Thursday, March 25, 2004
In a recent five-part series (Oct. 19-23), the Orlando Sentinel painted a stark picture of the opiate drug OxyContin: Prescribed for mild pain by a clueless doctor, the drug had destroyed a former policeman's life. Apparently, this story was typical:
Thousands had been derailed by the deadly drug. Within weeks, however, the drug's manufacturer, Purdue Pharmaceutical, and the ex-cop's mother-in-law revealed that the man—called an "accidental addict" by the writer, Doris Bloodsworth—was a former cocaine abuser with a federal trafficking conviction.
This was not the only error the Sentinel had to account for in a 2,000-word correction: The paper had also omitted that an overdose victim profiled in the series had actually taken multiple drugs, along with OxyContin, and had previously overdosed on different medications. Even now, the Sentinel still hasn't clarified that most of the overdose deaths cited in the "investigations"— about 90 percent according to other research—were not, in fact, caused by OxyContin alone but by deadly combinations of drugs (OxyContin along with alcohol and/or other depressants like benzodiazepines).
If the Orlando Sentinel were the only news organization to run massively misleading stories on OxyContin, the misinformation could be chalked up to error. But the first substantive column by the New York Times' ombudsman Daniel Okrent also dealt with OxyContin bias, albeit of a different sort—Okrent wrote that the paper shouldn't have allowed Times writer Barry Meier, author of the anti-OxyContin book Pain Killer, to cover the drug in an article in its "Science" section. Meier's article claimed that researchers now believe that "accidental" addiction is more common than previously thought—never mind the fact that there has been no new research suggesting this since OxyContin was introduced in 1995, only increased pressure from law-enforcement agents.
Indeed, various media outlets—from NPR to the New York Post—claim that numerous new OxyContin addicts have been created by doctors who cavalierly prescribe the drug. Articles or news segments assert that overdose frequently occurs among the innocent patients of careless doctors, but the profiled "victims" are overwhelmingly prior drug users who now get their fix by snorting or shooting OxyContin. The featured subjects almost always turn out—like the Sentinel's—not to be "accidental" addicts but just plain druggies. (In a 2001 story about the supposed "epidemic" in Appalachia, the New York Times Magazine didn't cite a single case of doctor-caused addiction; instead, it portrayed "casual" drug users who faked pain or otherwise illegally obtained OxyContin in a sympathetic light, claiming these "accidental addicts" didn't know that prescription opiates are addictive!)
All of which raises the question:
If accidental addiction is so common, why aren't there any telling anecdotes about the phenomenon?
In fact, the entire OxyContin "epidemic" is based on a false narrative that asserts that the majority of OxyContin addicts begin as drug-naive pain patients. The cop the Sentinel profiled was actually a typical Oxy addict—a prior drug user—but his real story wasn't what they wanted. If Bloodsworth had been looking for that, she would have noted that government data shows that 90 percent of OxyContin abusers have also taken cocaine, psychedelics, and other prescription painkillers. Readers would have been informed that investigators specializing in prescription drug abuse say the typical OxyContin addict has a lengthy history of multiple-drug abuse.
The paper also would have highlighted that addiction is the exception, not the rule, among people exposed to opiates. Studies consistently show that pain patients taking opiates are no more likely to become addicts than people in the general population (i.e., exposure alone does not cause addiction). That is to say, only between 1 percent and 20 percent of people in the general population experience a period of addiction to some substance, depending primarily on characteristics such as age, stress, family history of addiction, and mental illnesses. (Depression, manic depression, and schizophrenia all dramatically affect one's risk of addiction.) If you rule out prior abusers, the rate settles at the low end, in single digits. (Rush Limbaugh may be one such example, though we still don't know anything about his possible prior drug use.) Even among people who try the most demonized opiate, heroin, for recreation or in a situation of extreme stress, only a minority will become addicted. While nearly half of U.S. soldiers in Vietnam tried heroin while abroad, only 20 percent of users became addicts. And only 12 percent remained junkies—even though 60 percent of those addicted while in Vietnam tried heroin at least one more time back home. Research by the National Institute on Drug Abuse finds that most people simply don't enjoy the opiate "high," let alone want it daily.
Yet reporters don't like this narrative, so they ignore it. This tired, predictable story line leaves reporters with unsympathetic protagonists: Who wants to read about scummy addicts scamming doctors? Grandma's back pain making her into a pharmacy robber is much more compelling; unfortunately, it almost never happens.
In order to create their preferred story, reporters twist the facts. The Sentinel, for example, noted that prescribing rates for other opiates like morphine and Demerol increased 23 percent between 1996 and 2000—while the prescribing rate for OxyContin rose 2,000 percent. But these numbers say nothing about drug abuse. An analysis of rates of abuse as reported in emergency rooms compared with prescribing rates would be more informative.
Such an analysis was published in the Journal of the American Medical Association in 2000. The study covered the period from 1990-96, analyzing national records of opiate prescribing rates and emergency room drug-abuse "mentions"—and found that as prescribing increased, abuse of these drugs did not rise proportionately. In fact, for fentanyl, a stronger opiate than heroin, medical use rose 1,168 percent, but abuse reports fell 59 percent. The Sentinel neglected to mention the study.
Interestingly, this research also found that while Oxycodone (OxyContin is simply a time-release preparation of this drug, designed to deliver a steady dose over 12 hours) use rose 23 percent during that time, Oxycodone-abuse mentions in emergency rooms fell 29 percent, despite the 1995 introduction of OxyContin. Abuse accounts began to rise in 2001, only after the media—with help from prosecutors—discovered the "problem" and taught large numbers of drug users to defeat the drug's time-release mechanism by telling them that this could be accomplished by crushing the pill and snorting it. (Crushing maximized both overdose and addiction risk; a user can get 12 hours' worth of medicine in a minute.)
The fact is, if the media and the government were to acknowledge the truth—that OxyContin addiction occurs primarily among previous addicts—they would have to admit that easy solutions like prescription-drug registries and more physician prosecutions won't work. Multiple-drug users will switch substances, not quit, if one drug disappears. Pain patients will suffer or turn to street drugs when doctors refuse them. If duplicitous prescription-seeking, not accidental, addicts are the problem, the doctor we all want—the kind, empathetic, trusting one—will be incarcerated while the one who dismisses pain will thrive. (Barry Meier's article, for example, described what he called a South Carolina "pill mill" that sold prescriptions to addicts; the doctors in that clinic, however, claimed they were just treating patients' pain. One pleaded guilty to avoid decades in prison after being lambasted in the press; another committed suicide rather than testify against his colleagues.)
There have been some retractions and clarifications like those made by the Sentinel, but these have been aimed mainly at appeasing Purdue Pharma. The media haven't asked the forgiveness of its real victims: pain patients. Even after a decades-long fight by advocates, more than half of dying patients still don't get adequate relief, let alone chronic-pain sufferers. The Sentinel made much of Purdue's push to make OxyContin available for nonlethal pain, implying that this was cynical marketing, not sound medicine. (Apparently it's acceptable for people to have pain relief before death, but those with chronic pain will be forced to suffer for years.) The paper also failed to mention the fact that alternative drugs such as ibuprofen and similar medications are more likely to kill patients through side effects like bleeding if taken long-term as directed, while opiates are rarely deadly unless abused. Pain advocates say there are 30 million to 50 million chronic-pain patients and the worse their pain, the less likely they are to find relief because doctors fear prosecution for giving enough of the right drugs to help.
There is a story that needs to be told about prescription opiates:
Good drugs and good doctors are being defamed by reporters and prosecutors based on conventional—and discredited—wisdom about addiction. Opiates don't grab most people. Addiction isn't an accident. Drug companies aren't always wrong. Unfortunately, America seems to be hooked on the bad-companies/bad-doctors/innocent-victims narrative: The Bush administration recently announced that this year's national drug strategy will focus on prescription drug abuse by pushing prescription registries and physician prosecutions. Where is big pharma's clout when we need it?
Maia Szalavitz is a senior fellow at STATS.org. She is writing a book about behavior-modification programs for teenagers.