The opioid abuse epidemic ravaging the United States began in the late 1990s when more types of opioid painkillers had been approved for prescription use, and prescribing practices changed with the aim of providing better management to a broader range of patients.
Before 1996, prescribing practices around opioid medications were strict, insisting that these drugs not be prescribed outside of a very firm set of health circumstances. However, pharmaceutical companies began promoting new versions of opioid painkillers, particularly those based on oxycodone and hydrocodone, around the same time that medical professionals reexamined how they treated moderate-to-severe pain in their patients. This led to wider and greater prescribing of narcotic painkillers.
Hydrocodone, which was initially listed as Schedule III by the Drug Enforcement Administration (DEA) under the Controlled Substances Act (CSA), was very widely prescribed. It quickly became one of the most widely abused narcotic painkillers in the country. By 2009, according to the DEA, hydrocodone was the second most-frequently encountered opioid narcotic in drug abuse evidence submitted to federal, state, and local forensic labs.
Hydrocodone's Role in the Opioid Abuse Epidemic
Most opioid drugs are listed as Schedule II by the CSA, including oxycodone and morphine, so prescribing doctors and pharmacists can keep a close eye on how many times their patients refill prescriptions. This helps to monitor for signs of abuse, like receiving multiple prescriptions from multiple doctors, or “losing” pills and needing refills sooner than prescribed.
Because hydrocodone was a Schedule III drug for several years, it was not initially subject to this kind of scrutiny. In October 2014, hydrocodone was officially moved from Schedule III to Schedule II, but the damage already had been done. People all over the U.S. had become addicted to hydrocodone.
According to the U.S. Centers for Disease Control and Prevention (CDC), 115 people die, on average, every day in the U.S. from an opioid overdose. Between 1999 and 2016, more than 630,000 people died from a drug overdose, and about 66 percent of those people died from opioid overdoses specifically. Now, the bulk of the problem involves heroin and illicit fentanyl causing rapid highs and overdose deaths, but the problem began with prescription narcotics.
The National Institute on Drug Abuse (NIDA) found that 21 percent to 29 percent of people who are prescribed opioids to treat pain end up misusing these drugs; 8 percent to 12 percent develop an opioid use disorder; and 4 percent to 6 percent of those with prescription narcotic addiction move to heroin, often because it is cheaper and easier to find. Currently, about 80 percent of people who abuse heroin started by abusing prescription painkillers like hydrocodone first.
What is Hydrocodone?
Drugs with hydrocodone as the primary painkilling agent are still an important part of medical treatment, and are still, therefore, widely prescribed. Since they have been moved to Schedule II from Schedule III, it is possible to monitor prescriptions and potential abuse more closely.
Like codeine, another opioid, hydrocodone is an antitussive. This means it suppresses lung spasms that lead to coughing. More often, hydrocodone is used as a painkiller for moderate-to-severe pain, most often after surgery or an injury that will take some time to heal. Studies report that it is nearly equal to morphine, one of the first synthetic narcotic painkillers, in how well it reduces pain sensations.
There are two basic types of hydrocodone available for prescription use: immediate release (IR) and extended release (XR). Immediate-release versions of hydrocodone include acetaminophen. Doses may be 2.5 mg (milligrams), 5 mg, 7.5 mg, or 10 mg. Immediate-release pills are effective within 30 minutes after the dose is taken, and their effects last for about four hours to six hours for pain. Peak effects occur after one or two hours. There are no formulas of pure immediate-release hydrocodone that have been approved for prescription use.
Extended-release hydrocodone, however, typically does not include additional medications like acetaminophen; it is just hydrocodone by itself. These doses are designed for at least 12 hours of pain relief, although some versions may relieve pain for a full 24 hours. Dose sizes range from 10 mg to 120 mg; however, the larger doses are only given to people who have ongoing pain problems, like a chronic pain disease, and who have developed a tolerance to lower doses of hydrocodone or other narcotic medications.
Changes in Prescribing and Schedule
According to the DEA, the first report of hydrocodone’s potentially addictive effects occurred in 1923, when a publication reported habitual consumption patterns and euphoria associated with the drug. The first report of addiction and dependence specifically on hydrocodone was published in 1961. Since then, the federal and state governments have tried different tactics to safely prescribe hydrocodone while preventing widespread abuse of the drug. Until the 2010 recommendation that states implement prescription drug monitoring programs, people who struggled with hydrocodone addiction most often called in fake prescriptions to pharmacies, altered the prescriptions their doctors gave them, went to multiple doctors complaining of pain, bought the drugs illegally online, stole hydrocodone from friends or family, or stole money to buy illicit, street versions of hydrocodone.
Illicit formulations of hydrocodone may look like the prescription pills or tablets, but they also have been found in powder or liquid form. The most frequently encountered illicit form of this drug is the combination of hydrocodone and acetaminophen, most frequently known by the brand name Vicodin, suggesting that the drug is more often diverted from personal prescriptions or stolen from pharmacies, then sold illicitly, instead of being produced by clandestine labs as fentanyl and heroin are.
Thanks to state and federal changes in prescribing and legal use of hydrocodone, the overall rate of abuse appears to be declining. The National Survey on Drug Use and Health (NSDUH) in 2013 reported there were 24.4 million people in the U.S., age 12 and older, who abused hydrocodone for nonmedical reasons in their lifetime. In 2012, the previous survey year, there reportedly were 25.7 million people who struggled with this drug. The most striking declines in abuse occurred in adolescents between the ages of 12 and 17 as well as in young adults, ages 18 to 24.
Although you can develop side effects from your hydrocodone prescription, even when you take it as directed by your doctor, side effects are more common and risky in people who struggle with addiction to this drug. When you work with your doctor to control pain, the physician can moderate your dose of hydrocodone so that you do not experience many side effects. However, people who struggle with hydrocodone abuse will continue to take more of the drug to get high while their body becomes tolerant to the substance but dependent on it. They are more likely to ignore side effects, including serious health risks.
Common side effects associated with hydrocodone include:
- Stomach pain
- Nausea and vomiting
- Changes in appetite, especially a lower appetite
- Dry mouth
- Tiredness or fatigue
- Back pain
- Muscle tension or tightening
- Difficult, frequent, or painful urination
- Tinnitus or ringing in the ears
- Trouble falling or staying asleep
- Swelling in the feet, legs, or ankles
- Uncontrollable shaking in part of the body, especially the limbs
In addition to the above common symptoms, there is a risk that someone abusing hydrocodone could suffer other side effects, such as:
- Lightheadedness or dizziness
- Fear or paranoia
- Blurry vision
Abusing hydrocodone to get high can lead to serious short-term and long-term health problems. If you abuse this drug for a long time, you are at risk of developing a physical dependence on the drug, meaning your brain needs the presence of opioids to manage neurotransmitters. This can lead to withdrawal symptoms if you are not able to take the substance regularly.
It is possible to develop dependence on hydrocodone if you take it as prescribed, but because a doctor and pharmacist are working with you to manage your pain, dependence will be taken into account when you no longer need the drug. People who struggle with addiction do not have this type of oversight and are more likely to suffer the consequences when they try to quit.
- Breathing problems
- Damage to organs due to slow, long-lasting oxygen deprivation from slowed breathing
- Slower heart rate
Overdose Can Be Deadly
Like all opioid drugs, it is possible to overdose on hydrocodone. For some people, this is a medication mistake – maybe they have been prescribed regular painkillers, along with a benzodiazepine drug like Xanax for as-need anxiety treatment, and they accidentally mix too much of the two. Similarly, a person may take a large as-needed dose of Vicodin then have a few glasses of wine over a meal with friends. Sometimes, the person may forget they already took a dose of hydrocodone because they are still experiencing pain, and when they take a second or third dose, they overdose.
Unfortunately, too many hydrocodone overdoses do not involve an accident with a prescription; they are the result of nonmedical or recreational abuse of this drug. A person who has struggled with addiction to hydrocodone for months finally takes a dose so large that they overdose; someone takes an illicit version of hydrocodone that has been laced with fentanyl, a much more potent opioid, and overdoses; or they abuse hydrocodone with alcohol or other illicit opioids to get high and overdose. Narcotic drugs of all kinds carry the risk of overdose, which is increasingly likely to happen when the substance is abused.
Specific signs of a hydrocodone overdose are:
- Slowed, irregular, shallow, or stopped breathing
- Cyanosis, or blue-tinted skin from oxygen deprivation
- Extreme sleepiness
- Disorientation and cognitive trouble
- Muscle weakness
- Cold, clammy skin
- Narrowed or widened pupils
- Slowed heartbeat and low blood pressure
Call 911 if you see someone with any of these overdose symptoms. Medical professionals are capable of treating opioid overdoses, but the individual needs immediate medical attention, which may include several doses of naloxone to temporarily reverse the overdose. If you can, stay with the person until help arrives.
Hydrocodone with acetaminophen combination drugs, like Vicodin, may also lead to an overdose if you take too much acetaminophen. The average healthy adult should not take more than 4000 mg (or 4 grams) of acetaminophen in one day; however, numerous over-the-counter (OTC) drugs, including headache relievers, cold and flu medications, and cough suppressants contain acetaminophen as a secondary painkiller. Many people have suffered overdoses on this drug because they took a hydrocodone/acetaminophen painkiller, Tylenol, and another OTC drug containing acetaminophen.
The biggest risk of overdosing on acetaminophen is liver damage and failure. Hydrocodone alone does not cause extensive liver damage, although the opioid can cause other extreme health harms.
The Necessity of a Medically Supervised Detox
Basically, there are two phases of withdrawal from opioid drugs like hydrocodone. The first phase involves various symptoms, such as:
- Mood swings
- Watery eyes
- Muscle aches
- Excessive sweating
- Sleeplessness or insomnia
- Excessive yawning
- Low energy or fatigue
The second phase, which typically occurs two or three days after the first phase starts, includes a general intensifying of symptoms, which include:
- Abdominal cramps
- Appetite loss
- Nausea and vomiting
- Dilated pupils
- Rapid heartbeat
- Shallow, fast breathing
Without medical supervision, withdrawal symptoms can be very uncomfortable, and cravings may become intense, which can lead to relapse. At this point, relapse is more likely to cause an overdose. Working with a doctor to taper off opioids like hydrocodone, or to at least receive some supervision during the detox process, reduces the risk of relapse and can ease discomfort.
Mild withdrawal symptoms may include feeling like you have the flu. The aches and pains of this phase can be managed with OTC painkillers like ibuprofen, along with anti-nausea drugs. Fluids and rest are also important during this time.
More intense withdrawal symptoms require medication-assisted treatment (MAT) with drugs like buprenorphine or methadone to slowly taper the body off physical dependence on hydrocodone. Without MAT, hydrocodone withdrawal may take 10 days at most; with tapering and MAT, though, withdrawal can take several weeks or months, depending on how long you have struggled with hydrocodone addiction, how dependent your body is on the substance, and how large your dose was. However, MAT is a great process that works well for most people overcoming addiction to hydrocodone or other opioid drugs.
Avoid rapid detox, and do not attempt to detox alone. Addiction treatment has several core components that are important to follow after safely detoxing with the help of a medical professional.
Ending Addiction After Detox
Detox is the first step in overcoming addiction, but it is not the only component. The process is designed to end the body’s physical dependence on drugs, but detox does not address the compulsive behaviors associated with stress or specific triggers that lead to addiction. Rehabilitation provides that process with different approaches to behavioral therapy, such as group therapy and individual therapy, occupational and physical therapy, family therapy, and complementary treatments like meditation, nutritional support, and art therapy.
After rehabilitation, recovery is an ongoing process requiring social support from friends, family, and mutual support groups. You may continue individual therapy, develop a regular exercise or meditation routine, or find other approaches to maintaining sobriety as part of your aftercare plan. This will be developed with the help of a counselor during rehabilitation.
Although millions of people in the U.S. struggle with addiction to opioid drugs like hydrocodone, there is help. Evidence-based detox and rehabilitation are the foundation of recovery success.