A DRUG WAR

The Government Has Turned Its Attention To The Pain-Killer
Oxycontin. Is The Scare Campaign Justified?

Ralph Murray of Mission Viejo was a meatcutter for 15 years before
carpal tunnel syndrome, several surgeries and a host of wrist and hand
ailments pushed him onto disability. Despite surgeries (perhaps in
part because of them; they uncovered deeper neural problems than his
surgeons suspected) he has severe chronic pain - it hurts all the time.

"OxyContin is the only medication I've found that lets me sleep
pain-free all night," he told me recently. "With other prescription
pain medications I had to get up and take a pill every four hours. If
I didn't set an alarm the pain would wake me soon enough, and then it
would take a while for the medication to kick in. I know it is
potentially addictive and I discussed all the ramifications with my
doctor thoroughly before starting it. But it's really been a blessing."

Murray had tried several prescription pain medications before trying
OxyContin. Neurontin didn't touch his particular pain, even in
progressively heavier doses. Vicodin, which combines the opioid
hydrocodone with acetaminophen, helped some.

However, as Eric Chevlen, an assistant professor of medicine at
Northeastern Ohio Universities College of Medicine wrote in a recent
Weekly Standard article, acetaminophen in large doses (Murray was
taking 12 a day) "carries a risk of serious liver damage."

So Murray has paid close attention to the spate of scare stories about
OxyContin in recent weeks.

The Food and Drug Administration has announced that it will henceforth
carry the agency's strongest warning, a black box calling it
potentially addictive as morphine. The Drug Enforcement Agency has
announced a high-profile campaign to nail doctors and pharmacists it
deems responsible for abuse. The little town of Pulaski in southwest
Virginia wants to require pharmacists who dispense OxyContin to
require patients to provide fingerprints.

Doctors in Philadelphia and Florida have been arrested for
"over-prescribing" OxyContin. An ambitious lawyer has filed a suit
against the drug's manufacturer, Purdue Pharma of Stamford, Conn., for
getting people hooked.

Of course, most of the media, ever cooperative whenever the drug
warriors identify a new Drug Menace of the Month and provide a couple
of anecdotal horror stories, have been only too happy to feed the
panic. National Public Radio, feeding off a Washington Post story, did
an alarmed take on OxyContin in Virginia last week. Time, Newsweek,
The New York Times and the Philadelphia Inquirer have all done tales
of abuse and diversion replete with lurid details.

As happened during the crack cocaine "epidemic" of the 1980s, the
media stories raising alarms and tut-tutting about this latest
favorite of junkies have informed millions of people who would
otherwise never have heard of Oxy- Contin that there's a new drug out
there, and informed them how to abuse it. Thousands of people who
would otherwise not have learned of OxyContin will try it.

Some will become addicted or die, the self-fulfilling prophecy will
play itself out, and thousands of people will be hooked as a result of
publicity that those who pushed it claimed was supposed to be helpful.

Surely the drug warriors have to be intelligent enough to know that
this is the dynamic.

Why is OxyContin so useful to those in chronic pain and why is it
subject to abuse?

As Eric Chevlen explained, OxyContin's active ingredient, oxycodone,
an opioid (apparently the preferred term these days for what used to
be generally called narcotics), has been in pharmaceutical use in the
United States for 60 years. (Dr. Standiford Helm, Ralph Murray's
doctor, a principal at the Pacific Coast Medical Center in Newport
Beach, which specializes in pain management, says the ingredient has
been separated and used medicinally since the Middle Ages.)

What Purdue Pharma did was figure out a way to put it in a
time-release formula, so the drug is released gradually over 12 hours,
maintaining a steady presence in the bloodstream.

What those who want to use OxyContin as a recreational or escapist
euphoric do is crush the tablets, nullifying the time-release
qualities, and have a tablet with large doses of straight oxycodone,
which is apparently similar to heroin in characteristics, and quite
addictive. Having subverted the qualities that make OxyContin so
useful to people in chronic pain, they snort or inject this substance.

In the last several years a good deal of attention has been paid to
the problem of treating intractable pain in the United States. Heroin
was first effectively outlawed, as Dr. Helm reminded me not by an
outright ban, but by declaring that chronic pain was not a specific
disease, and treating it with potentially addictive opium derivatives
like heroin was therefore outside the scope of medical practice.

Medical authorities now recognize chronic pain - sometimes clearly
attributable to a specific injury or illness, less often with unknown
origins - as a condition in and of itself.

Patients and eventually Congress have held hearings on the inadequacy
of treatment of intractable pain, and Congress passed a law mandating
federal authorities to study ways to eliminate barriers to adequate
pain treatment.

Eric Chevlen estimates that 30 million to 50 million Americans live in
chronic pain. Dr. Helm would put the figure at 20 million to 30
million. Both figures are huge, and most authorities estimate that
only about a quarter of them are getting adequate treatment, even with
advances in understanding in the last few years.

OxyContin has become quite widely used since its approval by the Food
and Drug Administration in December 1995, growing from almost zero to
about 6 million prescriptions in 2000.

With its increased popularity has come some diversion from legitimate
medical uses to the recreational or persistent junkie market. It seems
to be a fairly serious problems in some rural Appalachian areas, where
serious pain is fairly widespread due to mining and agricultural
injuries and the authorities have little experience dealing with black
market drug problems.

The question is, to what extent is diversion and abuse a problem and
what kinds of actions might minimize such problems.

Eric Chevlen points out that last year about 16,000 Americans died
from treating arthritis with drugs like Advil and Aleve, because these
medications increase the risk of bleeding ulcers and liver problems
when used over long periods. About 200 people died in the same time
period from purposeful abuse - using in ways it was clearly not
intended to be used - of OxyContin. Naturally, the government in its
wisdom has decided the 200 deaths constitute the problem that requires
a public campaign and new restrictions.

In a letter responding to Chevlen's article Laura Nagel, the DEA
deputy assistant administrator, used the numbers that have appeared in
most news stories, but in a fascinating way. The number of OxyContin
prescriptions has increased 20-fold since 1996, she said, and the
number of oxycodone-related incidents - emergency room and medical
examiner reports - have increased by 400 percent and 100 percent
respectively.

But that's comparing apples to rocks. A 20-fold increase in
prescriptions is a 2,000 percent increase. You could say, with some
justification, that increases in reports of abuse that are 1/20 to 1/8
the increase in total prescriptions suggests that diversion into the
black market so far is a relatively minor problem - far from
inconsequential and certainly tragic for those who have become
addicted or have died, but not worthy of a full-court-press publicity
campaign.

The DEA has suggested two control programs. The first is cutting back
on overall production of OxyContin - DEA administrator Donnie Marshall
suggested rolling back quotas to 1996 levels, which would be a 95
percent cutback from current levels. The second is allowing only pain
management specialists to prescribe OxyContin.

There is no universally accepted criterion or licensing standard for
pain management specialization, but Chevlen estimates there are about
3,000 pain management specialists in the country, concentrated in
urban areas. If the total number of people in chronic pain is "only"
20 to 30 million, that's a heck of a caseload for those practitioners
- - or, more likely, millions of Americans deprived of effective relief.

Why would the DEA propose such a cruel remedy to a problem whose
magnitude is dubious and which it has purposely hyped and pumped up?
It's a familiar and fundamental dynamic, in my view. It might help to
consider the institutional incentives facing an agency like the DEA.
Every bureaucracy, private or public, has an incentive to grow and
increase its authority, power, influence and prestige. If the
government ever really "won" the War on Drugs the DEA and related
agencies would face the possibility of going out of business.

Their incentive, then, is to magnify perception of the problems they
are facing to convince journalists to help them sell the perception of
a crisis and Congress to increase their funding. This has worked well
over the years. Journalists are notoriously mathematically illiterate
and have their own vested interest in perceived crises. Politicians
love to respond to perceived crises with more programs and more of the
taxpayers' money.

Politicians and journalists are subsets of the general population
populated by greater percentages of people whose instinctive response
to a perceived problem is to propose a new government program or more
government spending as the obvious, logical and inevitable response.
In the case of hard drugs, however, there's a compelling case that
this approach is dead wrong.

The black markets for drugs, which increase profit margins for sellers
to obscene levels and are marked by crime and violence, are created by
heavy-handed government controls. The more draconian the controls, the
more lucrative the illicit trade.

In addition, controls feed into the American culture's (and maybe
humankind's) eternal propensity to avoid personal responsibility. Few
people want to acknowledge the role played by their own bad choices in
creating their personal problems. The stance of the victim - of a
troubled childhood, a bad neighborhood, lack of opportunity, racism,
corporate greed, or an all-powerful drug that makes one helpless - is
more psychologically attractive to many and is encouraged by the
general culture.

But any addiction specialist, while acknowledging that these and other
factors are important, will tell you that the addict taking personal
responsibility for his or her own choices is important, perhaps
essential to recovery. The world is full of conditions that impact
people deleteriously over which they have no control. The key, as the
Serenity Prayer puts it, is to accept the things you cannot change so
you can begin to change the things you cannot accept.

Piling on the controls designed to save people from themselves deters
and delays the acceptance of personal responsibility. You can make a
case that it prolongs drug abuse problems rather than resolving or
fixing them.

Besides the Weekly Standard magazine, these questions have also been
raised mainly by drug-reform groups like the Lindesmith Center and
DRCNet.

OxyContin provides invaluable relief to a wide variety of people who
suffer from chronic pain. It is also subject to misuse and abuse. It
is tempting to want to use government to try to control those
problems. But much of the evidence suggests that will only make the
problem worse. The public spinning of worst-case scenarios may have
done so already.

Note: Mr. Bock is a senior editorial writer for the Register.