Hydrocodone Half-truths Hath No Fury

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“America consumes 80% of the world opioid supply (99% of the world hydrocodone supply), but has about 5% of the world’s population. If you don’t think America has some kind of opioid problem, then move along because this rational, evidence-based, experience-laden way in which I’m going to discuss opioid use and misuse will not interest you.”  This is pasted from a post by Dr. Jen Gunter where she gives some honest insight on some of the issues that largely have gone unnoticed, or should I say IGNORED by mainstream media and otherwise rational thinkers.  I encourage you to read her post linked above.

The hydrocodone question” has also been addressed in Drug Topics.(1)

What we have seen in the press and on otherwise “reputable” news casts and blogs is fraught with half-truths surrounding the issue.  This has unfortunately had an adverse effect on legitimate pain patients and has served to fuel anger in those unfortunate families who remain to grieve over a loved one that has succumbed to opioid addiction, eventual overdose and death.  While addiction is a separate issued from legitimate opioid use, they can never be mutually exclusive because there is overlap which requires careful consideration when prescribing these drugs chronically, or even for acute pain.

Notwithstanding, the media has been grossly irresponsible by ignoring the whole truth, and [educated] politicians should be ashamed for using the misfortune and grieving of others to bolster a bully pulpit by which to gain popularity while hanging their legitimate pain patient constituents out to dry.

Dr. Timothy Atkinson put it well in our pending textbook chapter (2), The problem with chronic pain and opioid medications, where he compares these hydrocodone statistics to U.S. soccer. Dr. Atkinson, who is on his way to Tennessee to establish a practice in pain management, states the following within that chapter…

hellhathnofury“The claim that Americans use 99% of the hydrocodone available globally is a half-truth.  Hydrocodone in this regard can be compared to American football in a worldwide sense because no other country chooses to use it.  Just as the rest of the world plays soccer and calls it football, we use hydrocodone (which mg for mg is equivalent to oral morphine) in combined formulations with acetaminophen, aspirin, or ibuprofen.  In Europe, it’s more common to see dihydrocodeine, a codeine derivative and weaker analgesic compared to hydrocodone, used for mild to moderate pain or simply morphine itself.  Hydrocodone in Canada is only available in a cough syrup or elixir but not otherwise used for pain treatment.  Hydrocodone has also been used in Australia but has largely been replaced by morphine.  Ignoring this exclusivity of hydrocodone skews the picture of why the U.S. consumes the worldwide majority of hydrocodone and the reasons why hydrocodone has been prescribed more than any other prescription drug in the US.  The practical reality is that hydrocodone has become a favorite of physicians across the country because it is the only opioid analgesic of significant potency that over many years was not a schedule II controlled substance by United States federal regulation.  Hydrocodone combination products are schedule III controlled substances because it was originally believed the combination with acetaminophen or ibuprofen were less abusable compared to other products and potentially more effective in treating pain.”

Several studies have shown that the desirability, abusability, and/or likability of oxycodone is greater than that of hydrocodone, which at least in part is why the FDA originally scheduled hydrocodone as a III instead of II, another area of heated debate.  I don’t suggest that hydrocodone be treated the same or differently because of this, but I do wish to point out these facts here, because an added ingredient such as acetaminophen within the combination products such as Vicodin is not the only reason for the schedule III designation (3,4,5) and this has largely been ignored throughout media and political discussions.

Indeed, not only has the opioid pendulum swung too far (6), it has fallen off and knocked over heretofore clear-thinking clinicians and opioid overdose family victims to the point of an opioid-induced migraine, which I’m sure my colleagues know is a conundrum that is very difficult to treat.

We need to stop bickering!  Together, all of us need to encourage honest and open journalism, and work as a cohesive unit with regulatory agencies as a national community to make things right for pain patients and to protect against careless opioid prescribing.  We need to insist on accurate and honest reporting and squelch the hypocrisy of dishonest politicians such as Senator Joe Manchin who has a clear conflict of interest when it comes to opioid manufacturers as outlined here at When Politicians Play Doctor.

We have to insist on education to practicing clinicians and colleges, since the majority of those practicing medicine and pharmacy have scarce training on how to treat pain or addiction, and even less training on how to recognize and mitigate against opioid associated risks.  We need to recognize that for those that do have such training, the time for clinic visits have been cut to a minimum due to managed care reimbursement.  Furthermore, as pointed out in Dr. Gunter’s post hyperlinked above, expenses for alternative or adjuvant treatments other than inexpensive opioids, are not covered by insurance carriers and this must be addressed.

Many of you know that I have reached out to the “anti-opioid” community with an invitation to work in harmony, specifically Advocates for the Reform of Prescription Opioids (ARPO) with whom I would love to work.  Perhaps they are no more “anti-opioid” than I am “pro-opioid”, as it is not my intent to see the majority of pain patients on these drugs.  Instead I wish to see legitimate qualified patients on these drugs that have no other options and in whom proper safeguards are in place to monitor compliance and potential for subversive behavior.  I am not “pro-opioid”, but I am “anti-propaganda”, and this time I do not mean that as a pun!

For those involved with advocacy groups to curtail insouciant opioid prescribing and those involved with similar groups to preserve legitimate prescribing for patients requiring such therapy, please feel free to post a comment here and/or e-mail me to jeff@paindr.com.  My intent is to send a letter to the FDA as a collaborative effort requesting a forum by which all of our voices can be heard [TOGETHER] and new policies can be developed to address the needs of all in a civil and productive forum.

Please, let’s see some interaction here by sharing comments!

References

  1. Fudin J. The hydrocodone question [In My View]. Drug Topics. 2013 Dec. Vol. 157, No.12, Pages 14-16. (Also available online at http://drugtopics.modernmedicine.com/drug-topics/news/hydrocodone-question)
  2. Atkinson TJ, Fudin J. The problem with chronic pain and opioid medications. In ed., Peppin J, Kirsh K, Coleman J. Pain and Prescription Drug Diversion: Healthcare, Law Enforcement, and Policy Perspectives.  Publication pending. Oxford University Press. 2013.
  3. Wightman R, Perrone J, Portelli I, Lewis N. Likeability and abuse liability of commonly prescribed opioids. J Med Toxicol. 2012;8:335-340.
  4. Walsh SL, Nuzzon PA, Lofwall MR, Holtman JR. The relative abuse liability of oral oxycodone, hydrocodone and hydromorphone assessed in prescription opioid abusers. Drug Alcohol Depend. 2008;98(3):191-202.
  5. Wilsey BL, Fishman S, Li CS, Storment J, Albanese A. Markers of abuse liability of short- vs long-acting opioids in chronic pain patients: a randomized cross-over trial. Pharmacol Biochem Behav. 2009;94:98–107.
  6. Atkinson TJ, Schatman ME, Fudin J. The Damage Done By the War on Opioids: The Pendulum Has Swung Too Far. Journal of Pain Research. May 2014. 265-268.

 

16 thoughts on “Hydrocodone Half-truths Hath No Fury

  1. Thank you for the education and the ability to share our comments. I am a failed fusion where both nerve roots were compressed and damaged. I have pheriphral neuropathy and constant sciatica. Also dx with IC and IBS after losing 30% of colon. I have been a chronic pain patient for over 10 years. Have never lost my prescription or been arrested. How can the governor of Tennessee on Tennessee.gov under news say that only terminal or cancer pain should be treated. How can he decide that no one needs sleeping aides or tranquilizers? Chronic pain patients are not committing crime. Why does a police officer need access to my medication for a year at any traffic stop? I can walk for a short distance with my pain medication. I can sit only for brief periods. Pharmacies are playing God refusing to fill prescriptions. I know since I once went to 6 pharmacies in Tennessee before going back to Dr for him to locate and first place he tried had the medication. I am luckier than most because at least I have a pain management Dr where so many people can’t locate one. 1/5 of population suffering seems so unfair. Doctors and pharmacists hear our complaints daily. Please pray for help because limited life is better than no life and I will not suffer any worse.

  2. It seems the Citizens Petition PROP sent to the FDA has had some back lash on chronic pain sufferers.
    Dr. Kolodny joins Phoenix House after serving as Chair of Psychiatry at Maimonides Medical Center in Brooklyn, NY. Board-certified in psychiatry and addiction medicine, Dr. Kolodny is a national expert on the opioid addiction epidemic and has been a go-to expert for numerous media outlets, including CNN, The New York Times, The Wall Street Journal, and The Washington Post. In Dr. Kolodny’s clinical practice, he specializes in the treatment of opioid addiction. He is currently President of Physicians for Responsible Opioid Prescribing (PROP) and was previously the Medical Director for Special Projects in the Office of the Executive Deputy Commissioner for the New York City Department of Health and Mental Hygiene. For New York City, he helped develop and implement multiple programs to improve the health of New Yorkers and save lives.

    It Seems Dr. Kolodny and some of his followers from PROP are looking for fame yet they have forgotten the reason why they became doctors and took the “Oath of Maimonides”

    “The Oath of Maimonides ”

    The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily deceive me and make me forgetful of my lofty aim of doing good to Thy children.

    May I never see in the patient anything but a fellow creature in pain.

    Grant me the strength, time and opportunity always to correct what I have acquired, always to extend its domain; for knowledge is immense and the spirit of man can extend indefinitely to enrich itself daily with new requirements.

    Today he can discover his errors of yesterday and tomorrow he can obtain a new light on what he thinks himself sure of today. Oh, God, Thou has appointed me to watch over the life and death of Thy creatures; here am I ready for my vocation and now I turn unto my calling.

    Does anybody see the irony in this?

    1. Yes I am a chronic pain patient I have always followed all the rules. Never been in any trouble. I had Major neck surgery for spinal stenosis after that surgery my pain got much worse Because of the pill Mills here in Florida/ I am inadvertently punished. I am considering Suicide BC I can’t get pain relief. I’m being punished
      for unscrupulous Pharmacys and Mills. All I want is some of my life back… To spend time with my. Grandsons to become a productive member of our society again. Instead my pain is so all consuming. I’m actually considering suicide please give me the places. Where I can help fight this campaign against US legitimate severe pain patients. I can only function some days but Please let me assist for myself and all other legitimate pain patients. We are being persecuted to give politicians they’re re election bullshit. Thank you I want to assist all legitimate pain patients. Dawn Marie

  3. Dear Dr.Fudin,
    I have been meaning to submit my personal pain story to your website and will. I won’t address it here as it is like so many others. In short, it’s about an independent, educated woman who has suffered chronic pain since childhood. Not until a nerve was damaged during a carpal tunnel surgery and about 2 years searching for help, did I finally discover the dreaded acronym and diagnosis of RSD. After 4 years of a treatment regimen including medical and surgical intervention with a highly skilled, progressive and empathetic neurologist and also anesthesiologist did my life start to improve. I lost weight, got out of bed and even started on the treadmill & zumba. I finally finished grieving my old life and accepted my new one which is living with some level of pain daily, probably forever. My family relocated to Boston. I was scared to leave my medical team in the Atlanta area. My doctor hugged me goodbye and told me not to worry. Boston would be the best place to go. I was encouraged. I’m now here and find myself to able to receive any treatment. Even with a folder of documentation from my physicians, every doctor I have been to begin s the appointment with “we don’t prescribe opiods”. They will not do stellate blocks if you are on any opiods. I have been drug tested more times in 4 months than 4 years. I feel demeaned and humiliated and have spent days crying from the physical and emotional pain brought on by this lack of empathy and the fear of what will happen to me. I have lost my independence, my house, my savings and a career I loved to be forced on disability. Why in the name of reason would anyone choose this? I follow the rules. I don’t get “high”. The medicine helps me survive. I am going to fight. I strongly encourage all who can to post and write and follow the legislation and news. We must be heard. We must debunk the myths being propagated by the media and politicians who are interested in themselves. Thank you Dr. Fudin for your work. I apologize for any spelling any errors. The above article is right on point.

  4. Thank you Dr. Fudin for ringing the truth to the highest tree tops. As an author on Integrative Therapies, advocate, and as a chronic pain patient, everything you say here is a repeat of my values and my concerns.

    Any medication or therapy should be to improve patient function. If a patient needs opioids so they can do T’ai Chi or tolerate bodywork, then so be it! It’s about getting the patient out of the chair, or bed. If opioids give enough pain relief to get blood and lymph circulating, why shouldn’t it be part of a treatment program?. When physical needs are met, it fosters emotional and spiritual health that is important to who we are as human beings.

    I hope we, like Europe, will see the benefits of the many complimentary therapies that should be utilized in this country, but are not. Most patients in chronic pain use opioids as a last resort. For myself, myofascial therapy helps, but I cannot afford a body worker who specializes in treating myofascial trigger points. I self treat as much as possible, but research tells us that self-treatment should be an adjunct for the best outcome. Myofascial pain is the most predominant source of peripheral pain generation. So I ask, why would a healthcare system that blames the patient for pain management spending be willing to pay thousands of dollars for very invasive procedure such as epidurals, when they could spend 10% of that on myofascial therapies with better efficacy? Get the muscles moving appropriately and we can get our bodies moving. Get our bodies moving and it improves our overall health, a hidden healthcare cost to inappropriate pain management.

  5. In general, both Dr. Fudin’s and Dr. Gunter’s posts are very much to the point. However, what is lost in all of the discussions is the simple fact that some people have well defined conditions that are not going to get better no matter how much medication or therapy or any other intervention is provided. One of these is arachnoiditis. There is no “cure”. The pain, being generated and maintained in the central nervous system will not respond greatly to physical therapy or to medication. And all too frequently arachnoiditis is caused by interventional efforts including Epidural Steroid Injections and surgery. It is a condition that can be visualized on MRI but it is often overlooked as a diagnosis. THe lifetime suffering index (Intensity of pain times duration of pain) is far greater than cancer pain because of the years and decades of suffering that will occur. The real tragedy for them is that they become the primary target of the war on opioids., and that only magnifies their lifetime suffering index.

    At the same time these are the very patients that are refused medical care because they are one of “those chronic pain” patients. My own new doctor recently rolled his eyes with a look of disdain when I mentioned that I had specialized in the care of chronic pain patients. And there are no statistics on these very real and incurable pain patients. There are lots of patients and lots to be learned, but there is no desire among doctors in general to really take the time to learn and study the diseases of chronic intractable pain.

    Until the discussion moves to include CHRONIC maintenance treatment for very specific aspects of maximizing quality of life and quantity of activity with chronic incurable pain, we will continue to reinvent the wheel of treatments with limited track records.

    One last point, the “nirvana” of liberal access to multi or inter-disciplinary pain treatment is definitely not available to most people with chronic intractable pain. And keep in mind that this type of treatment was more common back in the 1980s but nearly became extinct when it suffered from the lack of any funding from insurance.

    1. Doc,
      I agree with everything you said, and that is the very point. It is why I said in the post, “Instead I wish to see legitimate qualified patients on these drugs that have no other options and in whom proper safeguards are in place…”

  6. Dr. Fudin,
    Thank you for all you have done to help those of us in pain.

    That being said, I would like to point out a few things both “sides ” of this controversial issue most likely have in common. I would think ALL people would like to see the following items without any opposition:

    1) Do we all want fewer people to die from overdoses of prescription drugs? YES
    2) Do we all want legitimate doctors who care about their patients and treat them as such? YES
    3) Do we all want to be treated with respect by our doctors, the DEA and police? YES
    4) Do we all want to know when a medication we are given is likely to cause adverse effects including the possibility of addiction? YES
    5) Do we want all want to be treated with respect when we are ill and must take any type of prescription medication? YES

    This list could obviously go on and on, but I think the point I am trying to make is that both “sides” of this issue may actually have far more in common than they themselves even realize.

    See Link for the following page:
    “Opposition to Kentucky HB 1-Reform HB 217 aka “Pill Mill Bill”
    https://www.facebook.com/pages/Opposition-to-Kentucky-HB-1-Reform-HB-217-aka-Pill-Mill-Bill/595049517218134

  7. Jeff – Please stop referring to an “anti-opioid” group. They’re not anti-opioid. They’re anti-pharma, anti-prescribing physician, and anti-patient – but not “anti-opioid”. Please don’t make it sound like they hate everyone and everything!! 😉 And please don’t pick on the poor, defenseless media!!!!! 😉

    As usual, brother, great job with the blog.

    Michael

    1. What an unfortunate and unhelpful comment.

      As a PROP member, I may be one of those viewed as “anti-opioid”. I am not. I do prescribe opioids from time to time, and sometimes for chronic pain. I have seen a small proportion of patients experience significant improvement in chronic pain as a result. More often I see patients fail to improve, or patients with adverse effects of opioid prescribing. (I also see plenty of patients with adverse effects of NSAIDs and other analgesics.)

      If I am “anti-pharma”, it is only because I think that drug companies exist primarily to make money. They are businesses, after all. At least one opioid manufacturer has admitted in a felony conviction of misleading doctors about the benefits and risks of their drug. Pharma’s objectives (monetary gain) are not aligned with my obligations to my patients.

      I am not “anti-prescribing physician.” As I said, I myself prescribe opioids to selected patients from time to time. I am opposed to the reckless prescribing of opioids that is so common and harms so many people, while helping so few. This is, to an extent, how doctors were taught to prescribe these drugs by “thought leaders” who received vast sums of money from pharma, because pharma liked what they had to say. I have no doubt these physicians believed in what they were preaching. People might want to read this piece in the Wall Street Journal to see one very prominent expert discuss the issue of opioids in chronic pain with the benefit of hindsight: http://online.wsj.com/news/articles/SB10001424127887324478304578173342657044604

      I assure you I am not “anti-patient”, nor is any other member of PROP. What a shameful, unproductive, invidious thing to say. This sort of antagonistic comment prevents constructive dialogue.

      That is not what patients need. They need safer, more effective treatment of pain. I think everyone on this blog can agree on that.

      D. Juurlink, MD, PhD
      Toronto

      1. Dr. Juurlink,

        Thank you for taking the time to comment here. First let me say that it is encouraging as a PROP signatory that you do prescribe opioids to some select patients for chronic use even though as you put it, “…reckless prescribing of opioids that is so common and harms so many people, while helping so few” is an issue. Perhaps this is an area that needs to be explored, as those “few” could be thousands of the millions that suffer from chronic pain syndromes unresponsive to other therapies, modalities, and/or alternatives including diet, exercise, and weight loss.

        I have not had such poor outcomes as you and others have suggested, but my entire practice is pain management and patients that are placed on chronic opioid therapy or remain on such therapy are very carefully chosen and monitored very closely for improved outcomes versus unacceptable risks. This tends to avert, as you suggest, “reckless prescribing of opioids that is so common and harms so many people”.

        Finally, I’d like to point out that the WSJ article you referenced regarding Dr. Russell Portenoy was commensurate with much of the sensationalized journalism we have seem run amuck as of late. The particular link you provided was discussed in great detail in one of my blogs, PROMPT Position Remains Unchanged! Regarding that report, Dr. Portenoy specifically clarified in a comment to me as follows; “The article quoted me accurately but selected a few quotes from a very long interview.”
        It lacks the voices of people with chronic pain, greatly overstates for dramatic effect both my influence on medical practice and the changes in my thinking, ignores the hyperbole and overreaching of those who seek to reduce overall use of these drugs without worrying about access for those who could benefit, and is in my opinion more about the reporter’s viewpoint than mine. I do not endorse its take-home message.”

        None-the-less, your position, message and comments are appreciated and I am hopeful that we can see more dialogue from healthcare providers and patients that tend to lean more towards avoiding opioids at all costs versus offering them in select patients chronically.

        And yes, we can all agree as you said regarding patients in pain, “They need safer, more effective treatment of pain. I think everyone on this blog can agree on that.”

      2. D. Juurlink, MD, PhD

        As a chronic pain patient, I would like to say that it is nice to see someone from PROP admit to using some opioids in their treatment of chronic pain patients. I found one thing you stated of particular interest to me.

        In reference to chronic pain patients, you stated, “They need safer, more effective treatment of pain. I think everyone on this blog can agree on that.” I couldn’t agree with you more. The problem therein lies with the fact that with many issues of the chronic pain community, there are no other appropriate medications for the particular conditions the patient suffers from.

        As a result, many patients are treated, somewhat poorly, with seizure medications and/or antidepressant medications that cause multiple, undesirable side effects and many times do little , if anything to help with the problems the patient is having.

        Many of the patents from the pain community will likely tell you they have been on many of the older versions of antidepressant medications as well as Neurontin, Topomax, and other seizure medications which left them feeling very ill along with, many times, no relief of the symptoms for which they originally came to see their doctor.

        This process of trying med after med until finally the medical provider refers the patient on or breaks down and gives up the blessed opioid seems like a bizarre way to reach the inevitable result. I realize you will most likely taut the successes of these drugs on some of your patients, but I question their honesty when they tell you they are better since they started taking that series of four different seizure and antidepressant medications.

        I submit to you a moderate regimen of one opioid medication would be far better for the patients’ overall health, than a barrage of 1960s era antidepressants mixed with seizure medications.

        Having gone through this barrage myself, more than one time, I can only offer the above as my opinion as a lay person.

        Sincerely.
        Kimberly K. Miller

  8. Dr. Fudin, thank you so much for finding a space within which we all can work toward a rational and yet compassionate environment for patients, while at the same time continuing to recognize and treat the disease of addiction. I agree with your earlier post discussing the polarization of our nation. I lived and worked in South Africa during the final years of apartheid rule, and returned home only to find that my own “beloved country”(Alan Paton, Cry the Beloved Country) was very like the old South Africa, in its mind-numbing anger and hatred of anyone who looked, spoke, or believed differently. I still believe we are better than this, and that we will pull ourselves together and work together for what is best for the country. Thanks again, for doing your part to begin that conversation.

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