Imagine being wheeled into an operating room for an eye lift. As the anesthesia begins to flow into your vein, you see that instead of small precision scalpels on the instrument tray next to you, your surgeon will be using a hatchet and an ax. Panic swells as you slide defenselessly out of consciousness…
Absurd you say? In that instance, yes. But to millions of Americans being treated for moderate to severe pain, not really. They watched Congress this month debate the Food and Drug Administration’s User Fee Act. They observed in dismay as the Senate attached an amendment to the bill authorizing the rescheduling of hydrocodone combination products (such as Vicodin) from Schedule III to Schedule II drugs — which would make the pain relievers harder to obtain.
The amendment was no surgical strike with a scalpel against drug abuse. It was more like the threatening gleam of a hatchet or an ax raised against pain patients and their physicians. The strict requirements for Schedule II drugs would mean no automatic refills and only written prescriptions — no more calling in, faxing, or electronic transmission of prescriptions would be allowed for hydrocodone pain relievers.
Fortunately, the amendment was removed in the final version of the bill and the FDA User Fee Act was passed by Congress without hydrocodone rescheduling.
“Totally bogus,” is what Andrew Kolodny, MD, says about complaints that patients would suffer from rescheduling. A member of Physicians for Responsible Opioid Prescribing, Kolodny claims that patients would actually benefit from rescheduling, because they would have to visit their doctors every three months to get their prescriptions renewed.
To assess this statement and the wider support to reschedule hydrocodone, it is first necessary to state what should be obvious: These medicines have for many years improved the lives of millions of Americans by helping them manage cancer and non-cancer chronic pain; allowing many to sleep, maintain family and social ties, keep up with their medical treatment, and return to work.
No Evidence Rescheduling Would Stop Abuse
According to Robert Twillman, Director of Policy and Advocacy at the Academy of Pain Management, there is no reliable evidence showing that drug misuse and abuse can be changed by reclassifying hydrocodone products.
“Much of what is going on now in efforts to control prescription drug abuse focuses on reducing supplies across the board and that strategy affects both those who misuse the drugs and those who use them appropriately,” said Twillman. “We need to be more precise in our interventions.”
The push to reschedule could easily lead to unintended consequences. All one has to do is examine the devastation wrought on pain patients in Washington state and Florida. I’ve written before about patients going from pharmacy to pharmacy, unable to get their prescriptions filled for pain relievers. Some become so desperate and overwhelmed with pain they commit suicide.
Cindy Steinberg, Policy Chair for the Massachusetts Pain Initiative and New England Director of the American Chronic Pain Association, says rescheduling would create an “enormous hardship for millions of Americans whose pain is well controlled at present by hydrocodone combination products.”
Rescheduling Would Increase Health Care Costs
Ms. Steinberg worries that rescheduling will means more visits to physicians — raising health care costs for patients and government programs like Medicare and Medicaid. It would also increase prescriber workload and clog an already overburdened healthcare system. She sees that leading to health care providers being less willing to prescribe these medicines and to the abandonment of patients who need help managing their debilitating pain.
Both Twillman and Steinberg also cite the additional burden placed on patients disabled by pain, who because of reduced income, compromised energy, and travel difficulties will be less able to get the care they need. This is especially burdensome for those who live in rural areas, who have to drive long distances to appointments.
So, is it “totally bogus” to say additional controls on hydrocodone will harm patients suffering from pain? Hardly. The only thing “bogus” here is the complete disregard for the treatment of legitimate pain patients.
According to a national survey on drug use, 70 percent of the people misusing prescription pain relievers obtain them from friends and family.
This suggests that the war on drugs is being fought on the backs of people with pain. Instead of rescheduling hydrocodone products, policies should be aimed at educating physicians and patients about the safe use of these medications. Teens who abuse prescription medications need to understand the harm they are causing themselves and others. And patients should be instructed to secure their medicines at home in lock boxes and dispose of them properly when they are no longer needed.
Twillman suggests a reasonable compromise. He wants hydrocodone combination products to remain as Schedule III drugs, but to limit call-in scripts to no more than a seven day supply — just enough to give the patient time to see their doctor. That’s really the only reason to do a call-in, if someone has an emergency or crisis and needs an immediate prescription.
Mark Maginn lives in the east bay of San Francisco where he is a poet, writer and social justice activist. Mark suffers from chronic pain and was a longtime volunteer with the American Pain Foundation. His blog can be found here.
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