When Medicine and Law Enforcement Mix, Patients Lose

The Drug Enforcement Agency (DEA) categorizes all drugs with the potential for abuse into 5 groups--Schedules I-V. Drugs in groups IV and V have little or no potential for addiction (although Valium is Schedule IV for some reason). Some can even be bought over the counter. Schedule III drugs have a moderate to low potential for physical and psychological dependence. This group currently includes Vicodin. Schedule II drugs have the highest addiction potential of all approved drugs. Percocet (oxycodone) and morphine are in this group. Schedule I drugs (e.g. heroin and LSD) have a very high potential for addiction and no accepted medical use in the US.

Last week, an FDA advisory panel recommended that hydrocodone, the narcotic component of Vicodin (the other component being Tylenol), should be reclassified as a Schedule II drug--a move designed to combat narcotic abuse. The vote was 19-to-10. In my opinion, all 29 got it wrong.

They certainly did get one thing right-- it never made much sense that Vicodin was restricted any more or less so than oxycodone (Percocet, OxyContin). The two are both synthetic derivatives of morphine and are very similar chemically and pharmacologically. Oxycodone is about 1.5-times more potent than hydrocodone.

Yet, somehow, 40 years ago, they were "separated." Hydrocodone was classified as a schedule III drug (less restricted) while oxycodone was put in the more restrictive schedule II category-- the most carefully controlled category of all prescription drugs. I just don't get it.

While Percocet and Vicodin are used more or less interchangeably, there is a real difference between these and other schedule II drugs, which include morphine and fentanyl--a synthetic opioid narcotic which is 100 times more potent than morphine.

So, putting oxycodone and hydrocodone in the same class makes sense, but should they both be more restricted or less? This is where medicine and law enforcement clash. I believe that whatever may be gained from making Vicodin harder to get pales by comparison to the harm it will do to those in need of sufficient pain management.

Further restrictions on Vicodin may or may not have an impact on narcotic abuse, but they will certainly have an impact on patients. The new classification means that doctors may no longer call or fax in a subscription, virtually guaranteeing that patients in need will face additional obstacles--a visit to the doctor being one of them. Nor will they be able to write refills for it. This will add days (weeks?) to the amount of time that those in severe pain will have to suffer needlessly, putting an especially high burden on the poor, elderly and people who live in areas where doctors are scarce.

Compounding this problem is the fact that--despite being in the 21st century--there is still no good way to control chronic pain. Every class of pain medications has its unique set of problems.

Tylenol (acetaminophen), a weak analgesic, won't touch anything more than mild-to-moderate pain. And it also has the serious disadvantage of having a low therapeutic index (the difference between the effective and toxic dose). As little as double the maximum daily dose of acetaminophen can be fatal. It is not uncommon for people who attempt suicide from taking large quantities of Vicodin to die from irreversible liver damage rather than the narcotic.

Non-steroidal anti-inflammatory drugs (NSAIDs) are better for pain management, but carry with them a whole different set of baggage--the potential for severe gastric toxicity (ulcers, bleeding). Even Celebrex--a novel NSAID designed to be easier on the stomach carries with it an increased risk of heart attacks.

Which leaves opioids (narcotics with properties similar to morphine). These are the heavy weapons of pain management, but they carry with them a host of problems--addiction, dependence, constipation, and central nervous system suppression, to name a few. But despite their deficiencies, opioids are the only option to control chronic, severe pain, which not only destroys one's quality of life, but can cause additional physical and psychological problems.

From the law enforcement point of view, I suppose it is possible that this restriction will make some difference in the magnitude of drug abuse in this country. But my guess is that addicts will do whatever is necessary to feed their addiction--even if it means turning to far more dangerous street drugs, such as heroin. I don't believe that this change will make a material difference--our longstanding, and abysmally unsuccessful "war on drugs" is evidence of this.

Doctors should practice medicine--not law enforcement. If they are running "pill mills" they should be tossed in jail. But the rest should not be prohibited from calling in a prescription for someone with a legitimate need, or writing refills for people with terminal cancer and intractable pain. Denying people in need of pain relief is barbaric. Leave the doctors out of this.

It is far more important to provide proper care to those in need than it is to try an easy fix for an eternal and probably unsolvable problem.

This is exactly why this regulation is misguided. You don't punish patients because of the illegal acts of others.

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