Bipartisan Legislation on “Pill Mills” and Hydrocodone Combinations

Congressmen Vern Johnson, Ed Markie and more than fifty other House members have introduced legislation (H.R. 1065, “The Pill Mill Crackdown Act of 2011) to reduce the number of “pills mills”, which dispense legal medications in a haphazard or blatantly criminal fashion. Florida Governor Scott, who very commendably has backed off from his prior opposition to prescription drug monitoring, testified this week in favor of the bill. That means a lot given that his state is ground zero for the pill mill problem.

I doubt the doubling of jail time and tripling of cash penalties the bill proposes will deter any pill mill operator who isn’t deterred by current penalties, so that aspect of the bill will make little difference. Far more consequential is the proposed re-scheduling of hydrocodone combination products (e.g., Vicodin, Lortab) from Schedule III to Schedule II. Such drugs are by far the most prescribed (100 million plus scripts a year) in the U.S. not just among pain medications, but among all medications.

From a pain management viewpoint, Schedule III offers the advantage of prescribers being able to phone in refills for patients. Some of the pain docs I have consulted on this bill wish there could be an interim schedule such that Vicodin et al. would be Schedule III for the first one or two prescriptions, and then would become Schedule II thereafter. It’s a nice idea in theory, but in practice it would require incredibly detailed electronic monitoring of all patients and prescribers that is hard to attain technologically and may also be impossibly politically. There are no half-measures of that sort available, unfortunately, making this is one of those challenging “to govern is to choose” situations.

On the other side of the ledger, hydrocodone combination projects are among the leading causes of fatal overdoses in the U.S., which have been skyrocketing (I still hear people saying that overdoses come about because drugs are illegal and people don’t know the content of the drugs — completely at odds with the data, which show that most overdoses involve legal drugs). Hydrocodone combination products are also implicated in a large number of emergency room admissions and non-fatal poisonings. In theory, the addition of acetaminophen in a combination product discourages the taking of large doses (pure hydrocodone is thus considered more dangerous and is already Schedule II) but that does not seem to be very effective with the addicted population, which puts them at risk for hepatotoxicity from the large doses of APA they ingest when they are abusing prescription opiates.

Those realities are driving the bipartisan coalition of Congressional representatives who are spearheading this legislation. Despite the reservations I have noted I come down in favor of their bill.