Another Drug War Disaster in the Making by Michael Gorback MD

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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.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  10 comments for “Another Drug War Disaster in the Making by Michael Gorback MD

  1. Bridget Reidy
    October 1, 2014 at 9:09 pm

    I don’t understand how what kind of pad the government wants us to use enters into our decisions about the risks and benefits of opiate use. Don’t let the turkeys get you down, or interfere with your medical judgement.

    I find the biggest abuse is the patients who present every three weeks or so to the same clinic getting hydrocodone for various acute pains, rarely with any physical exam findings consistent with any injury, with the doctors claiming they are somehow safe from scrutiny because they are not treating “chronic pain”, even if the end result is the prn hydrocodone is taken round the clock and never stopped. I suspect they are not at risk unless it’s a huge part of what they do, and frankly I do wonder sometimes if they do it because quick easy visits pay best. And I suspect they’d be less susceptible to scrutiny if their prescribing practices followed some kind of bell shaped curve with nothing for some acute injuries, few opiates for acute injuries known to cause severe pain and not easily faked or in a patient who rarely seeks care, and long actings for chronic pain with a prn for exacerbations, and the prn not continually refilled the same way if used around the clock.

    In the example given I would ask the pain specialist if he thinks the opiate is appropriate or not, irrespective of if he thinks other things the patient may or may not be able to afford would contribute or if continually writing them is in his job description. And if so tell the other doctor he agrees with the opiate management, or suggest a wiser way to do it, adding that he doesn’t think the patient needs his expertise for continued care. He’d be helping the other doctor feel safer, and educating them as well, never mind doing the best thing for the patient, which should be the main concern.

  2. Stella Fitzgibbons MD
    October 1, 2014 at 12:51 pm

    I beg to differ about family doctors being non-targets when they help Granny control her chronic pain. Some state boards are actively hunting for “over-prescribers”, targeting FP’s who write more Schedule 3 scripts than those on high consider “appropriate”. Any interaction with your state board is frightening, time-consuming and expensive; me, I guess I’ll buy some stock in lidocaine patches.

    • Michael Gorback
      October 1, 2014 at 3:04 pm

      Yes, medical boards are looking at “overprescribers” but speaking as someone who has done reviews for the Texas Board my experience has been that you have to be way over the line. As I mentioned before, resources are limited, in no small part because the War on Terror (so many “wars”) has diverted a lot of funding. The tallest blades of grass get cut.

      You need to send in investigators repeatedly to document that not only is there a lot of prescribing but that it’s inappropriate prescribing. Then you need lawyers and hearings. It’s expensive and time-consuming for them too.

      Don’t confuse a state prescription monitoring program with law enforcement surveillance. Your state may not have a PMP that you can access, but law enforcement can go through pharmacy computer records.

      If you just have a card table and a prescription pad in your office you’re in trouble. If you have documentation of disease, documentation of other treatments considered or tried, and documentation of your rationale it’s hard to believe you could get in trouble. The cases I reviewed for the board, which were usually prescribing cases, were so outrageous you wondered how it went on for so long.

      The criminal justice system is even worse. I was contacted a few years ago about testifying as an expert here in Houston because they couldn’t afford to fly their expert in from Dallas. He was testifying for free but they still couldn’t afford a Southwest Airlines plane ticket.

      • Stella Fitzgibbons MD
        October 1, 2014 at 4:06 pm

        I urge you to avoid testifying in Houston–the judges love 2-week dockets that force you to be on hold for longer than you can afford. Thanks for the TSBME insight.

    • Hueydoc
      October 1, 2014 at 8:50 pm

      Or Tylenol #3, or Tramadol…..
      Just had our Internal Medicine group nearby send out a notice that they would no longer prescribe hydrocodone to anyone.
      The Panic has started.

  3. Randy
    October 1, 2014 at 11:56 am

    I have a small percentage of my patients with demonstrated pathology on chronic narcotics with good control, many of them stable for 10 years or more. They have given me no reason to suspect they are misusing the medication and keep regular follow up visits. Several got put on narcotics back in the Pain Initiative era when we were being encouraged to give everyone narcotics. So what I am supposed to do with these patients? They are the success stories of that era (and lord knows there were a lot of failures and misuse) . As far as I am concerned they are fine, but the government apparently thinks otherwise.

    Most pain clinics in my area are geared towards injections. Injections often do not help or give only temporary relief, plus they are often painful and expensive. The few pain clinics that do medication management want to put everyone on gabapentin which frankly I have seen more side effects from than narcotics. Lyrica is expensive and difficult to get insurances to cover. TCA’s have many side effects. I have a bunch on duloxetine but that is rarely enough to control pain by itself.

  4. Chris Rhody D.O.
    October 1, 2014 at 10:46 am

    Also in Pennsylvania, there is no special prescription pad for narcotics. You cannot send those prescriptions through electronically either. (I personally think that violates DMCA). Several times criminal have successfully used prescriptions they printed and wrote themselves. The worst penalty I ever heard for this was 2 years probation. Of course with the frequency of data breaches sending Narcotic prescriptions securely would last about a week. So I suggest that we put all narcotics over the counter, the junkies will leave us alone. People who want to get better will have more time. I also believe that if you prescribe narcotics you must drug test at least every 60 days, if an insurance company says no to this I will not prescribe the drug.

  5. Chri Rhody D.O.
    October 1, 2014 at 10:27 am

    There is no tracking database in Pennsylvania. We are trying to get one but a group of lawyers filed suit to stop it as an invasion of privacy. Wonder what it feels like working for drug dealers.

  6. Michael Gorback
    October 1, 2014 at 10:19 am

    If you look at the history of the War on Drugs we had a an epidemic of drug abuse that led to increasing restrictions. During these early battles physicians opposed criminalization. They opposed it after the Harrison Act was hijacked and again when there was a push to criminalize marijuana.

    Prior to interdiction, doctors maintained their addicts with prescriptions. Not perfect, but at least it accomplished three things:

    1. Medical supervision.
    2. Inexpensive supply of medication.
    3. Known composition and dose.

    The medical journals after the Harrison Act reflect this. There were articles describing how their addicted patients had to go to the seedier parts of town to buy drugs of unknown purity and at greater expense.

    When they declared war on MJ, the AMA actually sent a representative to meet with the committee examining the issue. He clearly expressed their opposition to criminalization, yet when it came to a floor vote and someone asked about the AMA’s position, the committee chairman flat out lied and said the AMA supported criminalization.

    Now we have an epidemic plus organized crime. I know which situation I’d rather be in but stirring the cream back out of the coffee is not going to be easy. The longer you let dysfunctional policies persist the harder is it to undo them.

  7. Pat
    October 1, 2014 at 9:54 am

    Great piece Michael. While I agree with every word you wrote, most likely won’t agree with my radical prescription: end the stupid War on Drugs, surrender, admit failure, and bring our script pads back home!

    “But everyone will be hooked on drugs!” No they won’t, and those that are can take responsibility for themselves. Or not.
    “But all the drug addicts will be committing rape, robbery, murder, and driving impaired!” Those are all actual crimes that imperil other people, and should be prosecuted. Otherwise addiction only imperils one’s self, and again, not my problem.
    “But think of all the broken and disrupted families left behind this (presumed) rise in drug addiction.” Not my family, not my problem.
    “But what about the children??!” (this last screamed in a shrill, Congress-pleading voice). Anyone selling any intoxicant to children should be hammered.

    I’m fear an intrusive, prosecutorial government far, far more than I fear drug addicts now.

    Too long physicians have played the willling handmaiden to Big Government in nannying and nagging everyone else to do what we think is better for them, and the stupid, murderous War on Drugs is one awful result. Physicians should lead the way by advocating that we all mind our own business and stay out of every one else’s, unless they come to us for help.

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