TCS Daily

In Rx, Who's To Blame For Abuse?

By Duane D. Freese - February 14, 2002 12:00 AM

What should be done about the spike in emergency room visits and deaths in the Appalachian region due to overdoses of the narcotic oxycodone?

Your answer may rest on whom you blame for the problem to begin with.

OxyContin's time-release method provides the right amount of pain reliever at the right time for those suffering chronic moderate to severe pain. This overcomes the puke, pain-free, pain-feeling cycle, so people don't have to put up with nausea after first taking other oxycodone pain relievers and pain when those drugs' levels drop below that required needed to combat pain. But abusers crush the pills into powder, thus sidestepping the time-release mechanism to assure an intense high.

So now, Asa Hutchinson, head of the Drug Enforcement Administration, along with some trial lawyers and other critics are pointing their finger at Purdue Pharma, maker of OxyContin, dubbed "hillbilly heroin" by the media. The by-prescription-only pain reliever has been implicated in 117 of the oxycodone deaths and thousands of emergency room visits since it came on the market in 1995.

Hutchinson has gone so far as to threaten restrictions on OxyContin's key ingredient, oxycodone, in an attempt to limit supplies of the drug on the market. Some doctors have gone so far as to ask the Food and Drug Administration to put stricter controls on OxyContin itself.

At a panel presentation about this current drug furor moderated by Tech Central Station Host James K. Glassman last week, Purdue Pharma defended its drug and its response to misuse.

Purdue Pharma's J. David Haddox, senior medical director for health policy, said the company is working on other formulations of the drug that would neutralize the oxycodone so if crushed it wouldn't produce a high. But doing so also risks neutralizing its ability to combat pain.

Haddox said Purdue Pharma didn't anticipate any major problems with diversion of the drug for illicit uses because it had no problems with a previous time- release pain reliever, morphine-based MSContin. Furthermore, as a schedule two drug, OxyContin can be obtained only with a nonrefillable prescription, he noted..

Haddox also defended his company against charges of aggressive marketing, saying that doctors today under prescribe for pain management, meaning millions of people suffer needlessly even though safe and effective medicines are available if they are used properly. A 1997 study of the state of pain in Michigan, cited by Haddox, showed that 1.2 million of the state's 9.8 million residents suffered chronic pain for six months or longer, 77 percent of them for a year or more. More than a third missed four weeks or more of work, and 10 percent contemplated suicide. An undetermined number carried through.

While denying responsibility for abuse of its drug, Haddox said that his company is spending millions of dollars on educational awareness, an antidiversion campaign, a surveillance program, electronic data capture of drug orders and other measures.

That wasn't good enough for another panelist, Charleston, W.Va., journalist Greg Stone, who wrote a series about OxyContin abuse last year. "Hillbilly heroin is an epidemic," he said. Daily doses of the drug can sell for as much as $400 on the street, a huge markup on the pill itself. He said people are breaking into friends' homes to steal the drug and converting their welfare checks to buy it on the street. They are "losing their morals, ethics, standards and souls," he said.

And he blames Purdue Pharma. He says it has pushed the drug too hard, helping make it - at 5.8 million prescriptions last year -- too widely available. He said drug salesmen were telling doctors that they would be violating their duty to patients if they didn't prescribe it for pain. And he questioned the efficacy of the drug maker bringing doctors to resorts to tell them about the drug.

Furthermore, OxyContin's purity made its abuse foreseeable, he argues. Unlike other oxycodone based pain relievers, such as Percocet, OxyContin doesn't require acetaminophen or cutting with other drugs that can make some people ill if they try to abuse those drugs to get high. He would consider taking the drug off the market if Purdue Pharma can't reformulate it to discourage abuse.

Dr. Sally Satel, an American Enterprise Institute fellow who runs a methadone treatment center for addicts, doesn't buy that logic that the drug company is to blame. "I don't think the user is passive in addiction," she said.

She pointed out a misconception about drug addiction repeated in a New York Times Magazine article on the OxyContin epidemic. She noted that the article said that it "takes five seconds" to crush OxyContin for snorting or injection "and not much more to create an addict."

But it takes two weeks to develop a physiological dependence to OxyContin, she said, and that can be overcome through gradual reduction of use of the drug.

Those taking OxyContin who become addicted are doing so because they are seeking something else from the drug than pain relief. They may suffer from depression, low feelings of self worth, or merely want to get high, she said. They are making "conscious choices" to become high; they need help making the wiser choice of getting treatment to deal with their reasons for abusing drugs. But the bottom line is that it's not the drug that's causing the addiction.

A fourth panelist, resident AEI scholar John E. Calfee, who's written extensively on pharmaceutical markets, had only praise for Purdue Pharma's promotion of the legitimate uses of OxyContin. But he suggested that media hype over addiction might lead many people who otherwise could use its pain relief to not do so.

Panelist Erika King, a food and drug law attorney at the law firm Covington & Burling in Washington, D.C., said that even if the government decided it wanted to remove OxyContin from the mix of pain-relieving drugs or place more restrictions upon it, the Food and Drug Administration lacks the legal authority to do so. She likewise didn't think Purdue Pharma was at fault for the abuse of it by addicts.

Everyone on the panel agreed that abuse of pharmaceutical drugs is a problem. None of them favor legalization of drugs. Dr. Satel suggested that while she would not send drug addicts to prison but to treatment, nonetheless the possibility of criminal sanctions helps make drug abusers take treatment seriously.

For all the coverage it has received, OxyContin isn't even the biggest source of pharmaceutical drug abuse. As a USA Today editorial last year found, Valium and several other drugs cause more death and emergency room visits. Abuse of one group of drugs, hydrocodone, is double that of OxyContin, causes more deaths and has increased markedly in recent years, yet receives nary a mention in the press or in DEA reports.

A system for monitoring prescription drug sales, as is now in effect in Kentucky, California and several other states, could prevent the doctor shopping, multiple prescription, and other tactics of diversion. It could spot medical practices and pharmacies that over-supply pain relievers considering the size of their practices.

But ultimately, the most significant key to eliminating drug abuse is to find the best possible ways to deal with abusers. Take all the pharmaceuticals away, and you are still left with the oldest self-medication system of all - alcohol. And the body count for its abuse numbers in the thousands just in highway deaths each year.

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