February 29, 2004 - The Washington Post (DC)

A DEA Crackdown That's Going To Hurt Those In Pain

By Patrick J. Michaels, senior fellow in environmental studies at the Cato Institute

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This raises my blood pressure. The Drug Enforcement Administration (DEA) has acknowledged it wants to make hydrocodone, the most-prescribed painkiller in history, more difficult for Americans to obtain. Understandably, the agency wants to reduce abuse of this prescription drug, and thereby prevent needless deaths. But in trying to prevent one thing, it seems to me it's only going to cause a massive increase in others -- pain, expense and yes, inadvertently, even death.

I have some personal experience with chronic pain and its relief. Fifteen years ago, I got into a tremendous collision in a softball game, nearly breaking my neck. The trauma induced an arthritic process in my upper spine that resulted in an increasingly debilitating condition known as cervical facet syndrome. The pain became unremitting and intense. I lost weight because I could not sit to eat. My professional productivity plummeted. I snapped at my wife and kids and anyone else within earshot. I would wake up with panic attacks, hyperventilating from the pain.

After a year of misery and fruitless consults, I finally found a doctor who specializes in treating spinal pain. He told me that a combination of microsurgery and drugs could relieve about 80 percent of my problem.

He was right, thanks to two fairly awful procedures and daily use of hydrocodone, a fairly powerful narcotic. Nothing weaker worked, and as is common in middle-aged men, almost all of the alternatives raised my blood pressure unacceptably. We worked through the usual non-steroidal anti-inflammatory agents (NSAIDs) such as ibuprofen (Advil or Motrin) and diclofenac (Voltaren). Hydrocodone (Vicodin or Lortab) diminished the pain to a tolerable level, although it never completely went away.

My physician and I developed a long-standing relationship of trust. As a result, he prescribes hydrocodone over the phone. I keep a computer record of when I consume each and every pill and review this personally with him every six months. It is standard practice in pain management to require the patient to account for drug use in such a verifiable fashion.

Statistics, very slippery ones, suggest that about one in 30 patients who take hydrocodone aren't so diligent, and either abuses it personally or diverts it to others. Now, the DEA wants to make my life much more difficult as a result of their behavior. It wants to place hydrocodone in a more restricted class of drugs that will require sweeping changes in the way it is distributed. No more phoned-in prescriptions. No refills. The physician must see the patient for each and every prescription -- much smaller prescriptions than are allowed today.

Why am I, along with 28 others, being punished for the sins of one? This isn't Catholic school, it's real life.

DEA wants to classify hydrocodone the same way it does oxycodone, a more powerful analog that is the active ingredient in the long-lasting painkiller Oxycontin. How successful has that been? All that has happened is that abuse continues, and those who really need the drug are being abused. Oxycontin or hydrocodone alone are rarely the sole cause of a drug-induced death. More than 95 percent of these deaths are caused by "polypharmacy," the ingestion of multiple illicit compounds, usually laced with a lot of quite legal booze.

Picking on one drug won't do the trick, but picking on hydrocodone is a particularly bad idea, because the DEA's proposals could well kill more people from pain than they will save from abuse.

Let's discuss how much pain and suffering hydrocodone mitigates. There were 100 million new prescriptions for the drug last year in the United States, given to 38 million patients. (This doesn't even count in-hospital use.) It is by far the most prescribed drug in the nation.

Because there will be no more refills, DEA's proposal means at least 300 million office visits per year (figuring that most chronic pain prescriptions are refillable twice). Nowadays, one just doesn't walk in and out of a doc's office. Most pain doctors are so busy that appointments must be made months in advance, and appointment, travel and waiting easily burn half a day. That's 150 million worker days lost. Based upon average annual wages, employers will pay (and you and I will shoulder) about $13 billion in wages for doctor-visit induced absenteeism. And the office visits will add another $20 billion in cost, payable through the patient's insurance or someone else's taxes.

Add this to the fact that, according to Katherine Foley, a pain expert at Sloan-Kettering Cancer Center, pain already costs Americans $100 billion per year in treatment costs and labor-related losses. Making pain relief harder to get will only make it more expensive.

How risky is hydrocodone? According to the Drug Abuse Warning Network, a systematic effort to procure objective information on drug-related deaths, hydrocodone showed up in 46 bodies last year in Las Vegas, a town surely prone to a bit of drug abuse. The number of hydrocodone pills prescribed there in 2001 was around 27 million, and this doesn't even count the huge number that fly in with tourists, gamblers and others who engage in risk-taking behavior every weekend. I'd say it's a good bet that more people die in legal casinos and brothels in southern Nevada from heart attacks than are killed by hydrocodone.

Some other state data can be used to make fuzzy estimates of abuse-related deaths. In 2002, there were 150 findings of fatal concentrations of hydrocodone in postmortem examinations in Florida. Assuming conservatively that this may catch half the deaths, and way too conservatively that "Miami Vice" Florida is typical, this would maximize the number of deaths per year associated with fatal concentrations of this drug at around 6,000 nationwide.

Given the problem of polypharmacy, it's charitable to assume that the DEA's proposal may prevent half those deaths. Are 3,000 unprevented deaths pretty high overhead for pain relief? Well, consider NSAIDs. About 16,000 people who use these medications for arthritis alone die each year, due to the drugs' propensity to enhance internal bleeding. It would seem from this that DEA would save a lot more lives if it made ibuprofen harder to get, so that those with pain would have to switch to hydrocodone or oxycodone.

But that may be just one tip of the iceberg. Take a few deep breaths, lie down, and get out that blood-pressure cuff that's in every middle-aged household. Find your baseline.

This afternoon, about 20 or 30 middle-aged people reading this article are going to do something very bad to some muscles in their backs, from gardening, exercising or the like. You who have hurt yourselves, take your blood pressure again. The systolic (upper) reading is likely to be about 10 or 20 mm higher than it was, because pain raises blood pressure. A December 2002 article in the British medical journal the Lancet laid out the definitive meta-analysis of blood pressure, heart attack and stroke. Researchers found that every 10mm increase in systolic blood pressure results, on the average, in a 40 percent increase in risk of stroke and a 30 percent increase in risk of heart attack for your age class. I did a calculation, based on those numbers and National Institutes of Health statistics regarding annual deaths from heart attack and stroke.

The result? If hydrocodone became less available, we could expect potentially 8,000 more deaths from stroke and heart attack every year (the math's available upon request). Compare that with about 3,000 prevented by the DEA's proposal.

No one really knows what the hard numbers are, because causation is impossible to tease out in such an analysis. But I would like to know them, and DEA must know them before restricting use of the most-prescribed painkiller ever.

My own story has a happier ending. After three and a half years, much (not all -- it's hurting as I write this) of my neck pain mysteriously remitted, and my medication use has dropped to a third of its chronic level; many days I don't require any at all. Last summer, I hit .750 in Mall-ball for the Cato Running Dogs (and I was very careful not to run into anyone). I can't help feeling that if the DEA's proposal were in force, there's a not-so-small chance I might not have been around to do that.

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