Make Morphine Abuse Deterrent

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…and why you’re at it, do the same for generic Opana® ER (oxymorphone) 40mg, and oxycodone 30mg immediate release(IR) tablets.

As stated in previous blog posts, milligram for milligram hydrocodone and morphine are equivalent, so why the hype and push to require that Zohydro® ER (extended release hydrocodone) require an Abuse Deterrent formulation?
Because it sells stories and gives politicians a bully pulpit!
Unfortunately, in general neither group has a clue what they are talking about. So, here’s the facts…

Kadian® (extended release morphine) 200mg (Equals 4 capsules Zohydro® ER 50mg)
Avinza® (extended release morphine) 120mg (Equals 3 capsules Zohydro® ER 40mg)
MSContin® (extended release morphine) 100mg (Equals 2 capsules Zohydr® ER 50mg)
No drugs listed above are abuse deterrent.

Oxymorphone ER (extended release oxymorphone) 40mg (Equals 3 capsules Zohydro® ER 40mg)
No drugs listed above are abuse deterrent.

Oxycodone IR 30mg (Equals almost 50mg Zohydro ER 50mg), but generally oxycodone IR 30mg is taken four times daily. Therefore,
Oxycodone IR 30mg x 4 doses = 120mg (Equals 6 capsules Zohydro® ER 30mg)
No drugs listed above are abuse deterrent.

Now journalists and politicians; that’s something that should concern you!
But will it sell stories and promote popularity among politicians?

Sound Bites:
1. Zohydro® ER contains pure hydrocodone. TRUE
All the drugs listed above contain either pure hydrocodone, pure morphine, pure oxycodone, or pure oxymorphone. Tylenol® contains pure acetaminophen, Benadryl® contains pure diphenhydramine. It’s what the FDA requires of manufacturers, “pure” drug.
2. Until Zohydro® ER, the only form of hydrocodone commercially available contained acetaminophen. FALSE
Vicoprofen® contains ibuprofen, not acetaminophen.
Hycodan® Cough Syrup contains homatropine, not acetaminophen.
3. Until Zohydro® ER, hydrocodone was not available as a single entity within any commercially available dosage form within the United States. TRUE
Zohydro® ER could allow an important option for some pain patients, but not everyone. In fact, I’ll go a step further and say that hydrocodone as a single entity (without acetaminophen, ibuprofen, or homatropine) should be available in immediate release tablets for “as needed” use for acute pain in strengths varying from 2.5 to 10mg.

Countless journalists and politicians have been spewing statements that the real dangers of Zohydro® ER are because abusers will crush and snort the non-Abuse Deterrent formulation. But not one to my knowledge has attempted to (s)tell the real truth or why they believe this to be fact.

Point in fact – Drug abusers like to have a large milligram quantity of drug in a very small pile of powder so that they can feasibly snort the small amount of powder to quickly ingest a large milligram quantity of a potent narcotic. This was popular with the original formulation of OxyContin®, especially the 80mg and 160mg strengths, the latter of which was removed from the market for this reason. Prior to the reformulation, and after the 160mg strength was responsibly removed from the market by Purdue, in order to snort 160mg, an abuser would now need twice the powder volume (or 2 x 80mg tablets to achieve this). That wasn’t as desirable to abusers as the 160mg OxyContin® tablets.

Take a look back at the facts above; Kadian, Avinza, and MSContin® all allow a VERY significantly larger milligram quantity to be crushed and snorted within a smaller volume compared to Zohydro® ER.

And now for the final Sound Bite that I hear and see almost exclusively from anti-opioid zealots, most, if not all of whom are aligned with PROPagandists and unfortunately continue to suffer endlessly from the pain of losing a loved one to an opioid overdose – “OxyContin® and Zohydro® ER are synthetic Heroin.”

PLEASE! It would be far more accurate to say that canned Spam® is synthetic pork.  Ascorbic acid is in fact synthetic Vitamin C, otherwise extracted from rose hips or other natural sources. Morphine is a “natural opioid” which otherwise may be derived from nature’s poppy pods.
OxyContin® (oxycodone) is a semi-synthetic opioid manufactured in a lab that has similar chemistry to morphine. Zohydro® ER (hydrocodone) is a semi-synthetic opioid manufactured in a lab that has similar chemistry to morphine. Conversely, heroin is a chemically enhanced “natural opioid” containing two morphine molecules sandwiched together and attached by an acetic acid (vinegar) group to make di-acetyl-morphine. All of these, and many others, including buprenorphine (an ingredient in Suboxone®), and the dextromethorphan found in over-the-counter cough syrup share a common chemical nucleus known as phenanthrene – but I haven’t heard these anti-opioid zealots call these two drugs “synthetic heroin”. Fentanyl is a purely synthetic opioid of another chemical class, the phenylpiperidines – this is 100x more potent than morphine.intelligent-pyramid

I don’t really believe that politicians and journalists are as mentally challenged as they seem; to the contrary they are quite smart, as they have been able to hoodwink thousands of listeners and readers into believing that limiting Zohydro® ER will somehow solve or mitigate the “opioid epidemic”.

I do believe that many have “selective learning” in order to sell selective stories.

If I was an addict that liked to snort opioid narcotics, I’d say, bring me the oxycodone IR 30mg, generic extended release oxymorphone, or any extended release morphine in the highest possible strengths – they are cheaper than Zohydro® ER, more easily accessible, less scrutinized (thanks to all of you readers) and more concentrated for a euphoric escape from reality.

I will wrap this up by challenging politicians and journalists to tell the unpopular truths as outlined herein.  You really can’t logically dispute this content because what you see here is fact, not fiction or presumptions. Contact me or read my blogs if you want to know the real scoop!

And, as always, comments are welcome!

15 thoughts on “Make Morphine Abuse Deterrent

  1. I too, am grateful for the advocacy we are getting from Dr. Fudin and from the few other professional doctors out there, that are hearing us. If only more of them would help us with the problems we are ALL now facing in war against patients. At least by speaking out loud too. Why can’t the AMA do something more?
    I have to honestly wonder, if any of this will ever get better? I wonder if the FDA or any DEA rep ,Congressman and women ever see or hear about our troubles all over the internet?
    These problems in FL have going on for at least 3 and half years. When is it enough? Now that more states are experiencing some of our troubles that we are having in FL in their states too, I wish that everyone who works with pain patients that they will this get even louder!
    The inhumane cruelty is just getting to be over board in all directions now.
    I honestly hope that somehow, we can be heard. There are so many patients that don’t have the web to sound off on and if only we had all the patients sounding off, perhaps we could really get somewhere. Sadly, many of them are just too ill or having to experience withdraws so often now days that they just can’t get out to be heard. The morale is losing momentum here in a very BIG way.
    I pray, that somebody who has connections with people in Washington DC, would get Congress to investigate the DEA and all the harm they are causing people suffering with pain.
    When is it enough? Are legitimate pain patients ever going to be able to have any kind of a life ever again?
    I’m just so sick of it all. It has gotten so ridiculous!

    Thank you to the doctors who are trying to help. Honest. We just need more of you.

  2. Dr. Fudin,
    Thanks for the hard work you do making sense out of the damage politicians and journalists have done to Zohydro ER . We need to give this medication a chance and see how well it does , I have a feeling its going to be a excellent medication for those that cant take acetaminophen.
    You’ve done a excellent job explaining and comparing this new medication Zohydro ER to other pain medications. I hope anti-opioid zealots grasp what it is your explaining . Awesome job ,I admire your enthusiasm, I wish we had more doctors with your mindset.

  3. Kadian (branded and the selected generic formulation which was made by the original manufacturer) does have some abuse deterrent qualities. Oramorph has a better safety profile when mixed with alcohol. Avinza has a maximum dose limitation due to its inert ingredient. Embedda has not yet been re-released, but I understand plans are to revive it
    I agree with Dr. Fudin that FDA needs to level the playing field for standards of other generic formulations with abuse deterrent features for all long acting opioids, including the generic fentanyl patch.

    1. Thank you Dr. Hoffberg for your clarifications! I’m sure hoping it’s warmer down in your neck of the woods and that you are or will soon be enjoying the cherry blossoms.

  4. Why is someone always to blame? It’s big pharma? It’s uncaring, unscrupulous doctors. Whatever happened to personal responsibility? How many of these folks that NEED an abuse deterrent actually have a prescription for the Rx in question? My guess is very few. They are either stolen, scammed, diverted, etc.
    Who winds up paying more, often for less effective ‘abuse’ DETERRENT (not abuse proof) opioids? The cash strapped patients, many of whom are on fixed incomes with their backs up against the wall as it is. Thank god I am able to obtain methadone. It costs under $30 per month. I must add that haven’t needed nor requested an increase in dose since titration to 40mg almost 4 yrs ago. Pssst…..hey guess what no BUZZ either, now that’s what I call an abuse deterrent). Can we cut the crap and get these bozos to tell us what they are really after?

    Headlines for the get tough politicians? Ok I get that. Someone to blame, for the families who’s addicted son, husband, cousin, grandson, etc snorted 3-4 oxycodone IRs or Oxycontins washed down w/ Jack Daniels and a few Xanax thrown in for good measure? Can they not see they are pawns here? Can they not accept the fact that there are warning right on the bottle? Oh yeah they probably didn’t have an Rx.
    America-When did the land of the free and home of the brave become the land of the unaccountable, and the home of the blamed?

    For years I have had to suffer many many unrelenting symptoms from autoimmune disease that finally forced me to file for and receive SSDI in 2012. Up until recently pain was one symptom, thankfully, that I didn’t have to worry about. I have had a caring pain management doctor affiliated with and located on a major medical center’s campus in North Florida. (hint-My doc is a well respected PM doctor who was involved in the Zoginex Zohydro trials. I was offered free meds w/ entry, (I still have the trial’s outlining documents saved in email folder) I declined. Methadone worked so why fix what wasn’t broken. My PM also consults w/ the state of FL on how to distinguish pill mills from legitimate PM clinics, so I felt about as safe as one could feel in this climate of fear, UNTIL LAST WEEK)

    Last Monday I was ping-ponged back and forth between two pharmacies.. BOTH located on the same medical center, one in the main hospital one a block over in a separate building (but still on medical campus). Despite being a patient of this HOSPITAL in several departments including rheumatology, neurology, pulmonology, and pain management for almost 5 years neither one wanted to fill my Rx for methadone. Feeling poorly that day I wished to forgo the usual stroll/drive to the main hospital and took my Rx to building ‘X’. They informed me that they were not taking NEW patients that if they filled my Rx they wouldn’t have enough medication for their REGULAR customers. The pharmacist told me since I normally filled at the main hospital then I must take it there. Too sick to put up an argument I went to the main hospital pharmacy. Once there I was informed that since the Rx was written by a doctor from building ‘X’ I must fill it at the building ‘X’ pharmacy. (Of note: I had no problems filling this Rx at either for almost 4 years). Main hospital pharmacist phones other pharmacist and says you guys must fill it because that’s where it came from/was written; whereupon he was told NO, he’s YOUR customer you must fill it. Pharmacist gets off horn and tells me sorry no can do.

    WHY I ask? He says, ‘you haven’t filled here in 2 months’. I explain…..well, since I can’t fill early and my appts don’t always line up w/ my fill dates exactly sometimes I must fill them at home (over an hour and a half away (fine w/ both pharmacies and doctor until now), long story but it boils down to-when you have good docs you hold onto them like gold even if over 1 1/2 hrs away).Thank god I have a long standing relationship w/ a compassionate pharmacist at a local supermarket (god help me if he leaves). I would take them there every month if it wasn’t another half hour to drive, one way, and I didn’t recently have transportation issues.

    SO, hospital pharmacist says let me talk to head honcho pharmacist. Hear them chewing ‘problem’ over, berating the incompetence of the ‘other’ pharmacist, etc, etc. Finally hosp pharm comes back and informs me that he WILL fill my Rx, intimating as though he’s doing me some kind of favor as he explains to me ”we don’t even know if we’ll even have enough to fill the hospital’s patients” HELLO, what am I chopped liver, 5 years at a hospital and I’M not a hospital patient????? I ask what about next month? I explain that it will be on the 31st day as this is the only day that both my PM and rheumatologist will be there together that week. He says if they have it they will fill it but no guarantee.
    I ask if I call ahead would it be more helpful. NO.

    I REPEAT THIS IS AT A MAJOR HOSPITAL/MEDICAL CENTER THAT I HAVE BEEN A PATIENT AT FOR ALMOST 5 YEARS!!!! In PM for almost 4 yrs. NEVER FAILED A DRUG SCREEN, NEVER FILLED RX EARLY OR ‘LOST’ AN RX, USE TENS, OCCIPITAL BLOCKS, EUFLEXXA FOR KNEE, DEPOMEDROL FOR CHRONIC SHOULDER BURSITIS, SO NOT JUST PILLS. HECK, I HAVEN’T EVEN MISSED AN APPOINTMENT IN 4 YEARS !!!

    I called the hospital’s patient relations number the next day. A pleasant woman took down the information and told me that a patient advocate would be in touch with me soon. One week later no call no message so I call today. Left message, no return call as of yet from the director of outpatient services (pharmacy).

    I FEEL LIKE I STEPPED INTO THE TWILIGHT ZONE. WTHeck is going on here? No offense doctor Fudin, but arguing about wording and drug approval seems a little trivial if a patient with two verifiable systemic autoimmune diseases (one by biopsy-sarcoidosis; the other by [+]ANA and [+]anti-U1-antibodies) cannot get a legit prescription filled at a HOSPITAL that diagnosed him and treated him for almost 5 years. What good is it to get Zohydro or any other ‘evil’ opioid approved, abuse deterrent or not if we can’t even get a HOSPITAL pharmacist that wants to fill it?

    WHAT I WOULD LIKE TO KNOW IS WHY THE FUSS? What do these folks want? What is the motivation? I don’t believe for a second that it has anything to do w/ saving addicts from themselves. An addict can walk in and get 4 times the methadone I take for NO LEGITMATE MEDICAL NEED, JUST THAT HE ABUSED OPIATES FOR KICKS. HECK MARIJUANA IN SOME STATES FOR NO REASON SAVE TO GET HIGH. You cannot save a person bent on self destruction by passing laws and choking off supplies. I believe it was Gov Ventura who claimed, rightfully that you cannot legislate morality. This is shown to have failed for years upon years. It does not even work for cocaine or heroin in the most secure institutions in the country (jails and prisons), how can it work for legitimate pharmaceutical medications that are NEEDED by LEGITIMATE PATIENTS? Those of us disabled w/ systemic INCURABLE disease processes have enough on our plates with other symptoms w/out having to fear dealing with unrelenting pain and possible withdrawal. (or extortion for designer opioids to protect ‘patients’)

    Opioids have been around forever, they are cheap, or should be, plentiful (again, should be). What is the REAL reason for this pendulum swinging back from progressive, humanitarian, and compassionate care for sick people back to the stigma of opioids as evil incarnate? This is not a rhetorical question, I really want to know.

    Did anyone see USA TODAY’S front page on WED? Medical workers as hopeless addicts incapable or unwilling to police themselves and putting patients at risk. Is this news? As usual, not a word about legit patients being helped, just death and destruction and a lack of enforcement against criminals (rehabs in place are just not effective). WOW !!

    Thank you Dr.Fudin for your advocacy and attempts at reasoning with the unreasonable.

    From a puzzled and confounded Coonhound who’s nose is raw from following so many false trails looking for the TRUTH in this ‘epidemic’ and the crusader’s unpalatable remedies to solve/cure it. (*Sorry to have gotten off on such a tangent, I am very frustrated and frightened, please place this somewhere else if this is not the appropriate thread, I am sure it is an appropriate fit somewhere if not here)

    1. Thanks to Christopher for taking the time and effort to describe his frustration and agony at trying to get his legitimate prescriptions flllled.and to Dr Fudin for providing this blog as space for airing stories like this that are commonplace to many of us chronic pain sufferers.

      What did we law abiding citizens, veterans, retirees, do to deserve such treatment from so many of the “caregivers” who control access to ooioid pain relievers? Nothing, that’s what. We are just collateral damage, and PROP has made it perfectly clear that they could not care less what happens to people who get in the way of their anti-opioid jihad. Not their problem, as Judy Foreman makes clear in her new book, A Nation In Pain.

      1. Thanks Denis for your response and Dr Fudin for your forum..

        UPDATE:
        I finally received a return call from Baptist Medical Center’s Director of Retail Pharmacies.
        I was informed that I was a ‘special case’. I was told that most patients from the Institute of Pain Management fill their Rx at the Reid Building pharmacy, where the clinic is located, and most ‘hospital’ patients fill at the Pavilion Pharmacy, located in main hospital building.
        I told her the reason I went there was they always had my meds, and that I didn’t go back and forth. The only reason I went to the Reid Building Pharmacy on this particular day (1st time in 3yrs?) was I was feeling so horrible I wasn’t up for another stop (let alone an hours worth of their inane rigmarole)

        I was told that The Pavillion Pharmacy (located in main hospital building) fills for patients being treated in hospital, mainly from surgery, etc. She told me that the pharmacists were just following new protocol as the big bad DEA is just ‘sitting back watching’. I informed her that DEA or no DEA that this was a heck of a way to treat someone who has been a patient at their hospital since 2oo9. I also asked if she was familiar with the fact that methadone was rarely used as a post surgical medication and she admitted that she did (HELLO) Then I asked if I she would guarantee that my medicine be filled when I return for my appt on the 15th. At this point she asked for the name of my rheumatologist (after I told her all my docs and depts.I had been seen at) and told me that she needed to look into my condition and records!!!! I asked if this was now required of all patients filling schedule II meds at the hospital. A pause, well no, but……………I cant remember any BS past this point as I was shocked. I would expect a representative of the hospital to be bending over backwards apologizing for wasting my time as I was extremely nauseated that day. Instead I am being ‘investigated’ to see if I’m legit !!!!!. Unbelievable.

        I don’t know any other way to interpret their inquiry into who my doctors are (after I told them, I guess my word and the name on the Rx aren’t good enough. Are major regional hospitals going the Walgreens route now on their own longtime patients? Its seems to be the case, at least on those who assert their rights, don’t ‘know their place’ and fall into line. SHAME ON THEM. I would take my business elsewhere but it does not appear that there is anywhere else where the grass is greener, might as well stand put and fight it out.
        As I stated before, I thought that receiving treatment at a major medical center would insulate me from all the problems raining down on those w’ chronic pain. When big hospitals are being controlled/run in this manner it really shows how insidious this crusade has become.

        I assured her that my records indicate BOTH (+)ANA and antibodies (anti-U1-RNP-antibodies) ONLY associated w/ SLE(30-50%)/MCTD(95%)/MYOSITIS(20%).
        MCTD being a nasty combination of symptoms, tissue, and organ damage of lupus, scleroderma, and myositis. Also Dx @ J Hopkins w/ systemic sarcoidosis in 2000 by mediastinoscopy.(Chamberlain procedure)

        I told the representative that despite her protestations that there is only a limited supply of such medications, that both pharmacies had enough methadone on hand to fill my modest Rx (120), nevertheless I was denied at both. A newly diagnosed, less outspoken, experienced person might just have accepted their BS.

        *I always am always amazed how shocked these ‘authority figure’ types are, (pharmacist A) when their words are not taken as gospel and are challenged The poor old timer seemed absolutely flabbergasted when this young whippersnapper (42) asked if he had some explanation IN WRITING as to why I was being denied access to my medication from a medical center physician despite having it in stock. I guess we will see what happens now.
        I figure I’m either going to get the keys to the castle OR will be on the medical center’s hit list.

        Doesn’t ANYONE (outside the few heroes here on Dr Fudin’s blog and PainTxTopics) in the medical system have a pair [?], Is it required practice now to trade them in when receiving a medical doctorate? If the Student Doctor Network is any indication of what the future holds in regards to incoming professionals and their regard for patient’s quality of life issues, we are in deep poo-poo.

        *If it is not acceptable to name the institutions involved please block them out. I assumed with seeing Walgreens, CVS, several Pain Advocate organizations, and pain management doctors by name (PROP + PROMPT) that this was acceptable practice. I see no reason to give these people anonymity as I am telling exactly what happened and MY name is right out front and I have the most to lose here, [though still haven’t figured out why])

        Coonhound signing off

          1. Dr. Fudin,
            I take Xartemis, I have had chronic pain for over 10 years due to car accident. H

  5. Thanks for keeping the facts in the spotlight Dr. There seems to be a lot of fiction out there to correct and much is recycled just for publicity. Interesting comment on an immediate release lower dose Zohydro to challenge the necessity of acetaminophen or other additives as found in Vicodin, and other combo hydro formulas that all have added risks because of the added drugs.

    1. To concerned patient.

      Unless I’m mistaken, Xartemis acquires its “abuse-deterrent” status precisely because it contains acetaminophen, just like Vicodin.

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