A UPI report issued earlier this month highlighted a test case in how drug enforcement is often fraught with unintended consequences. Its thesis: that moving hydrocodone, otherwise known as Vicodin, from a Schedule III drug class to the more restrictive Schedule II classification has led to more opioids in the hands of patients just after surgery.
The DEA’s decision to re-schedule the drug in 2014 was far from baseless. Vicodin/hydrocodone is the most commonly prescribed painkiller by health professionals. Since 2012 approximately 142 million prescriptions have been dispensed and, obviously, counting. The United States has a particular taste for the drug, with 99% of all Vicodin being consumed within U.S. borders since it became a generic drug in 1983. And, while synthetic heroin, known as fentanyl, is largely to blame, drug overdose deaths continue to skyrocket, with over 72,000 people dying from ODs in 2017.
It must be stated that, considering medical professionals have implicitly endorsed Vicodin as their painkiller of choice, it’s clearly the route they feel safest to avoid the chance of addiction in patients. However, several doctors have confirmed the report that they feel specifics within the drug laws between different Schedules has forced their hands in perhaps overprescribing Vicodin, at least in the initial dose.
The first study cited surveyed 21,995 insured surgery patients in Michigan, and it found that following the change in Vicodin’s drug schedule category, ‘there was an immediate significant increase following the schedule change in the amount of opioids filled in the initial postoperative prescription, which was sustained for 1 year.’ (JAMA Surgery)
Though the inverse relationship between enforcement stringency and a the amount of Vicodin being prescribed seems counterintuitive, there’s a good explanation for this. Doctors, unable to phone in prescriptions for Schedule II drugs, prescribe more initially out of concern that their patients would not be able to attend the in-person meeting required for a refill of a Schedule II substance. Whether due to incapacitation, conflicts, or some other unforeseen circumstance, doctors simply err on the side of patients having the meds they need rather than being left high and dry.
Practicing general surgeon Jeffrey A. Singer was not surprised by the study’s findings. In fact, he’s personally experienced the qunadary and has acted in the manner that the study suggests he is most likely to. He describes his prescribing habits in the time when hydrocodone was a Schedule III narcotic:
‘Prior to the 2014 schedule change, I would often start off prescribing a small amount of hydrocodone to some of my post-op patients (depending upon the procedure and the patient’s medical history) with the knowledge that I can phone in a refill for those patients who were still in need of it for their pain after the initial supply ran out.’ (Cato Institute)
And after Vicodin was re-scheduled to Schedule II:
‘Once it was rescheduled, I changed my prescribing habits. Not wanting any of my patients to run out after hours, over a weekend, or on a holiday—when the office is closed and their only recourse would be to go to an emergency room or urgent care center to get a prescription refill—I increased the amount I prescribe (based on my best estimate of the maximum amount of days any individual patient might need hydrocodone) to reduce the chances of them needing a refill.’
It’s simply a matter of putting the interest of one’s patients ahead of the interests of bureaucrats and regulators, Singer says. A physician won’t leave a patient genuinely in need of relief in pain by prescribing the bare minimum, even if that means raising the odds that extra pills may be left available. It’s the inevitable result of a law lacking in nuance, Singer would say.
But some states have restricted the amount of pills that can be filled in the wake of surgery to as few as three days’ worth. The result: patients hobbling or being wheeled back into doctors’ offices days after an operation simply to show their face so the prescription can be filled.
Overkill, you ask?
Singer and many other physicians think so. Their sentiment informs the reason why the American Medical Association is opposing a proposal to impose a national three-day limit on opioid prescriptions.
When the black market and a national opioid abuse crisis demand legislation, the result is legitimate medical professionals and their patients bearing the brunt of the punishment. While measures to mitigate the effects of the worst drug epidemic in American history are certainly called for, so is the nuance that allows doctors to do their jobs and patients to be treated effectively and compassionately.
That is not, according to medical professionals, the tact that has been taken with respect to the re-scheduling of hydrocodone, also known by the brand name Vicodin. And the result, as can be seen through evidence, is the unintended consequences of good intentions doled out without input from those who will be affected the most.