Hydrocodone reclassification set for Oct. 6

Beginning Oct. 6, hydrocodone combination products such as Vicodin and Norco will be rescheduled as Schedule II drugs instead of Schedule III.

Dentists with a Drug Enforcement Administration (DEA) registration that does not include Schedule II authority will have to change it to continue prescribing/refilling certain pain-relieving medications for their patients. The DEA is permitting hydrocodone combination product prescriptions issued before Oct. 6 to be refilled until April 8, 2015, if the prescription authorizes refills.

CDA reminds dentists to use the same tamper-resistant forms used to prescribe Schedule III drugs. The tamper-resistant forms replaced the triplicate forms about 10 years ago. The forms must be purchased from state-approved printers. A list of those printers is available on the state Department of Justice website.

Telephone and faxed prescriptions for Schedule II drugs are not permitted. However, in emergency situations only, a prescriber may call in a prescription for up to a 72-hour supply and then follow it up with a written prescription to the pharmacy.

Dentists who are interested in prescribing alternatives to hydrocodone drugs have options. One alternative is prescribing a combination of 400-600 milligrams of ibuprofen and 500 milligrams of acetaminophen. Peter L. Jacobsen, PhD, DDS, is an adjunct professor at the University of the Pacific, Arthur A. Dugoni School of Dentistry and author of The Little Dental Drug Booklet, which has been used by dentists and dental offices for more than 20 years. He considers the combination an effective pain manager.

"This combination provides good pain management, based on the physiological effectiveness of these drugs," Jacobsen said. "Using a combination of ibuprofen and acetaminophen, alternating every two hours, is as effective at pain relief as many narcotic combinations, without the liability and risk of abuse associated with narcotic pain medication."

Jacobsen recommends the patient take 400 or 600 milligrams of ibuprofen, depending on the patient’s size and severity of expected pain. At hour two, they can take 500 milligrams of acetaminophen, and at hour four the patient takes another 400 or 600 milligrams dose of ibuprofen. At hour six, they can take another 500-milligram dose of acetaminophen. They continue this alternating once every two hours, with the same drug being taken four hours apart, for 24 to 48 hours after the dental pain episode, according to Jacobsen.

Kenneth M. Hargreaves, DDS, PhD, who is Chair of the Department of Endodontics at the University of Texas, San Antonio, a diplomate of the American Board of Endodontics and has published 150 papers and edited two textbooks, lectured at CDA Presents The Art and Science of Dentistry in San Francisco. He agrees that the combination of ibuprofen and acetaminophen is a good alternative to hydrocodone products.

"Growing recognition has occurred over the last 10 years that the combination of NSAIDS (nonsteroidal anti-inflammatory drugs) such as ibuprofen with acetaminophen increases the magnitude of analgesia, speeds up the onset of analgesia and has more of a consistent drug affect as compared to either ibuprofen or acetaminophen by itself," Hargreaves said. "Acetaminophen shows good absorption and ibuprofen blocks prostaglandin production both in the tooth and the brain. If you add these two drugs together for your patients it gives them a much stronger level of analgesia."

Hargreaves lectured on "Successful Management of Acute Dental Pain" at CDA Presents. Specifically, he offered attendees strategies for managing acute dental pain.

Hargreaves is a strong believer in the use of ibuprofen in general.

"Ibuprofen should be considered the NSAID of first choice in patients who can tolerate it. It is safe, if the correct dosage is prescribed, and also is effective and cheap," Hargreaves said.

Increased doses of ibuprofen can have some gastrointestinal tract side effects.

Aside from the ibuprofen and acetaminophen combination, Jacobsen says dentists also can use tramadol or a combination of acetaminophen and 60 milligrams of codeine.

Dentists who are interested in getting a new DEA registration with a Schedule II classification can use the following steps:

  • Access the DEA registration site.
  • Under “Registration Support” select “Registration Changes.”
  • Log in using your DEA registration information.
  • From Step 2: “Business Activity” select “Change.”
  • Check the applicable DEA schedules then select “Update.”
  • DEA registration schedule changes may be processed at any time and are posted within 24 hours (Monday-Friday).

If you have additional questions, contact CDA Practice Analyst Teresa Pichay at teresa.pichay@cda.org.

CDA also has a "Controlled Substances Prescribing and Dispensing" resource available on cda.org.