Hydrocodone & the Opioid Epidemic
Hydrocodone is an opioid pain reliever and a cough suppressant, similar to codeine. Hydrocodone blocks the receptors on nerve cells in the brain that give rise to the sensation of pain. Because it is similar to codeine (and may be seen as less addicting or dangerous) – it is very readily prescribed by primary care providers, dentists, emergency room providers, and many specialists. So, let me put things into perspective on the United States’ use of hydrocodone.
The United States has 1/20 of the population in the world. Still, it consumes 80% of its opioids (any narcotic given for pain relief)– and 99% of the world’s hydrocodone, the opiate that is in Vicodin and Lortab. So, the question is raised, are more Americans in pain? Is pain on the rise? How could this be? Well, the story began a long, long time ago.
History of Opioid Products
We can see the use of opioid products for pain as early as 1500 BC. The opium-containing preparation laudanum had been widely available since the 18th century. Morphine, cocaine, and even heroin were seen as miracle cures when they were first discovered. During the mid to late 19th century, many manufacturers proudly proclaimed that their products contained cocaine or opium. A few, like Mrs. Winslow’s Soothing Syrup for infants which contained morphine, were more guarded in divulging their principal ingredients. By the beginning of the 20th century, problems with the habitual use of cocaine and opiates were becoming increasingly apparent. This led to the removal of these substances from some products (e.g., Coca-Cola) and the introduction of the Pure Food and Drug Act (1906) in the United States, which required the listing of ingredients on product labels. Can you imagine – you walk into your local pharmacy and buy morphine or heroin over the counter to alleviate your painful tooth, low back pain, etc.? Suddenly, it was discovered that alcoholism and drug addiction were rising. This led to the Prohibition Act of 1920. When you think of Prohibition, you may automatically think of alcohol, but it included opioid-containing products as well. So, one day you could get whatever you need – the next day, nothing. What happened? Bootlegging – not only of alcohol but opioid-containing products as well
A minimalist view of pain and pain prescribing continued into the early 1990’s. Studies showed that many people, including cancer patients, were living with daily pain. Many patients were dying in pain – this was a travesty. So, in the early 1990’s, The American Pain Society began looking for guidelines in opioid pain prescribing. A few years later, the VA Hospital started to look up pain more closely. They started the campaign “pain is the 5th vital sign”. The original four vital signs are body temperature, heart rate, blood pressure, and respiratory rate. These are all objective findings that involve using a thermometer, a blood pressure monitor, and a watch. The stethoscope may be necessary as well. So the difference with pain being a vital sign is that it is a subjective quality while the others are quantitative. Plenty of people reject pain being a vital sign for this particular reason. However, in 1999 the Veterans Administration made pain their policy for being the 5th vital sign.
So, in nursing school, we are taught that “Pain is what the patient says it is”. My perception of pain and your perception of pain are usually very different. There is no blood test or way to objectively assess a patient’s pain level. Herein lies the problem.
What is the answer?
The United States has a very true prescription drug problem, but simply not prescribing opioids is NOT the answer. As providers, we must do the appropriate assessment and physical examination, which should include radiology testing. It is also imperative that patients be referred to orthopedists, neurologists, and rheumatologists where appropriate, as well as prescribing non-opioid therapies. Yet, there still exists a population of patients that must be managed with appropriate amounts of opioid therapy.
It may be surprising that pain relief is, in fact, not the goal in pain management. The true goal of pain management is increased quality of life. We are not doing our patients a service if they are so severely medicated that they cannot take care of their children, work, or continue family relationships. As a provider, I want a patient’s pain to be lessened without causing sedation – which in turn allows them to function at an optimal level. It is important that patients continue to care for their children and spouses, remain active, attend church and social functions, and participate in life.
So, what do you do if you are experiencing pain? Talk to your health care provider. Expect that they will order tests and make appropriate referrals. Become an active participant in your health care. Be willing to try alternative therapies as prescribed by your provider. They are there to help you, but first, you must help yourself.
It is evident that we have a problem here in the United States. The prescription drug problem is not one person’s fault, but it has become an epidemic. If we do not get this problem under control, there exists a real possibility that legislation could be mandated to prevent appropriate opioid prescribing. This could be detrimental to many patients and the care they receive. Access to appropriate pain providers is difficult at best and may become even more so – if we do not get ahold of this real problem.
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Brett Snodgrass, FNP-C, CPE, ACHPN, FAANP
Operations Director, Palliative Care Baptist Healthcare System
6027 Walnut Grove Rd, Suite 116
Memphis, TN 38120