Effect of Rescheduling Hydrocodone is Unknown

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Rescheduling of hydrocodone no doubt has many chronic pain patients concerned.   A barrage of e-mails and other communications over the last several hours have indicated panic among patients with several questions regarding opinions and options.

I am writing this post because I can’t answer the hundreds of e-mails.  I will start this by answering the most direct question asked to me, “What is PROMPT’s position on changing hydrocodone combinations from schedule III to schedule II?  The short answer is, we don’t have a position as of yet.  The short-answer reason for this is that we don’t know what the outcome will be, or if it’s a good or bad thing.  It’s difficult to make an argument one way or the other if data is lacking to support either position.  See PROMPT’s Mission Statement which advocates for recommendations based on validated evidence, which doesn’t exist for scheduling hydrocodone both ways.

It is therefore my personal opinion that Dr. Lynn Webster and his colleagues with the American Academy of Pain Medicine have once again hit the ball out of the park.  They took the high road by not offering a hard and fast position to the FDA; instead they provided  a “[No] Position Statement” writing that they “Encourage implementation of tested, proven, evidence-based strategies, such as public health demonstration models for prescription opioid use that reduces mortality and mitigates untoward risks of opioids in Society.  The Academy neither supports nor opposes rescheduling but takes the position that action is needed whether the schedule changes or remains the same.”  Dr. Webster nicely outlined the potential negative fallout from rescheduling, the potential advantages of rescheduling, and touched on the fact that inaction is unacceptable based on current statistics.”

So, what is my opinion?

I don’t support anything that can potentially harm patients.  I don’t know whether rescheduling hydrocodone will help or hurt the majority of chronic pain sufferers or society, as I believe that for the most part, chronic pain should be treated as other chronic disorders insofar as opioid therapy goes.  That is, extended release formulations are generally better tolerated than immediate release products, they avoid “chasing after the pain” as opposed to preventing it, and they afford extended blood levels such that the pain patient has better hope for a full night of sleep.  Nevertheless, extended release formulations are not without risks!

On the other hand, chronic pain sufferers do have occasion for breakthrough pain, especially if they remain active as we all hope.  If this necessitates breakthrough immediate release dosing, it needs to be done in a controlled fashion, not with 240 tablets of an immediate release formulation each month…this is not “as needed” if it is “always needed”.

What about what I like to call, “acute forms of chronic pain”?  This would include medullary kidney disease, sickle cell crisis, pancreatitis flare-ups, endometriosis, and other disorders.  This is a topic for another blog, but does make for interesting discussion that unfortunately was not contemplated in a big way at the FDA hearings.

Here’s what I really think!  If anyone believes that rescheduling hydrocodone is going to solve the problems they hope to, they will be sadly disappointed (check back here 6 months after it happens, if it happens…maybe I can link a “like” on Facebook for when this prediction comes true).  Some of those that really need it for legitimate reasons will no doubt suffer from the proverbial “Pharmacy Crawl”.  And, it will affect elderly patients in and out of nursing homes and cause logistical problems in such environments most probably creating a springboard to codeine prescriptions.  Unfortunately codeine is less effective, more constipating, has a similar toxicity profile to hydrocodone, but has a significantly [underappreciated] risk of drug interactions (usually, but not always, with antidepressants) that grossly reduces the analgesic effect.

Simply put, those that are abusing hydrocodone will move on to something else, especially if they are smart enough to realize diversion of schedule II’s comes with a harsher penalty; and believe me, many dealers know that.  This was seen in the late 70’s when the popular abuse combination was to inject oral pentazocine (Talwin®) in combination with pyribenzamine.  The wise scientists at Sterling-Winthrop reformulated their product to include naloxone in the tablets, which was later patented as Talwin-NX®.  That solved the problem for a few weeks until heroin use increased along within other abuse options.  After Purdue Pharma reformulated OxyContin®, the same thing happened and heroin use became more prevalent.  An almost comical knee-jerk (or perhaps marketing ploy) by Reckkitt-Benckiser was to include naloxone in their Suboxone® (buprenorphine + naloxone) formulation making an [flawed] argument that if crushed and injected, it would prevent abuse because of opioid-receptor blockade.  Well, guess what, naloxone never gets to the receptor because buprenorphine has a higher affinity (smart move though R-B, but generic sublingual plain buprenorphine is just as good and less expensive).

My personal recommendation to the FDA is as follows:

  1. Save yourselves some trouble up front; if you do in fact reschedule hydrocodone, do it for all opioid combinations, especially codeine, because that will be your next headache.  Make sure you include that nice-tasting branded Hycodan® Cough Syrup that has a sherry wine base and all its generic counterparts.
  2. FDA, if you think that NP’s or PA’s are less reliable than doctors, please prove to the world that they are less reliable or less trustworthy to prescribe hydrocodone, or any CII for that matter…what is that about?  If they are good enough to care for patients and prescribe drugs such as warfarin, they certainly are wise enough to renew an opioid RX.  Did I miss something?
  3. Require a certain number of pain education to all healthcare providers regardless of their practice area or intent to treat pain…pretty much the majority of all patients everywhere have pain at some time or another.
  4. Dentists and dental surgeons, with the exception of major maxillofacial surgery, it is rare that your patient needs anything more than an NSAID and/or acetaminophen for tooth extractions or root canals.  Treat preemptively with a COX-2 specific and/or other appropriate agents and limit or eliminate opioids altogether unless other viable options are contraindicated.  Perhaps the FDA should put a lid on allowable quantities without a refill option for such procedures if rescheduling does not occur.
  5. Education, education, education for each and every medical doctor in order to continue practicing medicine.
  6. Education, education, education for each and every pharmacist in order to continue practicing pharmacy.
  7. Education, education, education for each and every non-physician provider including but not limited to NPs, PAs, clinical pharmacists, etc.
  8. Education, education, education for each and every nurse, podiatrist, dentist, and other prescribers.
  9. Late Addition:
    Thank you Dr. Kral for reminding me that education is important for public and patients.
    Thank you Dr. Twillman for reminding me that we should in fact include optometrists.

For those chronic pain folks that have sent panicked communications, the FDA has not yet finalized their decision.  According to Sabrina Tavernise of the NY Times, “If the F.D.A. accepts the panel’s recommendation, it will be sent to officials at the Department of Health and Human Services, who will make the final determination. The F.D.A. denied a similar request by the D.E.A. in 2008, but the law enforcement agency requested that the F.D.A. reconsider its position in light of new research and data.”

Dr. Thomas Sachy, a forensic psychiatrist with expertise in pain medicine has agreed to write a guest blog on the topic of hydrocodone and the proposed rescheduling which will be posted within the next several hours/days.  I’m guessing it will be quite the heated topic!

As always, comments are welcome.

21 thoughts on “Effect of Rescheduling Hydrocodone is Unknown

  1. Dr, Fudin

    I highly respect you and what you do and I want to thank you for all your hard work. I would like to say that if this medication is rescheduled it will do more harm than good. Yes there a problem with addiction yes to point I do believe there is, however taking away the rights of Doctors to do what is best for their Patients is absurd.Also has anyone thought about the fact there are millions of uninsured people in this county who are in chronic pain who’s Doctor is caring enough to say OK you can come in every 3 months as apposed to every month. I know this law will hurt me for sure. As I live in KY where Doctors here are scared to death to write anything being a Pain Patient for 24 years and having the same Doctor for over 7 years in the state I formally lived in before I moved back to KY does when I can not afford to fly there calls this medication in for me, it keeps me functioning (Not as strong as the medications he gives me when I can go see him) but it helps. I have called and written letters to every official in KY over the fact that Not a single Doctor will treat me and Chronic Pain is by far my only issue. I think this would lead to people turning to other things to get relief from pain and possibly increase the suicide rate for many who now will have NO Pain relief what so ever. When will the FDA and DEA allow Doctors to be Doctors and treat their Patients as they see fit ? I agree what one DR see’s as a good treatment another may disagree with, But when will enough be enough? Thanks for all your Hard work for those of us who need a voice.

  2. Hi Dr Fudin,
    Well said!
    Also- As a retail pharmacist, I completely agree with your statement – it Is not “as needed” if it is “always needed”. I see patients prescriptions from a few pain management offices in my area come in every month like clockwork with their long acting opioid and their 4 to 6 times a day short acting “PRN” opioid, such as hydrocodone. I wish these physicians would adjust these patients meds accordingly!

    1. Alexa,

      I just want to add, that there are some conditions that require frequent “as-needed” short acting opioids doses to control acute pain episodes. I suffer from Ehlers-Danlos Syndrome, and have frequent, but unpredictable daily joint dislocations & soft tissue injuries. Adjusting the long acting medication might help overall daily pain (for some), which might require less short acting doses, i totally agree. However, some conditions require faster acting, rescue meds in order to continue to function & have some quality of life. The short-acting script may be written in a way that seems as though the patient takes “X” amount of pills per day, when in fact it could just mean that on one day the patient needed ONE PRN dose, and on another day, the patient needed FIVE PRN doses. Sometimes, patients with severe pain get frustrated when a Pharmacist (or Pharmacy staff), assume things without asking us. Most patients would rather be asked & explain things, than have people assume our docs don’t know what their doing! This isn’t meant to be a criticism, just an FYI.

      1. Agreed… there is certainly an exception to every rule. I just feel like many of my patients that i speak with could benefit from some easy dose adjustment to lessen their chances of having breakthrough pain…especially if they are using their PRN med to the max dosage every day for months on end. I understand that PRN meds will still be needed. Take care~

  3. So much irony in all of this. I wish more people were able to realize that you cannot save a self destructive person from themselves. It is unfortunate and quite sad, but some dysfunctional people cannot be helped or cured. People, especially in positions of authority, must recognize this. As of now, we have a lot of problems in society because too many people want to be heroes to people they can’t rescue. We can’t cure pedophiles, we can’t cure rapists, we can’t cure sociopaths, and we can’t cure drug addicts/abusers. The best a person with addiction can hope for is remission and that takes a lot of work and even more luck.

    The families and relatives of drug addicts/abusers think they are helping everyone, but in reality they are misguided and on track to ruin millions of lives if they get their way. The fact remains that addiction and drug abuse is a fundamentally unsolvable problem. I realize that may be a very bitter pill to swallow, but the evidence clearly supports this.

    The families and relatives of drug addicts/abusers cry out “Please help us big government. Please help us save our family members from their self destructive personalities. Let us hold inanimate substances as the cause and not humans with self-determination and consciousness.”

    The government puts pressure on the pharmaceutical industry to put tamper resistant chemicals in pain medicines. The result is people still abuse them or they switch to heroin. For example, more people have probably died from abuse proof Opana ER than the original non-tamper resistant formulation. The new Opana ER has killed quite a few drug abusers since its release (see http://americannewsreport.com/blood-disorder-linked-to-opana-abuse-8817457) . It is unclear how well those tamper resistant chemicals work because there are hundreds if not thousands of posts online describing techniques for defeating/removing tamper proof chemicals. So, the tamper proof medicines are essentially a failure in that regard. They don’t even come close to “solving,” the problem. Now the government is looking at restricting pain medicines even more. Everybody knows this will definitely just make drug addicts switch back to heroin or opium.

    Every solution to these problems has been and will be an utter failure. The government should just spend the money on mitigating the consequences because it is impossible to solve these problems.And these “solutions,” usually end up hurting chronic pain patients. It is a shame these zealous anti-pain medicine proponents are willing to sacrifice chronic pain patients in order to attempt to save drug addicts, who cannot be saved. Why should pain patients like me be sacrificed so people can make a feeble and ultimately unsuccessful attempt at “saving,” a drug addict?

  4. I am against rescheduling hydrocodone. Prescribers need a non-CII option for pain control. These regulations hurt people with pain while doing NOTHING to stop addiction and abuse. Abusers already know where to obtain these drugs illicitly. Our society doesn’t even offer treatment on demand for those who need it. Maybe we can start there and leave legitimate pain sufferers and prescribers of hydrocodone alone.

  5. As usual, Lynn Webster (above) is a voice of reason. When I first read the post by you, Jeff, and the AAPM letter, I thought there was a lot of waffling going on without committing to any direction. Then I realized that’s what fair balance looks like — rationally considering the many facets of a difficult problem, from an evidence-based perspective, and not leaping to conclusions about quick remedies. Unfortunately, there are many voices out there who do not understand the concept of fair balance and insist, without supportive good-quality evidence, that opioids are evil, addictive in all persons, and inappropriate for any and all cases of chronic noncancer pain.

    1. Thank you Stew for bringing that thought out! Here’s also an interesting point; some of the most well-respected voices in the pain arena throughout the country (including your own) have commented here. These have included Ph.D.’s, M.D.’s, a combo of both and double/triple certified, and Pharm.D.’s also with multiple credentials and certifications. All of them are singing in harmony. Yet we do have a single group of select practitioners who insist they know the answer. Perhaps they are smarter than all of us, but to me the disproportionality, sheer numbers, and secular group versus an interdisciplinary group says it all.

  6. Many people depend upon hydrocodone for their chronic pain, they cant get anything else because most doctors refuse to write C-II medications, they refuse to put their name on a C-II script and most primary care doctors don’t even have a C-II prescription pad in their office.
    For these people if they lose the only thing they can get for their chronic pain what will they do,where do they go,what will their doctors have to tell them.
    Many people will just say that’s it ,I give up , most will think suicide is their only other option.
    So please don’t make hydrocodone a C-II medication, it’s a mistake and some people will get overwhelmed with ongoing chronic pain and just give up.
    Please don’t give these people a reason to do the inevitable, they’ve been pushed around enough throughout their life.

    When people seek out pain medications for all the wrong reasons it affects all that suffer from chronic pain ,this will always be, we cant control it only make sure people that abuse these medications get the help they need. Lets not penalize innocent people that never asked to have chronic intractable pain in their body in the first place. Its all too consuming to have chronic pain in your body every day and you just cant make it go away no matter how hard you try.
    Everyone has said chronic pain patients will not be affected . But all this negative talk and outlook on opioids it has affected everyone that comes in contact with these medications ,even pharmacist refusing to fill these medications in fear of losing their job.

    I think this situation with pain medications has gotten out of control and only we can fix this,we cant fix it overnight, its going to take a couple of years if not longer.
    Making these medications more difficult to get for all that suffer is not the answer. I don’t have the answer to this out of control situation, but I do know many people suffer from chronic pain and I feel bad for these people. I have chronic pain myself but I will be okay , I just don’t think making hydrocodone a C-II prescription will solve any problems.

    Mark S. Barletta

  7. Great commentary everyone. This is a very sensitive issue. I am hopeful that FDA will be equally thoughtful when they consider the evidence presented and the advisory panel’s recommendation. Sadly, they seem to be more reactionary than advancing policy with a global purpose.
    A couple comments;
    Dr. Fudin – you forgot a HUGE group for education. Our patients and the public. My patients are pretty smart, and information is a powerful weapon. It is important to help them have realistic expectations and to strongly enforce proper use and storage of ALL prescriptions (to prevent others from helping themselves). Safety is paramount. I am fortunate enough to have access to 7th graders in our school district. We talk about “uncool” it is to take “pills” that are not prescribed for you. We have seen that curbing the availability of opioids (Washington State) has reduced the number of deaths, but this is not evaluating how well pain is being managed…

    I am not seeing a great deal of gloom and doom with rescheduling. Adjustment, yes. Right now, access is TOO easy in some cases. There are providers who have given their secretaries and clerical staff the “authority” to renew hydrocodone prescriptions over the phone. May I quote an orthopedic surgeon “Delores knows these patients better than I do”. Delores is his secretary, Is this what we want? And yet, the CSA allows it. At least with CII’s the provider must set eyes on the prescription and hand-sign it. Does it take some time? yes. Do patients with debilitating pain and taking potentially lethal medications deserve our attention long enough to review a chart and sign a prescription? yes.

    We don’t have access problems even in our rural state because
    1) we don’t make the stable patients come to the office every month to pick up a paper copy of the prescription and we never call in 5 refills of hydrocodone for anyone for any reason. Renewals are a PLANNED event and follow-up appts are scheduled with the pharmacist or the physician at reasonable intervals to allow assessment and monitoring. Patients who are not stable are seen more often and have smaller prescriptions as these may change. It’s about being a partner with the patient and being responsive to their needs.
    2) we mail prescriptions directly to the pharmacy, taking the patient out of the middle and preventing pharmacy crawling. Patients have told me many times that they appreciate not being put in the middle 3) We utilize the 3 month series option for our stable patients. This controls when refills may happen. Pharmacists who are not vigilant many times dispense refills as frequently as they are requested, be it monthly or weekly with CIII-CIV, etc. And if the medication is swiched to something else, there are still refills remaining on the hydrocodone at that pharmacy that may be filled…..

    I suspect that if hydrocodone moves up to CII status, that we will see more of a return to heroin as mentioned above. We have already seen this happen with introduction of abuse-deterrent formulations. While this would take the pressure off pain clinics, it will invariably stretch the addiction community past its already meager resources.

    This is a discussion that needs to continue, not only in the pain community but across the country. Possibly in a beter format than a People layout…

    keep bloggin’ J.

    1. Dr. Kral;

      Thank you so much for all your words of wisdom! Your comments added a lot to this blog post! You know, an interesting (and simple point) which a lot of people have ignored is that OxyContin® was a nightmare. Uhm, remind me, what schedule is that? Oh yeah, so up-scheduling hydrocodone will do what? I don’t think so.

      And yes, thank you for including public and patients. I have edited the original post with a big fat “thank you”.

  8. I have Medullary Sponge Kidney and am one of the symptomatic few. Prior to the onset of symptoms I was an active mother of 5, happy and content to raise my family and work hard. After my first kidney stone 10 years ago I have not returned to my healthy self. I am not an additct, I do not over use or buy meds. illegally. IF i could not have my (2) pills of hydrocodone a day, that my doctor and I agreed was “reasonable” for me to take, I don’t know how I would function. As it is now I plan my meds around the time I HAVE to be a MOM! I no longer paint, shop, dance, sing or do many of the things I HAVE to do or what I would LIKE to do. I do not like taking pills but since my diagnosis I have had to rely on Cymbalta for pain and to help me cope with this lifestyle and hydrocodone for the severe pain. I am at the mercy of these meds to help me live as “normal” of life I can, until the doctors figure out how to correct or fix my kidney stone issues. What’s a mom to do? I would be the first in line to get this fixed and get back to my GOOD LIFE! Don’t make it hard than it already is on us WHO REALLY SUFFER.

  9. Sitting through the FDA Advisory Committee meeting was a very interesting experience. It was clear that the committee was searching for solutions to what everyone realizes is a serious public health crisis. There were multiple requests for some “third way” apart from maintaining the status quo or rescheduling. Of course, the options presented to the committee for a vote were “yes” or “no” with respect to rescheduling–there was no third option for them to consider. One member commented on the Hobson’s choice represented by this vote; two or three talked about their vote to reschedule as a “wake-up call” to the medical profession, several cited the emotional testimony from families who lost children as perhaps the element that tipped them in the direction of a “yes” vote, and many, if not most, commented that they really don’t think that this step will significantly reduce the overall number of drug overdose deaths.

    I did propose to the committee a “third way forward”, one that increases controls over the supply of hydrocodone that gets onto the streets, but preserves the ability of NPs, PAs, optometrists (Who knew that they prescribe controlled substances? You should have seen some of the pictures illustrating why they do!) to prescribe for their patients. Unfortunately, I believe that making the changes I suggested would be in the bailiwick of the DEA, not the FDA, so while FDA might suggest it, they have no power to implement it.

    Just for the sake of discussion, the plan I suggested (which we also suggested to Senator Manchin’s staff last Spring when he had a rescheduling amendment added to the PDUFA legislation) includes the following: 1) Keep the products in Schedule III; 2) Limit the amount that can be called in to a 3-7 day supply–just enough to cover the patient until he/she can see the prescriber–with no refills; and 3) Limit the supply from the original prescription plus refills to a 90-day supply.

    There was a lot of discussion about the poorly-understood (and almost universally misquoted) regulation allowing a prescription series for C-II medications, but I also pointed out that that method actually gives you less control over those prescriptions than is provided by having refills. With a prescription series, each prescription can be filled at a different pharmacy, meaning there is no way to stop the prescriptions from being filled. With refills, a prescriber can use the PDMP to find out which pharmacy holds the prescription, and then call that pharmacy to cancel the prescription.

    I agree with you about what we’re going to need to do now (although I think you neglected to mention tramadol, which may well see a surge in prescribing as well, despite all of the problems with it). I think we in the pain community also need to start talking more about the fact that the correlation between drug supply and overdose deaths is just a crude indicator, and that there are dozens of ways to get from a prescription to an overdose death. Reducing the supply, which is what this is all about, is the crudest intervention, and we’d be more likely to achieve the right outcomes if we could use more focused interventions that affect only those using the medication in problematic ways. But that’s a topic for another day.

    1. Dr. Twillman;

      Yet another professional that puts every waking hours, his heart and soul into helping the world understand pain management and associated risks and benefits of opioids. You and Dr. Webster are my heroes. Thank you, and thank you for this very thoughtful post and review of the meeting. It is very helpful. I also gave you a big fat “thank you” in my original blog post above for convincing me to include optometrists…sure would like to hear from one on the post (if you know of any, please ask them for me).

      Regarding leaving out tramadol, I actually did that on purpose. No doubt, more prescribers will turn to this, and abuse may increase. From my experience though, most that abuse tramadol need to take very large amounts for any euphoric effect. Yes, of course there is a big risk of serotonin syndrome and/or seizure, but that’s a choice the abuser makes (just like too much acetaminophen with the schedule III combos). I guess I didn’t want to include it with possible abusable opioids (even though we know that to be fact) because the opioid receptor binding affinity is 6000x less that of morphine, similar to dextromethorphan. Considering the mechanism(s) of action, without giving too much away, abusers could acheive the same thing by combining certain other agents. But, if someone decides to abuse big doses of tramadol and refuses help for substance abuse, G-d bless them when they sit on the toilet constipated with palpitations and acathisia. Tramadol will be treated as a schedule drug in NYS beginning next month…we’ll see how that goes.

  10. Dr. Webster; Thank you for taking the time to post these comments. Your tireless service to the medical profession, chronic pain treatment, the patient community of chronic pain sufferers and also your understanding of addiction has helped to sort out many of the real issues.

  11. Thank you for being a voice of reason. When the issues are so clearly laid out, as you have them here, it makes me wonder why it is not so clear and obvious to the rest. At times, it seem people go out of their way to make matters far more complicated than they need to be and often, those with the authority to make change only create more problems. Hopefully, your opinion will be given meaningful consideration… for the sake of those who have real, chronic pain.

  12. That’s the problem Dr. Webster, all of us that suffer from never ending chronic pain are already paying a price from the fallout that has already occurred and nothing has been done yet, just talk. No rescheduling on hydrocodone -yet. Also the FDA has yet to make a decision on PROP’s petition but that’s coming up soon on February 7- 8th. This petition is the most ridiculous thing I’ve ever heard.

    Imagine if you can waking up in chronic pain, the first thing you feel when you open your eyes every morning is severe chronic pain in your neck. Now imagine 24 years of this chronic pain day and night, its hard to fathom isn’t it. And to think there are people out there worse off than me.
    I do hope all of this talk comes to a screaming halt and it stops affecting all the suffer from chronic pain.
    I’ve never suffered from depression, PTSD, ADHD or bipolar disease. But this ongoing deception about all opioids are evil is enough to get on anyone’s nerves.

    Thank you Dr. Fudin for yet another good topic and thanks for standing up for all the suffer from chronic pain.

    Mark S. Barletta

  13. Hydrocodone is next? I never got any relief from it…and I have yet to find a person with severe pain who does. This is getting beyond ridiculous. Whatever the FDA and the DEA are up to, I think it has more to do with new drugs coming on the market than with “addiction” issues with the old ones. If addiction is a disease, then it stands to reason it should be treated as one. The drug of choice isn’t the problem, it’s the addictive tendencies in a person, to my way of thinking. And since addiction never involves just one “substance” why is our government so up in arms about opiates? This issue has been a problem for thousands of years, but only now does the Press weigh in to bring a long-standing issue to light. And the issue is ADDICTION, not dependence. Thanks again for thoughtful reporting!

  14. Jeffrey,

    This is a complicated problem. The easiest step to take is to increase regulation (rescheduling). Rescheduling will probably decrease prescribed hydrocodone and this should mean less hydrocodone will be available for diversion. As a result fewer people should be harmed from the drug. Of course this is a good thing. Lets hope that this would be the predominate impact of rescheduling if that is the FDA’s decision. However it may not have much impact on the overall problem of prescription drug abuse because abuse and addiction is more than about the drug. Too often the attention is only on the drug and not the biology that drives abuse. We need to be honest about what drives abuse. Anxiety, depression, PTSD, ADHD, bipolar disease, hypo-hedonia, etc are all biological disorders crying for a therapy. Exposure to an opioid may temporarily and deceptively help people with these conditions feel more normal. People will always seek to feel good or normal if disturbed with mental disorders. In addition the thrill seeker is at risk when exposed to an opioid if they have a genetic vulnerability to “enjoy” opioids. They can get trapped.

    A drug that is rewarding contributes to the problem but generally is not sufficient to lead to addiction without other factors. As you said, we may see a balloon effect. Hopefully there will be less hydrocodone related abuse/deaths if rescheduling occurs but will there be a compensatory increase in alcohol, marijuana, cocaine, methamphetamine, heroin or drugs not on our radar? I don’t know and certainly hope not. Maybe decreased access to hydrocodone and other opioids will be necessary to curb the problem of opioid abuse. We need to do something and I hope in the process the people in pain will not pay the price for our inability to manage the problem.

    1. Dr. Webster; Thank you for taking the time to post these comments. Your tireless service to the medical profession, chronic pain treatment, the patient community of chronic pain sufferers and also your understanding of addiction has helped to sort out many of the real issues.

      Your comments regarding anxiety, depression, PTSD, ADHD, bipolar disease, and hypo-hedonia cannot be overstated, as their importance in this whole issue are key to the problem at hand.

      Thank you for all you do to teach professionals, administrators, lawmakers, and professional colleagues!

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