Keeping OxyContin Out of the Wrong Hands

The Boston Globe, August 11, 2001

By Sally Satel

It is the summer of OxyContin, the potent prescription painkiller. Pharmacies in cities such as Boston, Philadelphia, and Cleveland have been held up at gunpoint, and thousands of pills, worth millions on the street, have been stolen. On July 25, the FDA announced a tightened warning on the drug, and days later The New York Times Magazine ran as its cover story, “The OxyContin Underground: How a Prescription Painkiller is Turning Into a Pernicious Street Drug.”

OxyContin does a have small black market, and that seems to be growing. This is surely a problem, but instead of concentrating on drug users, dealers, and doctors who prescribe it, the media and the Drug Enforcement Administration are blasting the medication itself. The acting head of the DEA told Congress that he was “seriously considering” rolling back the quota that DEA sets for a chemical used in the production of OxyContin by 95 percent, although it has since backed off. In the end, patients suffering wrenching chronic pain – patients for whom OxyContin was the only painkiller that worked – may not be able to get it.

What exactly is OxyContin? It is a drug in the same category as morphine. OxyContin is not for toothaches and transient postoperative pain; it is for people with searing and prolonged agony due to diseases like cancer, neurological illness, and degenerative discs. The name is a contraction of oxycodone and the word continuous, referring to its slow release feature. Available since 1995, the medication is now the most prescribed narcotic, in large part because it is taken only twice a day; other narcotic painkillers are taken every three to six hours. The 12-hour controlled delivery keeps blood levels steady, an important feature when pain is constant and severe. Also, the fewer daily peaks in blood level and the slower the rate of increase in blood level – both afforded by regular administration of a time release drug – the lower its addictive potential.

Indeed, and ironically, OxyContin is an innovative substitute for other potent painkillers that can lead to physical dependence in patients. Those with a penchant for abusing drugs can get addicted – that is, they want more and more of the drug to regulate their mood.

Problems started about 18 months ago when drug users discovered that they could crush the pill – thereby inactivating the slow release feature – and snort or inject the contents for a euphoric rush similar to heroin. Referring to the ease of creating powder from an intact pill, The New York Times story says: “It takes five seconds to effect the transformation – and not much longer to create an addict.” The implication from that dramatic statement and from much of the news coverage is that innocent people, including perhaps the patients that OxyContin is designed to help, are accidentally stumbling into a powerful addiction.

By most reports, the typical Oxy user is someone with pre existing drug and alcohol problems. As the medical examiner’s office in Kentucky told the Cleveland Free Times, there were 27 oxycodone-related deaths in the year 2000; in all but two, a host of other drugs, including cocaine, heroin, and other prescription painkillers like Dilaudid and Fentanyl and alcohol, were found in the bodies.

It is not pain patients receiving OxyContin from their doctors who are showing up in emergency rooms. It is individuals who have bought it on the street because they heard it is a spectacular high. As media critic Tom Shales observed, “Yeah, more kids are using the drug to get high because they heard about it and even saw how to use it on the evening news.”

The first pharmacy robbery in Cleveland followed a news story in the Cleveland Plain Dealer, suggesting that the spread of OxyContin abuse may have been stimulated by media reports, rather than the other way around.

And what about the people who allowed themselves to become addicted? It may seem odd to pose such a question. After all, we have so medicalized the notion of addiction that the user himself is not seen as the actor, the drug is – and so it becomes the menace. Yet temptation abounds.

Because I am a psychiatrist, patients have confided to me that “I tried cocaine a few times and I loved it so much I knew I had to stay away.”

Why do some know they have to stay away and act on that knowledge while others don’t? Many things: conscience or character or freedom from mental anguish. Narcotics are an excellent short gap salve for depression, numbing boredom, self-loathing, fear. In short, the very people who seek drugs are often the ones least psychologically equipped to handle them. This is a tragic reality of addiction, but it is not fundamentally the fault of the drug.

The worst response we could make to the OxyContin phenomenon would be to restrict the supply, a classic toss of the baby out with the bathwater. Two weeks ago Vermont’s governor announced that Medicaid would stop paying for the medication for some welfare recipients. Five other states, Florida, Vermont, West Virginia, Ohio, and South Carolina, have introduced regulations making it more difficult for Medicaid recipients to get it.

Something must be done to keep OxyContin out of the wrong hands, but the true public health tragedy will be depriving patients who need it to survive in relative comfort day to day.

Sally Satel is a psychiatrist who practices in Washington, D.C.