Drug and Alcohol News (JoinTogether.com)
A new study dispels the myth that the most frequent users of hospital emergency rooms are people with mental illness and substance use disorders. This population accounts for only a small percentage of visits, the researchers found.
The study looked at emergency room visits made by more than 212,000 Medicaid patients in New York City since 2007, HealthDay reports. The researchers found patients who frequently use the ER tend to have multiple chronic health conditions and many hospitalizations.
“Urban legend has often characterized frequent emergency department patients as mentally ill substance users who are a costly drain on the health care system and who contribute to emergency department (ED) overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere,” the researchers wrote in the journal Health Affairs. “This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients’ total Medicaid costs.”
Four U.S. senators told the Commissioner of the Food and Drug Administration (FDA) they disagree with the agency’s decision to approve a pure version of the painkiller hydrocodone, Newsday reports.
Senators Kirsten Gillibrand of New York, Dianne Feinstein of California, Amy Klobuchar of Minnesota and Joe Manchin of West Virginia, wrote to FDA Commissioner Margaret Hamburg that the decision “will only contribute to the rising toll of addiction and death” caused by the prescription drug epidemic.
In October, the FDA approved the first pure hydrocodone drug in the United States. The drug, Zohydro ER (extended release), was approved for patients with pain that requires daily, around-the-clock, long-term treatment that cannot be treated with other drugs. Drugs such as Vicodin contain a combination of hydrocodone and other painkillers such as acetaminophen.
In December, a panel of experts assembled by the FDA voted against recommending approval of Zohydro ER. The panel cited concerns over the potential for addiction. In the 11-2 vote against approval, the panel said that while the drug’s maker, Zogenix, had met narrow targets for safety and efficacy, the painkiller could be used by people addicted to other opioids, including oxycodone.
The agency will require postmarketing studies of Zohydro ER to evaluate the known serious risks of misuse, abuse, increased sensitivity to pain, addiction, overdose, and death associated with long-term use beyond 12 weeks.
Zohydro is designed to be released over time, and can be crushed and snorted by people seeking a strong, quick high. The opioid drug OxyContin has been reformulated to make it harder to crush or dissolve, but Zohydro does not include similar tamper-resistant features, the newspaper notes. The senators said it was irresponsible of the FDA to approve Zohydro without similar safeguards.
In an email to the newspaper, FDA spokesman Morgan Liscinsky said “abuse-deterrent formulations” are not available for some extended-release painkillers.
The operator of the new Silk Road website, which sells illegal drugs, says he has distributed encrypted portions of the site’s source code to 500 locations in 17 countries. He claims this will allow the site to be relaunched immediately if law enforcement shuts it down again.
The Federal Bureau of Investigation shut down Silk Road in October, and arrested the operator in San Francisco on narcotics and money-laundering charges. Silk Road could only be accessed by using encryption software called Tor, which shields computers’ IP addresses, allowing people to make purchases anonymously. Silk Road facilitated more than $30 million in sales annually. It had been online since February 2011.
In November, a new online marketplace that sells illegal drugs opened. It also calls itself Silk Road. The new website looks the same as the shuttered Silk Road. It lists hundreds of ads for drugs including marijuana, cocaine and Ecstasy, and uses bitcoins, the anonymous digital currency used by the old site.
The new site says it includes measures to keep users from losing bitcoins if the site shuts down. Like the old site, the new Silk Road can only be accessed by using Tor encryption software.
Last week, the new Silk Road operator said the new backup scheme also includes distributing portions of the site’s cryptographic keys, to decrypt pieces of the site’s source code, to locations around the globe. According to Forbes, “the backup system may be a first step towards a decentralized system without a single point of failure for law enforcement to attack.”
Men who continue to smoke after they have received a diagnosis of cancer are more likely to die than those who find out they have cancer and quit smoking, according to a new study.
The findings come from a study of Chinese men, ages 45 to 64. Men who smoked after receiving a cancer diagnosis had a 59 percent higher risk of death from all causes, compared with men who did not smoke after receiving a diagnosis of cancer, HealthDay reports.
The risk of death among men who continued to smoke was 2.95-fold higher for men with bladder cancer, 2.36-fold higher for lung cancer, and 2.31-fold higher for colorectal cancer, compared with men who quit smoking after their diagnosis.
The findings are published in the journal Cancer Epidemiology, Biomarkers & Prevention.
“Many cancer patients and their health care providers assume that it is not worth the effort to stop smoking at a time when the damage from smoking has already been done, considering these patients have been diagnosed with cancer,” study author Dr. Li Tao of the Cancer Prevention Institute of California, said in a journal news release. “Our study provides evidence of the impact of postdiagnosis smoking on survival after cancer, and assists in addressing the critical issue of tobacco control in cancer survivorship.”
Tao said only a small percentage of cancer patients who are smokers when they are diagnosed with cancer receive formal smoking cessation counseling from their doctor, and less than half of these patients eventually quit smoking after their diagnosis.
Medication-Assisted Treatment (MAT) for opioid dependence is a science-based and proven-effective option for teens and young adults. It should be administered with age appropriate psychosocial therapy and drug testing. Unfortunately, it has been subject to controversy and stigma. Yet the neuroscience of addiction and cravings helps explain why MAT, when properly used and overseen, can be truly life saving for adolescents, young adults, and their families. I see it working all the time. When kids come into treatment, their lives are just chaotic. Parents are desperate — they don’t know what to do or where to turn. The most important thing is to bring stability into the situation, and the best way to do that is with medication.
The scientific evidence is incontrovertible: addiction is a brain disease – and can be especially severe when substance abuse starts early in life. Since the brain continues to grow and develop through the twenties, it’s very vulnerable to the effects of any exogenous substance. Early drug use makes almost permanent changes to both the structure and function of the brain, which has profound implications for the rest of a person’s life.
A parent bringing their child into treatment wants to maximize the chance that the child can abstain from the drug so the brain can heal and preclude the lifelong struggles of adult addiction. Scientific studies show that psychosocial treatments alone (i.e. without medication) show relatively poor results. Part of the reason has to do with cravings. Here’s why.
When a person takes a drug, the brain feels an enormous “high” in the reward system. It then implants a memory in the limbic system — the “lizard brain” — where memories of pleasures such as food and sex are stored. Anything having to do with procuring or using the drug becomes part of the memory and can produce a craving years later, even if a person hasn’t used the drug. The “trigger” could be a happy event, sadness, or seeing a syringe or some white powder or smelling an alcohol wipe. All of a sudden that memory flooding in generates an enormous craving to use the drug again.
One of the medications used in treatment, buprenorphine, is a partial agonist of the brain’s opiate receptors: when it “locks in”, it both eliminates cravings and blocks the “high” should someone inject heroin or take an opioid painkiller. As a partial agonist, buprenorphine has advantages over methadone, a full agonist, whose side-effects can include sleepiness, shallow breathing, or even death.
Studies suggest that over 60 percent of people on buprenorphine therapy have very positive outcomes. In our highly-structured program at Boston Children’s Hospital about a third of the children remain completely free from any alcohol and drug use. About another third remain free from opioid use but they might have an occasional slip on alcohol or marijuana. (We tend to not approve of that behavior and keep working with them). And the remaining third, particularly early on, will try opioids once or twice. But even after those early slips they show dramatic improvement over time.
In my 30-plus years as a pediatrician, I’ve always believed that the best treatment occurs in the least restrictive environment. Therefore our clinical program is outpatient-based. These children are living at home, and their parents are an integral part of the treatment team. We empower parents to supervise the prescription-taking, and both adolescents and parents participate in a 13-week education and support group.
As far as stigma, it breaks my heart when kids hear that “You’re not really clean and sober. Buprenorphine is just a substitute addiction.” I tell them, “Listen, you’re on replacement therapy. It does not make you high. It stabilizes your brain cells until they can recover. Please give it a year. Then we can talk about tapering off. OK?”
My advice to parents and teens is: check out medication in a reputable program. It could make the big difference in helping your child turn the corner and find sobriety. Over time medication can be tapered down. Does it always work? No. Are there accounts of abuse and unscrupulous practices? Unfortunately yes, and they must be investigated. But these negatives don’t negate MAT’s lifesaving value in helping treat the disease of addiction.
If someone says, “Well your child isn’t really clean,” walk away because those people just don’t know. The folks disseminating this misinformation are really doing a disservice because if we dissuade families from using this life-saving therapy we’re going to lose kids. We have to remember the tragedies: when kids are taken off or deprived of this medication they can die. And we don’t have any teens to spare. Not one. I’m not willing to see any more needless deaths.
John R. Knight, MD with Melissa M. Weiksnar
John Knight, MD, is a leading pediatrician at Harvard Medical School, specializing in the diagnosis and treatment of adolescent substance abuse. He is the Director of the Center for Adolescent Substance Abuse Research at Children’s Hospital Boston, and a nationally recognized advocate for families’ involvement in adolescent addiction treatment.
Melissa Weiksnar is a Program Coordinator at the Center for Adolescent Substance Abuse Research (CeASAR) at Boston Children’s Hospital. She is a also a writer, speaker, and advocate for substance abuse prevention and treatment. She earned an S.B. in Economics from MIT and an MBA from Harvard.
PHOTO CREDIT: Courtesy of Anders Brun and colleagues, Neuroimaging Research Center, McLean Hospital, Belmont, MA. ©Copyright Anders Brun/McLean Hospital 2013. All rights reserved.
States that have enacted more alcohol- and traffic-related laws have a lower proportion of traffic deaths, compared with states with fewer such laws, a new study indicates. Researchers say encouraging states to adopt more of these laws could significantly reduce preventable traffic-related deaths in the United States, especially among young people.
Researchers at New York University analyzed 27 types of state laws, including mandatory fines for DUI violations, beer taxes and child restraint laws. They examined the relationship between the proportion of the 27 laws that states adopted, and the number of deaths that resulted from traffic accidents. They found that being in the top 25 percent of laws passed was associated with a 14.5 percent decrease in traffic death rates, compared with being in the bottom 25 percent, according to News-Medical.net.
The study is published in the journal Public Health.
“Lagging behind in adopting the full range of the laws is not a theoretical concern—more people are dying as a result,” study co-author Diana Silver said in a news release. “Policymakers and advocates should focus attention on states where such protections are the weakest and bring them up to speed.”
A study of more than one million Swedish men finds those who had an alcohol use disorder in their late teens had a higher risk of heart disease over the next two decades than those without a drinking problem. Later hospitalization for substance use disorders was also associated with a higher heart disease risk.
The researchers found mental illness, including depression and schizophrenia, also was linked with an increased risk of heart disease, The Huffington Post reports.
“Our findings suggest that mental disorders pose a huge public health burden in terms of premature illness and death due to coronary heart disease,” study author Catharine Gale of the universities of Edinburgh and Southampton, said in a news release. “The physical health care of people with mental disorders needs to be a priority for clinicians if this burden is to be reduced.”
The men entered the study at an average age of 18, and were followed over a 22.6-year period. Those at highest risk for heart disease tended to be men whose mental conditions required hospital admission.
The findings appear in the journal Circulation.
A new study finds the use of e-cigarettes among teens is associated with heavier use of regular cigarettes. The researchers say their findings suggest that the devices are creating a new pathway for youth to become addicted to nicotine.
Researchers at the University of California, San Francisco, studied 75,000 South Korean teenagers. They found four out of five teens who use e-cigarettes also smoke tobacco cigarettes, according to the San Francisco Chronicle. Young e-cigarette smokers were more likely to have tried to quit smoking, which the researchers say suggests that some teens may be using e-cigarettes to try to quit smoking regular cigarettes.
“Use of e-cigarettes is associated with heavier use of conventional cigarettes, which raises the likelihood that actual use of e-cigarettes may increase harm by creating a new pathway for youth to become addicted to nicotine and by reducing the odds that an adolescent will stop smoking conventional cigarettes,” the researchers wrote in the Journal of Adolescent Health.
“We are witnessing the beginning of a new phase of the nicotine epidemic and a new route to nicotine addiction for kids,” study senior author Stanton A. Glantz, PhD, said in a news release. “Our paper raises serious concern about the effects of the Wild West marketing of e-cigarettes on youth.”
About 100 families of children with seizures have come to Colorado to gain access to a marijuana-based oil to treat their children, The New York Times reports. The children are being treated with the largely untested oil, which is considered legal in the state.
The families call themselves “marijuana refugees,” the article notes. They come from a range of religious and political backgrounds, from across the country. They have been drawn to Colorado by a marijuana oil called Charlotte’s Web, made by a medical marijuana dispensary in Colorado Springs. In order to obtain the product, they must have certifications from two doctors who practice in the state.
According to Joel Stanley, one of five brothers who run the dispensary, Charlotte’s Web is low in THC, the ingredient in marijuana that produces a high. He says the oil contains a large amount of a cannabidiol, a chemical that does not produce a high, but which medical researchers and marijuana advocates say has medical uses.
A month’s supply of Charlotte’s Web can cost $150 to $200. Some families say they are receiving financial help from a nonprofit group that is related to the dispensary.
There is limited medical research about the effectiveness of cannabidiol in treating seizures. Studies have suggested it can prevent spasms in lab animals. A study conducted by Dr. Margaret Gedde, a Colorado doctor who has recommended medical marijuana to dozens of families with severely epileptic children, found of 11 families who treated their children with high-cannabidiol oil, eight reported that their children’s seizures had been reduced by 98 to 100 percent. The other families said they saw smaller but noticeable decreases in seizures.
The study will be presented next week at a meeting of the American Epilepsy Society.
Large amounts of designer drugs are being imported into the United States legally, CBS News reports.
The drugs include synthetic marijuana, known as Spice. Drug Enforcement Administration Special Agent Doug Coleman says China is the main source of these drugs. CBS News found a Chinese manufacturer online that sells chemical compounds. The company offered to ship two pounds of synthetic marijuana for $2,500.
While Spice and several other synthetic drugs were outlawed by the federal government last year, chemists have been evading the law by continually coming up with chemical compounds that are slightly different from the ones that have been banned. Coleman says U.S. Customs authorities cannot stop imports of compounds that are still legal.
“It’s like whack a mole,” he told CBS News. “They pop their head up, we hit them, they go down and then they pop their head up in another spot. It’s always a cat-and-mouse game. This is just a more advanced type of cat-and-mouse because now we’ve got chemists manufacturing synthetic drugs as opposed to cartel members trafficking heroin, or coke, or methamphetamine.”
Another synthetic drug that has been growing in popularity is Molly, or Ecstasy. Emergency room visits related to Molly rose 128 percent among people younger than 21 between 2005 and 2011, according to a new government report.
Cigarette graphic warning labels could reduce the number of smokers in the United States by as much as 8.6 million people, saving millions of lives, according to a new study.
The study looked at the effect of the labels on smokers in Canada, and found they resulted in a 2.9 to 4.7 percentage point drop in smoking rates between 2000 and 2009. In the United States, a similar decrease would result in between 5.3 million and 8.6 million fewer smokers, HealthDay reports.
The study was conducted by the International Tobacco Control Policy Evaluation Project, a collaboration of more than 100 tobacco-control researchers and experts from 22 countries.
“These findings are important for the ongoing initiative to introduce graphic warnings in the United States,” study lead author Jidong Huang of the University of Illinois at Chicago, said in a news release. The study is published in the journal Tobacco Control.
Cigarette warning labels have been implemented in more than 40 countries, but not in the United States, the article notes.
In April, the U.S. Supreme Court rejected a challenge by the tobacco industry to a federal law requiring that cigarette packages carry graphic warning labels. Tobacco companies argued parts of the law violated their constitutional rights to free speech. The labels include graphic images of the consequences of smoking, including diseased lungs and rotting teeth. The cigarette labels are a result of the 2009 Family Smoking Prevention and Tobacco Control Act, which gave the Food and Drug Administration authority to regulate the content, marketing and sale of tobacco products. It could take years for the new warning labels to appear on cigarette packages.
Slightly less than 1 percent of anesthesiology residents in the United States have a substance use disorder, according to a new study. The incidence of substance use has been increasing, and relapse rates are not improving, the researchers said.
The study followed 45,000 anesthesiology residents who began their training between 1975 and 2009, HealthDay reports. They found the overall rate of substance abuse was 0.86 percent. Rates were higher at the beginning of the study, and decreased between 1996 and 2002. They began rising again in 2003.
Twenty-eight anesthesiology residents died due to substance abuse during the study period. Among others who abused substances, 43 percent had at least one relapse over the following 30 years, and 11 percent died from a substance use disorder. The most commonly abused substances were intravenous opioids, alcohol, marijuana, cocaine and anesthetics/hypnotics.
The findings are published in the Journal of the American Medical Association.
Drinking alcohol with an energy drink is more dangerous than drinking alcohol alone, according to a new study.
Researchers found college students tended to drink more heavily, and become more intoxicated, on days they used both energy drinks and alcohol, compared with days when they only drank alcohol, according to Science Daily.
The study included 652 college students, who answered questions about their consumption of energy drinks and alcohol during four two-week periods. They also explained any negative consequences they experienced from consuming both products.
Energy drink manufacturers in the United States are no longer allowed to make high-caffeine drinks with alcohol, but young people are mixing their own drinks, such as combining Red Bull and Jägermeister liquor.
The researchers warn that drinking alcohol with energy drinks pose physical risks, such as blacking out and alcohol poisoning. The trend also exposes the community to young adults who are “wide awake drunk” after a night of drinking.
The study appears in the Journal of Adolescent Health.
“Our findings suggest that the use of energy drinks and alcohol together may lead to heavier drinking and more serious alcohol-related problems,” Megan Patrick of the University of Michigan Institute for Social Research said in a news release. “As energy drinks become more and more popular, we should think about prevention strategies for reducing the negative consequences of using energy drinks and of combining energy drinks with alcohol.”
A study published last year found combining caffeinated energy drinks with alcohol can lead to risky sex for college students. The study of 648 students, published in the Journal of Caffeine Research, found 29 percent of sexually active participants said they had alcohol mixed with energy drinks in the past month. During their most recent sexual encounter, about 45 percent had a casual partner, 44 percent said they did not use a condom, and 25 said they were drunk.
Emergency room visits related to Molly, or Ecstasy, rose 128 percent among people younger than 21 between 2005 and 2011, according to a new government report.
The number of visits by young people to U.S. emergency rooms for complications from Molly increased from 4,460 to 10,176, CBS News reports. “I think people are looking for the ultimate and safe high they can achieve,” said Dr. Robert Glatter, an emergency room physician at Lenox Hill Hospital in New York. “There’s a mistaken belief that this is a safe drug with little toxicity.”
The drug, also known as MDMA, is usually taken in pill or powder form. It is sometimes mixed with substances such as cocaine, heroin or ketamine, the article notes. Glatter warned the drug can be even more dangerous if it is mixed with alcohol. “There’s a greater potential effect of toxicity,” he added. “Patients want to combine the two substances and have a greater effect that in and of itself is much more dangerous considerably.”
According to the Substance Abuse and Mental Health Services Administration, which released the report, Molly can produce a variety of undesirable health effects such as anxiety and confusion, which can last one week or longer after using the drug. Other serious health risks associated include becoming dangerously overheated, high blood pressure, and kidney and heart failure.
“This should be a wake-up call to everyone, but the problem is much bigger than what the data show,” said Steve Pasierb, president and CEO of The Partnership at Drugfree.org. “These are only the cases that roll into the emergency rooms. It’s just the tip of the iceberg.”
A new government report finds about 6 percent of U.S. teens say they use a psychiatric medicine as drug therapy, similar to the rate 10 years ago.
Boys are more likely than girls to be prescribed stimulants such as Ritalin for attention deficit hyperactivity disorder (ADHD), while girls are more likely to be given antidepressants, Bloomberg reports. ADHD drugs and antidepressants were the most commonly prescribed medicines for teens between 2005 and 2010, according to the report by the Centers for Disease Control and Prevention.
A survey of teens conducted between 1988 and 1994 found 1 percent of teens were prescribed psychiatric medications. A decade later, 6.8 percent of teens reported using psychiatric drugs to treat a mental health condition, a rate that has held steady since, according to Bruce Jonas, an author of the new study.
He noted prescriptions for psychiatric drugs may have risen because of an increased awareness of mental illness among teens, and the availability of new treatments for depression and ADHD.
The new survey found about half of teens who reported using psychiatric drugs had seen a mental health professional in the past year. Most of the teens surveyed said they were taking no more than one psychiatric drug.
The findings are published in a National Center for Health Statistics Data Brief.
A study of opioid-dependent patients entering drug-treatment programs across the country finds oxycodone is the most popular prescription opioid to abuse because of the quality of the high the drug produces.
Overall, 75 percent of people who abuse prescription opioids use either oxycodone or hydrocodone, Science Daily reports. The study of 3,520 people who abused opioids found 44.7 percent of patients preferred oxycodone, while 29.4 percent preferred hydrocodone. Ninety percent said they used opioids to alter their mood, while 50 of oxycodone users and 60 percent of those using hydrocodone said they also used the drugs to treat pain.
The findings are published in the journal Pain.
“The data show that hydrocodone is popular because it is relatively inexpensive, easily accessible through physicians, friends, and families, and is perceived as relatively safe to use, particularly by risk-averse users,” researcher Theodore J. Cicero, PhD, of the Department of Psychiatry at Washington University in St. Louis, said in a news release. “This group includes generally risk-averse women, elderly people, non-injectors, and those who prefer safer modes of acquisition than dealers, such as doctors, friends, or family members. In contrast, we found that oxycodone is much more attractive to risk-tolerant young male users who prefer to inject or snort their drugs to get high and are willing to use riskier forms of diversion despite paying twice as much for oxycodone than hydrocodone.”
The researchers noted people who abuse oxycodone are more likely to tamper with the drug in order to inhale or inject it, compared with those who use hydrocodone. While the introduction of an abuse-deterrent formulation of OxyContin in 2010 led to a significant decrease in abuse of the drug, oxycodone products remain more popular than hydrocodone products among people who abuse opioids, they said.
Employers in Colorado and Washington state, where recreational marijuana is now legal for adults, are wrestling with whether and how to adjust their drug policies to account for the new laws.
Legal questions facing employers include whether they can still fire workers who test positive for marijuana during a random drug test. Other questions include whether some types of workers, such as teachers, public transit drivers and police officers, can be held to a stricter standard than other workers, and how much discretion employers will have over what to do about employees who smoke marijuana while they are not at work.
Marijuana remains illegal under federal law.
“Employers big and small across the state are really struggling with these questions,” Danielle Durban, a Denver-based employment attorney at Fisher & Phillips LLP, told The Christian Science Monitor. “They have to come up with testing protocols that don’t alienate their own employees but cover themselves from liability, as well. Most are wishing legislators had given them more direction.”
Two court cases have addressed these issues. The Colorado Court of Appeals in April upheld the firing of a man who is a quadriplegic for his use of medical marijuana off the job. The court said that because marijuana is illegal under federal law, employees do not have protection to use it at any time.
A federal district court in August ruled an employee could be fired after testing positive for marijuana, even though the employee said he had never used the drug on company premises, and had never been under the influence of marijuana while at work.
A poll released in November found 64 percent of Americans say it is unacceptable for a company to fire employees for using marijuana during their free time in states where the drug has been legalized.
What’s in a (drug) name? The now-popular party drug named “Molly” sounds friendly and safe, and young people know that the name is supposed to refer to the pure crystalline powder form of 3,4-methylenedioxy-N-methylamphetamine or MDMA—what used to be taken in pill form as Ecstasy. But many are learning the hard way that, despite appearances, Molly is often not what it seems, and this version of MDMA is no more pure, safe, or innocent than its previous incarnation.
The first national Meth Awareness Week is being observed November 30 through December 7 in an effort to combat the abuse and use of methamphetamine. Coordinated by the Meth Project, which aims to significantly reduce meth use through public service messaging, public policy and community outreach, the week will kick off with provocative creative and social content dramatizing the dangerous and devastating effects of meth.
Last June, I testified before a Reference Committee at the annual meeting of the American Medical Association, explaining a resolution that American Society of Addiction Medicine had brought forward to encourage the Food and Drug Administration (FDA) to reschedule hydrocodone combination products from Schedule III to Schedule II. I expected there to be few others testifying. I wasn’t at all ready for the long line of individuals standing at the “con” microphone, ready to speak against the resolution.
There are some significant differences between Schedule II and Schedule III, but those of greatest import are the ones which impact prescribing practices. A physician can prescribe a Schedule III medication by making a phone call to the pharmacy or by calling in an order to, say, a nursing home. A physician can include refills on prescriptions or orders for Schedule III medications. These attributes are not present for Schedule II medications, so patients must be seen monthly and phone orders are not acceptable.
All full-agonist narcotics are similar to one another in terms of their potential risks and benefits. Hydrocodone is a narcotic which, when prescribed by itself, is in Schedule II. It is also manufactured as a combination product with a pain reliever, such as in brand Vicodin, in which hydrocodone is combined with acetaminophen. When in such a combination mixture, the drug has been in Schedule III. This has given the impression that hydrocodone combination products must be safer than other narcotic formulations since such products, along with low doses of certain infrequently prescribed drugs, are the only narcotic formulations on Schedule III.
Of course, the combination drugs have greater risk than the monoproduct. As patients become tolerant to the effects of the narcotic, their dose is often increased to such an extent that the toxicity of the secondary content becomes critically important. This is of particular concern in the nursing homes where use of such medication was widely implemented, as elderly patients often receive a medley of pharmaceuticals with potentially additive toxicities to consider, and where metabolic activity may be poor to start with.
The FDA ultimately agreed that there was little sense to having a drug with greater potential risk in Schedule III than the many drugs with lesser potential risks in Schedule II, announcing late last month their recommendation to reschedule the class. But what of all those physicians who were in line at the “con” microphone, who spoke against the change in classification?
I agree that there are some patients in whom long-term therapy with a hydrocodone combination product has value. Seeing such a patient monthly may represent a hardship in these cases, particularly for the individual with limited mobility. By and large, however, I believe there are many more patients who have been prescribed long-term hydrocodone combination products in error, particularly given the contribution these medications have had to the opioid prescribing epidemic over this past decade. The reclassification, by forcing physicians to consider the need for continued prescribing of the medication each month, will hopefully lead to a taper and discontinuation in such cases. This should lessen what seems to be an ever-increasing population of patients for those in the addiction treatment field.
Stuart Gitlow MD MPH MBA is a member of the American Medical Association’s Council on Science & Public Health, and President of the American Society of Addiction Medicine. This Op-Ed represents his personal opinion and does not imply any position or policy taken by either the AMA or ASAM.