Pain management experts say the rescheduling of hydrocodone by the U.S. Drug Enforcement Administration could have many unintended consequences, including higher healthcare costs, as well as more suicides, addiction and abuse of opioids. Many physicians may also refuse to write prescriptions for hydrocodone products, fearing fines or prosecution.
“I predict there are going to be a lot of people who are going to find it even more difficult to get access to medication that can help them,” said Lynn Webster, MD, past president of the American Academy of Pain Medicine.
“We may see an increase in the amount of deaths from opioids, not a decrease in the amount of harm. These are the sort things we just cannot perceive.”
The DEA estimates that seven million Americans abuse prescription medications, including opioid painkillers like hydrocodone, and that nearly 17,000 die annually from narcotic overdoses.
The rescheduling, which takes effect October 6th, means that pain patients taking Vicodin, Lortab, Lorcet or other hydrocodone combination painkillers will be limited to an initial 90-day supply — and then will have to see a doctor for a new prescription each time they need a refill. Prescriptions for Schedule II drugs cannot be phoned or faxed in by physicians.
“One of the unintended effects is that it’s going to raise healthcare costs tremendously. I don’t know if our healthcare system is ready to accommodate even a fraction of those additional visits,” said Steve Passik, PhD, Vice President of Research and Advocacy for Millennium Health.
“And what happens to all those people? Some of them are going to be abruptly stopped. There are going to be patients whose physiological dependence has been sort of underestimated. They’re going to turn up in emergency rooms. I think a lot of people are going to stop prescribing altogether. Some of the alternatives we know are problematic, NSAID’s, acetaminophen, Tylenol and so on.”
“Where are those patients going to go and what kinds of treatment are they going to get is the big question,” added Webster, who spoke to National Pain Report in Las Vegas during PAINWeek, a national conference of practitioners in the field of pain management.
“They’re going to look for an alternative like Tylenol with codeine — and we know that has a lot of inherent problems. And we’ll probably see a tremendous increase in Ultram. I’m not sure those are equal alternatives to hydrocodone. They’re still addictive drugs. There’s still potential harm from them.”
Patients May Turn to Black Market
Another possibility raised by Webster and others is that some patients may turn to heroin or other drugs on the black market to relieve their pain.
“To think that rescheduling of hydrocodone is going to have a huge positive in the war on drugs is really a big mistake,” said Dr. Jefferey Fudin, a pharmacist and advocate for pain patients.
“I think from a black market standpoint overall, you may see heroin use go up. We’ve already seen because of PDMPs (prescription drug monitoring programs), as we’re tracking drugs more closely, that heroin use went up because people that are trying to get these drugs can’t get it as readily as they could before. So if the same holds true and they can’t get hydrocodone, it’s one less thing that they can get their hands on. They may go to the street to get heroin because it’s relatively cheap.”
“What is it going to do to the black market? I’m not sure,” said John Burke, president of the National Association of Drug Diversion Investigators. “It’s obviously going to reduce the prescribing of it (hydrocodone). There’s some people (doctors) who are probably going to shy away from it is my guess, just because of the inherent fear of Schedule II and the fact that they can’t write for multiple refills or can’t call it in when they need to.”
For patients unwilling to use illicit drugs or turn to the black market, rescheduling could also mean more suicides, according to Webster.
“Without a doubt, in my view, if we are unable to provide adequate relief and treatment for people in pain that there will be an increase in suicides,” Webster said. “It’s an under-reported problem today. Certainly some of the opioid related deaths are people who took more medication than they should and die as a result, unintended or intended. It’s hard to know because they’re not here to tell us.”
The rescheduling will affect dozens of pain medications that contain hydrocodone (a complete list is available here). Typically in these products, the hydrocodone is combined with either acetaminophen or aspirin. Over 130 million prescriptions are written annually in the U.S. for hydrocodone products – making it the most commonly prescribed drug in the country.
Webster says it’s a “myth” that hydrocodone is abused more often than other opioid painkillers.
“Everyone knows that it’s the most common drug prescribed (for pain management). And yet there’s a myth that it is one of the most dangerous drugs. The truth is if you take a look at the harm that is caused by hydrocodone; it is one of the lowest, if not the lowest, of the Schedule II and above, relative to the amount prescribed,” he said.
Pain Patients Worried
Many patients worried about losing their access to hydrocodone wrote to National Pain Report about their concerns.
“The DEA needs to stay out of this! It really makes me angry that they keep making it harder and harder for pain patients to be treated. Saying chronic pain patients shouldn’t be treated with opiates, and then changing hydrocodone to a higher schedule just makes me so angry,” wrote Trudy Myers.
“I am a 62 year old woman in chronic pain from my back thru my hip down my leg and into my foot. If not for Vicodin taking the edge off every few hours I would not be here anymore because I live thru such pain every single day for 3 years,” said Marty. “All these changes in chronic pain patient’s medications will no doubt increase suicide in pain patients because without small amounts of pills to at least dull the pain a little, we have no life to live.”
“I have no insurance and being in Alabama I fall in the gap, too much income for state help and not enough to enroll in the plans offered by the healthcare law,” said Deborah. “Now I’ll have to pay out of pocket to see my doctor monthly. This will mean the money for these extra visits MUST come from somewhere and it will come from the food budget which is barely sustainable now. My family would be better off if I were dead.”
Millennium’s Passik says patients in rural areas may find it particularly hard to get pain relief when hydrocodone is rescheduled.
“What are rural patients going to do in the middle of the night when they have pain and they can’t get anything?” he asked.
“I’m very worried about the public health consequences of it. It’s not that I’m in favor or not. I think some of the intended effects are needed, but I’m worried about the unintended effects.”