Hydrocodone Rescheduling: Why It Won't Help

We saw this one coming. Lately there has been a lot of attention (and rightly so) on our drug addiction and overdose problem here in the United States. In particular, the role of hydrocodone as one of the most frequently prescribed narcotics and frequently implicated drugs of abuse has led the Drug Enforcement Administration (DEA) to move hydrocodone combination products to the more restrictive category of Schedule II.

This means no more phoning in prescriptions. This means no more refills. This means no more estimating of inventory counts, but rather a tablet-by-tablet perpetual record of each and every unit we sell.

Finally…our drug trafficking and addiction problem in the United States is solved. Right?

No. Not even close.

Clinically, some argument could be made that hydrocodone is metabolized to the more potent hydromorphone, so therefore it should be Schedule II. But when we dig deeper into the clinical and biochemical picture, we discover that this conversion is limited, and variable. Some people can’t convert it at all. And even those who do have only a small percentage of the original dose converted to the hydromorphone metabolite. It’s a stretch to say the least.

But even if that argument could be made (and I doubt it could), the really big push for making this move has been predominantly carried by those who insist it will help decrease our nation’s drug abuse and overdose problem. But the problem with that statement is that it is wrong. It won’t. It can’t. And I will tell you why.

First, it won’t help because the drug itself is not the problem. To quote from Karch’s Pathology of Drug Abuse, 3rd edition, “When hydrocodone overdose is reported, it is almost always co-ingested with other drugs” (page 372). In other words, the overdose problem is not truly “accidental”; rather, it is the deliberate attempt by individuals to abuse this drug and get high by mixing it with other drugs.

But secondly, and most importantly, changing the schedule of a controlled substance does NOTHING in and of itself to reduce demand by addicts or diminish the financial rewards for those who sell it. And THAT is the primary source of our nation’s epidemic. We need to be honest with ourselves and the public. Our drug trafficking problem is not driven by people who don’t know enough, it is primarily driven by people who don’t care enough.

Take, for example, the drug dealer. Is he put off by the rescheduling of hydrocodone combinations to CII status? No, of course he is not. Is he going to pack up his business and call it quits now that this drug is just a little harder to get? Don’t be silly. More likely, he’ll just raise his price a bit, that’s all.

Or consider the pill-mill prescriber. Is he going to close the doors on his shady little pain clinic and go back into practicing real medicine (if he even remembers how)? Is he going to give up his expensive car and home and vacations because he now has to write a few more prescriptions, rather than just phoning them in? Absurd. He’ll keep on writing, and they will keep on coming.

Or what about the rogue unethical pharmacist: Is she going to give up her big juicy profit margins on all those cash (albeit fake) prescriptions for hydrocodone combos that are phoned in? Will she start checking the PMP program & patient IDs more and turn away addicts who shop multiple pharmacies? Nope. She’s got bills to pay and luxuries to enjoy.

Or what about all the Medicaid-abusing, doctor-hopping addicts? Will they stop gaming the Medicaid system, hopping back and forth between a handful of hospital emergency departments, complaining of pain when all they really want is another prescription they can sell? I don’t buy it.

Or what about the desperate thug who jumps the counter at the local pharmacy, threatening to kill (and sometimes killing) anyone who interferes with his request for drugs? Will he be put off by the new rescheduling? Keep dreaming.

You’ll never solve any problem until you’re honest about it. Our drug abuse, addiction, and trafficking problem in our country is out of control. But rescheduling hydrocodone combinations is simply like rearranging the deck chairs on a sinking ship. The problem is not, ultimately, the drug itself. The problem is the people supplying it, dealing it, and abusing it. This move only inconveniences patients who truly need it for their chronic pain, and prescribers who are managing such patients appropriately.