Why is Tylenol #3 not a schedule 2 drug?

[TWR]

Hydrocodone, norco are # 2, why can we still write for Tylenol #3?  Thanks

[rev ronin]

Because it's Tylenol 3.

 

(Thanks, I'll be here all week)

 

In all seriousness, the FDA has not assessed it as having the same level of abuse potential.

[TWR]

Does it have anything to do with the amount of codeine?

[SocialMedicine]

what is the equivalent dose of codeine and hydrocodone ?  I believe hydrocodone has some of the highest abuse potential in the opioid class. I remember reading a theory as to why but long forgotten it. Interest, I believe certain europe countries sell a dose of codeine as cough suppressant OTC. 

[gbrothers98]

The real question is why is anyone writing for codeine anymore.....

G Brothers PA-C

[RetNavyPAC]

Agree with Gbrothers98.  Codeine isn't terribly effective I've found (although Navy dentists LOVE the stuff so much you'd think they all owned stock in it)

 

It all has to do with "sip-tootie-six" (CYP2D6).  A significant percentage of people are poor- or intermediate-metabolizers (or even

extensive metabolizers)

 

Good brief on it at:  http://www.worstpills.org/public/page.cfm?op_id=414

[EMEDPA]

The real question is why is anyone writing for codeine anymore.....

G Brothers PA-C

because it's safer than tramadol for when you want to give something, but don't want to give norco and the pt has already tried nsaids.

[EMEDPA]

Does it have anything to do with the amount of codeine?

yup, they make tyl#2, #3, and #4 with varying amounts of codeine. I never write any prep other than #3 because #4 is basically norco strength and causes a lot of nausea and #2 is basically regular tylenol with someone whispering "codeine" at it. ....

[taotaox1]

So based on my knowledge of the drug here is my assumption for c3 vs c2.

 

1. Less euphoria and more side effects in normal use than drugs like hydrocodone.   EMED illustrates this perfectly, his patients have a lot more nausea/itching/etc for eqi-analgesic doses compared to hydrocodone, and patients (or addicts) cant take as much without feeling bad. Addicts, at least the ones trying to scam drugs from me, generally don't ask for codeine, unless it is in "purple drank" form with promethazine.  I think others will echo this.

 

2. It is a prodrug. It turns into morphine and some other stuff as it is metabolized. You can't inject it for snort for a fast "rush" as the drug has to be metabolized first to have an effect and this takes time.  Once again, less desirable for junkies.  This is what makes hydrocodone and oxycodone (especially the old oxycontins..) such a problem, it has no need for metabolism first and there is lots of drug in a single pill.

 

3. To my understanding, there is a ceiling to the dose you can take with codeine and get an increased effect due to the limits of your body's conversion rate (via CYP2D6) to morphine/etc.  After 400mg you will not increase your high (or legitimately decrease pain) significantly due to this rate limitation .  This would only matter for junkies with huge tolerances, as opioid naive patients and abusers will OD long before this, or get very sick trying. No one gives those doses in a legitimate setting so it is a non issue from that standpoint.

 

 

 

Personally, I agree with EMED.  If I don't want to give norco/oxy but do feel they need something better than an NSAID I will use t3s WAY before I go to tramadol.  I have never written for tramadol unless I am covering refills another providers patient while they are on vacation or I am bridging a new patient on it as a chronic med and then sending them to pain management.  I plan to keep it that way.  Codeine is much safer and has similar abuse potential compared to tramadol (meaning there is still significant abuse potiental.....).  It is not a great drug for severe pain, but has its place for certain situations and patients.

[Guest Paula]

I've found a few patients like  T3 and they find them to be effective.  I figure they are the ones who get the morphine effect.  Isn't it about 15 % of the population who have the ability to metabolize it to morphine?

 

T3 are schedule 3 anyway.  I have schedule II - V prescribing rights.

 

I just had a conversation today with a pharmacist who felt all scheduled drugs should go back to the old rules (from way back) that allowed only a  30 day supply of any scheduled drug and the pt. had to see the physician before each and every prescription.  Not sure if this was our state law or if it was a federal law. 

[Guest Paula]

Nice tutorial from RetNavyPAC.  It corrected my somewhat misunderstanding of the metabolizing effect of the poor metabolizers vs. the ultrametabolizers. 

[ventana]

use T3 a fair amount now that Vic is a II - I can write II's but have to notify my doc - which just means faxing him the script- but it is still a PIA

 

Also, can do refills on the T3 - unlike Vic or Perc

 

Yup using it a fair amount these days....

[sk732]

In Canada, T3's are scheduled differently because they're a triple combination product - the addition of caffeine changes the scheduling under the Controlled Drug and Substances Act.  I still use them for some pain, however there was a significant abuse issue in the area I used to work in - the method of choice was actually crushing and snorting, since the pills are very powdery.  To counter this, I'd often prescribe folks Atasol 30's, which have an enteric coating, so slower onset of action and harder to crush.  I could generally tell the addicts or dealers if they'd freak out when they got them...and I put a no sub on the Rx to make sure :-).

 

SK