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.