Does restricting Vicodin make sense?

To understand the Vicodin story we first have to understand how habit-forming medicines are currently prescribed in the U.S. The Drug Enforcement Agency divides potentially addictive substances into different schedules. Schedule II controlled substances are prescription medicines that have a high potential for abuse and severe dependence. They include all the opiate (narcotic) pain medicines, like morphine, oxycodone, and fentanyl. These medications must be prescribed on a paper prescription that has special security markings that prevent copying. The prescription must be taken to the pharmacy by the patient, and cannot be faxed or phoned in. And the prescription can at most prescribe a 90 day supply of the medication without refills.

Schedule III controlled substances are prescription medicines that have less potential for abuse and dependence than the medicines in Schedule II. It includes many medications that include an opiate medicine with a non-opiate in the same tablet. Examples include hydrocodone with acetaminophen (marketed as Vicodin, Lortab, or Norco), Tylenol with codeine, and hydrocodone with ibuprofen (Vicoprofen). Prescriptions for these medicines can be called in or faxed by physicians to pharmacies, can be written for more than a 90 day supply at a time, and can include refills.

In the last decade the number of prescriptions for Schedule III pain relievers has skyrocketed, as has the number of people taking hydrocodone for non-medical reasons. Prescription drugs are now a leading cause of addiction.

After years of consideration and debate, the Food and Drug Administration released a statement recommending that all pain medications containing hydrocodone be reclassified as Schedule II. The new policy is likely to take effect next year. This would include medications such as Vicodin, Lortab, Norco, and Vicoprofen, as well as their generic equivalents.

Proponents of the plan hope this will stem the tide of prescription medicine misuse. Opponents, like the National Community Pharmacists Association and the American Cancer Society, charge that this will inconvenience legitimate patients seeking pain relief. I suspect both sides are right — both legitimate and illegitimate users of hydrocodone will be inconvenienced.

Though I’m ambivalent about the new policy, I’m reminded of a similar change a few years ago regarding pseudoephedrine (Sudafed), a nasal decongestant. Pseudoephedrine used to be over-the-counter, but because it was being used to manufacture methamphetamine — or crystal meth, a dangerous and illegal stimulant — the new law limited the amount of pseudoephedrine that can be purchased at one time and required that the patient show identification at the pharmacy to purchase it.

My objection to the pseudoephedrine rules is simply that in the several years since the new restrictions, no one has published a study (as far as I know) showing that the street price of crystal meth is higher, that the number of crystal meth addicts is lower, or any other objective measure suggesting that the new restrictions have been effective in decreasing the quantity of crystal meth available on the black market. Nevertheless, regardless of effectiveness, once a tighter regulation is in place, it is never rescinded.

I expect much the same with the new restrictions on hydrocodone — permanent inconvenience without ever measuring whether there is a benefit.

Albert Fuchs is an internal medicine physician who blogs at his self-titled site, Albert Fuchs, MD.

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  • alex

    Great post!

  • ninguem

    What seems to have made a difference with meth labs in my state, was the requirement that pseudoephedrine purchasers show photo ID. To the extent that meth lab busts could be considered reflective of the number of active meth labs, the biggest drop in meth lab busts followed the requirement that the purchaser show photo ID.

    That left the police with a paper trail to find the people who supply the people who cook the meth.

    I for one, was opposed to the hassle factor of writing a controlled substance prescription for pseudoephedrine, more work, that much more expense to medical care, to no good use. Pseudoephedrine is controlled in my state.

  • karen3

    With Propublica’s databank, based on Medicare data, Physician prescribing histories are public record. Medicare certainly has the data necessary to identify pill mill doctors and if they requested, so would state boards of Medicine. As should DEA. We already have documentation as to who is authorizing the illegal flow. Why add difficulties to legitimate patients because a small number of doctors are abusing their prescribing privileges.

    • Tiredoc

      Actually, Propublica’s website mostly identifies orthopedic surgeons, who have high numbers of patients as well as large numbers of completely appropriate narcotic prescriptions.

      If you really wanted to shine the light, how about we see the patient side of the Medicare database, too?

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Actually the GAO has published a report in January
    http://www.gao.gov/assets/660/651709.pdf
    All sorts of things dropped/increased, but there’s plenty of meth on the street and the imported version seems to be more addictive.

  • guest

    Maybe we should crack down harder on those who doctor shop, etc, rather than penalizing everyone.

    Patients need to take some responsibility. Once I was prescribed Lortab because the doctor was concerned that after discharge I would still have pain. I didn’t need it, so I didn’t fill it. It wouldn’t have been the doctor’s fault if I had chosen to fill a prescription I didn’t need.
    I hate to think that this will make doctors more leery of prescribing medications a patient might need.

    • querywoman

      Yup. Pain is something they can’t qualify The doc didn’t know how you would react.
      Lots of people who don’t need the pain meds fill them and sell them. Small time drug dealers making supplemental income!
      It’s amazing the price the true addicts will pay on the street for this stuff!
      It’s true that no one can stop all illegal activity.

  • James_94

    “Are you frickin’ kidding me? You are ambivalent about a policy restricting vicodin use?”

    The author is ambivalent about a policy restricting LEGAL, medically-appropriate Vicodin use. I would imagine that most of the people you see suffering addictions and overdoses are not using doctor-recommended doses of legally-prescribed Vicodin.

  • Shirie Leng, MD

    Wow. Way to shut down a useful discussion with hatred. The new Vicodin restrictions are largely restrictions on patients, the ones who put the pills in their mouths. Doctors can say “no” all they want but addicts will find a way to get pills in their mouths. Doctors cannot come to a patients house or their hotel or their street corner and prevent you from taking pills. I agree with the new policy, and I am certainly not ashamed.

    • querywoman

      Narcotics are a different matter than the stuff Conrad Murray got for Michael Jackson. It’s difficult for me to believe another doctor would have administered anesthesia in his home every night.
      I shared a public hospital room once with a woman who supposedly couldn’t afford a picture id so she could get painkillers in the hospital pharmacy program, so she used cocaine and heroin.
      I didn’t ask how she paid for the cocaine and heroin.

  • BK Berryman

    The United States consumes 99% of the world’s hydrocodone. Hydrocodone, clearly, has a high abuse potential, and should be more restricted. How about multi-state Prescription Monitoring Programs so I can see if a patient has filled a controlled substance prescription in another state? How about no refills and no phone-in prescriptions (because my EMR-generated Rx is less secure than someone pretending to be from my office calling in a fraudulent prescription?)? How about the
    federal government sponsoring manufacturing of generic agonist/antagonist medications? How about educating prescribers on Panlor (acetaminophen/caffeine/dihydrocodeine) — narcotic pain control equivalent to hydrocodone without the high and therefore no street value?

  • ButDoctorIHatePink

    Well, I’m not ambivalent about it. I have end stage cancer, and I cannot understand why I have to pay the price for people who abuse drugs, and I don’t understand why doctors can’t just say NO if that is what they suspect of their patients, and most of all, I cannot understand why the government has to get involved in the personal lives of its citizens before any evidence of a crime has taken place.

    As it stands, having breast cancer with mets to my liver – having had a mastectomy and resultant shoulder and back problems, a liver resection, colitis from c-diff, gamma knife radiation and 4 years of chemo plus joint pain along with my cancer pain – I take 10 mg oxycontin, 4 mg dilaudid and 10 mg norco. All of which, I might add, I take in fewer than the allowed amounts per month.

    Here is what I have to do to get my schedule III meds: The oxycontin and dilaudid require a 24 hour in advance phone call to my oncology office, (not accounting for weekends, holidays and the sick/vacation days of the specific staff member on the prescription desk’s). This means I’m counting and planning always – see above, I don’t take as much as I’m given) a phone call the next day morning as a “reminder” that I’m coming in and assurance that somebody has signed the prescription, then a 30 minute drive to the doctor, parking, a wait to get the prescription, a 30 minute drive home, a 10 minute drive to the pharmacy,a 30 minute wait there, and then a 10 minute drive home. Sometimes the pharmacy doesn’t have enough meds, so I have to go back the next day. All of this is extraordinarily hard on a cancer patient, one who is sick, in pain, likely in her last year. I’m still able to drive although not always – but what happens when I can’t? Medical offices close at 5:00. My husband gets off work at 6:00. He will now have to take time off?

    The norco is what tides me over. If feel sick, exhausted, nauseated in pain and don’t have the dilaudid because it’s a weekend or holiday or didn’t plan right (after 4 years of chemo, that is common) At least I have that. I can call it in with one of my five refills and just go pick it up or having my husband grab it after work since the pharmacy is open later than the doctor’s office. Ten minutes there, ten minutes back, done.

    Why on earth has the FDA decided to take this ease away from me? They are afraid I, a terminal cancer patient, will become addicted? Who cares? The truth is, those of us who use pain meds for real pain, cancer pain, don’t get addicted in the way others do anyway, a well-documented fact.

    Medications and opiods are supposed to help people like me, and people who have conditions which cause pain. If doctors are unable to say no to somebody who they believe doesn’t need it, or can’t tell the difference, and aren’t even smart enough to refer a patient to a pain clinic, then they should find another career. And, if a guy with a bad back ends up taking too many vicodin, than the doctor who prescribed it can kindly find a program and help the guy taper down, or hey, let him have the medication that allows him to live a pain free life. If a human isn’t running around from doctor to doctor, isn’t buying drugs off the street, hasn’t increased their dose and is rational and behaves normally, then they are not addicted in a way anybody should worry about and it means the medicine is helping them live normally. And if the drugs are being manufactured, imported or sold illegally – then how is this going to help?

    This is more nanny government and it is going to have a great impact on people like me, but we are not the people anybody cares about. I guess I just won’t be around to complain about it for long, but it is ridiculous that the weakest among us have to pay the price for addicts and doctors who can’t say no.

    When has one single person stopped using drugs because they become harder to get, or the formulation changed, or the government put them behind a counter instead of hanging on a wall? It hasn’t. An addict will find a way and it won’t be hard, just like getting pot isn’t hard and just like getting drugs isn’t hard.

    The only person this is going to impact is somebody like me, and it is going to make an already very, very difficult life even more difficult.

    Good job FDA.

    .

    • bonniez45

      Thank you, that is the question.
      What is being done for the pain patient, what steps are being taken that Drs. are not afraid or sign contracts limiting the treatment/meds that they may give.
      What is being done to protect the patient.

  • querywoman

    I always find it hard to believe that the US consumes 99% of the world’s hydrocodone supply. Hydrocodone is a narcotic plus Tylenol.
    I think it would be better to discuss the world’s opiate supply. Does the 99% statistic included unprescribed opiates?

    Iran, which is near Afghanistan, is full of opium addicts.
    Pain is part of the human condition. So what do other countries use for pain?
    Would drug legalization in the US help?

    Don’t real addicts consume as much as they can get their hands on?

  • querywoman

    Grivet, you answered one of my questions: don’t real addicts consume as much narcotics as they can get their hands on?
    The narcotic addicts do make it hard on those who use narcotics appropriately for pain.

  • querywoman

    Okay, I wiki’d it, and I see that the United States does use 99% of the world’s supply of hydrocodone. It’s a manufactured mix that is acceptable for prescription sale in the US.
    But that doesn’t mean other countries don’t prescribe opiates in other formulations in large quantities.
    So why pick on Americans who need painkillers?
    Drug addicts can get it legally or illegally.