Two years since the original idea was floated, the DEA, FDA and Department of Health Services are all on the same page when it comes to Hydrocodone combination products. Generic Vicodin, hydrocodone and acetaminophen, in its various iterations is the number one drug in America! In 45 days these HCPs will be on Schedule II of Controlled Substances. That’s the schedule which contains oxycodone, amphetamines, morphine, fentanyl and lots more. That means no more Rxs with refills, no more getting additional refills over the phone, it does mean getting a new written Rx each and every time. The doc can write 3 Rxs, each for a 30 day supply but for no more than a 90 day total.

We’ve come full circle with hydrocodone, which was paired with acetaminophen in 1978 with the launch of Vicodin. Previously, hydrocodone was in schedule II as a single entity with the dawn of the Controlled Substances Act in 1971. The first Vicodin contained 5mg of hydrocodone and 500mg of acetaminophen and was granted schedule III status which gave it the accessibility needed to become dominant in the marketplace. It was not until 2012 that the amount of acetaminophen per tablet was limited to 325mg. All of the new Vicodins have 300mg of acetaminophen, Vicodin with 5mg, Vicodin ES, 7.5mg and Vicodin HP, 10mg hydrocodone.

This will be painful for all involved. This country consumes an abundance of pain meds and now a clamp is being placed on the legal distribution of the most widely used narcotic analgesic in the country. Are we in that much pain? Are we a nation of cry-babies? Or do we just like getting high? Does our nanny government think that NOW is the time to stop our sniveling and buck the Hell up?

This is a change that will have significant ramifications at many levels of our society. We are already scrambling on where to secure the HCPs in our pharmacy. Our safe is full already! We have lots of large, 500-count bottles of HCPs, several of them in our “fast mover” section! So yes, a burden on pharmacies, and on prescribers to be sure. The patients in need of pain relief will be the ones to suffer the most, of course, with more frequent doctor visits, tightened access in supply, likely price increases, and that often-inferred stigma, whether self-imposed or seen in others’ suspicious looks, of being a narcotic user, and still little hope of effective pain management. I do know that we are far from the imagined Game of Thrones where knights and kings were only offered the milk of the poppy after having a limb lopped off or their guts spilled by a wild boar. Here in our own version of Westeros, our pain is chronic! For most, it is because we cannot undo or even identify the root cause of the pain, while for others it is just too damn much fun to keep that narcotic buzz going.

In my setting I am expecting some major shifts in my inventory, starting with a major move toward generic Tylenol #3 and #4 as they remain outside the C2 realm. Just a few days ago, on August 18, tramadol moved from a regular Rx to a controlled substance. The choices for prescription pain relievers are dwindling fast, especially for those that want to avoid addictive opiates. Most of what is left as a regular prescription drug is not far different from what you can buy over-the-counter. Fact is, people prefer hydrocodone over codeine, not for the analgesia (30mg of codeine as in T#3 is about equal to Hydrocodone 5mg for pain relief) but for the euphoria that can be achieved with hydrocodone. This change in schedule will make those fun-loving patients a little more obvious, especially when they start whining about having to take codeine. I expect it will be similar to the people who tell the ER doc that “um, oxy, um what is it?, oh, oxycodone is the only thing that works for me, I can’t take codeine, morphine, or whatever that shit is you’re trying to give me now.” Speaking of ER visits, it is expected that the new restrictions will decrease the too-prevelant abuse of HCPs by teens.

I expect to see increases in other categories of drugs, particularly the benzos like alprazolam (Xanax) and lorazepam (Ativan) to deal with all that anxiety of not getting hydrocodone as easily as before. Lidocaine patches, newly OTC TENS (Transcutaneous Electrical Nerve Stimulation) units, more and more NSAIDS, more tramadol and more “natural” remedies. It could get ugly. Many people in New Hampshire and elsewhere have turned to heroin as a cheaper alternative to oxycodone already. I’m sure big Pharma has scientists slaving away, tinkering with the molecular chemistry of opium-based narcotics hoping to find “the next big thing.” For now, the trend is to recycle old drugs by creating new delivery systems that offer longer dosing intervals, less GI upset, and even less abuse potential. Oh! These, of course, are usually ten times the price of the original drugs.

So here we go into a brave new era of battling pain with little more than new flavors of poppy milk. Somebody fetch Maester Luwin!