IN THE GRIP OF A DEEPER PAIN

Opioids: For people with chronic suffering, these powerful pills are a
godsend. For others, they're a prescription for abuse and misery

They were invented to stop pain, the kind that travels
up the spinal cord, and they're remarkably effective at it: the
synthetic opioids developed since the 1970s can mute the agony of
slipped disks, deteriorating joints, tooth decay and even terminal
cancer.

IF THAT WAS ALL they did, then it wouldn't be much of a problem; most
people acquire the drugs innocently enough by prescription and take
them only as long as they need to, and even the risk of dependence may
be worth running, if the alternative is lifelong pain. The problem
with painkillers is they also work on existential pain, the kind that
originates in the mind-such as might be experienced by a right-wing
radio host who doesn't have Bill Clinton to torture anymore.

Cindy McCain, the wife of the Arizona senator, took Vicodin, a common
opioid, for back pain, but she found it also helped her get through
the "Keating Five" investigation involving her husband. "The newspaper
articles didn't hurt as much, and I didn't hurt as much," she wrote in
NEWSWEEK in 2001. "I've had clients describe Vicodin as 'a four-hour
vacation'" from daily stress, says Robert Weathers, clinical director
at Passages, a Malibu, Calif., super-deluxe rehab facility catering to
clients who can afford monthly charges north of $30,000.

And more and more people are making that unfortunate discovery, it
seems. Illegitimate use of OxyContin (a trade name for oxycodone), one
of the drugs to which Rush Limbaugh was allegedly linked, has
skyrocketed in recent years.

At least 1.9 million Americans have admitted taking it illegitimately
at least once, the Drug Enforcement Administration recently reported.
"Right now it's one of the most abused prescription drugs," says one
DEA official. "It's certainly the most dangerous."

Limbaugh's other narcotic of choice, according to news reports, was
hydrocodone, the generic name for a family of drugs including Vicodin,
Lorcet and Lortab. These drugs also have a high potential for
abuse-although the DEA lists them on Schedule III, a lower level of
control than OxyContin, a Schedule II drug-and they accounted for
slightly more emergency-room visits than oxycodone last year. Both
classes of drugs work the same way, by locking on to a chemical
receptor called mu, which blocks the transmission of pain in the
spinal cord. Taken quickly and in large doses, the drugs also
stimulate the production of dopamine in the brain, which can produce
effects that mimic street narcotics.

Long-term use of Vicodin has been linked, in very rare cases, to
hearing loss; there's no published data yet on OxyContin.

There's one other big difference, which helps explain why OxyContin
has such a high profile in the DEA's view. Its great virtue is that it
can be formulated in time-release tablets, packing as much as 12 hours
worth of medication in one dose; hydrocodone pills, by contrast,
usually last only about four hours.

But that also opens the door to abuse; if you can defeat OxyContin's
time-release function by pulverizing the pills and then swallowing,
snorting or dissolving and injecting the powder, you can get seriously
high. People can and do become addicted to hydrocodone, which is more
widely prescribed than OxyContin. But Vicodin and its relatives also
contain acetaminophen (Tylenol), creating a built-in disincentive to
overdose: winding up in the hospital with liver failure.

Purdue Pharma, acutely aware of the negative publicity around
OxyContin, is working furiously to protect its $1.5 billion brand.

It has committed $150 million to measures including public-service ads
and the distribution of fraud-resistant prescription pads to
physicians (try to photocopy it, and the word "void" miraculously
appears). The company is also researching ways to make OxyContin less
addictive, by adding a compound such as naltrexone that binds to the
same receptors in the brain and blocks the action of oxycodone.

The trick is to formulate the naltrexone so that it gets into the
bloodstream in large amounts only when the pill is crushed in order to
get high. Purdue's goal-probably five or so years off-"is to make it
less desirable enough that abusers won't be interested in it," says
Dr. Paul D. Goldenheim, the company's chief scientist.

The company obviously can't talk about individual patients, even
famous ones. Goldenheim says, though, that it's extremely rare for a
person with no history of substance abuse to become addicted to
OxyContin after using it correctly.

Outside authorities agree with that assessment. Goldenheim is drawing
an important distinction between "dependence" and "addiction." Most
people who take a powerful drug like OxyContin long enough will become
physically dependent on it and suffer withdrawal symptoms (including
pain, restlessness and nausea) if it's taken away; doctors deal with
this by tapering down the dosage to zero and then, if all goes well,
it 's over. Or, if the pain is chronic, the patient stays on the drug
indefinitely. In principle there's no more shame or harm in being
dependent on painkillers than on, say, beta blockers for high blood
pressure.

By contrast, a drug addict has a psychological craving as well, which
returns even when the physical dependence is overcome.

That is what makes addiction so notoriously hard to treat; Limbaugh,
who headed straight for rehab after signing off last week, has
admitted attempting to kick his habit at least twice before.

The state of the art, for people who can afford it, is a monthlong
stay in a residential facility that offers both medically supervised
withdrawal and psychological and spiritual counseling, usually based
on the 12-step program.

The best-known treatment center is Hazelden, based in Minnesota but
with centers in four other states as well. For all forms of addiction,
Hazelden claims that 53 percent of its patients stay clean for a
year-in other words, after spending four weeks and $19,000, almost
half its clients relapse within months.

Nationwide, 12-step programs do poorly in treating painkiller abuse:
relapse rates after a year approach 80 percent.

The other route to getting clean is a protocol developed in the past
decade sometimes known as "rapid detox." It involves delivering a
large intravenous dose of naltrexone to a patient under anesthesia-a
dose so large it would be intolerable if the patient were conscious.

The Waismann Institute in Beverly Hills, which pioneered the
technique, says its program-which takes three to four days and costs
around $10,000-has a 65 percent one-year success rate. "Our patients
don't want to go to a 30-day program and 'talk about it' with a bunch
of drug addicts," Dr. Cliff Bernstein says dismissively. "They just
want to be off the drugs." Either way, it's not an easy thing to do.
As long as there is pain, people will try to escape it-and sometimes
wind up with something worse.

With Claudia Kalb, Debra Rosenberg, Mary Carmichael and Anne Underwood