The Agony and the Ecstasy

How the OxyContin crackdown hurts patients in pain

Melinda Ammann from the April 2003 issue

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There was a measure of truth to some of these epithets. "This is an isolated area where it's hard for people to get real street drugs," says Phil Fisher, head of the Appalachian Pain Foundation, a West Virginia�based group trying to educate the medical community and public about the benefits of OxyContin. "OxyContin is not a street drug in most places." As a legal prescription medicine, OxyContin also may appeal to drug users who are leery of black-market heroin -- especially if they've seen the newspaper, magazine, and TV stories that describe how great the high is and explain how to achieve it.

A "former OxyContin abuser" interviewed by ABC in March 2002 said the drug gave him "an immediate warm feeling, feeling of well-being, almost -- I don't want to say godliness, but a feeling there's nothing I can't handle." A July 2001 New York Times Magazine story, "The Alchemy of OxyContin," put it this way: "As a pill it brings potent pain relief. As a powder it brings euphoria. It takes about five seconds to effect the transformation -- and not much longer to create an addict." Similarly hyperbolic reporting has been featured by other prominent media outlets, including Time, Newsweek, CBS, and even MTV, which aired "I'm Hooked on OxyContin" as an episode of its True Life series in 2001.

OxyContin was compared to heroin so many times that some people concluded it should be treated the same way. After James Graves' conviction, West Virginia state Sen. Truman Chafin suggested reclassifying OxyContin as a Schedule I drug, which would make it illegal for any purpose. Pain patients breathed a sigh of relief when other state officials, doctors, and pharmacists dismissed the idea. "To prevent terminally ill patients who are in need of legitimate pain management from obtaining a drug that effectively relieves their pain is not the answer," said the West Virginia Board of Pharmacy.

Yet increased scrutiny of prescriptions is bound to have a chilling effect on doctors' decisions about which patients to treat and how. In addition to monitoring at the state level, the DEA requested $24.6 million and 133 new positions for 2003 to strengthen its diversion control efforts. The agency has drawn up a "National Action Plan" targeting key sources of OxyContin and other opioids, including medical professionals it considers unscrupulous as well as doctor shoppers, prescription forgers, and pharmacy robbers.

"The growing national plague of Oxy addictions, overdoses, and deaths caused by the illegal activity of some doctors, pharmacists, and patients has been focused on like a laser beam by this office and other U.S. attorneys' offices," Gene Rossi, a federal prosecutor in Alexandria, Virginia, told The Washington Post in August. "If any person falls into one of those three categories, our office will try our best to root that person out like the Taliban. Stay tuned."

The menace depicted by drug warriors like Rossi bears little resemblance to the medicine that helps patients keep agony at bay. Thomas Rogers, for instance, is a healthy 31-year-old man -- healthy, that is, except for the degenerative disc disease that gives him chronic back pain. He has opted to forgo spinal lumbar fusions, which would involve the removal of natural discs and the insertion of rods or screws in his back, in the hope that a less invasive procedure will soon be available. His pain has been treated effectively with OxyContin by an Atlanta-based physician for three years.

"I would give anything to have a healthy, strong back like most 31-year-olds have," Rogers says, "but this is the way things are for me, and thankfully OxyContin has given me some sort of a life since I've been taking it....As long as I have a good doctor who understands and science can produce meds like OxyContin, life is livable. I could not live with the constant pain in my lower back without the benefits of this drug."

Gerald M. Aronoff, medical director of the North American Pain and Disability Group, has written several books and articles about chronic pain management. In his view, OxyContin is an excellent sustained-action opioid that has gotten a bad rap. "We're in a mode where everyone's picking on opioids," Aronoff says. "They are not terrible drugs....They have a wider margin of safety than the nonsteroidal anti-inflammatory drugs" such as acetaminophen and ibuprofen, because they carry less risk to the liver and the gastrointestinal tract. Removing them from the market would mean a "major step backward in our ability to manage pain," he says.

Addicted to Pain Relief

Much of the concern about OxyContin stems from a misunderstanding of addiction. Aronoff observes that people mistakenly equate addiction with tolerance (the need for higher doses to achieve the same effect) and so-called physical dependence, changes in the body that lead to withdrawal symptoms if the drug is abruptly withdrawn. Anyone who takes an opioid like OxyContin every day will eventually develop tolerance and physical dependence, but addiction requires an attachment to the drug's psychoactive effects. "Addiction is characterized by the repeated, compulsive use of a substance despite adverse social, psychological, and/or physical consequences," says Aronoff. "Addiction is often, but not always, accompanied by physical dependence, withdrawal syndrome, and tolerance."

Conversely, people who take OxyContin and other opioids for pain may develop tolerance and physical dependence, but that doesn't mean they're addicted. Several studies conducted during the last few decades have found that patients who receive narcotics for pain rarely end up seeking the drug for nonmedical reasons. "One study found that only 4 out of about 12,000 patients who were given opioids for acute pain became addicted," the National Institute on Drug Abuse reports. "In a study of 38 chronic pain patients, most of whom received opioids for four to seven years, only two patients became addicted, and both had a history of drug abuse."

Geov Parrish, a Seattle-based writer who has been taking OxyContin for seven years, pokes fun at the confusion about addiction perpetuated by media hype. "OxyContin is a narcotic, and I am 'addicted' to it, in the sense that if I don't take it I'd get nasty withdrawal symptoms," he writes on WorkingForChange.com. "In terms of whether my body would be unhappy if I didn't ingest it, I'm also 'addicted' to a number of other prescribed drugs, and to food, water, oxygen, and my sweetie. Addiction is an overrated concept."

Parrish says he tried various pain medications after an organ transplant left him with debilitating pain, but oxycodone is the only one that works. "If I weren't on it, I couldn't function from day to day," he writes. "And for many, many people with cancer, AIDS, and other serious ailments, it's the difference between a relatively normal life and day after day of pure hell."

Thomas Rogers concedes that his 12-hour OxyContin dose has doubled, from 10 to 20 milligrams, since he began taking the drug three years ago. He is also well aware that he would have to go off OxyContin gradually to avoid withdrawal symptoms. But he doesn't consider himself an addict. "People like me who suffer every day aren't concerned about addiction or being labeled as druggies," he says.

"We just want out of pain, and OxyContin will do it when we are being treated by good doctors. Is a diabetic person who is dependent upon insulin considered an addict? Are people who take OxyContin any different? We depend on a drug to help our pain so that we don't get depressed and suicidal. I personally don't like waking up every single morning hurting and knowing that it may very well be this way the rest of my life."

Rogers resents anti-OxyContin crusaders who gloss over or ignore the drug's benefits for pain patients like him. "Their backs probably don't hurt," he says. "No matter what kind of drug is ever produced, there will always be people who will abuse it and give it a bad name. These people never represent the thousands of legitimate patients like me who are not addicted but depend on it for some kind of life, as pain-free as possible."