Painful Correction

Dr. Sally Satel, M.D. 09.06.04
http://www.forbes.com/business/forbes/2004/0906/048.html

OxyContin doesn't cause addiction. Its abusers are already addicts.

"Pain Pill leaves death trail." This lurid headline kicked off the Orlando Sentinel's series on OxyContin, a narcotic painkiller. According to the five-day, front page expos�, published last fall, 205 overdose deaths in Florida in 2001 and 2002 were linked to OxyContin. What's more, many of the victims were innocent patients, taking the medication for pain. They "put their faith in their doctors," said the Sentinel, "and ended up dead, or broken." The Sentinel's reporting galvanized Florida politicians. Governor Jeb Bush called for a computerized system to track prescribing of addictive medications. Last winter a Florida congressman and state legislators each held hearings.

In August the Sentinel recanted: Its OxyContin series was terribly wrong. Autopsies on two-thirds of the victims uncovered other drugs (e.g., alcohol, heroin, other painkillers) that alone or in combination with oxycodone could have been fatal. (Oxycodone, the active ingredient in OxyContin, has been available for more than 60 years.)

Of the remaining one-third, no one could tell how often OxyContin itself was involved because name-brand drugs were not identified in the autopsies. Only oxycodone is listed, and that compound is also found in Percocet, Percodan and Tylox, which are also abused.

The Sentinel had already conceded in a February story that its series falsely portrayed "accidental addict" David Rokisky, 36, a former policeman. Before his use of OxyContin he pleaded guilty to conspiracy to distribute cocaine in 1999. His attorney had told the Albuquerque Journal that Rokisky "had problems" with cocaine and steroids.

These two errors--that people are overdosing on OxyContin in huge numbers and that the typical OxyContin addict starts out as a pain patient who falls unwittingly into a drug habit--reflect common misconceptions.

Like all narcotics, OxyContin can be abused, but its virtue is its powerful effect on persistent moderate-to-severe pain. It is not intended for toothaches; it is for unremitting pain from diseases like cancer, neurological illness and deforming rheumatoid arthritis.

Available since 1996, OxyContin is now the most widely prescribed branded narcotic for serious pain. Last year 7.7 million prescriptions were dispensed, generating $1.6 billion in revenue for the drug's maker, Purdue Pharma in Stamford, Conn. Its popularity is due to the fact that it is taken only twice a day. Other narcotic painkillers have to be taken every 3 to 6 hours. The 12-hour controlled delivery keeps blood levels steady, an important feature when pain is constant and severe. The name OxyContin, in fact, is from oxycodone and continuous. And it is strong. For comparison: The strongest dose of a single Percocet pill contains 10 milligrams of oxycodone (plus acetaminophen), while OxyContin (which is pure oxycodone) has up to 80mg per pill.

Problems arise when the pill is crushed or chewed (thereby destroying the slow-release feature) and people snort or inject the contents for a euphoric rush similar to that delivered by heroin. Not surprisingly, the typical OxyContin abuser already has current or prior substance abuse problems. In other words, he is someone who seeks out the pill precisely because it can produce a spectacular high when crushed.

This has given the medication a serious image problem. A month before the Sentinel series appeared, the New York Times cited a member of a Food & Drug Administration advisory panel as pronouncing OxyContin to be responsible for 500 to 1,000 deaths a year, an estimate that has no basis in fact.

Yes, there are problems. Some doctors hand it out liberally, and there are cities where OxyContin is relatively easy to buy on the street. But in those regions drug abuse is not a new scourge. For example, Kentucky's 2001 drug-abuse raid, called Operation OxyFest, resulted in the arrest of 207 people. But in 1992 (before OxyContin even existed) another statewide sweep of illegal drugs resulted in 543 arrests. There were 27 oxycodone-related deaths in 2000 in Kentucky. In all but 2, however, additional drugs, including cocaine, heroin, other prescription painkillers and alcohol, were found in the bodies.

The Kentucky picture reflects a national trend. In 2003 the Journal of Analytical Toxicology reported on deaths related to oxycodone in 23 states over 29 months. In only 12 of the 919 drug-abuse deaths (1.3%) was OxyContin found alone.

In December 2003 the General Accounting Office summed up its investigation on OxyContin: "While Drug Enforcement Administration field offices continue to report OxyContin as a drug of choice among abusers, [it] has not been and is not now considered the most highly abused and diverted prescription drug nationally." That distinction goes to hydrocodone.

Yet OxyContin's maker is taking heat. To date, more than 300 suits have been brought against Purdue Pharma for failing to warn consumers of the risk of addiction. "They are corporate drug lords," says the lawyer representing a group of Virginia residents.

Such resentment may be part of the overall animus toward OxyContin. After all, it fits the popular cultural narrative that frames pharmaceutical companies as rapacious, self-interested entities that hurt consumers--sick, vulnerable consumers to boot. Add trial lawyers salivating at the thought of a product liability payday, and media that cannot resist the story of a villain (drug company) and a fair maiden (patient), and you have the script for a modern-day health scare.

The most worrisome consequence of the hype about OxyContin's dangers is that patients, and some doctors, have become fearful of it. The American Pain Foundation receives calls from patients who are doing well on the medication but are afraid to continue even though it is well established that addiction--the compulsive use of a drug to regulate one's mood--occurs infrequently among individuals who take OxyContin as prescribed.

The problem isn't OxyContin itself, but its deliberate misuse. The Sentinel apologized for having "created the misleading impression that most oxycodone overdoses resulted from patients' taking the drug to relieve pain from medical conditions." That misimpression has caused a lot of unnecessary pain.