Living with Pain: Rescheduling Hydrocodone

Living with Pain: Rescheduling Hydrocodone

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

The views, opinions and positions expressed in this column are the author’s alone. They do not inherently or expressly reflect the views, opinions and/or positions of American News Report, Microcast Media Group or any of its employees, directors, owners, contractors or affiliate organizations. American News Report makes no representations as to the accuracy, completeness, currentness, suitability, or validity of any information in this column, and is not responsible or liable for any errors, omissions, or delays (intentional or not) in this information; or any losses, injuries, and or damages arising from its display, publication, dissemination, interpretation or use.

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Mark Maginn

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Doreen Land

I have severe RSD. This pain condition is rated next to terminal cancer in pain. You are on fire. without pain meds I could not walk or have any life at all. I live in WA State.

pain advocate,(D.R.)

I have to make a correction on the last sentence that I wrote. I made a mistake. I ment to say that vicoden should remain a schedule III because it is a very mild pain reliever. Anyone that calls vicoden a strong medication is sorely wrong. It’s perfect for arthritis pain for the elderly. They don’t metabolize the medicines as quickly as the younger people, so this medicine is much safer that celebrex and saves their stomaches from bleeding ulcers. So, senators, Kolodny and his friends need to back off. I honestly feel that the other poster is right. Dr Kolondy is being funded to to say all the negative accusations against opioids. He is pushing suboxone and frankly the insert on that package states DO NOT USE IF YOU PAIN!! So I feel that anyone from PROP, needs to be closed down. They have NO place telling anyone what to ingest. They just need to worry about the minority of addicts that they treat. leave chronic pain alone. You are not qualified in my book, because you do NOT understand what pain is.. Period!!

Appeal to Reason

Hydrocodone combinations should stay as they are, a schedule III medication. To reschedule would cause hardships for patients.

To make a blanket statement, as PROP does, that chronic non-cancer pain does not merit long-term opioid prescriptions is ludicrous. Of course, no evidence is offered and there are many origins of chronic pain and its severity can differ greatly. Cancer is not necessarily the most painful condition a person can experience. In fact, pain is not well understood. What is understood is that patients on long-term opioid therapies report a much improved quality of life— millions of them report this the world over. Are they all liars and addicts, or do they know their own experiences?

I find it odd that PROP members rarely identify themselves as such, such as the hysterical Dr Gelfand. He wanted it to appear that he was just a neutral party, but he isn’t. What’s more, they do not identify their funding sources, individually and as an organization. I suspect that PROP members find personal monetary gain via the Addiction Industry to be a terrific source of motivation. Dr Kolodny, the PROP ringleader, never mentions his associations with Reckitt Benckiser, maker of suboxone. The comments made by PROP appear to be driven more by a lust for power and a desire for financial gain than by any sincere concern for patients or genuine understanding of chronic pain. Dr Gelfand and Dr Kolodny are NOT chronic pain experts! Dr Gelfand studied rheumatology and internal medicine. Dr Kolodny is a psychiatrist who treats opioid addiction with suboxone– surprise, surprise!

Yes, there is chronic pain and also addiction. They are 2 completely separate issues. If opioids disappeared from Earth today, addicts would move on to other addictive substances tomorrow. It is chronic pain patients who would suffer. We must not take medications away from the easier targets (chronic pain patients) as a substitute for identifying and treating addictions, a much more difficult task.

Bob Twillman, Ph.D.

To address one minor point in Dr. Gelfand’s comment, i.e., the one about needing to see the physician once every three months if hydrocodone was rescheduled: I don’t think it is unreasonable to expect a patient to be seen every three months if he or she is on chronic opioid therapy. It might wind up being unnecessarily often, but perhaps “better safe than sorry”. To that end, there was one additional element to the compromise language we suggested: Refills for prescriptions written for hydrocodone would be limited to the number needed to give a total of a 90-day supply.

Senator Manchin’s staff pointed out that, as a C-II medication, it would be permissible for physicians to write a series of prescriptions for up to a total of a 90-day supply; they were OK with that idea, even though, once the patient is out the door of the office, there would be no practical way to stop him or her from filling the remaining prescriptions in the series. In this respect, refills actually turn out to be safer, because all you have to do to stop the refills is to contact the pharmacy that holds the prescription and cancel the refills. Thus, our compromise language would have provided GREATER control over medication supplies than moving the medication to Schedule II would have.

Erica

Wow, ive been in pain management for roughly 3 1/2 years now and have a life back – in that 3 1/2 years ive had 18 surgeries in just this past year for 2 different shunts and shunt infection and endless revisions on top of a Port-a-Carh placement for weekly Enzyme replacement infusion, and other procedures. In the 3 1/2 years ive had over 25 surgeris much closer to 3 dozen + surgeries actually for major things like the shunts as mentioned above, cervical spine decompression secondary to my underlying disorder (MPS I H/S which id like to ask how can this ALL encompassing- every organ involved disorder be any less worse than cancer besides it wont kill me in 6 or 12 mo but instead years and years and years of endless surgeries and procedures and infusions..) Ive diligently kept in contact with my Pain Management dr, never sold medication, never lost medication and keep medications locked up as is recommended. Ive NEVER had an issue with drug abuse, addiction or even having to increase the med doses other than for short periods after each surgery. I also do weekly PT, supplements, stretching at home and am not over-weight.
Despite this disorder I take care of my health.

Wake UP PROP and instead of attacking patients why not try to actually make positive, legitimate pain patient centered changes to chronic and acute pain managment? Oh yes, I know that might actually take udnerstanding pain and getting down to the patients level apparently. =/

Erica

Unhinged

I’m still wondering about you, Mark “condoning the overprescribing of opioids ‘across the board'”. Do you think maybe Dr. Gelfand read tbe wrong article? It is sad to me, that the personal attacks come into play with comments, like, ” it is clear that the author and people in this article know little about quality medical care”. People who suffer from serious pain conditions would welcome civil dialogue with the “pro-pain” community, but name calling & personal attacks are much easier to use when there is NO SCIENCE behind claims & “clinical” hypothesis is used in its place. What I can’t get over is how anyone can lump together a huge population of chronic non-cancer pain as one big entity……NONE requiring the use of opioid analgesics. Or, should I use my personal favorites, “deadly painkillers” and “narcotics” in it’s place. That way, we can demonize the medication AND de-humanize the patients who use it. Thanks again for the article, Mark!

mark maginn

I wondered how long it would take PROP to start commenting here on my column, now I Know. Welcome Dr. Gelfand, I welcome comments from you and your organization, the more you comment the more these readers can judge for themselves, which I think is a good thing. However, I don’t see where my column exhibits a “callous disregard for human life.” If anything, there are in this piece suggestions on how to come up with a more balanced approach to these medicines, a balance I find lacking in many quarters.

Savy

We here in Florida we must see our doctors every month. We do not have the luxury of having a 90 day prescription to save us on monthly office visits and the fee’s associated with office visits. We also pay for drug testing that is conducted at each office visit. Like the previous commenter, I do not take more than I am prescribed for the same reason..I would suffer more than I already do from being short at the end of the month! I am an adult who IS NOT out to get”high”. I am educated in NOT combining prescription drugs. I am educated in NOT combining alcohol and pain medication.
When a person becomes a legitimate pain patient and must take narcotics to tolerate the pain they experience,it is a last resort. We have diseases, injuries,failed surgeries and more!
I have a disease that has caused me to experience horrible debilitating pain. I did everything I could and listened to what my doctors told me to do. I have taken over the counter medications, herbs and supplements. I have gone to PT,massage therapy and use a TENS unit. When I was at my whits end with the pain,in constant tears and thought I was going to go crazy from the pain, my doctor looked me in the eyes and said ” You need pain management”. With those words I burst in to tears. I was reassured that it did not make me a druggy or drug seeker. It meant that I needed help with my pain. After my first visit, with in 3 nights I finally slept in my bed and not sitting up on the sofa( my pain was so bad at that time I could not lay down). I finally could hold my arms up long enough to wash my hair! The pain I experience was at a 10(yes worse pain I have ever felt..it was worse than a drug free labor and birth,Which I have done 3 times). Now my pain with medication is at a 5. I can tolerate a 5.
I can confidently say that if any person,agency or legislator were to ever feel the way we as pain patient feels, with and without pain medication..they would have a whole new respect for what we endure.

tamu

Its amazing to me that people who seem to always mention opioids causing all these deaths but is never brought up that most of these deaths could have bee avoided if they were not taking a benzo or drinking alcohol while taking the opioid medicine why dont they go after the companies that distribute those or go after the liquor stores for selling alcohol. Why because they tried that before & it didnt work out. Also let me mention something about the D.E.A. it amazing there budget gets bigger every year & their own reports show their war on drugs has amounted to less control on drugs because once something becomes illegal you lose all controls to moniter who is doing drugs. What that has caused is that there are more drugs being used in this country, they have become stronger more addictive, cheaper & the amount of drugs in this country has continued to rise. If this was an employee working for any company he wolid have been fired along time ago not given raises every year.

david

The pain experts told Congress what chronic pain costs the Nation- and surprise surprise Congress in turn sought ways to lower costs of pain care-and so opioids were the quickest way to do it. Pain experts could have and should have focused on how much money would be saved by providing effective pain care. Now people in pain are paying the price for pain experts blunders and Congress’s wish to sacrifice the good of people in pain in the name of penny wise pound foolish politics. People in pain deserve better.

Jan Warren

It is so stupid to punish prople in severe pain! I have enough trouble dealing with pain that is only partially alleviated by my meds. Why should you make it harder for me to get my meds just because the government agencies are so zealous in their work? I am a 73 year old responsible person who has no one coming in to steal my meds! I am so angry at those who don’t comprehend how difficult life can be when you get older. I have also had ovarian cancer. If they live long enough, they’ll find out, but it will be too late to help my generation.

I am shocked by comments by Stephen G. Gelfand, MD below…no EVIDENCE? We are ALL living in denial that use pain medication as a last resort when all other avenues/options have been tried? I have personally been on pain medication for over a DECADE. Never ONCE was short, took more then needed (uh, then I would be short at end of month, and unable to participate in my own life), nor sold medication, etc. Try living with nerve pain (facial reconstructive surgery gone wrong, after 4 surgeries in a year, after bone infections, implants infections, etc). They all my condition the Suicide Disease…because my nerve damage was the result of infections etc, the typical anti-seizure medications have no effect. I have seen every specialist I could find on the eastern coast of our COUNTRY…If it were NOT for these medications, I would be dead. I cannot afford to abuse, divert etc, because my life literally depends on it.

It is insane to hear educated ‘professionals’ make these statements. You can not assess our lives in a lab, or clinical setting. Triggers of every day normal life (or in my case, weather, wind etc) have HUGE effects on pain levels. Do you really think those folks you see on the nightly news that were in a horrible car accident, fall, assaults, etc, are just put back together again with NO lasting effects? Really? You think all doctors are THAT GOOD? I used to think that, but they do the best they can and send these broken people on their way to try and live with the devastating effects of the physical trauma, or complications, and we are left to seek help. Some are lucky and are able to fix what is actually wrong, others, not so lucky, sometimes a body cannot just be fixed. NOT to mention those born with conditions I wouldn’t wish on my worse enemy. Perhaps get off your high horse and try speaking and understanding what these patients in ‘denial’ are really going through.

pain advocate

I find it very interesting that any doctor that does not have chronic pain or has never experienced that kind of pain would say that opioid pain medications would not improve the lives of patients. Far too many people that have chronic pain would not appreciate a doctor basically calling them addicts either. That is rediculous and very rude. If you have never lived with pain or walked anyone’s shoes that has to live like this everyday, then you do not have any idea. This exact non-sense needs to stop in America. So frankly, I will treat my pain the way I see fit. It is becoming increasingly clear that some doctors have absolutely no understanding of their patients and how they feel or what is best for them. I would also not imagine they would have many patients as a result of that. I wonder how they will control their arthritis pain? Possibly he may never have pain? I seriously doubt that. Anyone that makes the claims that this doctor just made is not a doctor. I can see that he only wants to be wise guy for some reason. It must be Dr Kolondny’s associate. So dear commentators, if you ever hear a doctor make these kinds of statements. Run for life and don’t look back. Find a better doctor that understands the pain you have because this one surely doesn’t. Thanks Mark for the great article once again! Vicoden does have a place for pain patients and should only be a schedule II because it is a very mild pain medication and for many that only have occasional or acute pain it is a very medication. Very good for arthitis pain in elderly patients.

Unhinged

It is interesting to me that anyone could see this as “condoning the overprescribing of opioids ‘across the board’ while the volume of addictions, overdose and death, continue to mount”. Overprescribing? Hmmm…. I guess, that’s one way of avoiding prescribing opioids for your patients. Tonight, when I get in to bed, and take my pain medication (that allows me to function, sleep, engage in life, walk my dog, take care of my family, and do P.T.), I will say an ‘extra’ prayer of gratitude, for my responsible doctor (who I see at least monthly), who saved me from the depths of hell and near suicide, due to my Intractable pain. By the way, absence of evidence IS NOT evidence of absence. Most pain patients are NOT in denial, they are in PAIN. Severe untreated pain is a sentence to a life of torture and hopelessness. The risk of addiction is low, and the risks of untreated or under treated severe chronic pain are very high. Addiction is a disease that can be devastating to the addict and those who love them. Just as devastating are the countless pain sufferers, and those that love them….especially so, when there is medication that can help them! Medication that is witheld from them because of fear, ignorance, scrutiny, lack of compassion, and the behaviors of others. Talk about a callous disregard for human life!

Editor’s Note: Stephen G. Gelfand, MD, is secretary of Physicians for Responsible Opioid Prescribing, the same organization that Dr. Andrew Kolodny belongs to. American News Report welcomes all points of view on this complex subject.

Stephen G. Gelfand, MD

There is no medical evidence in multiple systemic research studies and by widespread clinical experience that the lives of millions of Americans with chronic noncancer pain is improved with chronic opioid therapy. Although some patients with the most severe types of pain may marginally improve, the majority will not and are at risk for drug dependency, disability, addiction, overdose and death, especially if they have co-morbid mental health disorders, are on other psychoactive drugs, or have histories of substance abuse. Most patients who are addicted to opioids are in denial, while the disease of addiction is one of the most difficult diseases in medicine to treat. Moreover, it is clear that the author and people in this article know little about quality medical care, since the need to visit one’s physician every 3 months if hydrocodone products are re-classified from Schedule III to Schedule II, is good medical care, especially since opioid-related adverse effects become more common over time and patients must be closely monitored. I know no good physicians who would feel comfortable by seeing a patient on chronic opioid therapy every 6-12 months or longer while continuing to refill their prescriptions. In summary, this article shows a callous disregard for human life by condoning the overprescribing of opioids ‘across the board’ while the volume of addictions, overdose and deaths continues to mount.

Unhinged

Thank you, Mark. You’re right, what IS “totally bogus” is the “complete disregard for the treatment of legitimate pain patients”. Despite what most media reports, it is very difficult for legitimate severe, pain sufferers to find doctors with compassion, who are willing to treat them with opioids, and for those patients to find pharmacies to fill their legitimate, legal prescriptions. Adding more red tape, and more work for everyone involved in that whole process, will do nothing but put up MORE barriers between pain sufferers and adequate treatment. It will do NOTHING to deter these medications from getting into the wrong hands. The “War on Drugs” has been a complete failure, and of course, the “War on People in PAIN” has been a raving success. THAT’S the real story that needs to be told. Thanks Mark, for doing your part in telling it.

Unhinged

pain patient

I wish more of the main stream media, and politicians for that matter, would look at the war on drugs from the perspective of a pain patient. Love LOVE this article.