Despite the rampant abuse of hydrocodone/acetaminophen, the debate over its classification continues.
Recently, an attempt was made in Congress to reschedule hydrocodone combination products as CII. Support for the measure was widespread, including from my own organization, the National Association of Drug Diversion Investigators. This wasn’t the first attempt on the federal or state level to put hydrocodone into the most abused category of controlled substances, but this time it is being reported that it is falling short due to lobbying efforts.
Pure hydrocodone is already a CII product, so why does the addition of acetaminophen make it a CIII substance? Many oxycodone products contain acetaminophen, and all of them are CII controlled substances, so many individuals want to know why hydrocodone has been treated differently all these years.
The hydrocodone/acetaminophen combination is the #1 prescribed drug in the country. Most of you already know that by either reading about it, or more likely because you dispense it in large numbers every day. There is no extended-release version, so all hydrocodone combinations release quickly and work well to relieve acute pain.
In addition to being on top as far as number of dosage units prescribed every year, hydrocodone also leads the list of the most abused pharmaceuticals. There are many reasons for this, one of which I have mentioned many times before—the prescription drugs that are the best for pain are also typically the best for abuse. Mathematics comes into play—hydrocodone is very good for acute pain, thus prescribers write for it in large numbers, and a certain percentage of the substance is then abused.
Law enforcement and pharmacists have long known of the abuse and diversion of hydrocodone. Hydrocodone habits are typically 15 to 20 pills per day when they are detected, but numbers much higher can be achieved by more hardened addicts.
Our record was a young lady consuming just more than 100 hydrocodone combination pills per day! She had titrated her own dose upwards for some time. She had virtually an unlimited supply as the wife of a physician who was the office manager and easily ordered the drug, presumably for office dispensing. How she avoided acetaminophen toxicity was a mystery to me.
Proponents of the change in scheduling say that one of the reasons hydrocodone is so abused is that the CIII category allows for phony call-ins and manipulation of the refill section on the prescription. In addition, CIII drugs are not as scrutinized as the CII medications, and the feeling is that prescribers are less apt to balk at prescribing hydrocodone than its oxycodone cousin. The method of abuse of hydrocodone also differs from oxycodone. Virtually all of the hydrocodone abuse occurs by consuming the tablet intact and not injecting, snorting, smoking, or chewing, as with its CII cousin.
A sprinkling of law enforcement officials will tell you that they regularly see the snorting of hydrocodone in their jurisdiction. I don’t refute this, because they know their area better than anyone, but taking hydrocodone any way other than intact is far less the norm.
No question that moving hydrocodone into the CII category will impact sales, but are there other legitimate reasons for keeping it in CIII? Some prescribers and pain patient advocates believe moving it into the most abused schedule will cause problems with certain patients.
The fact that hydrocodone combination products can be called in by the prescriber under the right circumstances is an additional relief to those experiencing pain who do not need long-term relief, but for whom coming to the office and incurring the fee is not practical. Legitimate patients like the fact that refills can be added to the prescription for hydrocodone, especially in the case of a procedure or even surgery, when complications result or healing times are longer than anticipated.
However, in my opinion, when it is all said and done, hydrocodone combination products easily meet the CII category by being the most abused prescription drug in the United States for many years. If pharmaceuticals are deemed CII because of the extent of abuse and/or addiction, it is difficult to turn a blind eye to this proposed change.
It’s not that I don’t understand the thinking behind the patient push-back, but the overwhelming evidence over the past decade or 2 of being involved on the enforcement end of drug diversion makes it hard for me to argue against rescheduling hydrocodone combinations.
Cmdr Burke is a 40-year veteran of law enforcement and the current president of the National Association of Drug Diversion Investigators. He can be reached by e-mail at firstname.lastname@example.org, via the website www.rxdiversion.com, or by phone at 513-336-0070.