The upscheduling of hydrocodone combination medications (HCMs) from Schedule III to Schedule II has greatly affected the pain management practices of advanced practiced registered nurses (APRNs) in Oklahoma, a state where APRNs are prohibited from prescribing Schedule II narcotics, according to a study published in the Journal of the American Association of Nurse Practitioners.

Rachel Mack, PhD, DNP, APRN, C-FNP, CNE, used a phenomenological approach to assess the clinical pain management practices employed by APRNs since the upscheduling of HCMs, and to determine how these changes in prescriptive authority have affected the practice of APRNs in Oklahoma.

A total of 25 individuals aged ≥21 years with a minimum of a Master’s degree as an APRN were selected. All participants demonstrated the ability to conduct personal business and legal transactions, as well as to practice and prescribe in the state of Oklahoma.

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In addition to demographic information, information on clinical practice in pain management, including the effects of upscheduling of HCMs, was elicited by the use of open-ended questions posed during 60-minute interview sessions.

  1. How much of your practice time is devoted to pain management with your patients?
  2. Have you noticed a change in how you manage your patient’s pain since the upscheduling of hydrocodone?
  3. Can you tell me about (story) a patient whose pain management was affected by the change in upscheduling?
  4. As a clinician, how has this scheduling change affected you?

Upscheduling of HCMs was reported by participants to have created barriers to effective pain management in the primary care setting.  They reported having limited options available for the treatment of both acute and chronic pain.  The number of referrals to pain management specialists also increased, as did the number of emergency department visits, resulting in increased healthcare costs.

Since the upscheduling of HCMs, primary care APRNs report using alternative therapies such as physical therapy, massage, and herbal remedies more frequently. Complementary medicines such as over-the-counter rubs, patches, and stimulating units also help to alleviate chronic pain, and referral to interventional medicine specialists for steroid injections may also prove beneficial for pain relief.

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“Despite differences among the participants in education, number of pain management patients seen in practice, and experience, some distinct commonalities in their approach to pain management after the upscheduling of HCMs were identified,” Dr Mack concluded. “Based on these findings, it is recommended that future researchers conduct similar studies focusing on the pain management practices of APRNs after the upscheduling of HCMs.”


Mack R. Food and Drug Administration upscheduling of hydrocodone and the effects on nurse practitioner pain management practices. J Am Assoc Nurse Pract. 2018;30(6):312-319.