The Blue Ox

Have you every heard of Kicker, OC, Oxy, OX, Blue, Oxycotton,  or Hillybilly Heroin?

The National Drug Intelligence Center defines OxyContin®, as a trade name for the narcotic oxycodone hydrochloride, a painkiller (Schedule 11 controlled drug) available in the United States only by prescription. OxyContin is legitimately prescribed for relief of moderate to severe pain resulting from injuries, bursitis, neuralgia, arthritis, and cancer. Today, it is the most frequently prescribed opioid pain killer in North America. But, other individuals illegally abuse OxyContin for the euphoric effect it produces--an effect similar to that associated with heroin use.

Oxycodone is abused for its opiate-like effects. In addition to its equipotency to morphine in analgesic effects, it is also equipotent to morphine in relieving abstinence symptoms from chronic opiate (heroin, morphine) administration. For this reason, it is often used to alleviate or prevent the onset of opiate withdrawal by street users of heroin and methadone.

The Poor Man's Heroin

According to research by the National Institute of Mental Health, "OxyContin Diversion and Abuse," www.drug-addiction.com, 2003), OxyContin is designed to be swallowed whole; however, abusers ingest the drug in a variety of ways. Abusers often chew the tablets or crush the tablets and snort the powder. Because oxycodone is water soluble, crushed tablets can be dissolved in water and the solution injected. The latter two methods lead to the rapid release and absorption of oxycodone.

The alcohol and drug treatment staff at the Mountain Comprehensive Care Center, Prestonsburg, Kentucky, reported, "Individuals who have never injected drugs are using OxyContin  intravenously and they have never seen a drug 'proliferate like OxyContin has since May 2000.'" The staff at this center has over 90 cumulative years' experience conducting drug evaluations.

Since OxyContin and heroin are reported to have similar effects, both drugs are attractive to the same abuser population. OxyContin is sometimes referred to as "poor man's heroin," despite the high price it commands at the street level. A 40 mg tablet of OxyContin by prescription costs approximately $4 or $400 for a 100-tablet bottle in a retail pharmacy. Street prices vary depending on geographic location, but generally OxyContin sells for between 50 cents and $1 per milligram. Thus, the same 100-tablet bottle purchased for $400 at a retail pharmacy can sell for $2,000 to $4,000 illegally.

OxyContin is, however, relatively inexpensive for those covered by health insurance, since the insurance provider covers most costs associated with doctor visits and the prescription. Unfortunately, many OxyContin abusers whose health insurance will no longer pay for prescriptions and who cannot afford the high street-level prices are attracted to heroin. Here is some information from the U.S. Department of Justice about Oxy deaths:

"February 14, 2002, DEA has received 1,304 complete ME reports on OxyContin deaths from 32 states. Contrary to some reports, the documented evidence clearly shows that only 19% of the OxyContin deaths can be verified to be the result of a alcohol-drug interaction. Important also is the fact that only nine (9) deaths were associated with the presence of a "recent injection site", and only one death associated with snorting the drug; the vast majority of deaths have been associated with oral consumption of the drug.

"An additional caveat must be made regarding standard OxyContin treatment regimens as they apply to poly-drug use....Incident pain may occur as a result of the performance of normal activities of daily living, physical therapy, or simply ambulation to the physician’s office for treatment. Rescue medications are suggested to be immediate-release opiate formulations either alone or in combination with acetaminophen, aspirin, or other non-steroidal anti-inflammatory drugs (NSAID’s). These would include drugs like Vicodin®, Lortab®, Percodan®, Ketoprofen®, etc. The manufacturer’s product information clearly states, 'Food has no significant effect on the extent of absorption from OxyContin.' There is no adverse reaction notification for the co-administration of OxyContin and nicotine from cigarette smoking or with caffeine – a psychoactive drug found in many food products, including coffee. 

"By these treatment designs a "normal" patient receiving a standard OxyContin prescription regimen approved by the Food and Drug Administration may be a poly-drug user. One treatment strategy recommended for 'chronic pain' patients is the co-administration of opioids with anti-depressants – again, a treatment strategy, by its design, results in polydrug usage. With these facts in mind it was not surprising to find that many of the OxyContin deaths were associated with polydrug toxicologies. This does not minimize the significance of the role of OxyContin in these deaths....DEA can verify 146 deaths in which OxyContin was the direct 'cause of' or a contributing factor to the deaths; an additional 318 deaths lacking acetaminophen and/or salicylates in the toxicology findings most likely involved OxyContin, as well." (U.S. Department of Justice, Drug Enforcement Administration, Office of Diversion Control, 2002)

  
Who Uses OxyContin?

Oxycodone products have been illicitly abused for almost the last 40 years. (Drug Enforcement Administration, Congressional Testimony, Statement by Terrance W. Woodworth, Deputy Director, Officer of Diversion Control, Before the House Committeee on Energy and Commence, Subcommittee on Oversight and Investigations, August 28 2001)

Individuals of all ages abuse OxyContin--data reported in the National Household Survey on Drug Abuse indicate that nearly 1 million U. S. residents aged 12 and older used OxyContin nonmedically at least once in their lifetime.(National Drug Intelligence Center, www.justice.gov, Department of U.S. Justice) 

OxyContin abuse among high school students is a particular problem. Some studies say more than 3.5 million Americans over the age of 12 have reported using OxyContin on a regular basis. (Reported by Jill Gonzalez,
www.oxycontinabuse.com, 2007)

"Four percent of high school seniors in the United States abused the drug at least once in the past year," according to the University of Michigan's Monitoring the Future Survey. (National Drug Intelligence Center, www.justice.gov, Department of U.S. Justice, 2004) The 2005 MTF Survey shows annual use of OxyContin by 12th graders has risen from 4.0 percent in 2002 to 5.5 percent in 2005. (National Drug Intelligence Center, National Drug Threat Assessment, 2006) 

The abuse of a new sustained-release formulation of oxycodone, known as OxyContin7, has escalated over the last year. Drug abuse treatment centers, law enforcement personnel, and health care professionals have reported a dramatic increase in the abuse of these sustained release products in Maine, Virginia, West Virginia, Ohio, Kentucky and Maryland. Recently, abuse has spread to other states such as Pennsylvania and Florida.The number of Emergency Department episodes more than tripled from 1996 to 2000: 3,190 episodes in 1996 to 10,825 in 2000.
("What Is OxyContin?" www.prescription-drug-rehab.com, Narconon Vista Bay, 2009)

 
Efforts To Control the Problem

OxyContin is frequently made more available by "doctor shopping," where individuals, who do not have a legitimate illness, repeatedly visit many doctors to acquire large amounts of controlled substances. Other methods of obtaining oxyContin include pharmacy diversion, robbery, fake/stolen prescription, the internet and improper prescribing practices by physicians.

Here are the most common means of OxyContin Diversion: (Drug Enforcement Administration Office of Diversion Control

• Fraudulent prescriptions
  
• Doctor shopping
  
• Over-prescribing
  
• Pharmacy theft
  
• Organized rings of individuals diverting and selling OxyContin
• Foreign diversion and smuggling into the U.S.

Enforcement & Intelligence

Focus existing resources on investigations of illicit sales and abuse of OxyContin

• Investigate pharmacy thefts with other law enforcement agencies.
  
• Identify large volume purchasers.
  
• Participate in Healthcare Fraud Working Groups.
  
• Work with international organizations.

Regulatory & Administrative

• Utilize the full range of DEA’s authority to restrict abuser access to OxyContin.
• Work closely with the FDA urging reformulation to reduce abuse potential.

Seek Industry Cooperation

• Encourage Purdue Pharma to develop a balanced market strategy.
• Solicit support in providing educational programs.

So, Is There An Answer?

Despite all the increased efforts by the FDA, DEA, and state/local authorities such as better record keeping by pharmacies and physicians, and some states' banning of the drug over the internet, the illicit use of OxyContin is at an all time high.

In a relatively new study (Deni Carise, Karen Dugosh, A. Thomas McLellan, Amy Camilleri, George Woody, and Keven Lynch; Am J Psychiatry 164:1750-1756, November 2007) found the following:

“One main finding of this study was that most of the OxyContin use reported in the sample of individuals seeking addiction treatment did not originate from physician prescriptions, but rather from illicit sources, such as family, friends, or other illegitimate sources. Clearly, the pharmaceutical opioid problems of the individuals in this sample were part of a larger pattern of alcohol and other drug use—the problems were not “accidental,” secondary to prescribed use for pain or other medical problems. These results also suggest that those who suffer from OxyContin abuse or dependence share many characteristics with those who are dependent on other classes of drugs.”

The study also found that among those who abused OxyContin, 51% had experienced symptoms of depression in the past 30 days, and 36% had chronic medical problems. The study suggests that psychiatric problems are some of the strongest predictors of OxyContin abuse. Maybe, the finger for Oxy abuse should point in some new directions. Not only a microscopic investigation into pill clinics may be required to help solve the problem, but also mirrors into the family medicine cabinet and into family social practices may be helpful.

OxyContin and Appalachia

OxyContin Problem


First of all, I believe that working from a base of recent facts and statistics is very important in accessing the extent of any problem facing a community. I am, indeed, troubled by the increasing abuse of OxyContin in Appalachia, particularly in Scioto County, Ohio. Like college student Michelle Klassen, I wanted to know the answer to two questions. "Why OxyContin?" and "Why Appalachia?"

Is this the worst drug problem in our area? Statistics for a region such as Appalachia are very hard to find; however, I was able to research state sentencing statistics in Ohio for 2006. The Office of National Drug Control Policy, Drug Policy Information Clearing House, State of Ohio (January 2008) gave the following eye-opening findings:

Federal Sentencing Statistics, Drug Cases, Ohio, FY 2006

1. Power and crack cocaine are the primary drug threats in Ohio. (78.2% of arrests in 2006)

2. Heroin distribution and abuse are increasing in Ohio. (10.2 of arrests in 2006)

3. Marijuana continues to be the most widely abused and readily available illicit drug in Ohio. (13.2% of arrests in 2006)

4. Most areas of the state reported decreasing use of Methamphetamine availability and abuse. (5.8% of arrests in 2006)

5. The use of Club Drugs such as ecstasy, GHB, ketamine, and LSD has steadily increased in Ohio, and

6. The diversion and abuse of OxyContin represent a significant threat to Ohio. 

(A combined 2.7% of arrests in 2006)

So, with these facts in hand, I looked at the real OxyContin problem. After all, 2.7% or arrests does not make news as "Public Enemy Number One." For those trying to understand the abuse of OxyContin in Appalachia, we must look at non-medical use of prescription drugs. Therein, lies the problem of the panic over this drug.

Appalachian Use


The National Opinion Research Center at the University of Chicago reported that proportionately more Appalachian adults abuse prescription drugs than in the nation. That trend is increasing faster in Appalachia than in the rest of the nation, however. "Admission rates for the primary abuse of other opiates and synthetics are higher in Appalachia than in the rest of the nation," according to the report. "Further, while rates are rising both across the nation and in Appalachia, the rate of increase in Appalachia is greater." (Bill Bishop, "As Poverty Worsens in Appalachia, So Do Drug Abuse and Depression," www.dailyyonder.com, November 18 2009)

For example, statistics showed that neighboring Kentucky leads the nation in the non-medical use of prescription drugs. In 2008, there were 877 accidental deaths in the state from prescription drug overdoses, said Kentucky State Police Commissioner Rodney Brewer. (Bill Estep, "518 in 34 Counties to be Charged in State's Largest Drug Roundup," Lexington Herald-Leader, October 30 2009)

In order to begin to understand the elevated rates of prescription drug abuse in rural Appalachian Kentucky, substance use must be considered within the context of demographic, geographic, social, and economic conditions of the region. (Lisa Shannon, Jennifer Havens, Allison Mateyoke-Scrivner, Robert Walker Mateyoke-Scrivner, The American Journal of Drug and Alcohol Abuse, Volume 35, Number 2, March 2009)

Oxycodone and OxyContin In Poor Areas

According to an Associated Press analysis of statistics from the Drug Enforcement Administration, Oxycodone, the chemical used in OxyContin, is responsible for many of the addictions. Frank Bass of the Associated Press said, "Oxycodone use jumped nearly six-fold between 1997 and 2005." The drug gained notoriety as “hillbilly heroin,” often bought and sold illegally in Appalachia. But its highest rates of sale now occur in places such as suburban St. Louis; Columbus, Ohio; and Fort Lauderdale, Florida. ("World of Pain: Prescription Drug Use Way Up in U.S.," Pocono Record, August 17 2007)

Bass stated that in Appalachia, retail sales of hydrocodone — sold mostly as Vicodin — are the highest in the nation. Nine of the 10 areas with the highest per-capita sales are in mostly rural parts of West Virginia, Kentucky or Tennessee.

Counties in central Appalachia are very poor. Their economies are centered largely on coal mining. And the researchers found that the people who live there have greater drug abuse and mental health problems than Appalachians who live in regions that aren't dominated by a coal economy.

A report, compiled by the National Opinion Research Center at the University of Chicago, didn't explore the exact reasons for differences between coal counties and other Appalachian counties. But, the report showed that poverty, depression, mental illness and drug and alcohol abuse reinforce each other, especially in these coal mining regions of central Appalachia. (Bill Bishop, "As Poverty Worsens in Appalachia, So Do Drug Abuse and Depression," www.dailyyonder.com, November 18 2009)

So, economic status and the economy both play key roles in mental health and substance abuse issues. The findings reported by Bill Bishop demonstrated that adolescents in distressed and at-risk Appalachian counties "compared to adolescents in other Appalachian counties" had the highest rate of non-medical use of psychotherapeutics. 

The NORC researchers who came to central Appalachia (essentially Eastern Kentucky and contiguous portions of Virginia, West Virginia and Tennessee) also found in these coal counties, use of heroin and other opiates was "significantly higher" than in the rest of the region. And, the use of these drugs was increasing faster in these counties than in the rest of the nation.

 Why an Increase in Abuse of Non-medical Use of Prescription Drugs?

The AP investigation of statistics from the Drug Enforcement Administration found these reasons contributing to the increase of non-medical use of prescription drugs:

—The population is getting older. As age increases, so does the need for pain medications. In 2000, there were 35 million people older than 65. By 2020, the Census Bureau estimates the number of elderly in the U.S. will reach 54 million. 

—Drugmakers have embarked on unprecedented marketing campaigns. Spending on drug marketing has gone from $11 billion in 1997 to nearly $30 billion in 2005, congressional investigators found. Profit margins among the leading companies routinely have been three and four times higher than in other Fortune 500 industries. 

—A major change in pain management philosophy is now in its third decade. Doctors who once advised patients that pain is part of the healing process began reversing course in the early 1980s; most now see pain management as an important ingredient in overcoming illness. 

—More people are abusing prescription painkillers because the medications are more available. The vast majority of people with prescriptions use the drugs safely. But the number of emergency room visits from painkiller abuse has increased more than 160 percent since 1995, according to the government.

—Spooked by high-profile arrests and prosecutions by state and federal authorities, many pain-management specialists now say they offer guidance and support to patients but will not write prescriptions, even for the sickest people. The increase in painkiller retail sales continues to rise, but only barely. There was a 150 percent increase in volume in 2001. Four years later, the year-to-year increase was barely 2 percent.

—People who desperately need strong painkillers are forced to drive a long way — often to a different state — to find doctors willing to prescribe high doses of medicine. Siobhan Reynolds, the widow of a New Mexico patient who needed large amounts of painkillers for a connective tissue disorder, said she routinely drove her late husband to see an accommodating doctor in Oklahoma.

An ARC-commissioned study announced by Kentucky Governor Steven L. Beshear and ARC Federal Co-Chair Anne B. Pope announced Appalachia suffers from disproportionately high rates of substance abuse and mental health disorders, including the alarmingly increasing abuse of prescription painkillers. But, Appalachia is doing better than the rest of the nation in terms of access to treatment for substance abuse and mental health problems. ("ARC Study: Disproportionately High Rates of Substance Abuse in Appalachia," Appalachian Regional Commission, August 17 2007)

 Here are some detailed findings from the Appalachian Regional Commission report:


* A higher proportion of Appalachian adults than in the nation as a whole report serious psychological distress and major depressive disorders. These problems are independent of drug abuse. In Appalachia, 13.5% of adults have encountered a problem with serious psychological distress compared to 11.6% nationally.

* Drug abuse and mental illness among teenagers rose as the economy declined.

* Appalachians are less likely to use methamphetamines than the national average. Meth abuse rates are rising in Appalachia, but no faster than in the rest of the nation.
 
* Alcohol is still the predominant substance of abuse nationally and in Appalachia. Proportionately fewer Appalachian adults used alcohol in the last year compared to adults in the rest of the country. And while 20.6% of Appalachian adults were binge alcohol users in the last year, outside the region 24.5% of adults were binge drinkers. 

*Cigarette use is higher in Appalachia among both adults and teens than in the nation. 

Katherine Massey PhD., West Virginia State University, (2002) believed cigarette and alcohol use are also key concerns for adolescents in Appalachia. Proportionately more adolescents reported heavy alcohol use inside Appalachia than outside of Appalachia. Similarly, proportionately more adolescents used cigarettes in Appalachia than outside of Appalachia; usage was higher for lifetime use, past year use, and past-month use. Smokers binge drank, used alcohol, marijuana, and hard drugs (e.g., ecstacy) significantly more than nonsmokers. Smokers also were more motivated to use and had a higher loss of behavioral control concerning alcohol and other drug use than nonsmokers. (Department of Community Medicine, Prevention Research Center/Office of Drug Abuse Intervention Studies, wvu.edu., 2002)


*Marijuana use rates are also lower in Appalachia than in the nation. 

*There were greater incidences of addiction and abuse among Appalachian adolescents than among Appalachian adults.
 
* Access to substance abuse and mental health treatment in Appalachia "compares favorably to the United States as a whole." In fact, proportionately more adults in the region received outpatient assistance than in the nation in the latest year studied. Females and those under 24 years of age were more likely to be admitted to treatment centers than in the rest of Appalachia.

Fixing the Problem

Artie Ann Bates stated that oxycodone was heavily promoted to doctors in the Appalachian region beginning around 1996. Appalachia had already suffered from significant drug problems, high rates of disability, compensation work-related injuries, and unemployment rates above national levels conditions. Bates believes the conditions were a lure for the national narcotic producer Purdue Pharma. (Artie Ann Bates, "White Opium, Black Coal, and the Appalachian Revolution," Appalachian Heritage, Spring 2008)

As an example, during an eight-year period reflected in government figures, oxycodone distribution increased 800 percent in the area of Myrtle Beach, partly due to the campaign by Purdue Pharmaceuticals. The privately held company has pleaded guilty to lying to patients, physicians and federal regulators about the addictive nature of their drug.

Michelle Klassen (Pamplin College of Business, April 17, 2009) said that several state and federal government agencies tried to control the abuse problem to no avail, and the abuse of the drug has become more prevalent due to the rising number of illegal channels of distribution. Klassen concludes in her research that a solution "that holds doctors and pharmacists accountable for the distribution is needed, as well as one that helps eliminate the illegal market that has dominated the economies of these depressed towns."

And, finally, Bluefield Daily Telegraph's Don V. Hylton ("Bane of Appalachia — Drug Abuse Threatens Workplaces," August 17 2007)  reported Sister Beth Davies certainly enlightened him about the facts of the OxyContin dilemma now gripping the Appalachia community in her letter to the editor.

 "I think that the blame should encompass more than the pharmaceutical companies. Lobbyists, the FDA, Congress, doctors, and our own acceptance of today’s prescription drug-culture and our over-medicated society should all shoulder the blame for this terrible cancer that infests the fabric of our daily lives. Prescription drug addition has definitely become the bane of Appalachia.

"I can not fathom an addiction so overpowering that an individual would allow someone to drive over their leg so that a painkiller prescription could be acquired, as was reported in the Telegraph on Sunday, August 5. This is only one example of how addiction is robbing us of our neighbors, friends and family members. Understand, according to reports, many of the addicts do not begin as recreational drug users, but as patients under a doctor’s care. This issue must be addressed before law enforcement intervenes, before lives are ruined, before children find themselves in foster homes. 

"Naturally family members are hesitant to report suspected drug addiction to law enforcement agencies, particularly prescription drug misuse for a recent ailment such as a surgical procedure or an injury from an accident. This type of addiction is an easy trap to fall into but a difficult snare to escape."

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