Another Drug War Disaster in the Making by Michael Gorback MD


The DEA rescheduled hydrocodone to C-II as of October 6. That means hydrocodone preparations can’t be called in and special prescription pads must be used as for other narcotics like morphine or oxycodone.

Pharmacologically this makes sense. There is no magic to hydrocodone that makes it less dangerous than morphine. In social terms, however, there is potential for disaster as yet another Drug War cruise missile goes off course.

Much of the Drug War (which, by the way, the drugs are winning) is based on a misunderstanding of supply and demand – a failure to learn the lessons of Prohibition. The restriction on hydrocodone will make it harder to obtain but nothing has been done to decrease demand. Simple economics dictates that the price will go up. Since obtaining hydrodocone for illicit purposes is illegal, and it is now more difficult to obtain, the risk is higher. Higher risk usually entails higher reward.

We have, then, a toxic mix of higher prices and higher risks. Enter the risk-takers. These risk-takers are not white collar workers on Wall Street. That’s a different kind of crime. This is the gritty violent street variety that trails the drug trade like camp followers after an army.

Caught up in this net are people who have been getting hydrocodone from their family doctor for chronic pain. Most doctors are afraid to write prescriptions for C-II medications. The reasons vary, but center around some form of perceived risk. In the case of hydrocodone it’s hard to see any risk that’s change except for law enforcement scrutiny.

To a large extent this is negligible for the typical family doctor. Most importantly, law enforcement simply isn’t interested in a family doctor prescribing Granny some pain medication for her bad knee. Secondly, even if law enforcement agencies were interested in lurking in the bushes outside of every doctor’s office the budget simply isn’t there. Thirdly, whether it’s written on a regular prescription pad of a special C-II pad all controlled substance prescriptions are in a computerized database somewhere and the DEA and state law enforcement agencies can data mine that to their hearts’ delight.

But when you fear bogeymen it doesn’t matter if they don’t exist. Family doctors are running scared. My colleagues and I in the field of pain management are seeing referrals for assumption of hydrocodone prescribing from their family doctor.

Unfortunately, that is not how most pain specialists work. Most of us are interested in interventions that reduce or obviate the need for narcotic prescriptions. We are not running prescription-writing services.

I saw a young lady today who is a full time college student. She obviously doesn’t understand that the “A” in “ACA” stands for
“Affordable” because she insists that she can’t afford it. If she had a baby out of wedlock she could get Medicaid but she doesn’t want to go that route. Some people are just hard to help. I jest, but not by a whole lot.

Her family doctor has been managing her for years with hydrocodone prescriptions. Now she wants no part of it and has referred this young woman to me.

Someone has dug a hole and now expects me to fill it in. But my treatment philosophy is not to just throw pills at a problem. If you
just want pills that’s up to you. Whether or not I’m the source of your pills is up to me.

What am I to do? Break with my philosophy of care and what I consider proper treatment so this young woman can have her pain medication, or deny her the medicine that helps her function? Either way, I don’t like myself very much.

However, I didn’t force her to attend college and not have any income. That’s her choice, and I will not practice what I consider substandard medicine because of a situation she created. Therefore, my answer was to explain what I think the problem is and offer what I considered to be the best non-narcotic treatment. She can discuss it with her mother, and if they wish to try it we can work out a fee and payment plan.

What worries me is that if they can’t afford or don’t want to try the recommended treatment she will have to find someone to prescribe hydrocodone without any other type of pain management. Where will she go? Probably to the very pill mills that the DEA is trying to extinguish.

The reclassification of hydrocodone to C-II is only going to make matters worse.

59550cookie-checkAnother Drug War Disaster in the Making by Michael Gorback MD