Hillbilly Heroin Hoo-Hah

Back in a simpler America, it was the Drug Enforcement Administration and other prohibitionist butt-heads who made it increasingly difficult for pain patients to get the prescription painkiller Oxycontin (read all about that sad spectacle here, in Reason's April '03 cover story).

Now you can add trial lawyers, who have filed a class action suit against the drug's manufacturer, Purdue Pharma, on the grounds that the drug, well, works too well and has created a new population of addicts among the terminally and chronically ill. The Cincinnati Enquirer quotes a lawyer involved in the case:

"We have documents and evidence that no other group has," Frederick said. "It is the most prolific advertising and marketing campaign ever set forth for a Schedule II narcotic. They marketed these pills like they were M&M's to doctors. They tried to get these doctors to prescribe this drug like it was Tylenol for people with aches and pains."

Frederick said the drug is two and a half times as potent as morphine and it is highly addictive - information that was not provided to many physicians who were encouraged to prescribe it.

One upside of criminalizing marketing? Maybe it'll stop those TV ads for people to join class-action lawsuits.

One last point about Oxycontin. As the Enquirer notes,

The drug is targeted toward people who are terminally ill or intractable pain, such as cancer patients.

Comments

[Russ D]

"The only question is the behavior of the Pharma co."

Baloney.

Anyone who's worked in a pharmacy for a week learns one lesson real quick: most doctors don't know what the hell they're prescribing. Any pharmacy filling more than 120 scripts a day will have at least one case daily where the doctor needs to be called because he/she prescribed a drug that will seriously conflict with another drug the patient is taking. These cases happen for one of 2 reasons: the patient is not telling the doctor enough information, or the doctor is not asking for it.

Most physiscians have minimal training in drugs. They know enough to get by, things they pick up along the way... many of them rely on the drug companies to tell them what's up with the latest pharmaceuticals. If you're a GP, what are you supposed to do? You can't get too deep into one specialization and be a GP anymore, and that's where most of the drug expertise amongst doctors is.

No one would have to convince me of the shaky ethics of pharmceutical companies. The fact of the matter is that doctors are not doing due diligence in this area. Perhaps they are overworked, I don't know. But just because a doctor is licensed, that does not mean he or she has a good working knowledge of the drugs they are prescribing. This is a case of lazy doctors passing the blame onto a sales person. And it's bound to get worse when its the state Medicaid and Medicare boards telling doctors what to prescribe. As if these boards are loaded with pharmaceutical experts.

Of course, I know some car salesmen who tell me that doctors are their best suck- , I mean customers.

[M. Simon]

Joe,

Withdrawal has not been a problem for those with physical pain once the pain ended. I don't see it as a problem for PTSD type pain once that pain ends. In fact we know that 5% of all heroin addicts who get no treatment quit every year.

From studies of the amygdala in mice we know that pain memories decay over time so the 5% result is not inconsistient with pain memory decay. In fact we know that therapy does not increase the rate of users who quit. So therapy may not be the answer to a general decrease in users.

In any case we know how to do the detox to end the short term drug induced craving. What we do not know how to do is to eliminate the long term pain induced craving. There are some indications that we may be able to do this in times to come. We can't do it now.

[joe]

I think you're going way out on a limb to equate physhic "pain" with physical pain.

[Jim Walsh]

Oxycontin is (along with meth) the current scapegoat-drug of choice in the upper Midwest. Recently, at a high-profile murder trial here in Bismarck, we heard several witnesses (including the victim's grandfather) and even the judge (post-trial) blame it all on Oxy. "If it hadn't been for drugs," intoned His Honor, "this would never have happened."

(For the record, the defendant was accused of shaking his girlfriend's baby daughter to death. The jury acquitted him of murder, and convicted him of child abuse.)

The people involved in this case - well, calling them "trailer trash" would be too high a compliment (Friends and family alike all said they saw it coming; funny how none of them did anything about it). It was distressing enough to watch this bunch of losers sloughing off any vestige of responsibility by blaming it on "drugs." When the judge joined in, it went over the top into a kind of surrealistic no-man's-land..

The point: Drugs don't make good people do bad things. People are responsible for their own actions. Recognizing this fact is the first step toward breaking the "addiction" to the War on Drugs.

[dhex]

M. simon - do you really feel libertarians are less emotional than other political bents?

[jacob dreyer]

maybe this will stop those bizarre ads where there are a bunch of people standing around on a ple of steaming rocks then there are fields of purple flowers and it turns ut to be a drug for constipation

[M. Simon]

What we call addiction is a response to unrecognized pain. PTSD and similar problems.

Now if the government doesn't recognize your pain you can't get relief.

The idea of addiction is superstition. People take drugs for pain relief. Period.

http://windsofchange.net/archives/003370.html

[tm]

Perhaps we should buy Bill Clinton a lifetime supply of this stuff. You know, in gratitude for all those years of him feeling our pain.

[dhex]

doctors were somehow going to confuse an oncological painkiller with asprin?

if they ever come for the lawyers, i will not speak up. 🙂

[M. Simon]

You know it is funny. I think a lot about Clinton in this regard. It is so interesting to see the right mocking his appeal to their own detriment.

Pain is the whole appeal of the Democrats. The Democrat's promise is to relieve your pain. Just as the Republicans promise limited government. Neither side is serious but that is not the point. The point is to figure out the appeal and find a more libertarian way to satisfy it.

Elections are run more on emotion than reason.

Which is why Libertarians are in the .5% ghetto.

[Skeptikos]

This is a a tricky one, but the application of Reason, will shed some light on it.

I have recently come from a 3 year freelance gig with one of the bigger players in the land of big Pharma. It was interesting and enlightening. It was not surprising though. Pharma companies are not "freelove" companies. Their job is to sell you product. I would not say they were unethical, they were however pushers. Is that a bad thing? After all, isn't every sales person? A drug rep enters a doctors office. The rep does not work for the patient, they are a salesman. As such, they will use every sales technique legally available to them. A great example: Marketing studies. A Pharma company will do a series of studies with 10 to 20 people in them. Studies with this few people are not statistically significant, and the FDA and the science community would never except these types of studies as anything more than exploratory. But these marketing studies will not be presented for peer review, so they fall outside of basic science. 9 out of 10 of these small marketing studies will come back unfavorable to the point the Pharma co. wanted to make, but that's OK, they are highly classified, and like I pointed out, not subjected to peer review in Journals like JAMA or NEJM. The 10th study however maybe favorable, so the company takes it to a science/marketing writing group (they often won't do this in house, to further their disclaimer ability) They will then take this one favorable "article" and present it to doctors in the field, along with free lunch, concert tickets, and other items. (I was dating a girl who worked for a freelance Researcher MD, and among other things I got free tickets to see Dave Mathews in concert). The question is incredibly complex, because 7 out of ten times everything is above board. But sometimes executives at one of these companies decides that a drug should sell better than it has, and they will start pushing the Drug Reps in the field to start pushing the drug for alternative treatments. Lake any good sales associates.

This is all fine as long as you do not trust them. But most Americans have this problem. They want to trust. Well. Remember, tobacco in and of itself is not per say the greatest evil, but what if you hide the fact of it's addictive quality, hide it's dangers, and market it? Does that border on bad? I personally don't have a problem with any drug being legal, as long as you remember that it is not in the sale persons best interest to tell you the truth. So what? If your me, who doesn't believe anything I can't prove, and has the time to investigate, great. But even most MDs that I had occasion to know, had neither the interest nor the time to do that private research, and end up depending on the friendly Santa Claus, the drug rep.

In the end, if you can prove someone misrepresented a drug, shouldn't that person be held responsible? At what point is it OK to lie? When peoples lives are at stake? Any old time? Deep stuff, and goes to the foundation of our culture changes the past few years. I don't have the answers. But the only safe course I can commend it that of the eternal skeptic. Because, profit does come before basic human decency for the big Pharma companies. And Frankly, I can't tell if that is such a bad thing. As long as you don't trust them....

[rabidfox]

If this drug is being targeted to the terminally ill or those with intractable pain, what is the problem with its additive qualities? The important issue is 1) does it work, and 2) will it continue to work as long as is necessary? For the terminally ill, worry about addiction (in the absence of negative responses to ques. 1 & 2) smacks of puritanism. In my opinion.

[Drug War Target]

Brace yourself for another lengthy comment.

I have obsessive-compulsive disorder. It is an often debilitating condition, one that can land me in bed for hours stiff and terrorized with anxiety. Sheer anguish and torment. My career, my relationships, my romantic life -- all have suffered devastating blows because of my OCD.

Years in therapy didn't ease the pain. Years on the "sanctioned" pills -- the Prozacs, Zolofts, etc. -- didn't ease the pain. Years of suffering didn't ease the pain. But one thing does, which I accidentally discovered a couple of years ago after minor knee surgery: opiates.

Yes, a measly little Vicodin tablet does something to the malfunctioning mechanism in my brain that causes the OCD. It's not a case of some "opiate euphoria" simply "masking the pain." It actually does something, whatever it is, that FIXES the OCD.

I hit the Web after this little discovery, poked around a bit, and sure enough -- there were lots of bits and pieces, both anecdotal accounts and legitimate research on the topic. I took an impressive stack of printed materials to several doctors, none of whom would even give it a look. Because as soon as they heard the word "Vicodin," they stopped me short.

The government hawks, of course, would be all over their licenses in a flash if they saw opiate prescriptions that weren't backed up with an "endorsed" diagnosis. And OCD isn't one of those.

I have since found a reliable source of Vicodin on the "street" (it's actually a very tidy and pleasant house). My OCD is manageable for the first time since it hit me two decades ago. I am working again, productive again, in love again. I'm not on some "death train" to some "drug nightmare." I take what I need, when I need it.

The only real pain I have now is in my pocketbook. I pay more for my monthly relief than for my monthly rent or car payment. The black market, created by the government, doesn't make things cheap.

But it's worth it. I know it's worth it -- me and God and the universe all know it's worth it. The FDA can rot in hell. Maybe then they'll know what I just went through for 20 years.

[Skeptikos]

rabidfox:

That is actually the question, it was probably researched for "the terminally ill or those with intractable pain", but what was it pushed as? The drug is probably great, but what did they say to the doctors? It would fit within the profile to recomend it for anything they could get away with. It is only puritanical if you object to it being used for it's beneficial prupose. But what if they pushed it for sprained ankles and sore backs? Does that change the picture? Does it matter if I sell you a drug that I tell you is safe, and it isn't? If I say, this is not addictive, when it is? Big questions. How can I make choices without full information? Is the just puritanism versus pragmatism? Can you participate in the free market without information? If the only way to find out the side effects of a drug is after you take it, isn't that too late? The drug in the case is not really questionable. The only question is the behavior of the Pharma co. And we should not assume that they have behaved badly. But, we should neither assume that they have behaved ethically either. Only the facts can tell.

[Anonymous]

I really hope this does not effect my ability to get the stuff. It's great fun!

Jack Osborne

[M. Simon]

I cover the drug question here including the right to self medicate:

http://windsofchange.net/archives/003370.html

What I have found out about most compulsive behaviors including most "addictions" is this:

People in chronic pain will chronically behave in ways that relieve that pain. Because the pain involved is caused by such things as PTSD it is not recognized pain. Any one who self medicates for unrecognized pain is called an "addict". In other words our whole concept of "addiction" is rank superstition. Kind of like the idea of the earth as the center of the universe. You can make the idea work to a certain extent but a whole range of phenomenon gets much easier to explain with a sun centric system. just as the whole compulsive behavior gets much easier to explain in most cases if we relate it to pain. When we do that we see the behavior as adaptive rather than mal-adaptive.

Darwin was right after all. People do dot behave in ways likely to reduce their reproductive success unless the alternative is worse.

[M. Simon]

Darwin was right after all. People do not behave in ways likely to reduce their reproductive success unless the alternative is worse.

[Drug War Target]

M. Simon: Were you specifically addressing me in the post(s) above?

[M. Simon]

Drug War Target,

Yes. There are all kinds of medical problems whose nature is not well understood by medicine but whose victims are real.

These people will look for cures or at minimum some relief from symptoms. If their problem falls outside of real medical knowledge and relief involves opiates or any other of a host of banned drugs they will be persecuted.

In other cases fear will keep Drs. undermedicating real physical pain to avoid DEA scrutiny.

What we are doing in the name of the superstition of "addiction" is criminal. Basing law on superstition of course always leads to criminal results to varying degrees.

[Drug War Target]

OK, got it. I'd read your essay already, and am on board with your comments here as well.

I just got thrown off when you used the phrase "compulsive" in regard to "addictions," and wanted to make sure I'm being clear: I have OCD. That is the disorder. But my taking of Vicodin is not "compulsive behavior" itself. It is simply a means of relief from the disorder -- a disorder that just happens to have the word "compulsive" in its name.

My condition could just as well be panic disorder, PTSD, agoraphobia, whatever. Taking an opiate is simply a means to relieve the particular condition -- it is not a product of the OCD per se.

I hope I'm being clear, because it's an important distinction.

[joe]

M Simon,

Many heroin addicts take the drug to stop pain - the pain of withdrawing from a drug that they started taking becuase it was fun. Leg cramps, high fever, massive histamine reaction, severe nausea...

[TomD]

M. Simon

"What we call addiction is a response to unrecognized pain. PTSD and similar problems."

"People in chronic pain will chronically behave in ways that relieve that pain. Because the pain involved is caused by such things as PTSD it is not recognized pain. Any one who self medicates for unrecognized pain is called an "addict".

I am assuming by 'PTSD' you are referring to post-traumatic stress disorder, a psychiatric diagnosis that relates behaviors and psychological symptoms to past psychological trauma (e.g. saw someone get blown-up by a carbomb.) Please note that this must be distinguished from chronic (physical) pain states that develop as a result of past physical trauma (got blown up by a carbomb.)

Currently oxycodone, in any of its product forms, is not recognized by the medical or psychiatric professions as a viable agent for the treatment of ANY psychiatric or behavioral disorder. (There are other narcotic agents which are recognized and FDA approved for use in narcotic detox/withdrawal treatment of diagnosed addiction.) Likewise the manufacturer of Oxycontin does not list such use as appropriate in the Indications for Use section of their product labelling, and would not warranty such use. As per current standards of practice the prescribing of oxycodone for the treatment of a strictly psychiatric condition would be inappropriate at best, malpractice more likely so.

The use of oxycodone or any narcotic, by a patient, in any manner other than for which it was prescribed is considered abuse (or mis-use at a minimum.) As an example say your doctor prescribes Oxycontin in response to your complaints of severe chronic knee pain post auto accident but you actually take it to dull the psychic pain of having to watch other people die in said same accident then yes, by current standards, you are abusing the drug. But you are not necessarily an addict.

The term 'addiction' gets thrown around pretty fast and loose these days. Even worse, the psyhiatric definition (per Diagnostic and Statistics Manual - the shrink's Bible) keeps shifting, but the actual diagnosis is pretty narrow and probably excludes alot of indivuals who might be considered addicts by the population at large. Addiction (currently) encompases multiple behaviors and symptoms but it generally must include a behavioral element involving pleasure seeking/ risk taking along with other elements, i.e. the 'classic' looking to get high individual - but specifically excluding the under/mis-treated patient.

Pseudo-addiction is the new medical term essentially defined as the person who initially presents like an addict (drug-seeking behaviors etc.) but is actually just some poor soul with un/under treated pain and quite likely ongoing drug dependence. This is the guy with the blown vertebral disc, who has had two failed surgeries, refuses to go under the knife again, is to pain averse (or lazy) to try physical therapy and just wants more Oxycontin, or methadone, or whatever to dull the pain. This patient is often the pariah of the medical world. While he may not be a true 'addict' (per DSM) to anyone not well versed in his medical history he sure looks like one. And he most definitely is drug dependant. Because anyone who, no matter how much pain they have, takes potent narcotics chronically for more than a few weeks will begin to develop a PHYSICAL DEPENDANCE on the drug. Bottom line, lay terms for physical dependance: when you don't take them, you hurt. And you hurt bad.

Additionally there is a subset of individual who once had chronic pain, but whose underlying condition has resolved, and are now left solely as drug dependant patients. This physical dependance can be overcome but it will involve detox and withdrawal. Some of these patients will exhibit behavioral symptoms, often resulting from psychological dependance (e.g. fear of pain) that will straddle that grey line between addiction and pseudo-addiction. Heaven help them because their road is not an easy one.

If you are an individual, suffering from PTSD - but do not have any medically recognized source of physical pain, who has taken it upon himself to self medicate with Oxycontin be aware that you are operating well outside the currently defined standards of medical and psychiatric practice. This puts you squarely in the 'abuse/mis-use' category, if you have been doing it long you are also most likely physically dependant. Whether or not your course of treatment is justified, reasonable, safe, or effective I cannot completely judge from this vantage point. Lets just say that I suspect that the risks (including legal/social aspects) likely far outweigh the benefits. As a final point for consideration remember that you are essentially self-medicating by misrepresentation and are effectively operating without sanction or much recourse should your course of treatment fail.

[Stephen Fetchet]

I'm suffering pain... can somebody get me a martini, please?

And will medicare cover it? If it doesn't already, it should.

[unknown]

Oxycontin has ruined my life. I have lost everything I have ever loved in my life as a result of my addiction to this drug. I began taking it legitimately and sson found myself needing it more and more. I recognize this as a great drug for pain, but it can also result in a life destroying addiction.