JAMA Internal Medicine recently released a fascinating study1 looking at the prescribing rates of hydrocodone-acetaminophen combinations after the Drug Enforcement Administration (DEA) rescheduled hydrocodone-acetaminophen from a schedule III to a schedule II drug.
Unsurprisingly, the data show significantly decreased prescriptions being filled for hydrocodone-acetaminophen drugs, particularly related to refills. Schedule III drugs are more easily refilled, which can partially explain this decrease. The released data provide a snapshot that will undoubtedly be viewed as progress in the effort to decrease opioid abuse and misuse, but it may not be that simple.
Currently, 5 states prohibit physician assistants from prescribing schedule II medications – Georgia, Maine, Missouri, Oklahoma, and West Virginia – and 8 states prohibit nurse practitioner prescribing of schedule II medications. While the intent of the DEA was clearly intended to reduce abuse, what impact did this have on patient access to pain medication when appropriate?
As pain medication restrictions increase, unintended consequences abound. Nationwide, data show a marked decrease in opioid prescribing over the last several years, yet when looking at total opiate deaths (including heroin), there has not been a net decrease. This calls into question the heavy focus on prescription drug abuse without an accompanying focus on heroin use and deaths. It potentially sends a message to heroin users that their lives are not as valuable as non-heroin uses, something that many heroin users I have worked have long believed to be the prevailing thought in both the general and medical communities.
The recent meeting of the National Governors Association (NGA) in Washington, D.C. resulted in an increased effort to create laws limiting the number of pills that individual prescribers can prescribe to an individual. President Obama offered a cool response, citing his belief that such an effort is off the mark, and that it would more likely decrease patient access to legitimate pain treatment, particularly in rural areas.2
Vermont Governor Peter Shumlin also offered an opinion on the proposed laws in an interview with the Associated Press, citing a 2012 statistic that 250 million doses of opioids were prescribed in 2012:
“For nonchronic conditions, it should be no more than 10 [pills] … You can’t convince me that we’ve got 250 million Americans in chronic pain,” he said.
Most of us would agree that the last thing we need is politicians telling PAs how many pills they can prescribe. We all support reasonable, evidence-based efforts to decrease the harm to patients from opioid abuse, while still maintaining access to pain care for patients who need it. But the key words are “evidence-based,” and so far, there is a great shortage of such evidence to support these drastic efforts to limit pain medication prescribing. One excellent evidence-based resource is the recently updated Interagency Guideline on Prescribing Opioids for Pain,3 developed by the Washington State Agency Medical Directors’ Group (AMDG), which offers rich resources and guidance to pain medication prescribers. But even resources such as these will provide much more value when they are also accompanied by intensified efforts to increase addiction treatment. When pain medication deaths go down while heroin deaths go up, we’re not really making any progress.
Jim Anderson, MPAS, PA-C, ATC, DFAAPA, is a physician assistant in Seattle.
- Jones CM, Lurie PG, Throckmorton DC. Effect of US Drug Enforcement Administration’s rescheduling of hydrocodone combination analgesic products on opioid analgesic prescribing. JAMA Intern Med. 2016;176(3):339-402; doi: 10.1001/jamainternmed.2015.7799
- Nuckols B. President Barack Obama on Monday has declined to endorse the boldest proposal from the nation’s governors to tackle the heroin crisis: limiting the number of high-powered painkillers doctors can prescribe at a time. U.S. News & World Report. February 22, 2016. Accessed March 24, 2016.
- Washington State Agency Medical Directors’ Group (AMDG). Interagency Guidelines on Prescribing Opioids for Pain, 3rd Edition. Published June 2015; Accessed March 24, 2016.