OxyContin tablets, controlled-release pills for all-day relief from severe pain, seemed to be a miracle when they were introduced. Now they have turned into a major headache for three groups: 1) doctors who are becoming super-careful about prescribing them, 2) patients who are getting seriously worried that they won't be able to keep getting them, and 3) federal, state and local law enforcement agencies, who are finding that stopping their illegal sale is an almost-impossible job.
Patients Are Pleading Since they were introduced in 1996, OxyContin tablets have grown into a billion dollars a year seller for Purdue Pharma of Stamford, Connecticut. For thousands of patients like Patricia Kerbs, they are beyond price, because they have made it possible for her to live a normal life.
Until her doctor prescribed OxyContin, the California woman said, her chronic pain from a spinal condition was so bad she couldn't get out of bed. Since then, she told AMNews, an American Medical Association publication, her whole life changed. She has written the Drug Enforcement Administration, pleading with it not to take the pills off the market.
The DEA said the agency had no plans to do that. A spokesperson said the agency had conferred with the manufacturer, and had talked to pain management physicians about the drug's legitimate use. "There shouldn't be any fear," Rogene Waite said. "We're not changing the rules or regulations."
Doctors Are Wary Doctors have become very wary of writing prescriptions for OxyContin. "They're afraid the DEA will march into their office and cause them grief," said Edward David, M.D., chair of the board that licenses physicians in Maine, where illegal OxyContin is a huge problem. David said they don't need to be so worried, as long as they "do a good job and document what (they're) doing."
A Myrtle Beach, S.C., physician, Benjamin Moore, D.O., probably wouldn't believe that. His DEA number -- needed to write prescriptions for controlled substances -- was suspended after the death of two patients led to the federal agency investigating a pain management clinic where he worked.
The DEA said he wrote prescriptions "in many cases ... without any medical testing or complaint validation." Moore said that wasn't true. He told AMNews he never even saw one of the patients who died, and that he confirmed most patients' histories with records or tests, and sent away patients he suspected of faking.
"I never prescribed the stuff until I came to a pain clinic," he said, "but that's what you do at a pain clinic."
An Alabama doctor, Pascual Herrera Jr., M.D., lost his license in April because the State Board of Medical Examiners decided he had wrongly prescribed OxyContin. His lawyer says it was a bum rap. In the case reviewed by the board, Albert Agricola Jr. said, Herrera had a long relationship with the patient.
"This was not someone who walked in off the street and said 'I want some pain medication,' and the doctor never saw him again," Agricola said. "Now he's hearing from his patients who say, 'Nobody wants me, nobody will treat me because they're scared what happened to you will happen to them.'"
The executive director of the Alabama state board said doctors don't need to worry about being disciplined if they have a physician-patient relationship and documentation of sound medical judgment. "It takes a doctor who is writing large amounts of controlled substances and a patient who is a 'drug shopper,'" Larry Dixon said. "You get those two together and you've got a good relationship until we get you."
The problem is that the active ingredient of OxyContin tablets, oxycodone hydrochloride, is an opioid, a drug that works like morphine, heroin and other opium-like substances. It is one of the most effective pain relievers known to medicine, but like its chemical cousins it can be highly addictive.
Addicts Are Savvy Shoppers The tablets are formulated to release oxycodone into a patient's bloodstream gradually, giving long-term relief from pain. Addicts have discovered that crushing them into powder, which they then inhale like cocaine or dissolve and inject like heroin, releases the whole dose at once. As a result, "Oxy" or "O" -- two of the names by which it is known on the street -- has become so much in demand that in some places it brings higher prices than heroin or cocaine.
The traffic in OxyContin pills is hard to contain because there are so many ways to get the drug: "doctor shopping," looking for a doctor who will write a prescription without extensive examination and testing; seeing several doctors and getting a prescription from each; altering a prescription to order, for instance, 100 pills instead of 10; and buying the pills from someone who obtained them for a legitimate purpose, but who needs money.
It is stolen from pharmacies so frequently that some have stopped stocking it, which can make it necessary for patients to travel great distances to get their prescriptions filled. Increasingly it is being diverted from legitimate channels by organized criminal rings.
The problem had been concentrated in the Northeast and Midwest -- from Maine to Connecticut, and in a band of states from Pennsylvania to Kentucky. Now, however, it is a growing concern for medical and law enforcement officials in other states, including Florida, Alabama, New Mexico, Nevada and Alaska.
Stemming the flow of the drug into illegal sales has become more than law enforcement agencies can handle. "Criminal activities resulting from the abuse of OxyContin are quickly depleting the resources, financial as well as human, of local law enforcement," the DEA declared in a new publication, "Working to Prevent Diversion and Abuse of OxyContin." It said burglaries and other crimes against both property and persons are up 75 percent in areas where illegal OxyContin trafficking flourishes.
Feds Are Cracking Down The DEA is trying to lead and coordinate a nation-wide and international effort to counter the illegal sale of OxyContin. One item on its to-do list is restricting the supply of the chemicals needed to make the pills to just enough to meet legitimate medical needs.
Purdue Pharma, the manufacturer, says it is doing everything it can to help. It withdrew the strongest OxyContin pills from the market. They had accounted for only 1 percent of sales, but were especially attractive to criminals and abusers. The company is also trying to help doctors tell the difference between "doctor shoppers" and fakers and people suffering real pain, and offering them free tamper-resistant prescription pads. It has mailed half a million letters to doctors and more than 60,000 to pharmacists, suggesting how they can help prevent diversion of drugs from legitimate channels into the illegal markets.
Some physicians who specialize in pain management are as worried as their patients that the law enforcement drive will make it hard to treat the more than 50 million Americans who suffer from severe, chronic pain.
"The war on drugs shouldn't affect the war on pain," Joseph J. Fins, M.D., told AMNews. "We have made progress in treating pain, and this could have an undue negative effect." Fins is medical ethics director of the Weill Medical College at New York's Cornell-Presbyterian Hospital.
Ira Byock, M.D., director of Palliative Care Service in Missoula, Montana, put it more colorfully. "What's happened recently is tragic for those working in pain management, because OxyContin is a wonderful arrow in our quiver for treating pain," he said. "Now there is a chill in the environment."
In Friendship Katherine Findlay United Kingdom Adhesion Society mailto:kath.findlay@adhesions.org.uk http://www.adhesions.org.uk