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Published On: August 09, 2001          Updated On: January 26, 2002
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OxyContin
Is The Scare Campaign Justified

By Alan Block

August 5, 2001

The government has turned its attention to the pain-killer OxyContin. Is the scare campaign justified?

By Alan Bock. Sunday, August 5, 2001. This article was orginally published in the Orange County Register. Copyright 2001.
R
alph Murray of Mission Viejo was a meatcutter for 15 years before carpal tunnel syndrome, several surgeries and a host of wrist and hand ailments pushed him onto disability. Despite surgeries (perhaps in part because of them; they uncovered deeper neural problems than his surgeons suspected) he has severe chronic pain - it hurts all the time.

"OxyContin is the only medication I've found that lets me sleep pain-free all night," he told me recently. "With other prescription pain medications I had to get up and take a pill every four hours. If I didn't set an alarm the pain would wake me soon enough, and then it would take a while for the medication to kick in. I know it is potentially addictive and I discussed all the ramifications with my doctor thoroughly before starting it. But it's really been a blessing."

Murray had tried several prescription pain medications before trying OxyContin. Neurontin didn't touch his particular pain, even in progressively heavier doses. Vicodin, which combines the opioid hydrocodone with acetaminophen, helped some.

However, as Eric Chevlen, an assistant professor of medicine at Northeastern Ohio Universities College of Medicine wrote in a recent Weekly Standard article, acetaminophen in large doses (Murray was taking 12 a day) "carries a risk of serious liver damage."

So Murray has paid close attention to the spate of scare stories about OxyContin in recent weeks.

The Food and Drug Administration has announced that it will henceforth carry the agency's strongest warning, a black box calling it potentially addictive as morphine. The Drug Enforcement Agency has announced a high-profile campaign to nail doctors and pharmacists it deems responsible for abuse. The little town of Pulaski in southwest Virginia wants to require pharmacists who dispense OxyContin to require patients to provide fingerprints.

Doctors in Philadelphia and Florida have been arrested for "over-prescribing" OxyContin. An ambitious lawyer has filed a suit against the drug's manufacturer, Purdue Pharma of Stamford, Conn., for getting people hooked.

Of course, most of the media, ever cooperative whenever the drug warriors identify a new Drug Menace of the Month and provide a couple of anecdotal horror stories, have been only too happy to feed the panic. National Public Radio, feeding off a Washington Post story, did an alarmed take on OxyContin in Virginia last week. Time, Newsweek, The New York Times and the Philadelphia Inquirer have all done tales of abuse and diversion replete with lurid details.

As happened during the crack cocaine "epidemic" of the 1980s, the media stories raising alarms and tut-tutting about this latest favorite of junkies have informed millions of people who would otherwise never have heard of Oxy- Contin that there's a new drug out there, and informed them how to abuse it. Thousands of people who would otherwise not have learned of OxyContin will try it.

Some will become addicted or die, the self-fulfilling prophecy will play itself out, and thousands of people will be hooked as a result of publicity that those who pushed it claimed was supposed to be helpful.

Surely the drug warriors have to be intelligent enough to know that this is the dynamic.

Why is OxyContin so useful to those in chronic pain and why is it subject to abuse?

As Eric Chevlen explained, OxyContin's active ingredient, oxycodone, an opioid (apparently the preferred term these days for what used to be generally called narcotics), has been in pharmaceutical use in the United States for 60 years. (Dr. Standiford Helm, Ralph Murray's doctor, a principal at the Pacific Coast Medical Center in Newport Beach, which specializes in pain management, says the ingredient has been separated and used medicinally since the Middle Ages.)

What Purdue Pharma did was figure out a way to put it in a time-release formula, so the drug is released gradually over 12 hours, maintaining a steady presence in the bloodstream.

What those who want to use OxyContin as a recreational or escapist euphoric do is crush the tablets, nullifying the time-release qualities, and have a tablet with large doses of straight oxycodone, which is apparently similar to heroin in characteristics, and quite addictive. Having subverted the qualities that make OxyContin so useful to people in chronic pain, they snort or inject this substance.

In the last several years a good deal of attention has been paid to the problem of treating intractable pain in the United States. Heroin was first effectively outlawed, as Dr. Helm reminded me not by an outright ban, but by declaring that chronic pain was not a specific disease, and treating it with potentially addictive opium derivatives like heroin was therefore outside the scope of medical practice.

Medical authorities now recognize chronic pain - sometimes clearly attributable to a specific injury or illness, less often with unknown origins - as a condition in and of itself.

Patients and eventually Congress have held hearings on the inadequacy of treatment of intractable pain, and Congress passed a law mandating federal authorities to study ways to eliminate barriers to adequate pain treatment.

Eric Chevlen estimates that 30 million to 50 million Americans live in chronic pain. Dr. Helm would put the figure at 20 million to 30 million. Both figures are huge, and most authorities estimate that only about a quarter of them are getting adequate treatment, even with advances in understanding in the last few years.

OxyContin has become quite widely used since its approval by the Food and Drug Administration in December 1995, growing from almost zero to about 6 million prescriptions in 2000.

With its increased popularity has come some diversion from legitimate medical uses to the recreational or persistent junkie market. It seems to be a fairly serious problems in some rural Appalachian areas, where serious pain is fairly widespread due to mining and agricultural injuries and the authorities have little experience dealing with black market drug problems.

The question is, to what extent is diversion and abuse a problem and what kinds of actions might minimize such problems.

Eric Chevlen points out that last year about 16,000 Americans died from treating arthritis with drugs like Advil and Aleve, because these medications increase the risk of bleeding ulcers and liver problems when used over long periods. About 200 people died in the same time period from purposeful abuse - using in ways it was clearly not intended to be used - of OxyContin. Naturally, the government in its wisdom has decided the 200 deaths constitute the problem that requires a public campaign and new restrictions.

In a letter responding to Chevlen's article Laura Nagel, the DEA deputy assistant administrator, used the numbers that have appeared in most news stories, but in a fascinating way. The number of OxyContin prescriptions has increased 20-fold since 1996, she said, and the number of oxycodone-related incidents - emergency room and medical examiner reports - have increased by 400 percent and 100 percent respectively.

But that's comparing apples to rocks. A 20-fold increase in prescriptions is a 2,000 percent increase. You could say, with some justification, that increases in reports of abuse that are 1/20 to 1/8 the increase in total prescriptions suggests that diversion into the black market so far is a relatively minor problem - far from inconsequential and certainly tragic for those who have become addicted or have died, but not worthy of a full-court-press publicity campaign.

The DEA has suggested two control programs. The first is cutting back on overall production of OxyContin - DEA administrator Donnie Marshall suggested rolling back quotas to 1996 levels, which would be a 95 percent cutback from current levels. The second is allowing only pain management specialists to prescribe OxyContin.

There is no universally accepted criterion or licensing standard for pain management specialization, but Chevlen estimates there are about 3,000 pain management specialists in the country, concentrated in urban areas. If the total number of people in chronic pain is "only" 20 to 30 million, that's a heck of a caseload for those practitioners - or, more likely, millions of Americans deprived of effective relief.

Why would the DEA propose such a cruel remedy to a problem whose magnitude is dubious and which it has purposely hyped and pumped up? It's a familiar and fundamental dynamic, in my view. It might help to consider the institutional incentives facing an agency like the DEA. Every bureaucracy, private or public, has an incentive to grow and increase its authority, power, influence and prestige. If the government ever really "won" the War on Drugs the DEA and related agencies would face the possibility of going out of business.

Their incentive, then, is to magnify perception of the problems they are facing to convince journalists to help them sell the perception of a crisis and Congress to increase their funding. This has worked well over the years. Journalists are notoriously mathematically illiterate and have their own vested interest in perceived crises. Politicians love to respond to perceived crises with more programs and more of the taxpayers' money.

Politicians and journalists are subsets of the general population populated by greater percentages of people whose instinctive response to a perceived problem is to propose a new government program or more government spending as the obvious, logical and inevitable response. In the case of hard drugs, however, there's a compelling case that this approach is dead wrong.

The black markets for drugs, which increase profit margins for sellers to obscene levels and are marked by crime and violence, are created by heavy-handed government controls. The more draconian the controls, the more lucrative the illicit trade.

In addition, controls feed into the American culture's (and maybe humankind's) eternal propensity to avoid personal responsibility. Few people want to acknowledge the role played by their own bad choices in creating their personal problems. The stance of the victim - of a troubled childhood, a bad neighborhood, lack of opportunity, racism, corporate greed, or an all-powerful drug that makes one helpless - is more psychologically attractive to many and is encouraged by the general culture.

But any addiction specialist, while acknowledging that these and other factors are important, will tell you that the addict taking personal responsibility for his or her own choices is important, perhaps essential to recovery. The world is full of conditions that impact people deleteriously over which they have no control. The key, as the Serenity Prayer puts it, is to accept the things you cannot change so you can begin to change the things you cannot accept.

Piling on the controls designed to save people from themselves deters and delays the acceptance of personal responsibility. You can make a case that it prolongs drug abuse problems rather than resolving or fixing them.

Besides the Weekly Standard magazine, these questions have also been raised mainly by drug-reform groups like the Lindesmith Center and DRCNet.

OxyContin provides invaluable relief to a wide variety of people who suffer from chronic pain. It is also subject to misuse and abuse. It is tempting to want to use government to try to control those problems. But much of the evidence suggests that will only make the problem worse. The public spinning of worst-case scenarios may have done so already.

Mr. Bock is a senior editorial writer for the Orange County Register.

 

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