For those who need OxyContin, stigma hurts

[antiquity]

For those who need OxyContin, stigma hurts

Abuse of the painkiller has put doctors, insurance firms and pharmacists on alert.

By Elisa Ung
INQUIRER STAFF WRITER

Kim Bondarenko says her insurance company is making it harder for her to get OxyContin, the drug that annihilated her severe neurological pain and let her go back to work.

Orthopedic surgeon Norman A. Johanson has shied away from prescribing it after hearing about the region's recent spike in deaths linked to abuse of the drug.

And pain specialists across the country are concerned that increased vigilance in administering OxyContin may be causing people to suffer needlessly.

As officials scramble to curb abuse of OxyContin - coveted for the heroin-like high it delivers when the 12-hour, time-release tablets are crushed - it has become more difficult for legitimate patients to get it. For those struggling with relentless cancer pain, the obstacles have been especially cruel.

"I would say my prescriptions for OxyContin are less than 50 percent of what they were three months ago, just because of the fear factor," said Johanson, chairman of the orthopedic surgery department at Hahnemann University Hospital. He said he was now much more likely to prescribe other, weaker painkillers.

Pain centers across the region, meanwhile, have been deluged with calls from patients whose doctors have stopped prescribing OxyContin altogether.

"The pool of physicians willing to prescribe [OxyContin] is dwindling," said Andrea Cheville, director of cancer rehabilitation at the University of Pennsylvania Medical Center.

Cheville has spent hours reassuring her OxyContin patients, many of whom fear becoming addicted or being stigmatized. She says pharmacists have winked at some of her patients, telling them: "Hang on, I'll get your fix."

OxyContin was formulated by drug maker Purdue Pharma of Stamford, Conn., to deliver, with one tablet covering 12 hours, a sustained amount of the painkiller oxycodone for patients suffering moderate to severe pain. The tablets come in strengths of 10, 20, 40, and 80 milligrams, corresponding to their amount of oxycodone, a narcotic derived from opium that works by blocking pain receptors in the brain.

OxyContin's time-release formulation has made it wildly successful as a legitimate painkiller - and as an abused drug. The amount that is time-released allows patients to sleep through the night, but it also gives abusers a high when they crush a tablet, getting the full hit of oxycodone by chewing, snorting or injecting.

That high can shut down respiration and kill, especially when OxyContin is crushed and taken with alcohol or other prescription drugs. Medical examiners in the Philadelphia region report a rising oxycodone-related death toll; in the city alone, oxycodone was linked to 39 deaths by late June of this year, compared with 41 in all of 2000. Four area medical professionals have been arrested this year for illegally prescribing the drug, including Richard G. Paolino of Bensalem, a physician who authorities said was the number-one source of OxyContin as the drug ravaged Fishtown, Port Richmond and Kensington.

With reports of OxyContin addiction, abuse and deaths rising nationally, officials - among them Pennsylvania Attorney General Mike Fisher - have insisted that Purdue Pharma halt what they consider aggressive marketing of the drug, introduced in 1996. The manufacturer estimates about one million people took the drug last year. There were $1.2 billion in sales from May 2000 to May 2001.

Purdue announced last month that it would reformulate the drug to be abuse-proof, with an additive, naltrexone, that would block the drug's narcotic effect if tablets were crushed. That new version will not be available for at least three years, since naltrexone must undergo safety trials.

Critics said the manufacturer, too slow to react to OxyContin abuse in the first place, should offer a redesigned drug much sooner. Late last month, Purdue's senior medical director, J. David Haddox, said the company would try a quicker solution, adding naloxone, a chemical already tested and used in other painkillers to help prevent intravenous abuse.

In an interview last week, Haddox said the company could not predict when any new formulation might be available because of Food and Drug Administration testing requirements. And though Purdue has known it could use naloxone, he said there were concerns that it would add a ceiling effect to OxyContin.

"Our primary goal here is to make safe, effective medications for patients with pain," Haddox said. "The secondary goal is to try to make these medications in a formulation that will be resistant to abuse.

"When you look at the number of people who have benefited and continue to benefit from OxyContin, it would have been unethical for us to just have sat on that until we worked on every last technical glitch to make the drug abuse-resistant," he said. "Our primary obligation is to patients with legitimate medical need."

Many of those legitimate patients, like Bondarenko, struggle to get their OxyContin prescriptions filled.

Bondarenko, 35, of Mayfair, has taken the drug for two years. She and her doctor say she needs the drug to function.

Bondarenko, who has fibromyalgia and herniated discs in her neck and back, says severe pain left her unable to care for her children. She was forced to hire someone to cook meals for her family. Her marriage was strained.

She went through a long list of medications before her doctor prescribed OxyContin. It was a godsend. She was able to return to her job as a carrier for The Inquirer. Now able to care for her 3-year-old daughter, she has also decorated her home.

To control her pain, Bondarenko's doctors at Albert Einstein Medical Center switched her this year to a high dosage of OxyContin - 80 milligrams three times a day. Five or six months ago, her insurance company, Keystone Mercy, began requiring letters of medical justification from all doctors who prescribe OxyContin for ailments other than sickle-cell anemia, chronic pain, cancer or HIV.

Ever since, Bondarenko's OxyContin has been limited and sometimes denied to her, despite calls and letters from her doctor.

But Keystone Mercy defends its policy. "We really don't see a need for primary-care doctors to prescribe OxyContin since there is already short-term medications like Percocet available in the market," said Mesfin Tegenu, vice president of pharmacy services for Keystone Mercy. "The whole idea is to control the diversion and abuse."

The company also weeds out over-prescribing doctors and "doctor-shoppers," patients who seek prescriptions from more than one doctor.

Bondarenko's family doctor, Jody Borgman, is frustrated with the hassles, yet acknowledges he, too, has stepped up his vigilance.

"I thought I was going to be above all that and know that I was doing the right thing," Borgman, a general internist at Einstein Medical Center, said. "But in the last two to three weeks, I certainly have become more concerned with reports of doctors being arrested.. . . I think a lot more about who's getting [OxyContin] and documenting the reasons they are getting it for."

Pharmacists across the country are also making greater efforts to call doctors to verify OxyContin prescriptions.

"When they see an OxyContin prescription, they raise that high level of vigilance even higher because of the . . . incidence of abuse with this drug," said Douglas Hoey, a vice president of the National Community Pharmacists Association.

One lung-cancer patient, Joseph Cassada, 41, a pipe worker from California, said he had found it nearly impossible to get his OxyContin prescription filled in Philadelphia, where he has worked for several months.

"I went to pharmacies all up and down Broad Street, and none of them would fill my prescription," Cassada said. "I say to the pharmacist, 'You know me. You know I have cancer. You know I need this.' But the pharmacist just looked at me and said, 'Can't do it, Joe. There's too much heat on us right now.' "

State legislators, meanwhile, have held hearings and are drafting legislation to crack down on doctor-shoppers and those who steal prescription pads. Last week, U.S. Rep. James C. Greenwood (R., Pa.) called for the creation of a national, computerized prescription-oversight program to identify abusing patients and doctors.

But the nation's pain specialists, who for years have worked to help doctors overcome the stigma of narcotic prescription, are especially worried that the controversy will overshadow the need for more education about painkillers.

"We've probably lost some ground," said Michael Ashburn, president of the American Pain Society and medical director for pain programs at the University of Utah. "Our concern is that the measures taken don't have the unintended consequence of causing people to suffer needlessly with pain."

Compounding the issue is the lack of education about painkillers in medical schools, said Sanjay Gupta, director of Einstein's pain center. He said many patients who came to him after doctors stopped their OxyContin prescriptions did not need such potent medication to begin with.

If more physicians were educated about the nuances of painkillers, Gupta said, their attitudes toward opioids would not be subject to such controversies as the OxyContin scare. And patients would not get mixed signals.

"They were suffering when we were over-prescribing," he said. "Now they're suffering as we're under-prescribing. There's a poor understanding of the real problem."

[David Berg]

seneca,

About a month ago my local paper ran a front page article reciting all the media hype on OxyContin. I was irritated enough to write a commentary column for their editorial page in response. If you're interested, here's a copy of my column.

David Berg
========================

The Aug. 5 article in the News-Leader about OxyContin relates the tragedy of a handful of individuals who died through the inappropriate use of the drug. The sad truth is that these deaths were due to drug abuse. Taking OxyContin off the market wouldn't have avoided all of those tragic deaths, because if they didn't have access to OxyContin it's likely they would have abused another drug. Opiate-based drugs have been used for pain management for thousands of years and they have been misused for just as long.

One fact that must not be lost in this discussion is that for some patients, such as some cancer patients, OxyContin provides more effective pain relief that any other drug available. Many people live each day with torturous pain. It would be immoral to tell these people that they'll have to live in greater pain every day because of some bureaucrat's decision.

There are some types of severe pain that even OxyContin can't touch. I know a young girl who suffers from debilitating attacks of trigeminal neuralgia from injuries suffered in the Oklahoma City bombing. Her facial pain from this condition is so severe at times she will sometimes go for several days without eating. I know another individual who worked as a physician and obtained a law degree before being disabled in his early 40s by central pain syndrome, which causes constant, severe pain over his entire body. There are no drugs that offer effective relief for these and many other types of pain.

There is a solution to these problems, but it's not a quick or cheap fix. We need an entirely new class of painkiller, one that is not a narcotic. For example, if we knew exactly which neurotransmitters convey pain messages to the brain, then we could develop drugs that would stop all pain. There would be no more terminal cancer patients drugged out of their mind during their last days and no more worry about becoming addicted to prescription painkillers.

Scientists such as Clifford Woolf at Harvard, Tony Yaksh at University of California San Diego and Patrick Mantyh at the University of Minnesota are already on the track of some promising research. Everyone could benefit from this research, but it's going to take a lot of money. As it stands now, it's not uncommon for pain researchers to move on to other fields where money for research grants is more readily available. Anyone who cares about this issue should write Congress and request additional funding for basic pain research. And until scientists find better solutions, let's allow individuals suffering severe pain the best treatment that medical science can offer. Including OxyContin.

[antiquity]

Thank you David.

[craig]

Thanks David, I had written a long response but lost it somehow trying to post ..lol. So this will be short.

You have given me a new way to approach State and Federal Government Reps. I have already written to them about Oxycontin.

I was aware of the research going on for a new non narcotic pain relief. I thought the government was already funding this research.

I truly believe Purdue Pharma knew that some of their profits were coming from drug abuse. Why else would they act so slowly to make the changes they are working on now?

My general practineer is scared too death to prescribe Oxycontin to me with all the bad press. If I had not documented my medical records for 20 years he would not think of prescribing it.

Thanks for the info Seneca and David

craig

[David Berg]

Thanks, Craig. Gee, I feel like cyberspace cheated me out of your longer answer. But I've experienced that sort of thing myself, more times than I can count. Usually, the last thing you want to do is retype everything!

I'm inclined to give Purdue Pharma the benefit of the doubt, because I honestly think they realize they have more to lose than to gain if OxyContin is abused too much. It's easy to believe that they've been trying ot figure out what approach to take to limit abuse, but not to say anything about it until they were fairly confident that they could actually do what they said they're going to do.

It's not a matter of there being no funding for pain research. It's a matter of there being limited funds, so that it's not uncommon for top researchers moving to areas where money is more readily available, such as Alzheimer's. I'm not going to say that other areas aren't worthy of study, but pain research is something that will benefit virtually everyone at some point, and it deserves much better funding.

It just blows my mind that we're still relying on the opium poppy for serious pain management after, how long is it?, something like 4000+ years. And there's too many types of pain that don't respond to narcotics (see my newspaper column below about the little girl injured in the Oklahoma City bombing for another example), not to mention the side effects that narcotics have for people to use them. It's time for a new solution. The solutions aren't simple, but they're possible, as I detail in the article on PainOnline titled
Guessing at the Cause of Central Pain.

There's a lot more in that article than just information about the current research, but it's fairly up to date. The field is moving along, but it still has a long way to go.

The real trick is to understand the nervous system well enough to know how to tackle the problem. The science of the brain and nervous system is wide open, there's a WHOLE lot we still don't know. It's exciting to see some of the answers that researchers are coming up with, because they're all pieces of the puzzle. So, for now the research is still taking place on the level of understanding nerve cells and nerve chemicals. In a way, it's kind of like decoding DNA; they understand the basic way to approach the problem, but the problem has so many different angles that it's going to take a lot of work to get it all done.

David Berg

[mike bauer]

I absolutely would not survive if it we not for my pain medicine. I would not want to. Even with the drug, I live in hell. Without it... No way. But here is the thing. I take Oxy... but I don't feel anything. I feel the same as if I took an aspirin? How is it... that the few goofs that abuse it, could threaten those of us who use it correctly. Why do they care so much? I mean some of us, drink ourselves to death.. or to the stage of being sick? But, we cant get rid of adult beverages? Same for everything else. Why not , let these dumb enough to find a way to abuse it... let them go? we cant police things like this. We have to create medicines for those who use it correctly... I just dont see why we have to care so much for those abusing it.

[metronycguy]

mike have you built up a tolerance of it?
i know that 20 mg of oxycodone the new 10 mgs in me.
when i had bad pain originally usually 10 mg or 15 mgs would take care of it , now 10 mgs of oxycodone does just a liitle , so it will work when the ultram doesn't , and i take it on top of the ultram.
for over a year i needed to take 10 mg on top of my regular meds at night to be able to lie down to sleep, that was on my best nights, now it is 20 mg on top of regular meds on my best nights. the last couple nights it has been 20mg 20mg 15mg and i was still up all night with pain .
i am changing to morphine sulfate ms contin next week, see if that has any difference. i am only on 10 mg of oxycontin 3 times a day, i think i need to get my dose raised, that i think is the problem, but i will try ms contin first, whi knows maybe a low dose of that will work. i just hope it doesnt whack me out and make me dopey during the day

[rollin64]

same as mike, i don't feel anything, like a high anyways. likes been said..look at the countless number of deaths caused by alcohol abuse. but they don't dare take that off the market, hmmmmmm.

my insurance is fixin to quit payin for oxy also. they offer a couple of morphine based alternatives i've never heard of, that phen patch and methadone which i've heard is "VERY" addictive.

[smokymtn memories]

Good response to the media hype David. I enjoyed reading your article.

[sandim]

I have had my long standing pharmacy refuse to fill it, arguing with the doctor despite his explanation of why he ordered it, documenting the other meds that I had tried, the dosages, results, etc...she refused to fill it. I contacted the manager of the pharmacy and he said that she had a right to refuse to fill it if she disagreed with the dosage. I am not on a high amount, I don't think anyway, 30mg tid ( it stops working at around 7-8 hours). She also refused to fill my Lyrica because I am at the maximum daily dosage of that and my Baclofen. I have been a customer of that particular chain for 10 years, I don't doctor shop, I don't ask for fills early, or any of the "red flags". She just didn't want to fill it.
I don't get high from it, in fact, you would never know that I take it, and it allows me to get out of bed each day....I refuse higher doses because I don't want to get "high".
I hate the labels that we are subjected to, the looks, the sometimes sneers, and the fact that because I take legally prescribed medicine, I am looked at like some kind of junkie.
Sandi