Valley of the Dolls
In early January, Time Magazine became the first major media outlet in America to report on the growing abuse of a synthetic opioid prescription painkiller named OxyContin. According to the story, the drug was "so popular and addictive" that it was generating "a blizzard of a crime wave" in several "pockets of the nation." While the article admitted that it "has been hailed as a miracle" by legitimate users, it added that OxyContin pills were nicknamed "killers" in some areas due to the rapidly escalating toll of overdose deaths allegedly associated with its illicit use.
These two themes, that OxyContin is an ultra-powerful narcotic coveted by junkies for its uniquely intense high, and that it is responsible for scores if not hundreds of fatalities - the specific numbers would vary widely - were to be repeated ad nauseum in a spate of succeeding media accounts. Indeed, readers didn't know it at the time, but the Time piece was only the opening salvo in a sustained journalistic campaign - conducted over the angry protests of pain specialists and their patients - which has, in a space of a few short months, irredeemably stained the public image of a medication previously acknowledged as a major breakthrough in the treatment of debilitating, chronic pain.
In fact, in the last four months, reporting on OxyContin abuse has become a national media craze, with often sensational, fear-mongering stories appearing in hundreds of publications from Newsweek to small town newspapers in rural Midwestern hinterlands.
Taken together, all of these stories (and countless others)
have misleadingly and preemptively proclaimed a major epidemic of OxyContin abuse. Yet experts say no evidence exists that increases in the abuse of the drug are outpacing increases in prescriptions for the drug. In fact, several incidents seem to suggest that the media's sensational coverage - which advertises to the addicted the existence of the new drug and explains how to get it and use it - may be contributing to the increase in OxyContin abuse.
Meanwhile, doctors and legitimate users have become needlessly afraid of utilizing an important advance in the treatment of pain.
The Dukes of Hazard
OxyContin was an instant hit with doctors when first introduced in December 1995. Hailed by pain management specialists as a wonder drug, the oxycodone-based formulation was considered a major advance in the medical profession's expanding effort to battle the debilitating effects of chronic pain. As the good news spread, sales of the drug mushroomed, rising from $40 million in 1996 to more than $1 billion last year, outstripping even Viagra.
And the drug was a godsend for a bevy of patients who were not finding relief for their pain from other medications. Media accounts of OxyContin's effectiveness were also glowing, though relatively few in number. For instance, in a September 1996 article Oxy was said to be enjoying "a groundswell of international support" at the annual meeting of the International Association of the Study of Pain (IASP), as members touted it as "an excellent opiod for moderate to severe pain."
But about 18 months ago - roughly six months after OxyContin's auspicious debut - some cases involving the illegal use of the drug surfaced in rural Maine. Soon after, the drug's popularity began to rise in rural Appalachia, especially parts of eastern Kentucky, West Virginia and southern Ohio (in and around Cincinnati). If claims of epidemic levels of abuse are true anywhere, it's here, says Ashland, KY pain specialist, Dr. Shelley Freimark. "In this area right now it is a severe problem," she states.
This can largely be chalked up to the fact that the usual street drugs are simply not as readily available in these rural outposts, says Dr. Phil Fisher, head of the Appalachian Pain Foundation (APF), a group formed last year by pain doctors devoted to educating the medical community and public about the uses and benefits of OxyContin: "This is an isolated area where it's hard for people to get real street drugs. By and large, OxyContin is not a street drug in most places."
Also, demographic and economic conditions in Appalachia have contributed to an established, long-term problem with prescription drug abuse in the region. In general, the population is older, Fisher says, and many suffer from chronic illnesses and debilitating diseases born of years working in the mines, increasing both the number of addicts and the availability of such drugs.
Still, outside of the region this development initially went largely ignored by the press. The media lacked a "hook," some spectacular news event around which to build their coverage of OxyContin. But that all changed on February 6 with "Operation Oxyfest 2001:" more than 100 Kentucky cops fanned out in "the largest drug raids in state history." Sweeping a five county area, they netted 207 dealers and users.
Within days, the OxyContin "epidemic" was national news, turning small town cops into minor celebrities. For example, Detective Roger Hall of the Harlan County Kentucky Sheriff's Department had the distinction of being quoted in two separate AP articles printed in scores of papers, despite the fact his claim that abusers "will kick a bag of cocaine aside to get to the Oxy" failed to make the absolutely fundamental distinction between nervous system depressants like OxyContin and stimulants like cocaine - addicts of one are usually not addicted to the other.
Naturally, politicians weren't shy about chasing the free publicity either. With the heightened press interest, they convened a series of press conferences and public meetings in order to maximize press coverage of their efforts, such as on March 1 when Virginia Attorney General Mark Earley convened a major "summit" on the Oxy epidemic which included high ranking officials from five states. Not to be outdone by his neighbors, Kentucky governor Paul Patton, who had already proclaimed a "near epidemic" in his own state, announced the creation of the state-wide OxyContin task force, comprised of officials from 15 separate agencies.
Coverage built until April 9, the day Newsweek's cover screamed "Painkillers." Inside, the popular newsmagazine's writers penned two articles, one on the rising tide of prescription drug abuse in general and the other, titled "How One Town Got Hooked," on events in Hazard, KY, the town said to be at the center of the epidemic.
With the raids' success, and the massive press coverage they engendered, the existence of an Oxy epidemic became an integral part of the cultural zeitgeist, one which the press rapidly nationalized. After the wave of Kentucky stories by the big boys, the major urban newspapers in the East and Midwest assigned reporters to look for indications of a rising tide of abuse in their own localities. Unsurprisingly, they found what they were looking for.
Dying for a Fix
Many of the media's "thrill pill" stories have been centered on widely disseminated and divergent claims that OxyContin has been responsible for a shocking number of overdose deaths. Just how many is an open question. The numbers vary from paper to paper, and are at best unverifiable, at worst wildly inflated. Some of the published figures appear only once, in a single article, and leave no clue as to their origins. Others are widely used; most papers across the country claim that the drug has been responsible for more than 120 deaths, 59 since February 2000 in eastern Kentucky alone.
Repeated across the country, that latter figure originated in early February with public statements from Joseph Famularo, the U.S. Attorney for the Eastern District of Kentucky, who used it to justify the eight month investigation leading to Operation Oxyfest.
The press responded to these announcements with a flurry of stories. But none of the accounts, which repeatedly asserted these contentions of a fast-rising death toll in bold, large-type headlines and gut-punching story leads, bothered to ask how solid the numbers were and what they meant. If they had, they might have been a little more circumspect in their reporting.
"That figure was given to us by local law enforcement," says Wanda Roberts, U.S. Attorney Famularo's spokeswoman, about the 59 alleged Kentucky deaths. That it was generated by the same police officials who used it to justify Operation Oxyfest does not appear to trouble Ms. Roberts, though when asked she declines to confirm the figure as accurate.
The search for the truth leads to David W. Jones, executive director of the Kentucky State Medical Examiner's Office. "As far as deaths go, I've heard different numbers in different places at different times; I have no idea where these people are getting their facts and figures," he said. While he stresses that not every drug-related death is necessarily reported to his office, according to his data there were 27 oxycodone-related deaths in the entire state in 2000.
Of course at first glance 27 deaths over 12 months in a single state - even in Kentucky, a state at ground zero in the spread of OxyContin abuse - appears to support the implication that there has been an explosion in the number of Oxycontin drug abusers. But when Jones parses the numbers further, the situation appears far less grave.
Two of the 27 victims, he explains, were found to have traces of both oxycodone and alcohol in their bodies, with death caused by their interaction. What's more, 23 others evinced traces of a head-spinning multiplicity of other drugs in their systems, including highly potent prescription painkillers such as Dilaudid as well as powerful illegal drugs like heroin. In the final analysis, Jones reveals, only two of the 27 fatalities can be shown to have been due to the effects of oxycodone alone - not just two in eastern Kentucky, two in the entire state.
Moreover, there are additional facts that most accounts don't bother to mention: oxycodone is the opiod agent in around 40 separate brand-name prescription medications besides OxyContin; and OxyContin only accounts for about 25 percent of the oxycodone consumed annually. While OxyContin is the strongest oxycodone formulation available, there is absolutely no way of telling, Jones explains, whether an oxycodone-related fatality was due to OxyContin.
For that matter, not everyone who dies from an oxycodone overdose does so accidentally. For the long-suffering, often terminal patients who comprise the vanguard of legitimate OxyContin users, suicide by opiate overdose often seems like a painless way to escape a life of terrific suffering. Yet such suicide cases are often lumped in with accidental overdoses, making the already inflated Oxy death numbers appear even greater.
Even when the deaths can be reliably confirmed, for the most part they do not point to a vast increase in the overall number of prescription drug abusers. Rather, the evidence of multiple-drug usage implies that a substantial portion of OxyContin abusers are long-standing drug addicts who have either switched to Oxy from other prescription or illegal drugs, or alternatively, take OxyContin occasionally as a substitute for other more preferable drugs which may be in short supply in areas such as rural Kentucky.
"Most of these people have been abusing prescription drugs for awhile, and have just switched over to OxyContin," says Kentucky state representative Jack Coleman, a legislative expert on prescription drug abuse and a member of the recently state-formed OxyContin task force. "The problem is not particularly the abuse of OxyContin," he adds, "it's with prescription drug abuse in general."
His view is echoed by Dr. Karla Berkholz, board member of the American Academy of Family Physicians, who says that "6 to 7 percent of the American population uses illicit substances, and that number has held pretty steady over time."
Consistent with Berkholz's analysis is the number of oxycodone-related emergency room (ER) visits - a more reliable figure than oxycodone-related overdoses. There was a 72 percent increase in the number of oxycodone-derived ER incidents, from 3,060 in the first half of 1999 to 5,261 in the equivalent period in 2000, according to the federal government's Drug Abuse Warning Network (DAWN). But that's still tiny compared to other drugs; for example, there were 18 cocaine-related ER visits for each involving oxycodone.
And legitimate use of OxyContin rose by a similar amount, argues Fisher. Vicodin poses a much more serious prescription drug problem, since illegal usage of it as a percentage of total sales is rising much faster than with oxycodone: "Compared to it, Oxy only accounts for 10 percent of the cases but gets 90 percent of the attention," Dr. Fisher said.
The Real Victims
All of the media hype, complete with gripping headlines and fear-generating content, is provoking anger and derision from growing numbers of medical professionals who specialize in chronic pain management. For years, this area of medical treatment was largely ignored or underemphasized by most physicians, says Dr. June Dahl, president of the American Alliance of Cancer Pain Initiative. "Historically, there have been a lot of inaccurate preconceptions and over-sensitivity about opiod analgesics and other narcotics, which has kept them from being used as much as they should."
Now, the flurry of accounts surrounding Oxy has not only stalled progress in this area, but has sent the treatment of chronic pain reeling backwards into ignorance and fear.
As the media flurry has heightened, the Drug Enforcement Agency (DEA) has begun to take action against Purdue, the makers of OxyContin, and the doctors who prescribe OxyContin. In early May, in a first for the agency - it had never before fixed its sights on a single prescription drug - it began to pressure Purdue into discontinuing all marketing of OxyContin to general practitioners, who comprise the vast majority of doctors.
So far Purdue has resisted the DEA effort, much to the relief of pain experts. "It's a ridiculous idea," snorts Dr. Barry Cole of the American Academy of Pain Management. "There are only 7,000 pain doctors in the entire country, not nearly enough to treat everyone who needs this medication." However, Purdue has temporarily halted shipments of the largest 160mg size pills, introduced two years ago for the treatment of terminal cancer patients.
In addition, the DEA has publicly announced that it is launching a crackdown on "over-prescribing" physicians. One doctor in southern Virginia recently reported that 30 minutes after a visit from a Purdue sales representative, local DEA agents descended on his office to question him about what the rep had told him and whether he intended to prescribe the drug to any of his patients.
In light of such developments, more and more doctors are becoming leery of prescribing OxyContin though thousands of patients desperately need the medication, as even the Washington Post admitted in a May 2 story.
"As a pain specialist, my job is to take care of the worst of the worst cases," Dr. Fisher says, "but now I'm seeing run-of-the-mill patients whose doctors are afraid that they'll be prosecuted for prescribing OxyContin, or that they're somehow being duped and the drugs they prescribe will end up on the street."
In addition, the negative media attention is not only making it more difficult for legitimate patients to get the medicine they need, it is making them afraid of taking it when it is prescribed to them. "I'm treating two little old preacher's wives," Fisher relates. "Both are afraid of getting addicted, and one is sure someone's going to break into her home to get her supply of the drug Vicodin."
|l||Local Prof Weighs In On Oxy
In spite of mass media coverage and dozens of reported deaths related to OxyContin use in eastern Kentucky, University of Kentucky pharmacologist Dr. Robert Yokel said that addiction to the drug is not a problem solely restricted to that area.
"It's not unique to eastern Kentucky," Yokel said. "Why are we getting so much bad press? There are other places that have these problems as well."
The "other places" that Yokel speaks of are small towns spread throughout Appalachia, in West Virginia, Maine and southern Ohio. Yokel speculated that the reason for the focus on eastern Kentucky could be due to several factors.
"There is a history of illicit substance abuse by people in that part of the state," Yokel said. "In many ways, there are things in Kentucky that are not regulated like in other states."
Yokel said that OxyContin is only one of several drugs that contains oxycodone, the substance which absolves pain but can create a high if not used properly.
"From everything I've heard, based on the pharmacology, one would expect that a person could get similar effects from drugs in this family," Yokel said.
The availability of other drugs with the oxycodone component could mean extra caution when prescribing these drugs to patients in chronic pain.
"Its one of a whole mess of drugs used for severe pain. They have all the same type of pharmological properties and the same abuse potential," Yokel said. "I think a physician should be cautious of prescribing any of these drugs. Probably more so of OxyContin, because of the press."
For more information about the clinical uses and effects of OxyContin, go to www.oxycontin.com -LS
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