family practice issues and general life events

Archive for February, 2013

Why the FDA/DEA ruling on Vicodin may not matter

Several weeks ago, the FDA made a move to re-examine whether Vicodin (hydrocodone) should be moved from a schedule 3 narcotic to a schedule 2.  This was looked at in 2008, but decided that it would not be done.  However, since Vicodin is currently the most written prescription in the United States and it is one of the most overdosed drugs/medications they decided to take another look at the issue.

 

To begin with, a brief lesson in classification of what schedules are in the DEA.  The DEA uses a 5 classification schedule for narcotics.  Medications such as antibiotics, blood pressure medications, and other medications are not on this list and are not considered scheduled.  If you have a medical license (or NP or PA) you are allowed to prescribe these medications.  No authority or licensing from either your state or federal DEA agency are required.

Schedule 5 medications are considered to have the least potential for abuse.  Most of the cough syrups are in this group.  They are used for a limited amount of time and there is very limited amount of drug in the prescription.

Schedule 4 narcotics are considered slightly more addictive, but not as much.  This includes the muscle relaxer Soma, and the benzodiazepines (Though I would argue these are terribly addictive, this is based on the DEA DOJ site.)  Also recently added is the medication tramodol.  Lyrica, a medication for nerve pain also falls on this list.

Schedule 3 narcotics is where Vicodin and the other hydrocodone products fall.  This group also includes anabolic steroids like Testosterone, diet pills (Didrex and Phentermine), some tylenol with Codeine products, ketamine and Suboxone (bupropriene)  These are more addictive than schedule 4, but can currently be called in, and technically refills can be given, but many providers are not due to issues I will discuss later.

Schedule 2- the category they are looking to move Vicodin and other hydrocodone products.  This group is considered to have a high potential for addiction.  A monthly visit and hard script (in most states) is required.  There has been some change in federal law allowing for E-prescribing, but many states have not converted, and those that have, few if any pharmacies meet the criteria to e-prescribe.  This group contains the Oxycodone, morphine, dilaudid, methadone, and demerol.  It also contains most of the ADHD stimulants ritalin, adderall, vyvanse, etc.  This group also contains phenobarbital.

Schedule 1 is considered to have no medicinal benefit.  They are considered to have a high potential for abuse.  This group contains LSD, ecstasy, marijuana (this is not for argument, but how classified) and peyote.

So now with that description of schedules, I will discuss why changing may not matter.  

I write pain medications.  I never wanted to be a pain doctor, but there are limited avenues to get pain management in the area.  And half the time when I do, if they patient is not willing to do procedures the pain doctor refuses to see them.  So there is that problem.

I know the potential for addiction, in fact, looking at new guidelines coming in the near future for licensure, prescribing vicodin (hydrocodone) probably won’t be done without a monthly visit.  In fact, few if any of my patients on chronic pain medications get to go over a month without seeing me.

Currently, if you are writing the medications, pain contracts are to be in place.  My contract also includes those for benzodiazepines and ADHD medications.  I have enough forms that I believe in consolidating them whenever possible.  Additionally, those that write them frequently are expected to drug screen randomly or whenever suspected occurring at least every 3 months or as close to as possible.  And you should have a documented pain scale.  Sadly this pain scale means little, but I have it on the chart.  Patient are smiling saying they have a 10 out of 10 pain, while the little old arthritic grandmother says her pain is a 4, when it looks so painful I want to cry.

And I look for causes of pain.  Unfortunately I am being told that I write both too much and too little pain medication, and in doing both I am not doing a good job.  I am the reason for people to have too severe of pain, and I am the reason that the casino down the road is full of business due to my patients selling their pills despite the best stops I can put in place.  The states narcotic board wants me to be a cop, and the rest are yelling about patient confidentiality.  And for those that are addicts that want help, there is neither the facilities in the area nor the payers to pay for the rehab.  And sorry if I don’t think that I went to medical school to become a cop, nor do I think most addict benefit from jail.

Many have argued that the moving the vicodin to schedule 2 will not improve the recreational use of the drug, and will only result in those with legitimate cause of pain having more pain with greater difficulty for help.  While I don’t necessarily disagree with this assessment, I think the other problems with the system actually make this almost moot.  

Licensure and boards are discussing the introduction of requiring six to ten hours a year in narcotics prescription courses.  While I am all for education, new requirements for board certifications and malpractice and other issues have recently been implemented.  And for those specialists who write pain medications for a week or two after surgery will decide to then fall back to the primary physician writing the medication.  Because who wants the headaches.  

And in the end, none of this will really work anyway.  Studies after studies show that the more difficult you make a drug to get, the sooner the next black market drug will appear.  The drug ban on marijuana has helped to lead to the rise in methamphetamine and Mexican cartels into the inner cities.  

The physician is not a cop.  They are already overloaded with paperwork and government regulations.  Most of my patients on hydrocodone, well I already see them monthly, and those that don’t, well my nurses are talking to them once a month prior to filling their medications.  This law, while I don’t think it makes sense, it won’t make that much of a difference in the long run, not when all the other regulations are considered.  It is time to stop trying to make the physician a cop, and instead give tools to help with addiction and help the patient actually return to functional.

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