Oxycontin: The Good, The Bad, and The Ugly

July 7, 2009 - PRLog -- In April 2000, an article in the Journal of the American Medical Association reported information from two sources: ARCOS (via the DEA, Drug Enforcement Administration) and DAWN (Drug Abuse Warning Network). This report showed that the medical use of oxycodone (generic name of the opioid found in many prescription painkillers) had increased 23% from 1990 to 1996, with virtually little diversion onto the street. However, in the following year, deaths from oxycodone overdose had suddenly increased almost 100% and by 1999, emergency department visits for overdose had increased another 30%.

It is important to point out that addiction to opioids used for legitimate medical purposes, under carefully supervised conditions and especially for acute pain, is extremely unusual. Many of the problems arise in the treatment of chronic pain conditions by inexperienced or under-qualified physicians in the management of chronic pain who also have not had enough basic training in Addiction Medicine.  

Oxycodone is a CNS depressant; it activates the opioid receptors in the spinal cord, brain and body tissues, which, in turn, magnify the body’s own natural defense against pain. Oxycodone has been prescribed for many years for moderate to high pain relief associated with cancer, fractures, neuralgia, severe arthritis, lower back pain, and post-operative pain. Some of the familiar names are Percocet, Percodan, Roxicodone, and Tylox. In 1996, Purdue Pharma L.P. produced an oral controlled-release preparation that would deliver a high dose of oxycodone over a 12-hour period, called Oxycontin.

Typically, the earlier preparations, such as Percocet, are shorter acting and need to be taken as two to four pills every four to six hours. Percodan and Tylox contain 5 mg of oxycodone and Percocet contains dosing of 2.5 mg. On the other hand, Oxycontin was formulated with 10, 20, 40, and 80 mg of oxycodone; a 160 mg tablet became available in 2000, but has since been taken off the market.

Oxycontin was designed to be swallowed whole and the time-release mechanism takes over from there. Abusers, on the other hand, have found that they can chew the pill, crush the tablet into powder and snort it or dissolve it in water and inject it I.V. – all of these mechanisms deliver the full jolt of opioid at one time. Because of this high measured dose of opiate, Oxycontin has become highly coveted in the illicit market; it is highly addictive and has become very expensive on the street.

Oxycontin has been diverted from legitimate medical necessity channels via pharmacy corruption and diversion, “doctor shopping” and improper prescribing practices by physicians, from just plain dumb unsupervised prescribing to prescription mills (for profit), self-medication, and over-prescription in exchange for sex or other favors. The doctor shoppers may or may not have a legitimate medical condition, but visit multiple physicians, at times in several states, to acquire large amounts of the drug for abuse or to sell for a substantial profit. The startling rise in Oxycontin abuse has led, in turn, to a major increase in pharmacy theft, armed robbery and health care fraud.

In Massachusetts, well-organized doctor shopping rings were formed; in addition, the most common tactics have been forged and altered prescriptions and diversions from individuals’ prescriptions.

Cocaine and heroin continue to be primary drugs of abuse in Massachusetts, being sourced from Columbia and the Dominican Republic. However, in the past couple of years  Oxycontin has emerged as a popular heroin substitute primarily because it can be obtained legally and frequently paid for by health insurance. In response to the growing awareness of drug problems in general, the DEA (Drug Enforcement Administration, which regulates the prescription-writing of physicians) launched the RET – Regional Enforcement Teams – in 1999.

Further, through Chapter 189 of the Acts of 2004, the Commonwealth established the “Massachusetts Oxycontin and other Drug Abuse Commission” to investigate the effects of abuse of prescription medications on the citizens of Massachusetts. Prominently involved were Representative Ruth Balser, House Chair on the Joint Committee on Mental Health and Substance Abuse; and Senator Steven Tolman, Senate Chair on the Joint Committee of Mental Health and Substance Abuse. The Committee also addressed heart-breaking family stories and professional narratives concerning Klonopin, fentanyl, Vicodin, methadone as well as Oxycontin and other opioid variants.

The pace of governmental response frequently tends to lag behind the realities on the street. However, the Commission (newly re-constituted in 2007) led by the Boston Democrat, Senator Tolman, has developed 4 distinct areas with action steps to guide their work:
1.   Prevention, Education and Training
2.   Distribution, Dispensing, Handling, Disposal
3.   Prescribing and Monitoring
4.   Expanded access to treatment (services for prescription and other drug dependence and abuse)

There have also been many notable gains on the local level: 1. The Norfolk County Heroin Task Force has formed “Learn2Cope.org”,  a resource for parents who need to learn more about heroin and Oxycontin abuse  2. The Middlesex County District Attorney’s office created a 17-minute video, “All Jammed Up: A Prescription for Disaster”. This video is aimed at parents, teachers and other school personnel on how to spot and address prescription drug abuse, especially Oxycontin  3. The Essex County District Attorney has developed an educational curriculum called “Choose to Refuse: A Heroin and Oxycontin Prevention Education Program” This is a 6-session program targeting 13-18 year olds. It promotes decision-making skills, ways to refuse drugs, and ability to recognize risky situations.

The 13-member Massachusetts Oxycontin and Heroin Commission held a number of town-hall meetings in the spring of this year. One of the clear conclusions of these many meetings: the problem has not gotten better; it has gotten worse. Some legislators have called for an outright ban on Oxycontin. Many physicians, with fear of the wrath of oversight agencies, e.g. the DEA and Board of Registration in Medicine, are fearful of prescribing an effective medicine even if needed, or tend to avoid treating patients with chronic pain altogether. On the other hand, partly because of the lack of training in the fundamentals of Addiction Medicine, many PCPs tend to under-medicate their pain patients for fear of inducting addiction.

So, two practical solutions are emerging that may be helpful. The first is use of electronic prescriptions which will prevent forgeries, and associated with an assigned number  will alert pharmacies of “doctor shopping” while preserving the patient’s identity.

Secondly, the American Society of Addiction Medicine, in their most recent issue, June 2009, has presented a screener that has been found to be valid and reliable. It is called the SOAPP-R (Screener and Opioid Assessment for Patients with Pain – Revised).  It consists of 24 questions that were empirically derived from expert consensus. Each of the 24 items are rated from            0 = “never” to 4 = “very often.”  This is a self-report instrument that was developed primarily with chronic, non-cancer pain patients. A score over 18 should alert the physician to potential risks of non-compliant, aberrant medication-related behaviors. This may provide the basis for requesting more frequent office visits, pill counts, urine toxicology, or even discontinuation of therapy. The SOAPP-R should also alert the practitioner to the need for pursuing additional information from other sources, such as other members of the treatment “team,” family members, pharmacist, new lab findings and review of the medical record.

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Punyamurtula S. Kishore is the Medical Director of Preventive Medicine Associates (Brookline, Massachusetts). Kishore has been a practicing public health scientist for over 30 years. He began his medical career as a primary care/family practice physician and then moved into a position as the Medical Director of the Washingtonian Center for Addictions, the first organization in the U.S. to recognize addiction as a disease. Their philosophy was an early precursor to the AA or 12-step program movement. Kishore has been a member of the American Society of Addiction Medicine since 1986 and has helped treat more than 140,000 addicts.At Preventive Medicine Associates Kishore treats addictions with his ‘sobriety maintenance’ method. This unique health model stresses the prescription of non-toxic substances, provides patients with coping skills they need to remain sober and tailors treatment to specific medical conditions.