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

Oct. 20 issue -- 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.