Painkiller becomes legal drug of choice
By EMILY RICHMOND,
Las Vegas Sun
LAS VEGAS (September 16, 2001 1:48 p.m. EDT) - When she needed a fix, Helene would flip through the yellow pages, looking for a doctor she had not yet fooled.
Addicted to hydrocodone, a powerful prescription painkiller, Helene became an expert at "doctor shopping" - visiting numerous physicians to obtain multiple prescriptions.
"You go to the doctor and say your back hurts, that was always good for a few refills," said the Las Vegas woman, whose name has been changed to protect her privacy. "Supply was never a problem."
The state Board of Pharmacy's prescription drug-abuse task force, which monitors drug prescriptions, eventually caught on. The board sent warning letters to all of the pharmacies and doctors that Helene had visited, along with a printout of her prescription history.
"One of my doctors told me I had been flagged by the state," Helene said. "He told me to be careful, and said I could get in a lot more trouble than he would. And then he wrote me another prescription anyway."
Hydrocodone - a mix of synthetic codeine and acetaminophen - is the most abused prescription drug in the United States, according to the Drug Enforcement Administration.
The painkiller tops the list of abused pharmaceuticals in El Paso, Texas; New York City; San Diego; St. Louis; Atlanta; Chicago; Dallas; and Miami. It's known as Vicodin, Percocet, Lortab or Lorcet, and the roster of celebrities who have admitted addictions includes Green Bay Packers quarterback and three-time NFL Most Valuable Player Brett Favre, actor Matthew Perry and model Niki Taylor.
Nevada doctors in 2000 wrote prescriptions for more than 42 million doses of hydrocodone - or about 17 pills for every adult in the state.
In most cases, patients receive a single prescription for eight to 12 pills after dental surgery or because of an injury, according to the task force. The so-called doctor shoppers are less common, but are believed to be a significant portion of the hydrocodone prescriptions. For people with chronic, debilitating pain, hydrocodone can mean the difference between being able to function and being bedridden, doctors say.
"There's no question hydrocodone is effective, when properly prescribed, and can provide immediate relief," said Dr. Godwin Maduka, a pain-management specialist and anesthesiologist at University Medical Center. "But we also know there's a tremendous level of abuse occurring."
There's a difference between developing a tolerance for a drug and physical addiction, Maduka said. Tolerance occurs when a medication is no longer effective at reducing pain, even when a patient increases the dosage. Physical addiction occurs when a patient has been on a certain medication for such a lengthy period that they go through symptoms of withdrawal if they stop taking it.
Maduka, also a pharmacist, said by the time most patients arrive at his Las Vegas Pain Institute, they've visited a long list of primary-care doctors. Most pain patients are not abusers, but have simply developed a tolerance for medications and need additional help, he said.
It's the doctor shoppers who are at the greatest risk, Maduka said.
"We have no real way of knowing how many doctors a patient has seen before us, how many other prescriptions they have in their pocket," Maduka said.
One solution would be a centralized database in which doctors and pharmacists could look up a patient's history before writing or filling new prescriptions, Maduka said. The state task force's reports are helpful, but are only triggered after a patient has visited numerous physicians, Maduka said.
Helene was introduced to prescription painkillers through legitimate means. After dental surgery in the mid-1980s, her dentist prescribed a painkiller. She discovered the pills numbed her physical pain and gave her a sense of well-being. For the next 15 years, she struggled to get out of the drug's grasp. When her husband said he worried about how many pain pills she was taking, Helene cut back. She even tried quitting, but the night sweats, nausea and chills - symptoms of her withdrawal - always won out.
"You think of drug addicts as being out on street corners," Helene said. "I'm a housewife."
Tylenol is the nation's most popular over-the-counter painkiller - 8 billion to 9 billion tablets are sold each year - and the most common form of acetaminophen used in hydrocodone manufacturing.
"Hydrocodone is a very good medicine if you're having pain, but no one realized it would have such a high potential for abuse," said Dr. Caroline Riely, associate medical director of the American Liver Foundation. "It's the codeine portion of the drug that's addictive, but it's the acetaminophen that's destroying peoples' livers."
Experts say adults should not take more than four grams of acetaminophen each day; just 10 grams can cause lifelong liver problems or even death. Most hydrocodone pills come in either 2.5, 5 or 7.5 milligrams of synthetic codeine, each mixed with 500 milligrams of acetaminophen.
At the height of her addiction, Helene took up to 30 hydrocodone pills each day - nearly four times the recommended limit for acetaminophen.
"I know how lucky I am to still have a liver that works," Helene said. "Given everything I've done to myself, I shouldn't still be here at all."
The state prescription-drug task force wants the pharmaceutical companies to reduce the amount of acetaminophen in each hydrocodone pill, a request echoed by medical professionals across the nation. In response, at least one pharmaceutical company is now making a hydrocodone pill with 250 milligrams of acetaminophen.
McNeil Consumer Products Co., a subsidiary of Johnson & Johnson, the company that manufactures Tylenol, has added new warning labels about acetaminophen's potential for damaging the liver, especially when the drug is mixed with alcohol.
The DEA's prescription-drug classification system is based on the potential for abuse. Schedule I drugs include heroin and Ecstasy, which are both illegal in the United States. Schedule II drugs include powerful painkillers, such as codeine, morphine and Demerol. Cocaine is a Schedule II drug because it has some legitimate medical applications in hospital settings. Schedule III drugs include hydrocodone and anabolic steroids.
Schedule III drugs are easier to prescribe and ultimately easier to get. A doctor is permitted to phone in a Schedule III prescription refill to a pharmacy. Schedule II refills may only be written after the doctor re-examines the patient. The DEA also requires more stringent record-keeping of Schedule II prescriptions, and it tracks how many each doctor writes.
Florida, another state battling the hydrocodone epidemic, tried last year to reclassify the drug as a Schedule II. But the new rules were quickly derailed by protests from pharmacists, physicians and patients who said it would make it unreasonably difficult for people to manage day-to-day pain. Florida's attorney general took the unusual step of passing an emergency ordinance, restoring hydrocodone's status as a Schedule III drug.
Nine years ago the Nevada Board of Pharmacy considered moving hydrocodone to Schedule II, but ended up voting against the plan, according to its attorney, Louis Ling.
The argument that "carried the day" for the board was doctors' testimony that moving hydrocodone to Schedule II would make it unreasonably difficult for patients in rural areas to get refills, Ling said.
They call it the Las Vegas Cocktail, but you won't find it served at hotel bars or table-side in the casinos. A potent mix of hydrocodone and the muscle relaxer Soma gives the user a heroin-like euphoria without needle marks. It's also one of the most popular recreational drug combinations in the United States.
The street value of the cocktail's ingredients is high. One former Las Vegas physician-turned-dealer made as much as $1 million selling the drugs on the black market, according to federal prosecutors.
Luisito Evangelista, banned from practicing medicine in Nevada, used his Illinois DEA registration to buy more than 500,000 hydrocodone pills. Evangelista, who pleaded guilty to drug trafficking in 1999, died in a federal prison last year.
Soma is the nation's most abused noncontrolled substance, according to the DEA. Nevada's pharmacy board is considering reclassifying it, making it more difficult for addicts to gather the cocktail's ingredients.
Because Soma isn't a scheduled narcotic, Nevada officials aren't sure how many prescriptions are being written each year.
"If we do schedule Soma and start to track it, we expect the numbers to match those for hydrocodone," Ling said. "And we know the two being used together can be a hallmark of abuse."
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