Hydrocodone – All About America’s Opioid

Hydrocodone is a uniquely American drug. Every day, there is a new headline about the ongoing – and worsening – opioid epidemic. But in spite of that, US doctors still prescribe powerful painkillers at rates unthinkable in other countries around the world. Since prescription drugs sparked the opioid crisis, let’s take a closer look at one of the most popular pain medications – hydrocodone.

First Things First—What is Hydrocodone?

Hydrocodone is a semi-synthetic opioid made from codeine, which is itself made from the opium poppy. “Semi-synthetic” means that hydrocodone is a mixture of compounds found in nature and those that are manufactured exclusively in a laboratory. Hydrocodone was first synthesized in Germany in 1920, in 1943, it gained approval by the Food and Drug Administration for sale in the United States. Available by prescription only, hydrocodone is used medically to treat moderate-to-severe pain, or as a cough suppressant. Although hydrocodone is only 59% as potent as morphine, when taken orally, the two drugs are roughly equivalent to reducing pain. When taken as a painkiller, hydrocodone begins acting in approximately 10 to 30 minutes, with a duration of effects of between 4 and 8 hours. Interestingly, although hydrocodone is not as strong as oxycodone, a study of emergency room patients determined that the two drugs were equally effective at treating the pain associated with broken bones. As a cough suppressant, hydrocodone is superior to codeine.

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Hydrocodone Statistics

• According to the International Narcotics Control Board, the United States consumes up to 99% of the world’s hydrocodone supply.
• The DEA reports that hydrocodone is the most-prescribed opiate in America.
• In 2011 alone, there were more than 80,000 emergency room visits related to hydrocodone misuse.
• In 2013 and 2014, close to 140 million hydrocodone prescriptions were dispensed annually.
• The National Survey on Drug Use and Health says that over 24 million Americans have used hydrocodone non-medically.
• Per the 2017 Monitoring the Future Survey, at least 1.3% of respondents in the 8th, 10th, and 12th grades have used a hydrocodone-containing medicine illicitly.

List of Medications Containing Hydrocodone

Hydrocodone is available in both short-acting and long-acting/extended-release formulations. The American Pain Society recommends using a short-acting opioid for treating breakthrough pain, while long-acting opioids are given for around-the-clock pain. The appropriate hydrocodone dosage range is between 2.5 mg and 10 mg four times per day. Hydrocodone is an ingredient in hundreds of brand-name and generic combination medications, including:

• Immediate-Release Hydrocodone with Acetaminophen. The biggest consideration with these medications is how much acetaminophen is contained because the maximum dosage is 4 mg within a 24-hour period. Acetaminophen is associated with liver damage.
  • Lorcet – hydrocodone bitartrate 10 mg/acetaminophen 650 mg
  • Lortab:
    • Elixir/Oral Solution – 7.5 mg/500 mg per 15 mL
    • 2.5 Tablets – 2.5 mg/500 mg
    • 5 Tablets – 5 mg/500 mg
    • 7.5 Tablets – 7.5 mg/500 mg
    • 10 Tablets – 10 mg/500 mg
  • Norco:
    • 5 Tablets – 5 mg/325 mg
    • 10 Tablets – 10 mg/325 mg
  • Vicodin – 5 mg/300 mg
    • ES – 7.5 mg/300 mg
    • HP 10 mg/300 mg

• IR Hydrocodone with Ibuprofen. The biggest consideration of these medications is how much ibuprofen is contained because the maximum dosage is 800 mg per dose or 3200 mg within a 24-hour period. Ibuprofen is associated with stomach or intestinal damage.
  • Reprexain:
    • 2.5 tablets – hydrocodone bitartrate 2.5 mg/ibuprofen 200 mg
    • 5 tablets – 5 mg/200 mg
    • 10 tablets – 10 mg/200 mg
  • Vicoprofen – 7.5 mg/200 mg

• Extended-Release Hydrocodone
  • Hysingla ER – Available in tablet form at dosages of 20 mg, 30 mg, 40 mg, 60 mg, 80 mg, 100 mg, and 120 mg.
  • Zohydro ER – Available in capsule form at dosages of 10 mg, 15 mg, 20 mg, 30 mg, 40 mg, or 50 mg.

What Are the Side Effects of Hydrocodone Abuse?

Like other opioid medications, hydrocodone carries a risk of numerous side effects, such as:

• Amnesia
• Anxiety
• Birth Defects
• Brain Damage
• Constipation
• Cross-Addiction—Opioid addicts are 40 times more likely to also abuse heroin.
• Dizziness
• Drowsiness
• Dry Mouth
• Hearing Loss
• Itching
• Lightheadedness
• Mood Swings
• Nausea
• Pneumonia
• Rash
• Respiratory Depression – at high doses, hydrocodone can fatally interfere with breathing.
• Tightness in the Chest
• Urinary Difficulty
• Vomiting

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Hydrocodone and Dangerous Drug Interactions

Hydrocodone and other prescription painkillers produce central nervous system depression and should not be used in combination with certain other substances.

• Alcohol
• Anticholinergic agents – Dramamine, Spiriva, medications for COPD or Parkinson’s disease
• Antidepressants – Specifically, tricyclic antidepressants (TCAs)
• Antihistamines – Benadryl, Unisom, Advil PM, Chlor-Trimeton, etc.
• Antipsychotics – Abilify, Latuda, Seroquel, Risperdal, etc.
• Benzodiazepines – Xanax, Klonopin, Valium, Ativan, Seresta, Restoril, etc.
• Barbiturates – Luminal, Seconal, etc.
• Dextromethorphan
• Opioids – Codeine, fentanyl, Methadone, OxyContin, etc.

Using hydrocodone with alcohol or any of these other medications can magnify CNS depression, potentially to a fatal degree:

• Inhibited brain activity
• Decreased rate of breathing
• Slowed heartbeat
• Lowered blood pressure
• Unconsciousness
• Coma
• Death

Significantly, 75% of all overdoses – and 98% of those that turn fatal – involve more than one substance.

Why Do People Abuse Hydrocodone?

One of the biggest hazards of hydrocodone use or misuse is an extremely high potential for dependence and addiction. The FIRST reason why people misuse hydrocodone medications is simply that they like getting high. Hydrocodone works by blocking pain messages from the brain. But it also tricks the brain into artificially increasing the production of dopamine – the neurotransmitter associated with pleasure, reward, learning, and motivation. Elevated levels of dopamine create a euphoric sense of profound well-being in the user – the “high”. Very quickly, their brain learns that taking hydrocodone results in a pleasurable reward, and so the person is motivated to repeat the behavior. In other words, they choose to take the drug to feel good. But the SECOND reason why people abuse hydrocodone is much darker – they are compelled to take the drug to keep from feeling bad. Choice isn’t even a factor.

Hydrocodone and Addiction

This artificial over-stimulation has a rebound effect. Soon, the body begins to slow down natural dopamine production. This means that the person has to take more and more of the medication in order to realize the same effects. This is known as tolerance. Opioid tolerance can occur even when the medication is used exactly as prescribed, but misuse speeds up the development of the problem. Eventually, natural dopamine production stops altogether, and the only way for the user to experience pleasure – or even feel normal – is to take more hydrocodone. In fact, when the drug is discontinued or isn’t available, their body goes into a kind of shock known as withdrawal. While not particularly dangerous, hydrocodone withdrawal can be so painfully uncomfortable as to trigger uncontrollable drug cravings and use. Opioid withdrawal can manifest in as little as 12 hours following the last dose. The habit-forming nature of hydrocodone has been known to medical professionals for decades, with reports of euphoria and habituation published as far back as 1923. In 1961, the first medical report describing hydrocodone dependence and addiction were published. Celebrities who have struggled with hydrocodone addiction:

• George Carlin, comedian
• Jamie Lee Curtis, actress
• Eminem, rapper
• Brett Favre, Hall of Fame football player
• Rush Limbaugh, radio host
• Courtney Love, musician
• Cindy McCain, wife of Senator John McCain
• Walter Payton, Hall of Fame football player
• Matthew Perry, actor
• Nicole Richie, television personality

Symptoms of Hydrocodone Withdrawal

The symptoms of hydrocodone withdrawal begin 12-30 hours following the previous dosage and typically last about five days. In heavy or long-term hydrocodone users/abusers, some symptoms may persist up to two weeks.

• Heightened anxiety
• Profound agitation or restlessness
• Hot flashes and chills
• Sexual dysfunction
• Confusion/Inability to concentrate
• Lack of motivation
• Excessive fatigue
• Uncontrollable yawning
• Sneezing
• Muscle aches
• Cramps
• Sweating
• Runny nose and tearing
• Dehydration
• A skin-crawling sensation, as if bugs are walking on one’s skin
• Nausea and vomiting
• Stomach cramps and diarrhea
• Goosebumps

Most people in hydrocodone withdrawal talk about an overall feeling of being ill, as if they have a bad case of the flu. This is why opioid addicts in withdrawal will describe themselves as “sick”. Fortunately, there are some FDA-approved medications that can help ease the symptoms of hydrocodone withdrawal. Treatment professionals may recommend opioid replacement therapy (ORT) – replacing the abused opioid with a longer-acting and less-euphoric one.

• Methadone
• Buprenorphine
• Naltrexone

This allows the recovering addict to regain some stability while experiencing fewer symptoms and cravings. With ORT and behavioral counseling, up to two-thirds of rehab clients are able to completely abstain from use, and up to 95% significantly reduce illicit opioid misuse. ORT has been endorsed by the World Health Organization and the United Nations Office on Drugs.

Warning Signs of Hydrocodone Misuse

Substance abuse does not exist in a vacuum – there are recognizable signs of a developing or existing problem.

• Taking more hydrocodone than recommended
• Always running out of medication
• “Lost” Prescriptions
• “Doctor shopping” to obtain multiple prescriptions
• Asking for specific medications by brand name or dosage
• Faking or exaggerating injuries or pain
• Using opioids to treat anxiety or depression
• Hiding medication use – how much and how often
• Loss of interest in hobbies and other activities
• Mood swings
• Multiple ER Trips
• Anxiety or irritability when the drug isn’t available
• Unexplained missing money or credit card charges
• Asking for (or stealing) pills from friends or family
• Purchasing drugs from shady online pharmacies
• Physical signs – confusion, drowsiness, excessive sleeping, accidental overdoses
• Criminal charges – DUIs, Public Intoxication, hot checks, fraud, embezzlement, etc.

Overdose: The Chief Danger of Hydrocodone Abuse

Besides the aforementioned side effects, the biggest hazard of hydrocodone abuse is an increased risk of overdose. In 2017, it is estimated that an all-time high of almost 74,000 Americans died because of accidental drug overdoses, and one-third of those were due to prescription opioids like hydrocodone. Here’s the scary part – while 2017 was a record year for drug poisoning deaths in this country, EVERY recent year has set a new record over the previous year. In fact, if the estimate for 2017 is correct, then the number of drug deaths in America has doubled in the past 10 years. In 2008, there were “only” 36,450 accidental fatal overdoses. Hydrocodone overdose victims typically die from respiratory depression – they choke to death because they can’t get enough oxygen to supply the demands of their brain, major organs, and bodily systems. There are three main reasons why this happens:

• Hydrocodone’s sedating effects suppress the area of the brain responsible for controlling the rate of breathing.
• There is an interruption in signals to the diaphragm, the muscle that helps the lungs expand and contract.
• Opioids also impede the brain’s ability to effectively monitor and respond to levels of carbon dioxide in the blood.

Recognizing a Hydrocodone Overdose

Hydrocodone overdoses can be especially difficult to distinguish, because during a “normal” high, a user might normally nod off or even pass out. This very typical reaction is virtually identical to an overdose. To ease the confusion, here are some warning signs of a potential overdose:

• Bluish fingertips or lips – reported in 1 out of every 5 opioid overdoses
• Gasping, gurgling, or snoring sounds – also known as the “death rattle”, reported in 1 out of every 8 cases.
• Muscle rigidity or seizures – 1 out of every 7
• Foaming from the mouth
• Strange behavior/confusion
• Skin discoloration: Light-skinned individuals will turn blue or purple, and those with darker complexions will turn gray or ashen.
• Shallow, slow breathing
• Weak pulse, to the point of being almost undetectable
• Exceedingly low blood pressure
• Tiny, pinpoint pupils
• Clammy, cold skin
• Tongue discoloration
• Vomiting
• Unconsciousness/Unresponsiveness
• Coma

There are two critically-important things to remember about a possible opioid overdose: FIRST, someone who is merely “extra- high” will still be able to respond to outside stimulus such as hearing the name, being shaken, pain, etc. Conversely, overdose victims are typically total in unresponsive. SECOND –  people do not normally die immediately during a hydrocodone overdose. In fact, and overdose is progressive, taking between 1 and 3 hours. This is especially important, because there still may be time to save their life – IF the proper measures are taken.

Responding During A Hydrocodone Overdose

Here are some life-saving guidelines, released by the Harm Reduction Coalition. First Step: Assess the warning signs:

• Breathing – if the person is not breathing, administer a few rescue breaths
• Responsiveness – loudly call their name and vigorously shake them
• Ability to talk
• Color of their lips, skin, and fingertips – bluish-gray for people with like complexions, ashy gray for dark-skinned individuals

Second Step: If they won’t answer or wake up, try to get a response through direct pain stimulation:

• Rub your knuckles – HARD – on their upper lip or sternum.

If they respond, try to get them to fully wake up and focus on what you are saying.  If they complain that their chest feels tight or they are short of breath, call 911 and Do NOT let them fall asleep again. If they do NOT respond, this is a medical emergency – call 911. While waiting for emergency personnel, put the overdose victims in the “recovery position”. Place them on one side, with one knee bent for support. This maintains a clear and open airway and prevents them from accidentally choking on their own vomit and aspirating it into their lungs. Third Step: If you have any Narcan, administer it immediately. If they do not wake up, you may need to give them multiple doses. Even if they wake up, they will still need medical treatment.

Are There Any Safer Alternatives to Hydrocodone?

The newest federal prescribing guidelines recommend first attempting to manage pain via non-opioid options, including:

• Diet
• Exercise
• Weight Loss
• Physical Therapy
• Yoga
• Massage
• Acupuncture
• Hypnosis
• Meditation
• Cognitive Behavioral Therapy
• Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

When hydrocodone or another opioid absolutely MUST be dispensed because different pain management methods have proven to be ineffective, they should be given for the lowest dose and the shortest duration possible, with frequent follow-ups by the prescribing physician.

Treatment for Hydrocodone Addiction

Because hydrocodone abuse is so powerfully addictive, effective treatment must be multi-faceted and must address the condition on multiple levels. Needed recovery services may include any or all of the following:

• Education about the disease of addiction in general and opioid addiction in particular
• Individual psychotherapy
• Peer group counseling
• Cognitive Behavioral Therapy
• Trauma processing
• Stress reduction
• Healthy coping methods
• Couples/Family counseling
• Relapse prevention
• 12-Step meetings
• Medication-Assisted Therapy (MAT)
• Exercise
• Nutritional guidance
• Hypnosis
• Yoga
• Acupuncture
• Pet or Equine therapy
• Art or Poetry therapy

Rehab programs may be needed in some combination of inpatient/residential, intensive outpatient opioid addiction treatment, and long-term aftercare, depending upon the individual needs of the patient. Recovery from hydrocodone dependence or addiction requires a lot of work, combined with professional assistance and support, but in the end, it is the surest and safest way to successfully regain sobriety, stability, and sanity.