THE PRESCRIPTION FOR DRUG LAWS: A MEDICAL OPINION

A 47-year-old woman was treated by surgery for a torn ligament in her
knee. Following surgery, rehabilitation exercises caused moderate to
severe pain. She requested pain medication containing oxycodone, a
narcotic, and Tylenol (which she had used in the hospital) to take
before exercising. Her doctor refused, stating she exaggerated her
pain, had recovered enough and "should not" have pain. Relieving her
pain, he said, was a disincentive for exercising, and she might get
"addicted." Millions of patients are denied adequate pain treatment
and experience degrading behavior from health-care professionals like
this.

Oxycodone is a narcotic as potent as morphine and is used to treat
moderate to severe pain. A long-acting form of oxycodone, called
Oxycontin, releases a controlled, uniform dose of oxycodone over a
12-hour period. The regular form of oxycodone fails to maintain
steady pain relief and requires more doses every 24 hours. These
features make Oxycontin attractive, and physicians choose it for a
high percentage of patients.

However, Oxycontin has joined other narcotics as a drug of abuse. For
users to experience a "rush" or "high" with Oxycontin, it must be
administered intravenously or "sniffed." Abusers crush the tablets
and either dissolve them in a solution or sniff the powder. Crushing
destroys the tablet's 12-hour release mechanism, and the entire
12-hour dose is immediately available to the abuser. Oxycontin is
manufactured in concentrations of 10, 20, 40, 80 and 160 milligrams
of oxycodone per tablet.

Depending on the individual's tolerance, any of these doses could be
lethal if given at once. Doses exceeding their tolerance have
resulted in 120 deaths nationwide.

As deplorable as these deaths are, the number of individuals dying
from overdosing pales in comparison to the millions of chronic-pain
suffers who suffer from untreated or unrelieved pain. One recent
study by the Center for Ethics in Healthcare showed that 33 percent
of dying patients experience moderate to severe pain in the final
week of life. Undertreated pain diminishes the quality of their
lives. Inadequate education of health-care professionals about pain
treatment, societal and cultural biases, prejudices, misinformation
about narcotics and fear of sanctions from state regulatory or
licensing boards and law enforcement agencies act as barriers to
adequate treatment of pain. Any solution to overcome these barriers
must address all three aspects.

However, fear of sanctions has the greatest potential for worsening
undertreatment. Several deaths involving the gross misuse of
Oxycontin have occurred in clusters in small towns in Kentucky and
suggest there is a pandemic of abuse of the drug. Law enforcement
agencies are quick to publicize these acts by psychologically ill
individuals as a danger to our social structure. Similarly, these
events are fodder for sensational media coverage. Combined, this
creates a nationwide hysteria about the actions of a minuscule number
of individuals.

If past actions by law enforcement agencies serve as a model for a
solution to the "problem," a blanket restriction on the availability
of Oxycontin is likely. This will hurt pain patients who struggle
every day to get adequate medication to function normally. For the
abusers, if Oxycontin is not available they will simply abuse any
drug available.

Deaths from the abuse of legitimate drugs call for a calm and
well-reasoned solution, rather than overzealous and draconian action.
To put the number of deaths caused by Oxycontin overdose in
perspective, the Texas Commission on Alcohol and Drug Abuse reported
2,101 deaths directly attributable to alcohol consumption for the
year 1999. This is 16 times greater than the number of deaths
attributable to Oxycontin in the entire United States.

Three major medical societies -- American Pain Society, American
Academy of Pain Medicine and American Society of Addiction Medicine
- -- share law enforcement's concern about abuse of the drug, and are
studying signs physicians should be aware of that signal
inappropriate use of narcotics. Also, they are addressing the problem
of prescribing narcotics for pain to active drug abusers and
individuals with a history of drug abuse. Prescribing narcotics for
these patients requires the prescriber to exercise greater monitoring
skills than is required for patients without abuse problems.

Any regulation directed to the problem of drug abuse must assure the
availability of narcotics for patients in pain. The regulation should
be a joint endeavor of law enforcement agencies and appropriate
medical groups. Medical input in establishing regulations was
extremely limited in the past and has been almost exclusively the
domain of law enforcement and legal authorities. This reflects our
society's concept of drug abuse as a legal problem rather than a
medical one.

Before any new drug regulation is adopted, a study of the impact
regulation will have on patients requiring these drugs should be
done. Narcotics strongly influence the quality of life of patients in
pain. They should not be denied or restricted adequate access to them.