October 6, 2015 marks the one year anniversary of hydrocodone becoming a schedule II drug with more restrictive access.
The final rule was issued by the Drug Enforcement Administration to deter abuse. The CDC had cited a dramatic increase in opioid prescription related deaths (1). Since 1999, analgesics prescriptions and sales in the United States had almost quadrupled, with the most common drugs being: hydrocodone, oxycodone, oxymorphone, and methadone. In 2013, nearly 2 million Americans abused prescription painkillers with greater than 16,000 deaths annually related to overdose. About 7000 people each day are treated in emergency departments for adverse events related to these drugs. Under the new ruling, physicians are required to comply with Schedule II regulations-- this means: no refills, no phone-ins, and no faxes (except in rare, "emergency" settings).
So, has life been better under these new rules?
With the new ruling, certainly, I have seen greater reluctance among my colleagues to write prescriptions for hydrocodone. Many patients were switched to tramadol (which has seizure risks and potential to interact with selective serotonin reuptake inhibitors to cause serotonin syndrome), Tylenol #3 (which has limited efficacy), or higher doses of nonsteroidal anti-inflammatory drugs (NSAIDS) that increase GI and renal risks for our rheumatic disease patients. I have given up altogether on writing hydrocodone due to the time commitment involved with random urine toxicology screens and looking on the state website prescription drug monitoring program (PDMP). For those who are not familiar with PDMPs, these are state-sponsored programs to help providers see what controlled substances patients have been prescribed and when/where they were filled—a great resource to track narcotic use and determine if a patient has been abusing their prescriptions.
How did the new ruling do? The amount of hydrocodone prescriptions dropped from 129.5 million to 119.2 million. Do we congratulate ourselves?
According to several news sites, many patients have had difficulties finding doctors willing to prescribe hydrocodone or pharmacies willing to fill valid prescriptions (2). Many pain patients had suicidal thoughts after being denied a prescription; others found the rescheduling detrimental to the patient-doctor relationship. Heroin deaths have risen, quadrupling in 2011-2013. According to CDC director, Dr. Tom Frieden, "What's most striking and troubling is that we're seeing heroin diffusing throughout society to groups that it hasn't touched before." The reason for this is simple: prescription opioids are harder to obtain. Heroin is five times cheaper than hydrocodone sold on the street. Heroin users say after they become addicted to prescription drugs during legitimate use for a medical issue, they will turn to heroin after they can no longer access the prescription narcotic. It would not be surprising if heroin-related death rates are even higher for 2014-2015. The White House had responded to the rise in heroin trafficking, abuse, and deaths. On August 17, 2015, the Office of National Drug Control Policy will provide $2.5 million to emphasize drug treatment rather than prosecution of addicts. In addition, the plan is to pair law enforcement officials with public health care workers to address the causes of the problem.
I applaud the government's move to try to deal with the problem of addiction in limiting hydrocodone access and addressing heroin abuse, but I still feel unsettled by the fact that many patients are left to find alternatives to a medicine that has helped them. Perhaps better provider education on pain management may help stem the tide of abuse.