EK HEALTH

by Richard Thompson, MD
EK Health Services' Chief Medical Officer

These are all powerful opioid medications. I believe monitoring patient usage of these controlled prescription drugs, including the detection of addiction and diversion, should be a major concern and responsibility of prescribing physicians. Many of us feel that the broadening use and increasing doses of these drugs are out of control.

Remember, the California Intractable Pain Treatment Act prohibits a physician from prescribing controlled substances to a person the physician knows to be using the drug/substance for non-therapeutic purposes. The California Medical Board can deny, revoke, or suspend the license of any physician who prescribes controlled substances for such non-therapeutic purposes. See below for the MTUS recommendations for serious opioid non-adherence and evidence of illegal activity including diversion.

Below are some highlights of the pharmacology of Oxycodone, Fentanyl and Hydrocodone:

Oxycodone

(Further MTUS recommendations for opioid management and treatment are listed at the end of the article.)

1. Common brand names include Oxycontin®, Percocet®,Percodan®.
2. A semisynthetic opioid, class II controlled medication.
3. Lasts 2 - 4 days in the urine.
4. Introduced in 1996 in 10, 20, and 40 mgm strength. 80 mgm strength introduced in 1997 and 160 mgm introduced in 2000.
5. Very addictive and withdrawal is very difficult.
6. Per Oxycontin® package insert: Persons at increased risk for opioid abuse include those with a personal or family history of substance abuse (including drug or alcohol abuse or addiction) or mental illness (e.g., major depression). Patients should be assessed for their clinical risks for opioid abuse or addiction prior to being prescribed opioids. All patients receiving opioids should be routinely monitored for signs of misuse, abuse and addiction.
7. Per OxyContin® package insert: Tablets are a controlled-release oral formulation of oxycodone hydrochloride indicated for the management of moderate to severe pain when a continuous, around-the-clock opioid analgesic is needed for an extended period of time.
8. Per Oxycontin® package insert: Oxycodone is an opioid agonist of the morphine-type. Such drugs are sought by drug abusers and people with addiction disorders and are subject to criminal diversion. Oxycodone can be abused in a manner similar to other opioid agonists, legal or illicit.
9. Per Oxycontin® insert: “Drug-seeking” behavior is very common in addicts and drug abusers. Drug-seeking tactics include emergency calls or visits near the end of office hours, refusal to undergo appropriate examination, testing or referral, repeated “loss” of prescriptions, tampering with prescriptions and reluctance to provide prior medical records or contact information for other treating physician(s). “Doctor shopping” to obtain additional prescriptions is common among drug abusers and people suffering from untreated addiction.

Fentanyl

(Further MTUS recommendations for opioid management and treatment are listed at the end of the article.)

1. Common brand names include Actiq® “lollipops”, Fentora® “buccal tablets”, Duragesic®
2. A synthetic opioid, class II controlled medication.
3. Approximately 80 - 100 times more potent than morphine.
4. Lasts 2 – 3 days in the urine.
5. Multiple “Black Box” warnings, including the indication only for the management of breakthrough pain in cancer patients.
6. Although approved only for cancer pain, >90% is used for non-cancer pain.
7. Many new Fentanyl products continue to be produced for breakthrough pain, less abuse potential, and lower incidence of side effects. Within the last two years, multiple Fentanyl preparations reparations became available, including buccal tablets, buccal patches, nasal sprays, inhalers, and transdermal patches.
8. Because of its rapid onset and short duration of action, it has been a long-time favorite anesthetic in the operating room. In the 80’s it was the drug of choice for abuse in the medical community, i.e., anesthesiologists.
9. Very addictive, and withdrawal is very difficult.
10. For MTUS opioid treatment recommendations see table at end of article.

Hydrocodone

(Further MTUS recommendations for opioid management and treatment are listed at the end of the article.)

1. Common brand names include Lorcet®, Lortab®, Vicodin®, Norco®, Hycodan®, Vicoprofen®.
2. A semisynthetic opioid, class II controlled medication.
3. Often combined with acetaminophen.
4. Lasts 2 - 4 days in the urine.
5. Very addictive, and withdrawal is very difficult.
6. For MTUS treatment recommendations see table at end of article.
7. Globally, the United States consumes 99% of all hydrocodone.