non-Hispanic white male with chronic pain diagnoses participated in a 2-day pilot protocol. The participant attended two 7-hour in-lab days where he received 10 blood draws each day and completed self-administered pain and anxiety surveys. For both days, the participant took his prescribed dose of hydrocodone/acetaminophen (1/2 tablet of 7.5 mg/325 mg combination product) with the addition of 1 smoked pre-rolled marijuana cigarette (labeled as 0.5 g; 22.17% Δ9-tetrahydrocannabinol; 0.12% cannabidiol) on Day 2. Blood specimens were analyzed using mass spectrometry to quantify the difference of plasma hydrocodone levels between Day 1 and Day 2.

Results: Compared to Day 1, lower levels of pain and anxiety were reported during Day 2 with the addition of cannabis to oral hydrocodone/acetaminophen. Day 2 pharmacokinetic analysis also revealed more rapid absorption and overall lower levels of hydrocodone in plasma. Discussion: Lower hydrocodone plasma levels in Day 2 may indicate cannabis’s effect on metabolism and reduce the risk of opioid toxicity. The quicker absorption rate of hydrocodone could explain lower pain and anxiety scores reported on the second day. Conclusion and Relevance: A 2-day protocol was able to capture differences across time in pharmacokinetic and pharmacodynamic measurements. Larger studies can be designed to better characterize the potential drug-drug interaction of cannabis and opioids.

Program Evaluation of a Home Exercise Program for Chronic Back Pain in the Outpatient Setting

Xiang Jing, DNP and Jamie Lewis, MD

Research indicates many different interventions are potentially therapeutic in managing chronic back pain. While home exercise programs may be cost-effective for individuals, little has been published on the subject of how best to combine functional and psychologic instruments to measure structured exercise programs in an outpatient setting. This DNP project conducted a program evaluation of a pilot project which reviewed the efficacy of a home exercise program for people with chronic back pain. The project was approved by a multi-disciplinary team at a private spine and pain specialty practice. Participants were recruited from patients at this practice, 14 of whom completed this three-month pilot project with no reported adverse events. The program measured participants’ exercise pattern changes, back functional improvement, and compliance to the change of routine through the use of three validated questionnaires: Fear-Avoidance Beliefs Questionnaires (FABQ), Low Back Pain Disability Questionnaire (OSWESTRY), Exercise Self Efficacy Scale (ESES). The program evaluation provided valuable information on how a HEP may further adapt these measurement tools to provide relevant data in a fast-paced outpatient pain management setting.

Interpreting Urine Drug Test Results in the Context of Chronic Opioid Analgesic Therapy and Poppy Seed Consumption

Citation: Jamie Lewis, MD, Karlee De Monnin, BS, Jonathan Smith, BS, Evan Lewis, Marian Wilson, PhD, MPH, RN (12 March 2021). Pain Medicine, pnab082, https://doi.org/10.1093/pm/pnab082

Goalistics Chronic Pain Program

Northwest Spine and Pain Medicine partnered with Washington State University on a research program looking at efficacy of Goalistics Online Pain Program combined with health coaching at treating chronic pain. Validating the effectiveness of Goalistics Chronic Pain Program and other online modalities helps to increase the scope of treatment options readily available to those suffering from chronic pain.

Building Efficacy for Successful Opioid Tapering

It can be challenging to decrease or discontinue opioid pain medication. Northwest Spine and Pain Medicine partnered with Goalistics, LLC to evaluate a new tool to help patients who are undergoing medically supervised opioid tapering. The development and testing of the Building Efficacy for Successful Tapering (BEST) Program is funded by a grant from the National Institute on Drug Abuse. The online BEST Program was designed to:

  • Teach pain patients about different methods of pain management that don’t involve pain medication
  • Help them to build their own custom list of “pain reducers”
  • Allow them to track and test the effectiveness of each method
  • Identify the best strategies for them
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Two studies were conducted. The first study is a review of the BEST program by patients who are currently undergoing opioid tapering. Their feedback will help ensure that the BEST Program is user-friendly and beneficial to future program users. The second study is a pilot randomized controlled trial to examine the efficacy of the program.

Cannabis use is related to self-efficacy but not sleep or pain symptoms: A survey of adults prescribed opioids for pain or opioid use disorders.

T. Bigand, M. Wilson, S. Riedy, J. Lewis (2017). Cannabis use is related to self-efficacy but not sleep or pain symptoms: A survey of adults prescribed opioids for pain or opioid use disorders [abstract]. The Journal of Pain. 12.121

Inadequate pain management and sleep difficulties are commonly reported by people using opioids to treat persistent pain or for medication-assisted treatment of Opioid Use Disorder (OUD). Cannabis use is frequently reported within both populations to manage pain and sleep problems, although how cannabis influences co-occurring symptoms is uncertain. Self-efficacy, the confidence that one can control symptoms, can improve pain and sleep symptoms. It remains unknown how cannabis use relates to self-efficacy in managing symptoms of pain and sleep. To explore relationships between cannabis use, sleep quality, pain intensity, and self-efficacy, survey data of adults prescribed opioids for OUD (n = 150) and persistent pain (n = 150) were analyzed. The Pittsburgh Sleep Quality Index (PSQI) global score and Patient-Reported Outcomes Measurement Information System (PROMIS) pain intensity and self-efficacy subscale scores were used to assess sleep quality, pain intensity, and self-efficacy, respectively and a questionnaire assessed cannabis use. Data were analyzed using linear regression with main effects for sample (OUD and persistent pain) and cannabis use (yes/no) in the last month and their interaction. Overall, 87% of all surveyed adults had clinically relevant poor sleep quality (PSQI > 5). Better sleep quality was associated with greater self-efficacy (F1,225 = 23.30, P < .001) and less pain intensity (F1,230 = 29.95, P < .001). Cannabis use in the last month did not predict sleep quality or pain intensity (P > .70). Cannabis users had higher self-efficacy scores than non-users (F1,277 = 6.78, P = .01). Persistent pain patients had poorer sleep quality (F1,225 = 10.14, P = .001) and greater pain intensity (F1,281 = 32.43, P < .001) than OUD patients; self-efficacy did not differ (F1,277 = .27, P = .60). Evidence does not support cannabis for improving pain or sleep for either group, yet cannabis users have more confidence in symptom control. Future studies should focus on interventions that reduce symptom burden while enhancing self-efficacy.

Laws and Regulations

Follow the instructions below to view the most current versions of the laws and regulations governing controlled substances and the official prescription forms in New York State.

Article 33 Public Health Law

Part 80 Controlled Substance Regulations

Part 910 Official New York State Prescription Forms Regulations

Ioflupane Removed From Controlled Substance Schedules

Effective August 18, 2016, Ioflupane, an injectable radiopharmaceutical diagnostic tool, that is derived from cocoa leaves, and is used in testing for adult patients with suspected Parkinsonism syndromes, was removed from Schedule II of the New York State Controlled Substance Schedules. This substance is now considered a non-controlled substance. Please see Article 33 of New York State Public Health Law, Section 3306(4)(b).

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New Legislation Enacted to Limit Initial Opioid Prescribing to a 7 Day Supply for Acute Pain.

TO FURTHER REDUCE OVERPRESCRIBING OF OPIOID MEDICATIONS, EFFECTIVE JULY 22, 2016, INITIAL OPIOID PRESCRIBING FOR ACUTE PAIN IS LIMITED TO A 7 DAY SUPPLY. A practitioner may not initially prescribe more than a 7-day supply of an opioid medication for acute pain. Acute pain is defined as pain, whether resulting from disease, accidental or intentional trauma, or other cause, that the practitioner reasonably expects to last only a short period of time. This rule SHALL NOT include prescribing for chronic pain, pain being treated as a part of cancer care, hospice or other end-of-life care, or pain being treated as part of palliative care practices. Upon any subsequent consultations for the same pain, the practitioner may issue, in accordance with existing rules and regulations, any appropriate renewal, refill, or new prescription for an opioid.

Changes to Controlled Substance Schedules Section 3306 of the Public Health Law

Effective November 25, 2012 the following changes will be made to the controlled substance schedules in Section 3306 of the New York State Public Health Law. Where applicable, some common brand name pharmaceutical preparations containing the controlled substances are listed in bold:

Schedule II Additions:

  • Tapentadol (Nucynta™)
  • Immediate precursor to fentanyl: 4-anilino-N-phenethyl-4-piperidine (ANPP)
  • Boldione (androsta-1,4-diene-3,17-dione)
  • Desoxymethyltestosterone (17[alpha]-methyl-5[alpha]-androst-2-en-17[beta]-ol) (a.k.a., madol)
  • 19-nor-4,9(10)-androstadienedione (estra-4,9(10)-diene-3,17-dione)

Schedule II Amendments:

  • Language defining an anabolic steroid was amended: Unless specifically excepted or unless listed in another schedule, "anabolic steroid" shall mean any drug or hormonal substance, chemically and pharmacologically related to testosterone (other than estrogens, progestins, corticosteroids and dehydroepiandrosterone).

Schedule III Amendments:

  • Language to clarify the description of dronabinol.

Schedule IV Additions:

  • Fospropofol (Lusedra™)
  • Carisoprodol (Soma ® )

Schedule V Additions:

  • Ezogabine (Potiga™)
  • Lacosamide (Vimpat ® )

Effective February 23, 2013 the following changes will be made to the controlled substance schedules in Section 3306 of the New York State Public Health Law. Where applicable, some common brand name pharmaceutical preparations containing the controlled substances are listed in bold:

Schedule II Additions:

  • Hydrocodone (dihydrocodeinone) (Vicodin ® , Lortab ® , Tussionex ® ) This action renders all products containing hydrocodone, including but not limited to hydrocodone in combination with acetaminophen or ibuprofen, Schedule II.

Schedule III Deletions:

  • Hydrocodone (dihydrocodeinone) (Vicodin ® , Lortab ® , Tussionex ® ) This action renders all products containing hydrocodone, including but not limited to hydrocodone in combination with acetaminophen or ibuprofen, Schedule II.

Schedule IV Additions:

  • Tramadol (Ultram ® , Ultracet ® , Ryzolt™)

Practitioners and pharmacists are responsible for ensuring prescriptions for all controlled substances including the medications listed above conform to all requirements of the law and regulations, both federal and state. Article 33 of the Public Health Law and Title 10 Part 80 Rules and Regulations on Controlled Substances in New York State may be accessed via the Bureau of Narcotic Enforcement webpage

Electronic Prescribing and Dispensing of Controlled Substances is now permissible in New York State Effective March 27, 2013 – Updated April 2013

Amendments to Title 10 NYCRR Part 80 Rules and Regulations on Controlled Substances have been adopted and became effective as final regulations on March 27, 2013. The amendments authorize a practitioner to issue an electronic prescription for controlled substances in Schedules II through V and allow a pharmacist to accept, annotate, dispense and electronically archive such prescriptions.

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The amendments require the following;

  • Computer applications utilized must meet federal security requirements. The federal requirements are included in the Drug Enforcement Administration Interim Final Rule regarding Electronic Prescriptions for Controlled Substances. The rule may be accessed via the U.S Department of Justice DEA Office of Diversion Control website. Contact your software vendor to determine if your application meets the above mentioned requirements.
  • Computer applications meeting federal security requirements must be registered with the Department of Health, Bureau of Narcotic Enforcement.
  • Pharmacy computer applications must use American Society for Automation in Pharmacy (ASAP) Version 4.2 or greater in order to receive electronic prescriptions for controlled substances and to report those transactions to the Department of Health, Bureau of Narcotic Enforcement.
  • Pursuant to Public Health Law section 3302(37), an electronic prescription for controlled substances may only be issued in accordance with Department of Health regulations, as well as NYS Education Department regulations and federal requirements.NYS Education Department regulations may be accessed electronically.

On March 13, 2015, the New York State Legislature amended the Public Health Law and the Education Law to extend the implementation date for mandatory electronic prescribing to March 27, 2016.

Information regarding e-prescribing may be accessed at the following link: Electronic Prescribing of Controlled Substances

Electronic Prescriptions and Records for Hypodermic Needles and Hypodermic Syringes – Updated October, 2013

Amendments to Title 10 NYCRR Part 80 Rules and Regulations on Controlled Substances have been adopted and became effective as final regulations on October 9, 2013. The amendments specify the manner in which a practitioner may issue a prescription, including an electronic prescription, for hypodermic needles and syringes and would specify how a pharmacist should dispense and electronically archive such prescriptions. Pursuant to Public Health Law section 3381, a prescription for hypodermic needles and syringes may only be issued in accordance with Department of Health and NYS Education Department regulations.

To view the Department of Health Recently Adopted Regulations, amendments to Title 10 NYCRR Part 80 Rules and Regulations on Controlled Substances may be accessed electronically:

  • Go to www.health.ny.gov
  • On the right side of the Home Page click on Laws and Regulations
  • Under Rules and Regulations click on Recently Adopted Regulations (Prior Six Months)
  • Click on October 9, 2013 – Electronic Prescriptions and Records for Hypodermic Needles and Hypodermic Syringes

Prescription Drug Reform Act Internet System for Tracking Over-Prescribing (I-STOP) – Updated September, 2013

Amendments to Title 10 NYCRR Part 80 Rules and Regulations on Controlled Substances have been adopted and became effective as final regulations on August 27, 2013. The amendments specify the manner in which a practitioner must consult the Prescription Monitoring Program (PMP), and certain exceptions to that requirement. They clarify the practitioner’s and pharmacist’s ability to authorize a designee to consult the PMP on their behalf. The amendments change the frequency by which dispensing practitioners and pharmacies must submit dispensed controlled substance data to the Department of Health (Department), and include a requirement for reporting that no controlled substances were dispensed.

To view the Department of Health Recently Adopted Regulations, amendments to Title 10 NYCRR Part 80 Rules and Regulations on Controlled Substances may be accessed electronically: