Mythbusters: Hydrocodone is NOT a ProDrug!

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Many urban myths have surfaced of late, perhaps as a result of the newfound interest among politicians professing to be experts on appropriate use, misuse, and abuse of opioids.  Irrespective of the niggling rhetoric we’ve seen from various ill-informed politicians nationwide, hydrocodone is here to stay.  Extended release formulations of single entity hydrocodone as Zogenix Inc’s twice daily Zohydro ER and the anticipated release of Purdue Pharma’s once daily Hysingla ER are welcomed additions to the opioid armamentarium for various pharmacologic, pharmacokinetic, pharmacogenetic, and therapeutic reasons which no doubt are foreign to non-medical politicians that are either ignorant to the facts or unwilling to learn. But, I do offer kudos to those politicians that have taken the time to learn and understand some of the unique properties.

Fortunate for our readers, Dr. Thien Pham agreed to separate fact from fiction and tell the whole truth and nothing but the truth.  It just doesn’t get better than watching such a rising star in action!  Here’s what Dr. Pham has to say…

Prescription opioid medications have been especially scrutinized over the last few years including a heightened public awareness of prescription and illicit opioid-related overdoses and death.  According to the Substance Abuse and Mental Health Services Administration (SAMHSA) Drug Abuse Warning Network (DAWN), between 2004 and 2011 hydrocodone was the second most identified opioid (second to oxycodone) attributing to drug-related Emergency Department visits (1).  As a result of this public health concern, physician-prescribing practices are under a microscope; prescription drug monitoring programs are in full swing, the development and distribution of naloxone kits including the first FDA-approved naloxone auto-injector EVZIO, and now the highly anticipated reclassification of hydrocodone combination products has come to fruition.

On August 22, 2014, the Drug Enforcement Agency announced the reclassification of hydrocodone combination products from schedule III to schedule II of the Controlled Substance Act which will be effective as of October 6, 2014.  Historically, hydrocodone was listed in schedule II upon the enactment of the Controlled Substance Act in 1971.  At that time, hydrocodone combination products in regulated doses “containing no greater than 15 milligrams (mg) hydrocodone per dosage unit or not more than 300 mg hydrocodone per 100 milliliters” were classified as schedule III if formulated with other “therapeutically active nonnarcotic ingredients” such as acetaminophen or ibuprofen.  However single-entity hydrocodone or combinations of hydrocodone outside the aforementioned regulated doses were classified as schedule II (2).

There are many misconceptions regarding the metabolism of hydrocodone, its metabolites, as well as its abuse potential.

hydrocodone metabolism

MYTH:  “If hydrocodone were not a prodrug, pharmaceutical companies would have developed a parenteral version many years ago.”
FACT:  Hydrocodone a prodrug?  I don’t think so – more to follow below! In a study by Cicero et al, “Oxycodone was the choice of significantly more users (44.7%) than hydrocodone (29.4%) because the quality of the high was viewed to be much better by 54% of the sample, compared to just 20% in hydrocodone users, who cited acetaminophen as a deterrent to dose escalation to get high and hence, its low euphoric rating” (3).  This preference is also reflected within the popular Bluelight.org and Opiophile.org internet forums (4, 5).  However Stoops et al, concluded in their study that potency differences were modest when oral formulations of oxycodone, hydrocodone and morphine were administered intravenously, implying similar abuse potential (6).  This puts a whole new spin on PO to IV conversion.
RESULT:  UNANSWERABLE, since hydrocodone is not a “prodrug”.

MYTH:  “Hydromorphone is the primary metabolite of hydrocodone.”
FACT:  Nearly 60% of hydrocodone’s metabolism is mediated through the combined CYP 2D6 and CYP 3A4 pathways resulting in the formation of hydromorphone and norhydrocodone (7).  Studies looking at the metabolism and excretion patterns of hydrocodone in urine, found that norhydrocodone was the most abundant metabolite and frequently detected in combination with hydrocodone within 2 hours of drug administration (8-9).
RESULT:  POSSIBLE BUT NOT PROBABLE, with an ultrarapid 2D6 metabolizer or in patients receiving potent 3A4 inhibiting drugs.

MYTH:  “Norhydrocodone, formed via the CYP 3A4 pathway, is an active metabolite having WEAK analgesic activity compared to hydromorphone.”
FACT:   When administered intracerebroventricular, norhydrocodone displayed similar potency to hydrocodone in producing analgesia (10).
RESULT:  CONFIRMED

MYTH:  “Norhydrocodone, formed via the CYP 3A4 pathway, is an active metabolite having WEAK analgesic activity compared to hydrocodone.”
FACT:  “Binding studies established that norhydrocodone, similar to hydrocodone and hydromorphone, is a μ-selective opioid ligand. In vivo analgesia studies (tail flick) demonstrated that, following subcutaneous, intrathecal, and intracerebroventricular administration, norhydrocodone produced analgesia. Following subcutaneous administration, norhydrocodone was ∼70-fold less potent…”  “Following intrathecal administration, norhydrocodone produced a shallow analgesia dose-response curve and maximal effect of 15-45%, whereas hydrocodone and hydromorphone produced dose-dependent analgesia. Intrathecal hydromorphone was ∼174-fold more potent than intrathecal hydrocodone.)”
RESULT:  CONFIRMED

PRODRUG:  For the record, by definition, a “prodrug” does not have any pharmacological activity until metabolically converted to the active form (examples include codeine → morphine and tramadol → O-desmethyl tramadol).

MYTH:  “Hydrocodone is nothing more than a prodrug with absolutely no inherent activity of its own.  It must first be metabolized via CYP 2D6 to hydromorphone in order to achieve any activity whatsoever.”
FACT:  By no means is hydrocodone inert in nature as analgesia was induced following subcutaneous, intrathecal, and intracerebroventricular administration of hydrocodone (10).
RESULT:  BUSTED

ThienThien Pham, B.S., Pharm.D. is a PGY2 Pain & palliative Care Resident at the Stratton VA Medical Center in Albany.  His participation in this blog was not a part of his government duty and represents his opinion (confirmed accurate by Dr. Jeffrey Fudin).  A navy veteran, Dr. Pharm completed a PGY1 General Practice Residency at Veterans Affairs Medical Center in Palo Alto CA.  Prior to receiving his Doctor of Pharmacy at Touro University California in Vallejo CA, he received his Bachelors Degree in Biochemistry with Medical Sciences emphasis from the University of California Riverside in Riverside CA.

References:

  1. SAMHSA. Detailed Tables:  National Estimates, Drug-Related Emergency Department Visits for 2004–2011. Rockville, MD: Office of Applied Studies, 2011. Available at: http://www.samhsa.gov/data/DAWN.aspx#DAWN%202011%20ED%20Excel%20Files%20-%20National%20Tables.
  2. Nerenberg DM, Fudin J. Letter to the editor in AJHP. Maximum daily dose of hydrocodone. Am J Health-Syst Pharm—Vol 67 Oct 1, 2010. 1588.
  3. Cicero TJ, et al. Factors influencing the selection of hydrocodone and oxycodone as primary opioids in substance abusers seeking treatment in the United States. Pain. 2013 Dec;154(12):2639-48.
  4. Bluelight.org [internet]. Accessed at: http://forum.opiophile.org/showthread.php?6250-Shooting-Hydrocodone-%28experiences-problems-etc..&s=f8ff84f42b69179dac8d23974731db7e
  5. Opiophile.org [internet]. Accessed at: http://www.bluelight.org/vb/threads/356209-Injecting-hydrocodone-amp-oxycodone
  6. Stoops WW, et al. Intravenous oxycodone, hydrocodone, and morphine in recreational opioid users: abuse potential and relative potencies. Psychopharmacology (Berl). 2010 Oct;212(2):193-203.
  7. Hutchinson MR, et al. CYP2D6 and CYP3A4 involvement in the primary oxidative metabolism of hydrocodone by human liver microsomes. Br J Clin Pharmacol. 2004 Mar;57(3):287-97.
  8. Cone EJ, et al. Prescription opioids. II. Metabolism and excretion patterns of hydrocodone in urine following controlled single-dose administration. J Anal Toxicol. 2013 Oct;37(8):486-94.
  9. Valtier S and Bebarta VS (2012) Excretion profile of hydrocodone, hydromorphone and norhydrocodone in urine following single dose administration of hydrocodone to healthy volunteers. J Anal Toxicol 36:507–514.
  10. Navani DM, et al. In vivo activity of norhydrocodone: an active metabolite of hydrocodone. J Pharmacol Exp Ther. 2013 Nov;347(2):497-505.
  11. Navani DM, Yoburn BC. In vivo activity of norhydrocodone: an active metabolite of hydrocodone. J Pharmacol Exp Ther. 2013 Nov;347(2):497-505.

 

 

41 thoughts on “Mythbusters: Hydrocodone is NOT a ProDrug!

  1. It bothers me that no one on this board has mentioned the legalization of marijuana. John Boehner is heading the push to legalize it. What better way to get MJ legalized than to torture people in constant pain??? He spearheaded the opioid epidemic for $$$$ from marijuana.
    I wake up in the morning & all I can think about is pain. Most days I can make it to the shower & all I can think about is pain. I go to my Dr & all she can think about is pushing me out the door, while I’m thinking about pain. There is no more fun, no more happiness. Nothing to look forward to because I can’t break free from pain. There is nothing I do that can be considered “living”. I’m simply existing.
    Wait til MJ is legalized then they’ll loosen the reigns (I hope).

  2. I have a 78yo chronic pain patient who takes Norco 10/325 q6-8h prn BTP in addition to methadone 5 mg q8h. Her opiate gc/ms showed high levels of HC, but no HM. Since I had zero suspicion of ‘urine spiking’ (and the possibility was r/o’d by the presence of NHC), I suspected she was a 2D6 poor/non metabolizer. I re-did the test a few months later and got the same result: high HC, high NHC, zero HM.
    So I brought it to the patient’s attention that due to a normal liver variation, codeine-based drugs were probably not a great match for her and she would probably get better analgesia from Dilaudid + APAP.
    She thought the Norco was working great but agreed to give it a try. I gave her an rx for HM 2mg, q4-6h prn BTP + APAP 325 q6h prn.
    She came back a few weeks later and said she wanted to go back to the Norco! She repeated that the Norco had been working great, that the Dilaudid was significantly less effective, and that she preferred taking the ‘2 in 1’ because it was fewer pills that she could take less frequently.
    I switched her back to Norco, as requested, but I’m having trouble coming up with an explanation for why HC would work better than HM in a 2D6 non-metabolizer, other than perhaps placebo effect based on pt expectation. Any better ideas? Anyone seen this before?
    I generally see no reason not to follow patient preferences so long as they’re safe and medically justifiable. Is it medically justifiable to keep a patient on HC in these circumstances? It’s very hard to argue with “what works!”

    1. JR, Opioids combine with various mu receptor subtypes, and it is therefore possible that a patient could respond better the one than the other. I have seen this before even after confirming with pharmacogenetic testing. She could be both a poor CYP2D6 metabolizer AND a poor CYP3A4 metabolizer, the latter of which would result in parent hydrocodone staying around longer. As you know, hydromorphone only undergoes Phase II metabolism, so neither enzyme would affect it. I suspect she would do fine by simply raising her methadone dose, but that leaves nothing for breakthrough pain which I’m assuming is your intent. Unless you’re okay with leaving her on hydrocodone/APAP PRN, you may want to get a genetics test. And while you’re at it, since she’s on methadone, I’d be be sure to get at CYP2B6 and 2C19 due to methadone enantiomer, and might as well test OPMR-1, MTHFR, and COMT.

  3. The rationale presented for concluding that hydrocodone is not a prodrug is incorrect. If I understand correctly it seems you are implying that because hydrocodone is active via parental routes it can not be a pro-drug? Many pro-drugs are active without oral first-pass metabolism. Look at heroin which is a 6-MAM/morphine pro-drug and has rapid parental activity despite requiring metabolism. Although this deacetylation is not CYP dependent it is still relevant. Distribution via parental routes occurs to all tissues rapidly and significant hepatic metabolism to hydromorphone will still occur rapidly via parental routes likewise CYP enzymes are expressed elsewhere in lower levels including the CNS.

    Hydrocodone has substantially less mu opioid receptor (MOR) affinity than hydromorphone as do oxycodone relative to oxymorphone and codeine relative to morphine. These compounds may be weakly active on their own as they do have MOR affinity but at the very least they seem to have active metabolites which are very important to their pharmacological activity especially at lower doses. See: http://www.sciencedirect.com/science/article/pii/002432059190150A
    People with low CYP2D6 expression levels show poor analgesic responses to hydrocodone further support the pro-drug hypothesis.
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2148980/?page=1 and http://www.sciencedirect.com/science/article/pii/S0009898113004622
    Again I imagine that the effect is dose dependent and that at higher doses CYP2D6 deficient patients may show response to hydrocodone. The case with oxycodone being a prodrug is less clear as it does seem to have activity on its own but still active metabolites appear very important to its activity. http://www.sciencedirect.com/science/article/pii/S0033318203702400

    1. Jason,
      Thank you for your comments. Specifically what was stated is “by definition, a “prodrug” does not have any pharmacological activity until metabolically converted to the active form (examples include codeine → morphine and tramadol → O-desmethyl tramadol)”. We did not state or imply that “…because hydrocodone is active via parental routes it can not be a pro-drug”.

      1. I was responding to this comment but maybe I misunderstood.

        MYTH: “Hydrocodone is nothing more than a prodrug with absolutely no inherent activity of its own. It must first be metabolized via CYP 2D6 to hydromorphone in order to achieve any activity whatsoever.”
        FACT: By no means is hydrocodone inert in nature as analgesia was induced following subcutaneous, intrathecal, and intracerebroventricular administration of hydrocodone (10).
        RESULT: BUSTED

  4. I had a urine test done. I am prescribed Tylenol with codeine No. 3. The urine test was correct in stating a positive test result. The problem is that it also reflected medications or metabolites detected that were not listed on the lab requisition. This drug was Nor hydrocodone. I do not take any type of other drugs for pain…just the Tylenol with codeine No. 3. It has created serious trust problems with my family and medical staff. Can you help?

    1. Pamela,
      If you are on high doses of codeine regularly, a natural metabolite of codeine (converted in your liver) is hydrodcodone. Hydrocodone is then metabolized to norhydrocodone.

      See my wesbite under RESOURCES, then OPIOIDs, then,
      Opioid Serum Predictabilities – This comprehensive table provides expected serum predictabilities in patients receiving commonly prescribed opioids. You may want to print it out and bring it to your doctor or direct him/her to that section of my website.

  5. Let me understand In this article you are saying that hydro condone is a prodrug but has some effects on its own and produces a high after the initial injection into the blood stream while it is in the process of going through the two conversion pathways in the liver to produce the two analgesic compounds. But is hydro condone alone analgesic prior to conversion? Could this be why it was never developed for intervenus analgesic use because when these sort of drugs are injected the expectation is immediate pain relief.

  6. Mare distinguishes between her dependence (relatively benign) on opioid pain relievers and addiction (totally evil).

    It should come as no surprise that the anti-opioid jihadists at PROP pooh-pooh that whole dependence concept as a creation of the “opioid industry.” On page 141 of Judy Foreman’s excellent book A Nation In Pain, she states that “Andrew Kolodny. …adheres to a radically different — and significantly expanded — definition of “addiction” compared to other groups.

    The more addicts that PROP can claim in its propaganda, the scarier that number looks to PROP’s intended audience: politicians and uninformed journalists.

    As a PHN sufferer for over 8 years, I am for sure dependent for a normal life on 120 mg/day of morphine sulfate, plus up to 3 oxycodone pills. I have nothing to fear from legitimate science and scientists, but everything to fear from unscrupulous true believers (See the book of that name by Eric Hoffer) who literally could not care less whether I live in pain or die.

  7. My dear friend Myra Christopher will be speaking at the National Institutes of Health “Pathways to Prevention” workshop on “The Role of Opioids in the Treatment of Chronic Pain” in Washington, DC, on Sept. 29-30. Though I am sure she is armed for bear, I will share this blog with her. Thank you for all you do and taking the time to respond to everyone, physicians and patients alike. I always learn something not only from the blog, but in your replies. In healing and hope.

  8. I suggest everyone that truly suffers from chronic pain start titrating down to the lowest dose possible and that dose still cover your chronic pain. Many surprises are yet to come and its best to be prepared rather than be caught with a high tolerance of whatever you take for chronic pain. Over the last 6 months I titrated down and it was my intentions to take myself off this pain med. but I forgot how bad the chronic pain can get after 12 years passing me by. So I had to stop at the lowest dose possible and it still have some kind of pain control.
    Back in the late 1990’s and early 2000 doctors got too lenient prescribing opiates to anyone claiming to have chronic pain without proof of pain from a MRI or Cat Scan etc. People addicted to drugs messed things up for us that truly suffer from chronic pain. Now their being weeded out and it might take a good year to get things back to on track , hope all that truly suffer make it by okay. Keep a low profile and low tolerance till this mess passes. It may even do you some good to detox to the lowest dose possible till these druggies get weeded out. I’m looking forward in to the future and what it will take to get by on the lowest dose possible, seems things got out of control , now its time to get things back on track.
    What a mess this has all been , FDA Petitions , Anti – Opiate haters leave us alone and get a life as we suffer ours away doing The Pharmacy Crawl . Its pathetic how low some people will go to make our lives a little bit more miserable as we suffer on.

    1. Here it is, 2018 and the war on patients in chronic pain continues. Yours was a prophetic comment for having been written in 2014.

  9. What they are not doing a study on is how many of us chronic pain sufferers do, or constantly think about, commit suicide from the pain when we can get no help. The VA does not give pain meds unless you have had surgery and when on disability can one afford to go the Medicare route where the co-pays are so high and you may still not get help. Get your nose out of my pain if you can’t help!

  10. I will say this let one of them pass as many kidney stones as i have ( I am a factory for making them and passing them without surgical assistance for the most part ) and also have fibromyalgia. I am in pain often all i can say is how dare they judge our pain. Leave the docs alone.

  11. l too am suffering from this of not being able to find a pain clinic to except me to get my pain meds l been on the phone callng everyone on the info sheet l get from the ER n from lnternal meds dr n they say there not excepting new patiences now or no medicaid I’m on disabiity an l can’t get any help l been out of my pain meds for over 2 weeks I moved here to Florida from Alaska because l can’t live in that cold weather anymore l hurt to much n now l have to still live in pain cause l can’t get my pain meds filled down here they say l have to go to a pain clinic,l have 2 Arthrits, Lupus, Fibromyalga an l’m in pain all the time can’t sleep much because of the pain and can’t really do much of anything some days are worse than others l just want to scream,ls there any way l canget help with my pain???

    1. I have suffered severe pain/ chronic pain since the age of 18 it started with Migraines on a daily bases. I went to neuro doctors and they actually gave me darvocet 4 times per day. I found out 12 years ago I have fibromyalgia which my doctor treated me for with better medication. I finally got in to a Pain management clinic and my doctor is very understanding of my pain. I am lucky I finally got into the pain management, It actually took my medical dr 7 years to get me in. Pain Management is the best place for you, they are specialist in that field and are not afraid to treat you. Good luck

      1. I’m glad you found help and relief with your pain mgmt. clinic doctor. Me? Not so much. I have been “living” with chronic pain due to Fibromyalgia for close to 10 years now and have been with a pain mgmt. clinic for 1 year. Unfortunately, my pain is neither controlled or managed as well as it could be. The doctor currently has me on the lowest possible dose of both oxycodone (5 mg.) and oxycontin (10 mg. 2x) which was lower than what I was previously prescribed by my primary doctor. That the PMC dr. should lower my dosage after being sent to him because my primary care doctor felt that she wasn’t doing everything possible to help relieve my chronic, severe pain is unbelievable but true. After the 1st month of following the PMC rules and jumping through their hoops, I told the PMC dr. that the oxycodone and oxycontin weren’t helping and he just basically ignored me and said “give it time”. Every time I went back to get my script refills he ignored me when I told him that at the current dosage, these drugs only eased my pain enough that I was able to sit up in bed–not get out of bed and participate in life. At my last visit with the PMC dr., when I told him that I don’t know how much more of this horrible pain I can take and wasn’t there something else to try he says to me “Well, you look very nice today; even your shirt matches your shoes”. Yep…he actually said that to me. Is it because I’m a woman? I’m pretty sure he would never tell a male patient, after said male patient told him his pain was not under control, that his football jersey was cool! I’m a patient suffering with chronic severe pain 24/7 365 and he’s commenting on what I’m wearing? So not all PMC drs. are created equal. I go back to see this PMC dr. in the beginning of October and if he does not raise the dosage of my current meds or present to me a better medicinal pain reliever to help control and manage my overall severe physical pain, I will be firing him. I need a doctor not afraid to treat me with respect and appropriately with everything in his medicinal locker to help relieve my pain so that I can get out of bed and participate in my life. That’s my idea of what a good pain mgmt. clinic doctor should be doing. NOT commenting on what I’m wearing while I’m telling him that I can’t find any pain relief with this current pain med regimen. I’ve wasted a year, in my opinion, with this doctor in my opinion which caused me undue physical and emotional pain.

        So again, kudos to you for finding that one doctor that works with you in relieving your physical pain. I just wish I was lucky in that respect.

        1. Mare,
          Your body has become tolerant to oxycodone, oxcontin ,the same thing happened to me many years ago requiring a increase in dose to achieve the same pain relief. You need opioid rotation. Try a different long lasting pain medication like methadone ,but be careful its many times stronger than oxycodone. Start at a very low dose and give it time. Try to relax and don’t get so worked up ,its just not worth it to let what’s going on with pain sufferers get to you. I’ve been up and down the ladder of chronic pain treatment , I’ve found its best to stay on the lowest dose possible. Take care , Mark

  12. I have to take MS Contn & hydrocodone for severe pain. It doesn’t get rid of the pain altogether but it does enable me to function. It is irritating as hell to see the FDA or DEA once again coming between the patient & doctor. Changing hydrocodone to CII will do very little if anything to address OD’s or diversion. Just as with pot, those who want it bad enough will find ways to purchase it. Once again the patient is punished in the name of “fixing a problem”. It all sounds good as a PR push but in reality hurts those needing help & gives doctors more paperwork…

    1. Dear Pain Patient,

      Not only does it cause problems for currently prescribed patients and for doctors as far as more paperwork, but pharmacists are more likely to turn down the prescriptions as they do with other schedule ll drugs. Also, these drugs must know go in the lock box with the other schedule ll drugs and be counted by the pharmacist, not the tech, logged and all the other procedures that make schedule ll drugs slow everything down.

      I feel like first-time recipients of a schedule ll drug who have been receiving hydrocodone all alone are going to go into some form of culture shock, a sort of, “What IS this stuff I have been taking or what did I do wrong that I am having to go through all of this?”

      It’s a whole new type of craziness we are having to endure in the land of chronic pain.

      ***** SEPTEMBER IS PAIN AWARENESS MONTH ******
      >>COME SEE WHAT WE ARE DOING FOR PAIN PATIENTS<<
      “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

  13. confirmed :

    On August 22, 2014, the Drug Enforcement Agency announced the reclassification of hydrocodone combination products from schedule III to schedule II of the Controlled Substance Act which will be effective as of October 6, 2014.

    unanswered :

    What medication will doctors / dentist call in when a person has an emergency that needs appropriate quick pain relief of uncontrolled pain before seeing the doctor / dentist for medical treatment however long that may be.

    result :

    People with uncontrolled pain will suffer because these doctors / dentist can no longer call in hydrocodone until seen in person.

    future:

    We don’t torture people here in the U.S. leaving good people to suffer until seen by doctor / dentist will be known as unforeseen, unfortunate circumstances .
    In other words just tough it out while other health issues could occur .

    1. Mark,
      The answer to your question is either acetaminophen with codeine or tramadol. The problem here is that codeine presents significant risks to that population which genetically are known as ultra rapid 2D6 metabolizers because they can die from unexpected high morphine peaks when the liver converts codeine to morphine. In fact, there is a black box warning now because infants have died like this by receiving morphine (converted to morphine by mom’s liver) through breast milk. Tramadol is relatively safe, but requires conversion metabolically as well and has far more side effects and is generally less well tolerated than hydrocodone. Both codeine and tramadol have far more drug-drug interactions compared to hydrocodone.

      1. Dr. Fudin ,

        Thank you for your response ,acetaminophen with codeine or Tylenol 3 made me itch all over and the ER doctor had to administer a injection of Benadryl to stop this allergic reaction.

        Tramadol gave me a very rapid heart beat , the ER doctor could not figure out why.
        Again a injection of Benadryl to rescue me from yet another allergic reaction.

        This is even more reason why hydrocodone should have never been made a schedule II medication by the Controlled Substance Act . With every drastic change we face subsequent
        consequences .This conclusion reached through invalid deductive reasoning in my opinion will cause more problems than good.

        1. Dr. Fudin ,

          Thank you for your response ,acetaminophen with codeine or Tylenol 3 made me itch all over and the ER doctor had to administer a injection of Benadryl to stop this allergic reaction.

          Tramadol gave me a very rapid heart beat , the ER doctor could not figure out why.
          Again a injection of Benadryl to rescue me from yet another allergic reaction.

          This is even more reason why hydrocodone should have never been made a schedule II medication by the Controlled Substance Act . With every drastic change we face subsequent consequences .This conclusion reached through invalid deductive reasoning in my opinion will cause more problems than good.

        2. I, too, suffered severe allergic reactions to both Tramadol (which didn’t help relieve my pain anyway) and codeine w/aspirin (again, very little pain relief). What happens to us, those patients that can’t take the above drugs but suffer little or no side effects when taking oxycodone or oxycontin? Both of these drugs do ease my pain but I’m hitting a roadblock with my PMC dr. on him prescribing the best dosage to treat my chronic pain. Right now he has had me on the lowest possible dosage for a year now; lower than what my primary care dr. was giving me even. My primary dr. sent me to the pain mgmt. clinic because she felt that I needed an increase in my dosage of oxycodone and oxycontin or a change to another pain relieving drug to help manage my severe pain. When I told her that he lowered the dosage, she said she didn’t understand but that since I signed a contract with the PMC, then I would have to talk to him. Feel free to read my last post on my experience with this PMC drs. non-effective treatment of my chronic pain due to Fibromyalgia. So what do we do now? Those of us that suffer from severe chronic pain 24/7 365? Are we to suffer physically and mentally while they weed out the addicts? Do we not have any protection–legally or morally? All I see from the FDA reclassifying these drugs are more chronic pain sufferers doing drastic things like buying the drugs they need to survive on the street or committing their last and final act of suicide.

      2. Tramadol gives me night terrors and Tylenol 3 do nothing for my chronic pain. I have had chronic pain for 12 years now. I have been to many doctors and pain clinics. Hydrocodone is the only thing that gives relief and that does not take all the pain away. I have neuropathy and fibromyalgia. Both began in 2001 during treatment for stage 3 breast cancer.

        1. I dont understand any of this. I have been disabled since 96 and have been called every name in the book by doctors. I have nerve damage in my lower back, Fibromyalgia, Chronic Pain, Chronic Fatigue, Arthritis, degenerative disc disease, Lumbar Facet arthropathy, just to name a few…the only thing that allows me to move in the morning is Norco, it is fast acting and i would not be able to move without it. My doctor said he doesn’t like it as it is fast acting therefore more addicting…I only take my meds as prescribed and needed. I take something else with it, I don’t believe works, I told the doctor I can tell when the other med wears off and he said it was impossible. But when I read up on it, I found that it should be taken every 4=6 hrs. I hate being lied to and treated like a drug addict, when I have proven disabilities from SEVERAL doctors. It really p-sses me off. Im sick to death of insurance companies and others deciding what I need. Every single person is different, they feel pain differently and the losers that use the medication for a high are killing us. I have never gotten high off of Norco, that is laughable. But it has allowed me to live as long as I have. If ppl with proven chronic pain and other health issues lose their meds that help, you will see more deaths from that than you would from idiots overdosing to get high, these diseases are not something you can just cope with., or meditate about. They are real, they are debilitating and without the meds to keep us going, there would be no quality of life.

          1. Theresa, you could not have said it any better than that. I feel your pain everyday too. I have severe fibromyalgia for 24 years now. Raised two sons last 17 years on my own on a small budget, but I did it. Keep strong!

          2. I agree and experience every thing you said and do. I too have nerve damage in my lower back, Fibromyalgia, Chronic Pain, Chronic Fatigue, Arthritis, degenerative disc disease, TMJ, etc. and have the MRIs, xrays, etc. to prove it. I fell down the cellar stairs and hit the wall at the bottom which started my chronic pain journey in 2005. I take both oxycodone (5 mg.) and oxycontin (10 mg.) and they do nothing but ease my pain enough that I can breathe normally and unclench my hands and teeth because the pain is so bad. I do not experience any high that doctors talk about. smh What I also don’t experience is any side effects of taking these drugs and for that I’m thankful and think that these drugs would help lessen my chronic pain IF they were given to me in the proper dosage. My PMC dr. is apparently too afraid to treat my properly and I will deal with him at my next appt. in early October. Does he treat me like a drug addict? Frankly, I don’t know how he sees me. He communicates very little and during our last appt. when I again informed him that these drugs, at the current dosage, were not helping me he says to me “Well, you look very nice today; your shirt matches your shoes”. Yep, he actually said that to me. Meanwhile, he handed over my new script with the same drugs and same dosage. I left his office in tears…again. And my pain was so bad that day that I sat in my car and gasped when I realized that Fibromyalgia, etc. will not take my life. I will die by suicide. How horrible is that!!??? First to think that your final day will be probably be by your hand because your physical pain is so horrible and never ending and it’s emotionally and mentally taking a toll on you too and it’s because your dr., who took an oath to care for you in a manner you deserved. was afraid of the DEA’s stand on drugs and won’t treat your properly.

            And I agree, I am NOT addicted to these drugs. I DEPEND on these drugs to relieve my pain enough so that I am able to get out of bed every day and do some chores and visit with family and friends without physically hurting all the time. But without the proper dosage being prescribed, I have missed birthday parties, graduations, weddings, vacations, family/friend lunches and dinners as well as being unable to do normal daily household chores, cook dinner, laundry, run errands or even sit and watch a full movie on TV. I’m ALWAYS in bed because the current dosage my dr. think should be effective enough isn’t. It’s a fighting battle to find a good dr. who is thinking first of his patient, not the DEA.

            I see a lot of medical malpractice lawsuits coming up because patients are going to fight back on the inadequate care they receive for their chronic, debilitating, severe pain and I bet you that the DEA will not involve themselves in those lawsuits.

            This is an American tragedy where the government has hands and a say of what goes on in our lives without true knowledge of us as a people. Big Brother telling us that this is good for us whether we like it or not. And, in the meantime, the street dealers are smiling all the way to the bank. The DEA is fighting a losing battle because they are going about it all wrong and targeting the wrong people.

      3. So im confused, is vicedens 5/350 not safe to take? I suffer from fms and its the only thing that works, I like to switch now and then to tramadol so the rx still works when I go bk to hydrocodone but that’s all that works! Explain in a way I can understand whats safe and whats not! I do not do oxy or strong meds just vicodens and tramadol, methocarbomal for headaches has been a miracle, I cant concore the depression from pain but im working on that! Lyrica sucks!

        1. I see vicidon is going from scheduled 3 to 2 which its going to be harder to get, well tremedol will do! Guess God will have to do the rest until I find a pain management doc! I have done massage therapy, by the next day the pain is back it mildly touches on my deep tissue pain, yoga does work when I stretch it definitely helps! I have made a dairy, NOTHING POPS OUT that creates flares….they just happen! Every am my hands fce and feet are swollen! A positive attitude helps behind closed doors im often in tears idk what to do with this pain. Recently I had a sitiutuion where I had to sit in hard chairs ALLLLL day then a 5hr car drive, I was squirming in my seat. For 4/5 days I couldn’t sit on my butt laying down even hurt, depleted s/1…..some lady at my job said she cured hers, I then asked did she have spinal cord injuries she said no it was all trauma losses of family members so fourth, I said your doctor diagnosed you wrong sounded like depression to me fms isn’t curable if it was I wouldn’t cry behind closed doors in pain my POSITIVE ATTITUDE AT WORK WOULD CARRY ON TO HOME, so my mental is because of my physical pain, while others mental creates physical I KNOW MY BODY BETTER THAN ANY DOCTOR, they need to not diagnose if they are not sure! FMS is spinal and neurological, so once doctors understand WHAT THE ROOT IS THEY WILL FIND A CURE! MUSCLE ACHES FATIGUE ALL OF OUR SYMPTOMS ARE FROM SPINAL INJURIES AS DRUGS HAVE SIDE EFFECTS SO DOES PAIN its like herniated discs in C areas create headaches and lumbar areas effect your legs! ITS SPINAL AND NUEROLIGICAL so for now yoga and CONTROLLED DRUGS IT IS! Cymbalta and Lyrica DOES NOT WORK KEEP TRYING SCIENTISTS AND DOCTORS

          1. Sorry I’m reading this late.I to have F.M.S.& C.F. So far here in Canada medications are not being handled this way although we have had problems with availability .This will change no doubt. I to have been to chronic pain clinics that took years to get into only to be told that pain can be controlled through mental powers. Fortunately I have a doctor that knows how to treat FMS. I have found some help through massage,acupuncture,chiropractic treatments etc. but meds. Are the most important! I take 120 mg. of Morphine Sulfate daily with 100 mg. of Lyrica as well as a host of supplements that I have fine tuned .All of this just keeps me out of bed! I have to say that Lyrica has been extremely helpfull but took time starting with a low dose to work .You might want to try it again. I truely hope your situation changes & will be watching to see what happens.

        2. Hi Susan. Thank you for your interest in reading my first blog post regarding this topic. I’m not familiar with your past medical history, but I’ll do my best to answer your questions and hopefully clarify some things.

          Question: Is hydrocodone/acetaminophen 5/325mg safe to take?
          Answer: Yes, (assuming no contraindications for use) but only for a short duration as short-acting opioids such as hydrocodone are not intended for chronic use. It is expected that you would experience some form of relief from hydrocodone or tramadol for your fibromyalgia (FMS), but your pain will not be adequately managed in the long-term with this kind of pain regimen as it is only masking your pain perception. The switching you are referring to is called an opioid rotation to minimize your tolerance and “washout” your pain receptors so to speak. Thats why it may feel like hydrocodone is “working again” after being off it for some time. However, adjuvant analgesics such as gabapentin, pregabalin (Lyrica), venlafaxine, or duloxetine may be the best options for managing your FMS in the long-term depending on which is most appropriate for you. You have to understand that these kinds of medications take some time (several weeks) at a therapeutic dose in order to experience benefit from them. They usually are started at a low dose to ensure it is tolerated, then the dose can be increased every week or so depending on how well you do. Regarding methocarbamol, it is a muscle relaxant and is not FDA-indicated for headaches so it wouldn’t be appropriate for that indication. You must get benefit for your headaches, because I presume there are some muscle tightness or spasms around your shoulder or neck area that is resulting in some tension and is causing the headaches? I hope I was able to clear up some confusion and gave you a better understanding with your medications. In my experience, I notice that patients such as yourself just are not educated enough by their providers about their medications. What they are getting it for, how they are taking it, and what to expect from their medication. I recommend that your follow-up with your doctor and Pain Management referral and come prepared with questions so that you can be fully informed about the treatment you are receiving. Remember, medications are only a piece of the pain management puzzle. Good luck to you!

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