Here's my response to a column by Maia Szalavitz on the recent recommendation by an FDA panel to change hydrocodone (Vicodin, Norco and others) from Schedule III (where prescriptions can be phoned or faxed in) to Schedule II (where prescriptions have to be printed.)
You can access her column here.
I think the idea is to reduce the number of opioid pain medications circulating in the community. Opioids are now the most prescribed medications in the US. Between 1998 and 2008 the number of prescriptions for hydrocodone (the opioid in Vicodin, Norco and others) increased 53%, from about 80 million to 120 million, whereas the increase in other opioids was 20-34%. Hydrocodone accounts for more emergency department visits than any other opioid as well. As someone who treats chronic pain as well as addiction, I don't like the restrictions on schedule II drugs, and I worry about undertreatment of chronic pain. But deaths from overdosing on opioid painkillers has more than tripled since 1990. I think there is a major gap in the continuum of care for people with chronic pain, especially the lack of pain medicine specialists, as opposed to interventional pain specialists, who like to do a lot of very lucrative injections. Strategies to close this gap are needed. As you note, Maia, most opioids used for non-medical purposes come from medications prescribed for someone else. Thus, the strategy to make prescribing them more difficult in order to reduce the availability. The issue is complex and there are no easy solutions. However, one thing I would like to see everyone get behind is that anyone who is addicted to opioids have immediate and affordable access to opioid maintenance therapy with Suboxone or methadone. If we aren't doing that, we aren't getting serious about opioid addiction in America
I don't think that we are serious about the opioid problem in the US until we recognize a few basic facts that nobody seems to make explicit. First, opioids are not the magic bullet for chronic pain. It has been demonstrated in double blind placebo controlled studies that opioids offer modest relief that is the equivalent of several non-opioid medications in those people who can tolerate them. Second, if you are genetically predisposed to a euphorigenic and in many cases hypomanic effect from the initial doses of opioids - it will place you at high risk for addiction. We do not know the genetics of the subjective response to opioids or any other addicting drug for that matter so it is not possible to predict who is at risk. In that vacuum - some education about the subjective response being a risk factor might be important. Third, once we acknowledge that opioids are not the magic bullet, it follows that continuing to escalate the dose of a medication that does not provide more analgesia does not make any sense. There are numerous studies suggesting a limit on morphine equivalents per day based on this principle and also the idea that beyond a certain level, the accidental overdose rate is significantly higher.
ReplyDeleteMany of these concepts are neatly wrapped up in the NICE guideline for treating chronic neuropathic pain. That guideline brings us back to the standard of care in Minnesota in the 1990s. There should also be broad public education that focuses on these reality-based aspects of pain relief rather than just reducing access.