Our neverending focus on narcotics

The realities of this situation may not readily be resolved by good science, although it is important to acknowledge the lack of good science in this area.

To be fair to the DEA, the fact driving their interest in rescheduling hydrocodone to level II is the very substantial recent rise in abuse of prescription narcotics. No matter which numbers you track, and all have flaws, every single available statistic suggests substantial and possibly massive increases in the abuse of prescription pain medication in the past 3-10 years.

That fact justifies a careful response on the part of society, but it does not lead ineluctably to justifying the DEA’s intent to reschedule hydrocodone, given its positive uses on behalf of patients.

The obvious use for outpatient opiates is for pain control. The trial data is limited, but suggests outpatient opiates for noncancer pain do work to reduce pain and possibly to increase functioning. In at least one survey of >300 patients on opiates in outpatient pain clinics, >90% felt that their pain relief (which was generally moderate pain relief) really improved their overall quality of life and functioning. We would not want to stop the appropriate treatment of these patients.

Observational studies of pain control in these contexts leave it fairly unclear what percentage of carefully managed chronic pain patients actually develop true addictive problems. It is not even proven that carefully managed prescribing by doctors is the actual source of all the prescription drug abuse going on out there, ie it may be some totally careless doctors or pharmacy-level diversion that is at work. Putting pressure on all doctors to reduce prescribing of opiates may not reduce the amount of abuse going on at all, but it may result in loss of access to pain medicine for patients who do have pain.

In one study I have seen presented, if one simply counts the percentage of patients who take their opiates perfectly and exactly as the doctor prescribed without ever losing a prescription, taking an extra pill, etc. it is about 55% (ie the same percentage who take antihypertensives exactly as prescribed). The misbehaviors of the remaining 45% include some who probably are engaging in addictive or abusive behaviors, and many whose behavior is “not quite right” but probably not a sign of abuse, ie taking an extra pill from time to time. The best clinical teaching I have seen on this issue advocates the use of close monitoring and follow-up by physicians, along with the development of information networks that would help physicians check up on on their own patients to sort out if any are obtaining prescriptions from multiple sources, There is little data to prove the value of these practices but they seem sensible to me until we have data.

Rescheduling the drugs may induce many doctors to stop prescribing pain meds where they are needed.I would favor education of physicians and the availability of systems to help physicians identify doctor-shoppers, etc. as opposed to generalized inducements not to prescribe pain medication. I believe rescheduling to Schedule II may be unhelpful to patients who have pain.

This rescheduling could also have the unintended consequence of increasing Schedule II medication prescription. In Texas, any med above Schedule III needs a government issued prescription, with a state monopoly on printing and distribution, and some reasonably restrictive rules about keeping copies, etc.

So, my choice for my patient with a broken arm is Tylenol #3 (acetaminophen with 30mg of codeine, a study-proven dog of a pain killer), or filling out a special order form for my patient with acute pain.

Here’s where this backfires: if I’m going to the trouble of getting and filling out the state prescription, why not give percocet, which is a better pain med, and is still Schedule II? I’m giving even better pain meds that I’ve been avoiding due to, mainly, the paperwork and oversight hassels, but this could compell me to get the State prescriptions and start using them.

The Law of Unintended Consequences awaits another government regulation.

(Cross posted on my blog).

Personnaly, I take Vicodin, but avoid it whenever possible. It’s great when my backpain feels like half a kidney stone, but too annoying when the pain is less. This month I’ve taken it once; last month probably 10 times. Is there some reason that we can’t trust most folks to know when they hurt?