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video on addiction

Posted: September 8, 2010 in Uncategorized

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Photo illustration by Suellen Parker for The New York Times
Published: June 17, 2007 in the NY Times

Corrections Appended

Ronald McIver is a prisoner in a medium-security federal compound in Butner, N.C. He is 63 years old, of medium height and overweight, with a white Santa Claus beard, white hair and a calm, direct and intelligent manner. He is serving 30 years for drug trafficking, and so will likely live there the rest of his life. McIver (pronounced mi-KEE-ver) has not been convicted of drug trafficking in the classic sense. He is a doctor who for years treated patients suffering from chronic pain. At the Pain Therapy Center, his small storefront office not far from Main Street in Greenwood, S.C., he cracked backs, gave trigger-point injections and put patients through physical therapy. He administered ultrasound and gravity-inversion therapy and devised exercise regimens. And he wrote prescriptions for high doses of opioid drugs like OxyContin.

McIver was a particularly aggressive pain doctor. Pain can be measured only by how patients say they feel: on a scale from 0 to 10, a report of 0 signifies the absence of pain; 10 is unbearable pain. Many pain doctors will try to reduce a patient’s pain to the level of 5. McIver tried for a 2. He prescribed more, and sooner, than most doctors.

Some of his patients sold their pills. Some abused them. One man, Larry Shealy, died with high doses of opioids that McIver had prescribed him in his bloodstream. In April 2005, McIver was convicted in federal court of one count of conspiracy to distribute controlled substances and eight counts of distribution. (He was also acquitted of six counts of distribution.) The jury also found that Shealy was killed by the drugs McIver prescribed. McIver is serving concurrent sentences of 20 years for distribution and 30 years for dispensing drugs that resulted in Shealy’s death. His appeals to the U.S. Court of Appeals for the Fourth Circuit and the Supreme Court were rejected.

McIver’s case is not simply the story of a narcotics conviction. It has enormous relevance to the lives of the one in five adult Americans who, according to a 2005 survey by Stanford University Medical Center, ABC News and USA Today, reported they suffered from chronic pain — pain lasting for several months or longer. According to a 2003 study in The Journal of the American Medical Association, pain costs American workers more than $61 billion a year in lost productive time — and that doesn’t include medical bills.

Contrary to the old saw, pain kills. A body in pain produces high levels of hormones that cause stress to the heart and lungs. Pain can cause blood pressure to spike, leading to heart attacks and strokes. Pain can also consume so much of the body’s energy that the immune system degrades. Severe chronic pain sometimes leads to suicide. There are, of course, many ways to treat pain: some pain sufferers respond well to surgery, physical therapy, ultrasound, acupuncture, trigger-point injections, meditation or over-the-counter painkillers like Advil (ibuprofen) or Tylenol (acetaminophen). But for many people in severe chronic pain, an opioid (an opiumlike compound) like OxyContin, Dilaudid, Vicodin, Percocet, oxycodone, methadone or morphine is the only thing that allows them to get out of bed. Yet most doctors prescribe opioids conservatively, and many patients and their families are just as cautious as their doctors. Men, especially, will simply tough it out, reasoning that pain is better than addiction.

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It’s a false choice. Virtually everyone who takes opioids will become physically dependent on them, which means that withdrawal symptoms like nausea and sweats can occur if usage ends abruptly. But tapering off gradually allows most people to avoid those symptoms, and physical dependence is not the same thing as addiction. Addiction — which is defined by cravings, loss of control and a psychological compulsion to take a drug even when it is harmful — occurs in patients with a predisposition (biological or otherwise) to become addicted. At the very least, these include just below 10 percent of Americans, the number estimated by the United States Department of Health and Human Services to have active substance-abuse problems. Even a predisposition to addiction, however, doesn’t mean a patient will become addicted to opioids. Vast numbers do not. Pain patients without prior abuse problems most likely run little risk. “Someone who has never abused alcohol or other drugs would be extremely unlikely to become addicted to opioid pain medicines, particularly if he or she is older,” says Russell K. Portenoy, chairman of pain medicine and palliative care at Beth Israel Medical Center in New York and a leading authority on the treatment of pain.

The other popular misconception is that a high dose of opioids is always a dangerous dose. Even many doctors assume it; but they are nonetheless incorrect. It is true that high doses can cause respiratory failure in people who are not already taking the drugs. But that same high dose will not cause respiratory failure in someone whose drug levels have been increased gradually over time, a process called titration. For individuals who are properly titrated and monitored, there is no ceiling on opioid dosage. In this sense, high-dose prescription opioids can be safer than taking high doses of aspirin, Tylenol or Advil, which cause organ damage in high doses, regardless of how those doses are administered. (Every year, an estimated 5,000 to 6,000 Americans die from gastrointestinal bleeding associated with drugs like ibuprofen or aspirin, according to a paper published in The American Journal of Gastroenterology.)

Still, doctors who put patients on long-term high-dose opioids must be very careful. They must monitor the patients often to ensure that the drugs are being used correctly and that side effects like constipation and mental cloudiness are not too severe. Doctors should also not automatically assume that if small doses aren’t working, that high doses will — opioids don’t help everyone. And research indicates that in some cases, high doses of opioids can lose their effectiveness and that some patients are better off if they take drug “holidays” or alternate between different medicines. Pain doctors also concede that more studies are needed to determine the safety of long-term opioid use.

But with careful treatment, many patients whose opioid levels are increased gradually can function well on high doses for years. “Dose alone says nothing about proper medical practice,” Portenoy says. “Very few patients require doses that exceed even 200 milligrams of OxyContin on a daily basis. Having said this, pain specialists are very familiar with a subpopulation of patients who require higher doses to gain effect. I myself have several patients who take more than 1,000 milligrams of OxyContin or its equivalent every day. One is a high-functioning executive who is pain-free most of the time, and the others have a level of pain control that allows a reasonable quality of life.”

PAGES

Tina Rosenberg is a contributing writer for the magazine.

Correction: June 17, 2007

An article on Page 48 of The Times Magazine today, about Dr. Ronald McIver, who is imprisoned for drug trafficking, gives an erroneous account of the trial testimony of one of his patients, Leslie Smith. Mr. Smith testified that he injected drugs that Dr. McIver prescribed; he did not testify that Dr. McIver sold the drugs.

Correction: June 19, 2007

An article in The Magazine on Sunday about Dr. Ronald McIver, who is imprisoned for drug trafficking, gave an erroneous account of the trial testimony of one of his patients, Leslie Smith. And a correction in this space on Sunday again referred incorrectly to that testimony. The only point Mr. Smith made in his testimony was that he acknowledged injecting drugs prescribed by Dr. McIver. Mr. Smith never raised the issue of whether he himself sold any drugs that were left over to buy other drugs. And he never referred to Dr. McIver in the context of the leftover drugs — either that Dr. McIver sold them or did not sell them.

03:21 PM
Sep 07
2010
AP Photo/This photo taken Aug. 5, 2010 shows dottles of drugs commonly targeted by thieves at Hospital Discount Pharmacy that was robbed in July in Edmond, Okla. Across the country, pharmacy robberies are on the rise, partly because of the increasing demand for prescription drugs, according to law enforcement officers and industry officials. Prescription painkillers rank second behind marijuana as the country's most common illegal drug problem, according to the Office of National Drug Control Policy.
OKLAHOMA

Across the country, pharmacy robberies are on the rise, partly because of the increasing demand for prescription drugs, according to law enforcement officers and industry officials.

Prescription painkillers rank second behind marijuana as the country’s most common illegal drug problem, according to the Office of National Drug Control Policy.

There are no official numbers on how many pharmacies are robbed each year nationwide. The federal government does not track them and states vary in how they classify the crimes: some are logged as break-ins, others as drug thefts. But federal drug officials, drug companies, pharmacies, state authorities and local police departments nationwide all say they’ve noticed an increase in recent years.

“It’s not surprising that pharmacies have become the object of crime, given the popularity of prescription drugs,” said Barbara Carreno, a Drug Enforcement Administration spokeswoman. “Communities must take this threat as seriously as the threat posed by street drugs like heroin and cocaine.”

Robbers hold up pharmacies in upscale neighborhoods and those full of blight. Stores sitting just off highways and nestled in towns small and large have also been hit. The most valuable pills are the heavy painkillers that on the street can go for up to $60 a tablet.

“It’s just unfortunate that people who have become addicted to drugs, they know where they can get a source of a reliable high,” Curtin said.

In Ohio, officials say the problem is mainly armed robbery of pharmacies. There were 32 in 2007 and that more than doubled to 68 in 2008, according to state records.

In Oklahoma only one pharmacy reported an armed robbery in 2007, but that shot to 12 in 2008. Last year, there were 19. Burglaries went from 31 in 2007 to 42 in 2008. In 2009, the tally was 51, according to the Oklahoma Bureau of Narcotics and Dangerous Drugs Control.

“There isn’t any doubt we’ve seen a spike in the past five years or so in pharmacy break-ins,” said Mark Woodward, spokesman for the bureau.

Missouri has also seen more drug thefts at pharmacies in the past few years, said Mike Boeger, administrator of the Missouri Bureau of Narcotics & Dangerous Drugs.

In 2007, the state received 518 drug theft reports; in 2008, it logged 606. Then in 2009, the number dipped to 490, but through August of this year, Missouri has received 360 reports, and Boeger said that would put the state back on track to have well over 500 by the year’s end.

In many of those cases, the employees are the thieves, Boeger said. One girl stole more than 49,000 doses of the painkiller hydrocodone before getting caught.

“They’re stealing us blind every day,” Boeger said. “Hundreds of thousands of doses.”

One high-profile pharmacy case was in Oklahoma last year in which a pharmacist Jerome Ersland pulled a gun on two robbers. Ersland shot one, a 16-year-old boy, in the head, and chased the other away. He returned to the store and pumped five more bullets into the teenager, which the coroner said were the fatal shots. Ersland’s awaiting trial for first-degree murder and he says he acted in self-defense.

More common incidents are like the one in Missoula, Mont. where a woman demanded all the oxycontin and oxycodone in the store and made off with 1,900 pills worth about $35,000 on the street; or the teenager in Boynton Beach, Fla., who ordered six people to the ground at gunpoint and fled with more than 1,500 painkillers.

The increase of robberies has some employees locking up powerful narcotics like oxycodone in safes, installing security cameras and using trickery — one pharmacist in suburban Oklahoma City filled bottles labeled ‘hydrocodone’ with M&Ms — to thwart drug-seeking burglars.

“Pharmacies just typically haven’t had to deal with this,” says Rick Zenuch, director of law enforcement liaison and education at Purdue Pharma L.P. “I don’t think we want to get to the point where we see teller-style windows.”

Law enforcement officials say there’s not much they can do to prevent the robberies and they don’t have the extra staffing to step up patrols of pharmacies.

Larger drugstore chains such as CVS and Walgreen Co. say they have programs in place to protect employees and customers. They wouldn’t elaborate, though Walgreen recently upgraded its surveillance system to digital to have clearer images.

Not to be confused with oxytocin, oxandrolone, hydrocodone, or oxazepam.
Oxycodone
Systematic (IUPAC) name
(5R,9R,13S,14S)-4,5α-epoxy-14-hydroxy-3-methoxy-17-methylmorphinan-6-one
Identifiers
CAS number 76-42-6
ATC code N02AA05
N02AA55 (in combinations)
PubChem CID 5284603
DrugBank DB00497
ChemSpider 4447649
Chemical data
Formula C18H21NO4
Mol. mass 315.364 g/mol
SMILES eMolecules & PubChem
Synonyms dihydrohydroxycodeinone, 14-hydroxydihydrocodeinone, 6-deoxy-7,8-dihydro-14-hydroxy-3-O-methyl-6-oxomorphine[1]
Pharmacokinetic data
Bioavailability Up to 87%
Protein binding 45%
Metabolism Hepatic (CYP450: 2D6 substrate)
Half-life 3 – 4.5 hr
Excretion Urine (19% unchanged)
Therapeutic considerations
Pregnancy cat. B/D (prolonged use or in high doses at term)
Legal status Controlled (S8) (AU) Schedule I (CA) ? (UK) Schedule II (US)
Dependence Liability Moderate – High
Routes oral, intramuscular, intravenous, intranasal, subcutaneous, transdermal, rectal, epidural[2]
YesY(what is this?) (verify)

Oxycodone is an opioid analgesic medication synthesized from opium-derived thebaine. It was developed in 1916 in Germany, as one of several new semi-synthetic opioids in an attempt to improve on the existing opiates: morphine, diacetylmorphine (heroin), and codeine.[2]

Oxycodone oral medications are generally prescribed for the relief of moderate to severe pain. Currently it is formulated as single ingredient products or compounded products. Some common examples of compounding are oxycodone with acetaminophen/paracetamol or NSAIDs such as ibuprofen. The formulations are available as generics but are also made under various brand names.

OxyContin is Purdue Pharma’s brand for time-release single-ingredient oxycodone oral medication. The manufacturing rights to time-released generic oxycodone are under dispute.

Contents

History

Freund and Speyer of the University of Frankfurt in Germany first synthesized oxycodone from thebaine in 1916,[9] a few years after the German pharmaceutical company Bayer had stopped the mass production of heroin due to hazardous use, harmful use, and dependence. It was hoped that a thebaine-derived drug would retain the analgesic effects of morphine and heroin with less dependence. To some extent this was achieved, as oxycodone does not have the same immediate effect as heroin or morphine nor does it last as long.

The first clinical use of the drug was documented in 1917.[6] It was first introduced to the US market in May 1939..

The International Narcotics Control Board estimates that 11.5 tons[clarification needed] of oxycodone were manufactured worldwide in 1998, which grew to 75.2 tons in 2007.[10] Of all countries, the United States had the highest total consumption of oxycodone in 2007 (82% of the world total of 51.6 tons).[10] In addition, in 2007 the U.S. had the highest per capita consumption of oxycodone, followed by Canada, Denmark, Australia, and Norway.[10]

Clinical use

In a 2008 review written by authors who “are members of advisory boards and speaker panels for Mundipharma,” prolonged-release oxycodone (i.e., OxyContin) was found to be superior to placebo in randomized controlled trials concerning diabetic neuropathy, postherpetic neuralgia, osteoarthritis, ambulatory laparoscopic tubal ligation surgery, unilateral total knee arthroplasty, and abdominal/gynaecological surgery.[47]

In 2001, the European Association for Palliative Care recommended that oral hydromorphone or oxycodone, “if available in both normal release and modified release formulations for oral administration,” be second-line alternatives to oral morphine for cancer pain.[48] There is no evidence that any opioids are superior to morphine in relieving the pain of cancer, and no controlled trials have shown oxycodone to be superior to morphine.[49] However, switching to an alternative opioid can be useful if adverse effects are troublesome, although the switch can be in either direction, i.e. some patients have fewer adverse effects on switching from morphine to oxycodone and vice versa.

Illicit use and diversion

Canada

A study at St. Michael’s Hospital and the Institute for Clinical Evaluative Sciences (ICES) in Toronto, found that deaths from opioid pain relievers nearly doubled from 13.7 deaths per million residents in 1991 to 27.2 deaths per million residents in 2004.[72]

United States

Instances of recreational use and diversion of OxyContin have increased in the U.S. beginning in the late 1990s.[73] The slang term hillbilly heroin for OxyContin refers to the occurrence of the “earliest reported cases of Oxycontin abuse” in the U.S. in rural areas such as Appalachia.[74] Diversion of OxyContin in the U.S. may occur through “fraudulent prescriptions, doctor shopping, over-prescribing, and pharmacy theft.”[73]

A 2003 study by the Government Accountability Office found four factors that may have contributed to the illicit use and distribution of OxyContin in the U.S.:[11]

  • OxyContin contains a large amount of oxycodone compared with other types of oxycodone containing pills.
  • OxyContin’s warning label said to not crush the controlled-release tablets because of the potential for rapid release of oxycodone, which led to many people crushing the tablets and injecting or snorting the drug.
  • By 2001, sales of OxyContin in the U.S. exceeded $1 billion per year.
  • People who received prescriptions for OxyContin from across the United States and almost all socioeconomic status have perceived a “profit potential” in selling the pills to drug dealers (e.g., 20 mg of OxyContin could be bought for $2 but sold for $5-20)[citation needed].

A study published in 2005 examined the prevalence of opiate analgesic use among “recreational drug users and street addicts” as perceived by “key informants”[who?] throughout the U.S.; the authors found that non-clinical use of opiates was increasing in general, but that of the drugs studied use of OxyContin “was mentioned most frequently.”[75] Purdue Pharma has attempted to reformulate the 10–40 mg strengths of OxyContin to prevent the release of a high percentage of the oxycodone by crushing; however, in 2008 a joint panel convened by the U.S. Food and Drug Administration was “concerned that abusers could find a way to manipulate the new formulation.”[76]

One investigation in Boston found that OxyContin was a “gateway” drug for heroin, which addicts turned to as cheaper alternative.[77]

Other countries

The illegal use of OxyContin began in Australia in the early 2000s. By 2007, 51% of a national sample of injection drug users in Australia had reported using oxycodone, and 27% had injected it in the last six months.[78]

Hazardous use, harmful use, and diversion of OxyContin in the U.K. commenced in the early- to mid-2000s.[79] The first known death due to OxyContin overdose in the U.K. occurred in 2002.[80]