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Wed May 29, 2013
How OxyContin's Pain Relief Built 'A World Of Hurt'
Originally published on Thu May 30, 2013 11:40 am
Prescription painkillers are among the most widely used drugs in America. In the decade since New York Times reporter Barry Meier began investigating their use and abuse, he says he has seen the number of people dying from overdoses quadruple — an increase Meier calls "staggering."
"The current statistic is that about 16,000 people a year die of overdoses involving prescription narcotics. ... It's a huge problem. The number of people dying from these drugs is second only to the number of people that die in car accidents," he tells Fresh Air's Terry Gross.
Meier's new e-book, A World of Hurt: Fixing Pain Medicine's Biggest Mistake, is published by The New York Times Co. and explores opiate painkillers and the consequences of long-term use. He focuses in particular on OxyContin — how it came to be prescribed for chronic pain, what the consequences have been, and how it became a street drug.
Meier explains how, in its initial form, OxyContin was designed as a time-released version of oxycodone — meant to ease pain for many hours at a time without interruption. It became a street drug when people looking to get high found a way to get around the time-release design of the pill.
"All you needed to do was to crush it, chew it, grind it down," Meier says, "and basically the entire narcotic pain [reducing] load that was contained within the drug was released immediately, which is why it was [such a] powerful high and such an addictive drug when it was abused that way."
Meier's previous book, Pain Killer, was published in 2003. He explains that for patients, part of the danger when it comes to the long-term medical use of painkillers like OxyContin comes from the body's ability to develop a tolerance for it.
"Unlike many other types of medications where you can be prescribed a dosage and stay on that dosage for a long time," Meier says, "your body adapts to these drugs. "[Essentially], you require more of the [narcotic] to get the same ... effect. And what happens is a steady escalation in dosage, and it can keep going and going and going and going to the point where, after a year or two of treatment, you are on extremely high levels of these drugs."
That doesn't mean, however, that Meier is unilaterally opposed to these narcotics.
"There is no question that these drugs are extremely beneficial," he tells Gross. "They are valuable, vital drugs. There should be no hesitation in their use after conditions like surgery, or accidents, or cancer treatment or end-of-life use. ... [T]he question becomes: How effective are these drugs in long-term treatment of chronic pain?"
On the promotion of OxyContin for chronic pain relief
"The company that produces OxyContin — Purdue Pharma — launched ... an innovative and huge campaign to introduce drugs that had previously been used for cancer treatment into [use for the relief of] general pain. That involved training hundreds of doctors to go out and speak to their medical colleagues about the benefits of these drugs and, most importantly, the FDA allowed Purdue to make an unusual claim ... that because OxyContin was a time-release drug it would be less prone to causing addiction and less attractive to people who abuse drugs. This became part of a steady drumbeat that was sounded by not only the company, but by leading pain experts — that, in fact, with this drug we had what was really a unique new weapon to deal with an age-old problem."
On the first signs of problems with OxyContin
"The first person who sounded the alarm about this was a doctor in Boston. Her name is Jane Ballantyne, and she was the head of pain treatment at Massachusetts General. In 2003 she had accepted that these drugs were beneficial. She was a soldier in this war on pain, and as she kind of walked around Mass General, she started seeing things that caught her attention. For example, chronic pain patients who were given these drugs started improving. They would improve for a while, and suddenly their improvement would stop. Their pain would return. They would lose function, or the improvement in function they had achieved would be lost, and she began to wonder why this was going on. That led her to start studying animal tests involving these drugs, and basically began to lead her to question whether these drugs were really beneficial for patients in the long term."
On the side-effect of becoming disengaged from life
"I had a doctor who I greatly respect who said, 'We thought the great problem with these drugs is addiction. What we didn't realize [was] that the people who take them would opt out of life.' And you see it across the spectrum: One of the more startling things is in the area of workplace injuries; things like back strains are very common problems. But what folks have discovered is the more patients — workers — who are treated with these drugs for back strain, the longer and longer and longer they stay away from work. In fact, we've kind of created a legion of chronically unemployed people who are dependent on these drugs."
On widespread use of OxyContin in Appalachia
"If you look at the atlas of how drugs are prescribed in different parts of the country, there usually is a pretty straight correlation between the use of narcotic painkillers and areas where you have physical labor jobs, like mining, farming, logging — [places] where people get a lot of back problems and muscle injuries and things of that nature. In many of these areas you have doctors who are generalists; they're not specialists. So most folks are going to a general practitioner — a family doctor — and when they were told that OxyContin was a less abusable drug than drugs that had preceded it, they said, 'Great. This sounds like a good thing for my patients.' So they started prescribing it very heavily."
On the rise of pill mills
"You basically had these pain clinics [with] doctors that supposedly specialized in treating pain. These, in fact, were doctors who had no experience in treating pain. These are essentially clinics where you could walk in and the doctor would say, 'How do you feel?' 'I'm in pain. I think OxyContin would work for me.' And the doctor would write your prescription. You would pay cash for the appointment, and the cycle would start. And these ... proliferated throughout the U.S."
TERRY GROSS, HOST:
This is FRESH AIR. I'm Terry Gross. Prescription painkillers have become the most widely used drugs in America. My guest Barry Meier has been investigating painkillers for more than 10 years. He's a reporter for the New York Times who covers the intersection of business, medicine and public health. His new e-book, "A World of Hurt," was published today.
It's about high-dose opioid painkillers and the consequences that come with long-term use. It focuses especially on OxyContin, how it came to be prescribed for chronic pain, and what the consequences have been. It also examines how Oxy became a street drug. Meier's previous book, published in 2003, is called "Painkiller."
Barry Meier, welcome to FRESH AIR. Let's start with an overview. What is Oxy, and how does it compare to, say, morphine or Percocet or Vicodin?
BARRY MEIER: Sure. OxyContin is basically a time-release form of a narcotic called oxycodone. It's in the same class of drugs as morphine, codeine. They're basically all natural or synthetic variations of the - from the poppy seed. What made OxyContin so unique is that it was a pure version of the drug. It wasn't mixed with aspirin or acetaminophen the way it's found in other narcotic painkillers like Percocet.
And it was in a time-release form, so the drug was supposed to - you take it, and you are supposed to get pain relief for about 12 hours or so.
GROSS: But people who wanted to use it to get high found a way around that.
MEIER: Correct. All you needed to do was to crush it, chew it, grind it down, and basically the entire narcotic pain load that was contained within the drug was released immediately, which is why it was such a powerful high and such an addictive drug when it was abused that way.
GROSS: You've been writing about how medical and social attitudes toward opiate painkillers keep shifting. You write a lot about the war on pain, which started, what, in the '80s, where attitudes shifted to be more open to the long-term use of opioids in the treatment of pain. This actually started with cancer and with people who were, you know, terminally ill and sought pain relief. Let's start there.
MEIER: Sure, that's correct. I mean basically in the 1980s or '70s, drugs like morphine were not widely used in this country because of fears of addiction related to them. And as a result of that, a lot of people at their end of their lives, be it cancer sufferers or people who were dying, were denied these drugs.
And there was a lot of suffering as a result of that. In the '80s there was a realization that these drugs could be used successfully on cancer patients and terminally ill patients. And then in the mid-1990s there was really a revolution that took place. There was a study done here in New York by a pain expert who found that if I gave these same drugs to people with non-cancer pain, common pain like back pain, arthritis, facial pain, that it appeared that they also weren't getting addicted.
And that opened the door to the widespread medical use of drugs that had previously been reserved for cancer patients into the general patient population.
GROSS: Did the manufacturer of OxyContin do anything to promote the long-term use of the drug for pain patients who didn't have cancer, people with back pain and nerve damage?
MEIER: Oh, absolutely. The company that makes OxyContin, Purdue Pharma, launched what was an innovative and huge campaign to introduce drugs that had previously used for cancer treatment into general pain. That involved training hundreds of doctors to go out and speak to their medical colleagues about the benefits of these drugs.
And most importantly, the FDA allowed them to make an unusual claim, and that is that because OxyContin was a time-release drug, it would be less prone to causing addiction and less attractive to people who abuse drugs. So this became part of what was a steady drumbeat that was sounded not only by the company but by many leading pain experts, that in fact with this drug we had what was really a unique new weapon to deal with an age-old problem.
GROSS: When OxyContin started entering the realm of medical use for long-term chronic pain, like back problems and nerve pain, was it controversial within the medical field?
MEIER: There was some controversy. You know, prior to that there had been other approaches to treating pain, sometimes successfully, sometimes unsuccessfully. It basically involved, you know, physical therapy, behavioral therapy. Pain is a very, very complex condition, particularly chronic pain. And what happened was that with the introduction of what seemed to be kind of a wonder drug, insurers shifted to basically paying only for drugs, much as they did when antidepressants replaced psychotherapy.
So whatever controversy there was at the point of introduction, it was kind of quickly swept aside by economic forces, and these drugs, OxyContin in particular, were very quickly and widely accepted by many, many doctors.
GROSS: You write about how pharmaceutical companies who manufacture painkillers have actually funded medical and patient pain groups. Would you describe the funding and the relationship of the pharmaceutical companies to these groups?
MEIER: Sure, these types of arrangements are found throughout medicine, where you have drug companies funding patient or advocacy groups that represent a particular disease or particular interest that they have. This in the area of use of opioids became very, very well-funded with the launch of OxyContin and continued for about a decade or so.
The dilemma here is that companies have legitimate commercial interests, and that is to make sure these drugs are available for patients, and that became the drumbeat to which the patient groups marched as well, and so it became very focused on changing state laws or deterring any effort that might limit the availability of these drugs to patients, rather on the issue of whether these drugs were actually beneficial to the patients who were taking them.
GROSS: What were some of the early problems that pain specialists started reporting?
MEIER: Well, the person that sort of first sounded the alarm about this was a doctor in Boston, her name is Jane Ballantyne, and she was the head of pain treatment at Massachusetts General. And in 2003, I mean she accepted that these drugs were beneficial. She was a soldier in this war on pain, and as she kind of walked around Massachusetts General, she started seeing things that caught her attention.
For example, chronic pain patients who were given these drugs started improving. They would improve for a while, and suddenly their improvement would stop. Their pain would return, they would lose function, or the improvement in function they had achieved would be lost, and she began to wonder why this was going on.
And that led her to start studying animal tests involved in these drugs and basically began to lead her to question whether these drugs were really beneficial for many patients in the long term.
GROSS: And what some doctors started finding, you write, is that patients would become tolerant of the drug. They would develop a tolerance and require increased doses. Does that frequently happen?
MEIER: It's a very common thing, and it's sort of part and parcel of using these drugs. Essentially, unlike many other types of medications, where you can sort of be prescribed a dosage and stay on that dosage for a long time, your body adapts to these drugs. And when your body adapts to these drugs, which is the situation called tolerance, essentially you require more of the drug to get the same killing effect.
And so what happens then is a steady escalation in dosage, and it can keep going and going and going and going and going, to the point where after a year or two of treatment, you are on extremely high levels of these drugs, and the higher level you take these drugs at, the more potential side effects that can occur.
So you had people who became addicted to it through its medical use, and increasingly we're seeing evidence that patients become dependent upon it. We're seeing consequences where people's hormonal balance is basically being affected and their production of sexual hormones is being decreased, which is leading to lethargy.
We're seeing a variety of ill effects that are being produced by the long-term medical use of these drugs as opposed to their abuse.
GROSS: And one of the side effects you write about is basically disengaging from life.
MEIER: Correct. I mean I had a doctor who I greatly respect mention to me that, you know, we thought the big problem with these drugs was addiction. What we didn't realize is that people who take them would opt out of life. And, you know, you see it across the spectrum. One of the more startling things is in the area of workplace injuries. I mean things like back strains are very common problems.
But what folks have discovered is that the more patients that - you know, workers who are treated with these drugs for back strain, the longer and longer and longer they stay away from work. In fact, we've kind of created kind of a legion of chronically unemployed people who are dependent on these drugs.
GROSS: It makes me wonder, though, maybe the people who became dependent on drugs were the people who didn't respond to other forms of therapy like physical therapy, or maybe they were in more severe pain than the other people who were able to return to work, and consequently stayed on drugs longer.
MEIER: That's possible, but we don't know that because the way our medical system is set up right now is that we really don't finance the treatment of these chronic pain conditions through alternative means. If you look at data from other countries where there is more aggressive use of alternative pain treatments, what you'll see is that in many cases people recover far more quickly from chronic pain conditions when they're given alternative forms of treatments than when they're given opioids.
GROSS: So I don't want to unnecessarily scare people about using painkillers when they come out of surgery or when they've been in a terrible accident. So would you just address that? I mean...
GROSS: I think it's good to have cautionary advice, but there's times when you really need a painkiller.
MEIER: There is no question that these drugs are extremely beneficial. They're valuable, vital drugs. And there should be no hesitation in their use after conditions like surgery or accidents or cancer treatment or end-of-life use. One does not want to turn the clock back to the limitations of these drugs in certain medical treatments.
The question becomes how effective are these drugs in the long-term treatment of chronic pain, and the dilemma that we're facing now, after an experiment that began 15 years ago, is we really don't know that answer. And what we're seeing the longer these drugs are being used are consequences from their long-term use that weren't envisioned when this experiment began.
GROSS: If you're just joining us, we're talking about pain medicine, particularly various forms of oxycodone. My guest is Barry Meier. He's a New York Times reporter who covers the intersection of business, medicine and public health. He's the author of a new New York Times e-book, which is called "A World of Hurt: Fixing Pain Medicine's Biggest Mistake." It's his second book about painkillers.
So OxyContin also has an underground history. How did it start catching on as a high?
MEIER: Well, it started catching on pretty soon after it appeared on the street. This is going back about a decade ago or so. And people that abuse drugs are very clever in finding ways of abusing whatever new drug comes onto the market, and it was quickly discovered that OxyContin could be crushed and snorted or chewed.
And it sort of became the hottest drug on the street...
GROSS: And as you explained before, the advantage of crushing it is that it was a time-release capsule, and if you crushed it, all of the opiate would be released at once. So you'd get...
GROSS: ...a bigger hit at one time.
MEIER: Absolutely. I mean you got a huge hit at one time. And you know, to people who had never tried it before, it was extraordinarily dangerous as well, because that big hit could actually kill you from an overdose. So people in areas like Appalachia and Maine, where there was a large-scale use of painkillers for work-related problems, et cetera, started catching on to that there was this really great new drug on the street if this is the way I'd like to get high.
And it kind of ran like wildfire. It really started catching on in 1999, and by 2001 it was all over much of the Eastern United States and then spread across the country.
GROSS: So one of the first places it caught on was in Appalachia because of work-related pain problems? Is that what you're saying?
MEIER: There was - you know, if you look at sort of the atlas, if you will, of how drugs are prescribed around the country, what types of drugs are prescribed in different parts of the country, there usually is a pretty straight correlation between the use of narcotic painkillers in areas where you have physical labor, jobs like mining, farming, logging, where people get a lot of back problems and muscle injuries and things of that nature.
And it also - in many of these areas you have doctors who are generalists, you know, they're not specialists. So most folks are going to a general practitioner, a family doctor, and when they were told that OxyContin was a less abusable drug than drugs that had preceded it, they said great, this sounds like a good thing for my patients. So they, you know, they started prescribing it very heavily.
GROSS: When Oxy started to catch on on the street, what kind of pill mills grew up around that new craving for it?
MEIER: Basically an industry. You basically had these pain clinics open up, doctors that supposedly specialize in treating pain. These in fact were doctors who had no experience in treating pain and were probably the wrong person to go to see if you actually had pain.
But they were essentially clinics where you could walk in and the doctor would say to you, How do you feel? Well, I'm in pain and I think OxyContin would work for me. And the doctor would write you a prescription, you would pay cash for the appointment, and the cycle would start.
And these literally proliferated throughout the United States. I mean, they started in places where Oxy abuse first started. But more recently you would go to states like Florida and there would be literally hundreds of these pain clinics that would draw drug abusers from around the country.
GROSS: Why Florida?
MEIER: Florida's kind of interesting because Florida's one of the states where Oxycontin abuse did start early. But there's also a unique - or there was until very recently a unique aspect to Florida law, which allowed doctors to not only prescribe a drug but dispense a drug as well. So if you went to your doctor and your doctor said to you, you needed X drug, and you said fine, normally you would take it to a drugstore. In this case the doctor would say to you, you need X drug and as a matter of fact I can sell it to you, or you can go to the office next door to my office and buy it there. So it became very financially rewarding for these doctors to set up clinics in Florida and attract people from all over the Eastern Seaboard.
GROSS: The street use of Oxy has led to overdoses. Can you give us a sense of what the scope is?
MEIER: It's enormous. I mean the current statistic is that about 16,000 people a year die of overdoses involving prescription narcotics.
GROSS: But this is the street use of it.
MEIER: Right. The presumption is that the vast majority of overdoses involve the abuse of the drug. There may be a small fraction of those that involve people who become medically addicted to the drugs who then go on to abuse them. You know, it's a huge problem. I mean the number of people dying from these drugs is second only to the number of people that die in car accidents.
And what's been startling to me over time is seeing this number grow. I mean, you asked me before about what was most sort of - what I've seen over the years. And what I've seen is the number of people dying of overdoses quadrupling between 2003 and today, and that's a staggering increase.
GROSS: What approach has the Drug Enforcement Agency and other law enforcement groups taken to trying to crack down on the street use of Oxy?
MEIER: The DEA has arrested hundreds of doctors who worked in pain clinics. It's prosecuted many of these doctors. I mean some of these doctors are criminals. The folks that run these clinics do it for money. But many of the doctors that work there are well-meaning; they're, you know, often retired doctors; they're doctors looking for added income.
You know, the problem is, is that many of the doctors that work in these clinics don't understand how to treat pain, they don't understand how to recognize symptoms of abuse, and they unfortunately become facilitators of this entire system.
GROSS: This is FRESH AIR. I'm Terry Gross back with Barry Meier, author of a new e-book about opioid painkillers called "A World of Hurt." Meier is a New York Times reporter who covers the intersection of business, medicine and public health. He's also the author of the 2003 book "Painkiller." Earlier, he was telling us how OxyContin became a street drug. One reason was that the original time-released version - approved by the FDA in 1995 - could easily be crushed and that would release the entire narcotic payload at once so the user could get a big hit and get high.
OxyContin changed its formula to prevent smashing from releasing the full dose at one time. So what's the state of OxyContin now in terms of its, you know, capacity to be a good, quick high like the previous version?
MEIER: OxyContin right now is probably not a good high. When you try to smash it now, it turns it kind of into this gummy goo. So it can't be easily injected or abused in the way that it was abused prior to the reformulation. Even going back a number of years ago, doctors, because of the uproar over OxyContin abuse, started shying away from it. They'd moved on, then, to drugs like methadone. And methadone, while it's most popularly known as an addiction treatment, is also a widely used painkiller. So people abusing the drug, let's say OxyContin, would then go on to methadone. Or doctors would start prescribing sort of the generic oxycodone tablets and people abusing drugs would go on to that. So you kind of had this game of leapfrog between doctors and people seeking out drugs to abuse.
GROSS: Painkillers are not just recommended by pain specialists, other doctors can recommend them too. It's very easy to get addicted to drugs. When you overuse them it's difficult to wean yourself from those drugs. Do you think the doctors who prescribe pain medicines are necessarily trained in how to wean patients off of those medicines?
MEIER: Well, I think that's absolutely true, but it's - to expand beyond that just a little bit, that doctors who prescribe these drugs are not really that well-trained, and in many cases, not trained at all in pain treatment. So basically you have patients who are coming into these offices with extremely complex conditions. And, you know, chronic pain can be part physical, it can evolve or begin as a psychological or emotional problem, and they're very complex patients to treat, and most general practitioners, family doctors, don't have the time, training, skill or interest in treating these patients, which is often the reason why they prescribe them a drug.
You know, one of the big dilemmas that's spun out over this past decade has been the lack of people who can specialize in pain treatment, who know this area. And I think that's an area that is extremely important for both the medical industry and the medical profession and society to come to grips with - that is making sure that there is a cadre of well-trained, knowledgeable doctors that can properly treat these patients.
GROSS: You've been writing about pain medication for over 10 years. You wrote a book about the subject back in 2003, so you seen this whole story evolve. You've been reporting on it as it's evolved. What are some of the biggest surprises you've witnessed?
MEIER: I would say the biggest surprise that I've witnessed is, you know, back in 2003, when "Painkiller" came out, the prevailing medical thought and my thought was that there was a line of demarcation - a bright line - between the benefits of these drugs for patients and their abuse on the street. So one of the big realizations for me is that that bright line is certainly not very bright and in fact may be a mirage.
GROSS: What changed your mind?
MEIER: Basically, the scientific evidence that's been coming out, the experience of patients. Because back when I wrote the book, the use of these drugs for chronic pain was a fairly new phenomenon. There wasn't really a lot of data that had been gathered about their effectiveness. And now that this experiment's been going on for more than a decade, there is increasing evidence that for, while these drugs are very beneficial for some patients, they are, in fact, not beneficial at all for many patients.
GROSS: You mean they won't even help the pain at all?
MEIER: Well, they will help the pain for a period of time until you get to that point of tolerance and then you'll need more, and unfortunately for some patients, their ability to function will start to decline as the amount of medication they take increases. So that's the dilemma.
GROSS: You know, you have forces from both ends of the spectrum. I mean, there has for a long time been resistance to the use of morphine from people who are just like anti-drug for moral reasons and are afraid like any use of morphine is going to be addictive - even if like you're dying of cancer, you have like two weeks to live, you know, there was this fear, oh no, you can't let the patient get addicted. What's the problem? They're dying. They're not even going to be around in two weeks, so why is addiction a problem? And then on the other end, you know, you write about how there's people who are saying well, let's not worry about addiction because it's going to solve the pain problem. And I guess, what's the controversy in the field now?
MEIER: Well, I mean the issue that you brought up is a very important one and sort of central to this. John Hockenberry put it very well when he said, when he wrote an essay one time, when you try to balance the damage caused by pain against the damage caused by drug abuse, nobody wins. And that's absolutely right. How do you balance these two things against each other? How do you give pain patients relief and avoid these drugs kind of spilling over into the street and causing abuse? And I think that whole issue is perhaps being in the process of being reframed from the standpoint of, you know, if we really just focus on what is the best way of treating pain, then we kind of address the second issue, because maybe we need to put more patients into other ways of treating pain than simply doling out drugs and dealing with, you know, alternative pain treatments and things of that nature.
GROSS: Barry Meier, thank you so much for talking with us.
MEIER: Thank you, Terry. It was a real pleasure.
GROSS: Barry Meier's new e-book, "A World of Hurt," was published today.
Coming up, John Powers tells us about the Cannes Film Festival, the film that won the top prize, the films he liked best and the one that got the most boos.
This is FRESH AIR.
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