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.

Comments

  1. RickG says

    I can’t say that I am enthralled with another “scheduled” drug regulation regimen which while putting some onus on the doctors and dispensers, ultimately WILL inflict inconvenience and in many cases major pain episodes upon folks who rely on meds to control pain. I am well aware, because of where I live, of people who sell off their prescriptions for profit. But the approaches to the problem outlined above seem the typical blunt instrument regulation all too familiar.

    For one thing, there’s a real difference between short term and long term scrips. Most doctors writing for acute pain relief after a procedure will do a short term scrip with maybe one refill. There’s not a great deal of profit selling off those kinds of volumes, and likewise it won’t take a junkie all that long to use it up. Secondly, it seems that big brother et al, might find some way to determine what individuals are having scrips filled from multiple doctors. That’s another classic pattern. A real pain patient isn’t running around getting multiple scrips, because they don’t spend the days when they have mobility, in doctor’s offices scamming new scrips.

    Then, of course the moniker of “pill mill” leaves out some of the really large, lobbyist represented mills like Medco and their ilk. Medco, for example to cut costs, sends out scheduled substances via cheapest method possible without any tracking on packages. Of course, they cooperate with states that have decided that PO boxes are the root of evil, and which ban delivery of such meds to PO boxes. And of course, if a Medco shipment doesn’t get delivered by say, the USPS, Medco refuses to pay return postage so the package goes to limbo. Meanwhile, the patient, pays, gets no medicine, and the drug company skips out on all responsibility.

    So I guess it comes down to, if Florida has a problem with Pill Mills, design something to deal with it, rather than casting the large net. If you want to design some massive large scale dragnet, then spend the money to design some sophistication into the tracking of per patient prescriptions. Hard to do? When was the last time you didn’t have to cough up your SSN to get Medical procedures?

  2. Keith Humphreys says

    RickG: As I said, I see the individualized solution as ideal, but it;s simply very hard to do. A minority of prescribers participate in the monitoring systems available now, and they are much less detailed than what would be required to make prescription by prescription control judgments. And many citizens simply will not consent to that level of monitoring of their health records. Hence we have no rapier handy, just a cudgel.