PLAYING WITH PAIN KILLERS

Over The Past Decade, Doctors Have Focused New Energy On Managing
Their Patients' Pain, And Sales Of Prescription Painkillers Have
Tripled Since 1996. For Most People, These Drugs Are A Blessing.

For Some, They're A Nightmare

It all started innocently enough.

Three years ago, when Michelle Brown got pregnant, her doctor wrote her a
prescription for Lortab, a potentially addictive painkiller similar to
Vicodin, for relief from migraine headaches.

HER MIGRAINES EVENTUALLY got worse; the Lortab made her life bearable.

But it had a devastating side effect: "Slowly," says Brown, who is from
Sanford, Maine, "I started to get addicted." She became a classic "doctor
shopper," hopping from one physician to the next to get multiple
prescriptions. She discovered Percocet, and soon she was mixing Lortab with
OxyContin, a new, superstrength pain-killer she got through a dealer.

By early last year, Brown, 25 years old, and the mother of two small
children, worked up the nerve to commit fraud.

Pretending to be phoning from her doctor's office, she called her local
pharmacy, read her physician's identification number off a prescription
bottle and won, she says, "my key to the palace."

=46or millions of Americans, painkillers are a godsend.

Cancer patients suffer the agony a little bit more easily.

People battling severe arthritis can, for the first time, take walks and
play with their grandchildren. Realizing that for years doctors neglected
to include pain management in patient care, the medical establishment has,
over the past decade, taken a new, more aggressive approach to treating
pain. In January a national accrediting board issued new standards
requiring doctors in hospitals and other facilities to treat pain as a
vital sign, meaning that they must measure it and treat it as they would
blood pressure or heart rate. Even Congress has gotten into the act, last
fall passing a law declaring the next 10 years the "Decade of Pain Control
and Research."

SURGING SALES

In this environment, pharmaceutical companies are experimenting with new
formulations of painkillers, and existing painkillers themselves are more
widely distributed than ever before.

While the pharmaceutical market doubled to $145 billion between 1996 and
2000, the painkiller market tripled to $1.8 billion over the same period.

Yet at the same time, the incidence of reported first-time abuse of
painkillers has also surged.

Many of these painkillers aren't new, and "there's not necessarily
something wrong with" the increase in controlled substances, says Michael
Moy in the Drug Enforcement Administration's Office of Diversion Control.
"But once you put something into the food chain, someone's going to want to
bite."

Although there are no perfect statistics on how many people misuse or abuse
prescription drugs, in 1999 an estimated 4 million Americans over the age
of 12 used prescription pain relievers, sedatives and stimulants for
"nonmedical" reasons in the past month, with almost half say-ing they'd
done so for the first time. According to the DEA, the most-abused
prescription drugs include the oxycodone and hydrocodone types of
painkillers, which contain potentially addictive opioids (the two drugs
differ slightly in chemical structure, but both work similarly on the
body). And emergency-room data suggest that certain drugs have seen
dramatic spikes in abuse in recent years.

ER visits involving hydrocodone medications like Vicodin and Lortab jumped
from an estimated 6,100 incidents in 1992 to more than 14,000 in 1999,
oxycodone painkillers like Percodan and OxyContin rose from about 3,750 to
6,430 and the anti-anxiety drug Xanax (including generic formulations)
increased from 16,500 to more than 20,500. Illegal drugs, abused in much
higher numbers, also increased: cocaine from 120,000 to 169,000 and heroin
and morphine from 48,000 to 84,400.

Reports of painkiller abuse from Hollywood catch the attention of the
public more than any statistic ever will. In the last six months, Melanie
Griffith and Matthew Perry each checked into rehab, publicly acknowledging
their addiction to prescription painkillers. TV shows fill their scripts
with the problem: on "ER," Dr. John Carter gets hooked on painkillers after
he's stabbed, and on the new show, "The Job," Denis Leary plays a detective
who takes painkillers on a stakeout.

Even Homer Simpson battles a compulsion for the drugs in a season-ender
where he's catapulted into a surreal celebrity existence.

After looking at the data and following the news reports, the National
Institute on Drug Abuse (NIDA) will announce next week a major
public-health initiative about prescription-drug abuse. "Once you get into
millions of people [abusing]," says Dr. Alan Leshner, NIDA's director, "you
have a serious public-health issue on your hands."

Addiction to prescription drugs is not a new problem.

Remember "Valley of the Dolls"? The uppers, the downers, the sleeping pills?

But some of today's drugs are far more sophisticated than anything
Jacqueline Susann could have envisioned. OxyContin, which hit the market in
1996, is by far the most powerful: it's a 12-hour time-release incarnation
of the molecular compound oxycodone, the active ingredient in older drugs
like Percodan and Percocet. Unlike drugs in the hydrocodone category,
OxyContin and several other oxycodones don't contain acetaminophen, which
can damage the liver in high doses and limits the extent to which those
drugs can be safely used. OxyContin allows patients to swallow fewer pills,
and offers pain relief three times longer than earlier versions.

But when the drug is crushed and snorted, eliminating its time-release
feature, it's a huge narcotic rush to the brain. "You feel vitalized, like
you can do whatever you want," says Eric, 38, of Portland, Maine, who has
spent as much as $525 a week buying the drug from a street dealer.

Abuse of OxyContin has gotten so bad that in some areas users are robbing
pharmacies to get the drug-just last month, Hannaford, a major chain in
Maine, decided that "for the safety of our associates and customers," it
would no longer stock the drug on its shelves.

NO TYPICAL ABUSER

When it comes to prescription painkillers, there is no typical abuser.
Police departments say they've seen every variety, from teenagers to
stay-at-home moms to executives who started taking drugs for their tennis
elbow. Particularly at risk are chronic substance abusers who may divert to
prescription drugs when their preferred poisons, like heroin, run out. In
Hollywood clubs, cocaine and ecstasy still dominate, one 30-year-old actor
says, but people also share Vicodin, Xanax and Valium, then wash them down
with alcohol.

Health-care professionals, with easy access to drugs, often succumb. Among
arrests in Cincinnati, which carefully tracks prescription-drug abuse, 30
percent of cases involve medical employees. Landon Gibbs, a Virginia state
police officer, says his department arrested a doctor last year who would
"write a prescription, drive that person to the pharmacy and then split the
pills."

Prescription painkillers are appealing in part because users think of them
as "safe." They're FDA approved, easy to take on the sly and don't have the
same stigma as illegal drugs.

Cindy Mogil started taking Valium at 20 to ease the trauma after a car
accident, and "liked the feeling of euphoria." As a manager in a health
clinic, she had easy access to sample pills, then found her way to Vicodin
and Percodan, visiting different doctors to get her supply. "Boy, it's so
easy," says Mogil, who lives in suburban Atlanta. "I'd walk in and tell
them I had a migraine; that's all I had to say." Her family never
questioned the pills: "They think you're taking it for medical reasons."
Finally, after two decades of abuse, Mogil collapsed-her face numb, her
speech slurred-and checked into rehab. "I was no better than a street
addict," she says.

All pain passes through the brain.

Pills like Vicodin and OxyContin lock onto a cell receptor called mu, found
most prominently in the brain, spinal cord and gut. When the drug connects
to the receptors in the spinal cord, pain signals from nerves are blocked;
in the brain, the receptors seem to promote an overall sense of well-being;
in the gut, they have the unfortunate side effect of constipation. While
any patient who takes an opioid painkiller or any other addictive drug over
a long period will develop a physical dependence-meaning the body adjusts
to the chemicals now swirling about and thinks that's normal-that
dependence can be properly managed. When it's time to go off the drug, a
good physician will taper the prescription so there's no withdrawal or
rebound effect.

But a genetic tendency, an underlying mental illness, a history of
substance abuse or a combination of factors may lead a small group of
patients to go beyond just physical dependence. They become compulsive
about taking the drug, even when it threatens their health or social and
professional lives.

TALES OF CUNNING AND DESPERATION

Once you're hooked, getting more becomes an obsession.

Many abusers, like Michelle Brown, become doctor shoppers.

Others buy their fix on the street: one Vicodin goes for about $6, Percocet
and Percodan, up to $8, and an 80mg OxyContin for as much as $80. Tales of
cunning and desperation abound-the weekend visits to the ER claiming a
toothache, the stolen prescription pads. Dr. Sheila Calderon, an internist
in Dallas, says a former employee used her name to call in a prescription
for Vicodin (she was never charged). Cathy Napier, a former Percodan addict
and now head of the chemical-dependency program at Presbyterian Hospital in
Dallas, says she knows women who go to real-estate open houses, "then go
through the medicine cabinets and steal the Lortab."

So who's to blame for the misuse of these drugs?

Many abusers point the finger at doctors, who they say tend to prescribe
medications too quickly without warning patients that certain drugs can be
highly addictive.

But once patients begin deceiving doctors and pharmacists by phoning in
fake scripts or seeking prescriptions from multiple doctors, they become
the culprits. Seventeen states currently have prescription-monitoring
programs, which vary widely-some track drugs like OxyContin (a schedule II
drug, deemed "high potential for abuse"), but not Vicodin (schedule III,
"some potential"). But many states don't dedicate resources to full-time
oversight. Nor does the DEA, which is largely watching out for abuse by
health professionals. If abusers are caught, they're charged with fraud-a
misdemeanor in some states and a felony in others.

Brown says she is "so thankful" for the DEA agent who handled her case
after a suspicious pharmacist called the police. "He knew I needed help. He
told my family everything. And it just blew open from there." Now, says
Brown, she's in treatment, taking methadone to ease her off her addiction
and finally "learning how to live a normal life."

With all the focus on abusers, pain specialists worry that legitimate
patients will suffer.

Too many doctors succumb to "opiophobia," fear of prescribing much-needed
medications for appropriate patients who suffer moderate to severe pain,
says Dr. Russell Portenoy, chair of pain medicine at New York's Beth Israel
Medical Center. Dr. Kenneth Pollack, a pain specialist in Des Moines, Iowa,
says he recently prescribed OxyContin for a woman who had suffered painful
nerve tumors in her feet for 11 years and could barely stand up. Last time
Pollack saw her, "she was practically in tears," he says. "She said, 'Thank
you for giving me my life back'." Says David E. Joranson, director of the
Pain & Policy Studies Group at the University of Wisconsin: "My fear is
that some patients and doctors are going to start looking at this stuff
like it's nuclear material.

There is a real risk of losing recent gains made in pain management."

'THERE IS A POTENTIAL FOR ABUSE HERE'

Pharmaceutical companies acknowledge that misuse is a problem.

Pharmacia, which manufactures Xanax, says "all of our peer-group companies
realize there is a potential for abuse here." They say they educate as many
people as possible about the importance of taking the drug safely under a
doctor's care; the drug is also marketed generically by other companies.

Abbott Labs, which manufactures Vicodin, offers symposiums for prescribers
and pharmacists to teach about abuse potential. And Purdue Pharma, which
manufactures OxyContin, has been actively addressing the problem through
education sessions and meetings with the

DEA and the FDA.

Maryann Timmons, 51, says she needs her medication. After lifelong ear
infections and a broken eardrum, Timmons, 51, of Concord Township, Ohio,
takes Vicodin to dull the pain. Initially, she says, her doctor didn't want
to prescribe the pills; he ultimately did, but told Timmons to use them
sparingly because of their addictive potential. "I felt like a criminal,"
she says. "It shouldn't be a battle to get help with pain relief." Pain
relief and criminal activity.

The new challenge for doctors and public-health officials is to provide one
without advancing the other.