Alexander DeLuca, M.D.
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All the 'analysis'  the NY Times article, "Boon for Pain Suffers, and Thrill Seekers" deserves
--
The NY Times published this article by David Musto on 12/17/2003. My dopey, darkly humorous commentary is interspersed into the copy of that article [in  smaller, tahoma, purple font].

by Alexander DeLuca, M.D., 12/19/2003.  [www.doctordeluca.com/BoonAnalysis03.htm]. See also: "Boon for Pain Suffers, and Thrill Seekers" by David Musto, NYT, 12/17/2003, unsullied by my efforts.] Extensively reformatted and revised: 8/19/2004.

[Print version]


In the 1860's a new drug-delivery system, the hypodermic syringe, was perfected. An injection of a small amount of morphine was found to produce the same effect as a larger dose by mouth. Physicians assumed, therefore, that hypodermic injections offered more protection against addiction. Patients with chronic but not life-threatening pain, say osteoarthritis, were provided with morphine and a syringe and told to inject themselves when there was pain.

 

It took some years to appreciate the mistake, but the sad outcome was that the hypodermic syringe not only did not protect from addiction, but it also facilitated it. By 1920 the president of the American Medical Association, Dr. Alexander Lambert of Cornell, somberly stated that "nearly 80 percent of the morphine addicts have acquired the habit from legitimate medication" provided by physicians.

[The AMA circa 1920 (or 1940, or 1960) was hardly a reputable source of information regarding drug abuse, and their pronouncements on pain have been sometimes twisted by their attempts to placate law enforcement liars and bullies. For example, see, "The Weed of Madness and the Little Flower," Chap 9 of Rufus King, "The Drug Hang-Up - America's Fifty Year Folly," 1972.]

During the 1920's the fear of prescribing addictive medicine permeated American medical practice.

[Let me see if I've got this: The cause of the doctors "fear of prescribing addictive medicine" was because of all the addiction caused by the introduction of the syringe. Whew! What a relief. I thought this distortion of medical practice regarding the best understood medicine of its day might have something to with the criminalization of drug users in the aftermath of the Harrison Act and the 'reign of terror' waged against them and the doctors who would care for them; which would have been ever so much more complicated. <bad doctors!> From Rufus King's 1953 Yale Law Journal article, "The Narcotics Bureau And The Harrison Act: Jailing The Healers And The Sick:"

 

The medical profession was shamelessly bullied and threatened, until it withdrew, totally and irrevocably, as the addict's last point of contact with society... In 1924 a special committee of the American Medical Association docilely reported its "firm conviction" that ambulatory treatment of narcotics addicts "begets deception, extends the abuse of habit-forming narcotic drugs, and causes an increase in crime."

<www.doctordeluca.com/Library/WOD/JailingHealers&Sick53.htm>]
 

Pain medication had to be doled out with great care and parsimony. [<bad doctors!>] Inadequate pain relief characterized the life of some cancer sufferers as well as postoperative patients. In the 1960's a movement to bring adequate pain relief attracted both researchers and practitioners.
 

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This brings us to the years covered by "Pain Killer," an outgrowth of Barry Meier's reports for The New York Times on OxyContin misuse. His fascinating account of OxyContin's story has echoes of the hypodermic syringe episode in the 19th century. OxyContin was initially marketed as less addicting than other opioids because of a special mechanism that made the tablet release the active ingredient slowly, a characteristic, it was assumed, that would make OxyContin unattractive to misusers who wanted a big jolt. [No, only naïve and lazy people assumed that. It was designed to make it less likely to cause addiction in people taking the drug legitimately for pain. There is no way to render opiates entirely un-abusable without rendering them useless.]

 

This assumption was a big mistake. [What can I say? Naïve and lazy has consequences.] Recreational users discovered that merely chewing the pill would release all of the active ingredient, and produce a powerful high. [How can I say this? Hello, you can chew MS-Contin, cook up darvon and get one hell of a chemical sclerosis, crush 10 Vicodin in hot water and drink it all at once, etc. etc. <bad doctors?> 'This is an example of the improper use of a technology' - Please see my poem, "The Truth About OxyContin from a Medical Point of View."]

 

Mr. Meier specifically takes aim at the company that makes OxyContin, Purdue Pharma of Stamford, Conn. He suggests that it was slow to address reports of OxyContin's misuse because the drug brings in revenue of about a billion dollars annually. The Food and Drug Administration also comes in for strong criticism for permitting the early marketing of OxyContin as a relatively nonaddicting pain medication. [<bad drug company!>]

 

OxyContin entered the market in 1996 and quickly found favor as an excellent pain medication for cancer patients. Up to 12 hours of pain relief allowed patients to get a night's rest rather than experience the return of pain every three or four hours with shorter-acting medicines. If the drug had remained limited to patients with the most severe pain, the story would probably be different, but advocates for pain treatment minimized the danger of addiction and recommenced prescribing OxyContin for milder and chronic pains. Mr. Meier cites other physicians, who said the drug was being marketed too broadly and uncritically for such a powerful anodyne. [Ashcroft: "OK, I think we have enough here for a federal indictment. Good docs and legitimate patients and Rush Limbaugh to the right, the rest of you into the paddy-wagon! OK, now you people on the right throw stones. Excellent!"]

 

Respected pain authorities estimated that OxyContin's addiction rate among those in pain could be a mere 1 percent, perhaps less. The low figure came from postoperative hospital patients, not from out-patients on long-term opioid therapy. No studies on prolonged treatment with OxyContin had been conducted. Nevertheless, [some naïve and lazy] doctors acted as if OxyContin had solved the difficult balancing act between offering pain relief and avoiding addiction, and began prescribing it for many kinds of pain for which milder pharmaceuticals would be much more appropriate. [What can I say? Naïve and lazy has consequences. Not to defend such behavior - which might be likened to, ahh, crack-dealing, yeah drug-kingpin MDs hiding behind white coats, that's the ticket - but us dopey docs sometimes find it hard to think straight with a loaded gun to our heads. <go figure>]

 

Then the problems began. [Wait a sec - you were talking about the risk of addiction in pain patients and now you're switching to the risk of addiction in, ahh, addicts?? Ohh Kay, got it. What the hell: drug addicts... pain patients… close enough. Hey, they both take that hillbilly heroin every day, right?] By early 2000 in the southwest corner of Virginia and in four or five other areas of the country, an explosion [Define, please; if there are two traffic collisions at 93rd and Central Park West this week I guess we could say there was an "explosion" of MVAs but, so what?] of OxyContin misuse had spread among teenagers and their parents. [And "OxyContin misuse" is a national problem compared to what, exactly?] With some doctors prescribing the drug liberally [Oh, now I see! In that case by all means suspend my civil rights and my states' rights and call in the jack-boot thugs to protect us from, ahh, us] and purveyors hawking it on the street, families were being devastated and nonmedical users of OxyContin swamped drug treatment programs.

 

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Doctors and other health workers appealed for help and also wrote to Purdue Pharma telling the company of the multiple problems that were occurring in their area. ["Dear Purdue, Please be advised that a few people are diverting your  Schedule II opiate to non-medical use." Jeez! And anyway, compared to what is this anecdotal tripe 'devastating'? For the record:
 

"[In 2000 about] 16,000 died from treating their arthritis with... [NSAIDs, while only around] 200 died from the purposeful abuse of oxycodone, the active ingredient of OxyContin...With terrible shortsightedness, [the Fed has]  decided the second number is the problem."

From: "A Bad Prescription from the DEA" by Eric Chevlen, The (conservative) Weekly Standard, 6/4/01

 

Purdue Pharma officials said that the company first heard of these problems in February 2000, although Mr. Meier says that information reached the company a year earlier. When Purdue knew about the difficulties is relevant to Mr. Meier's contention that the company dragged its feet in making changes in the drug's description and indications. Because Purdue is privately owned, access to its records is much more restricted than would be the case with a publicly owned company. [<yawn>]

 

The Food and Drug Administration, which was so cooperative with Purdue in the early stages of its marketing, is now taking a closer look at its responsibilities. Purdue agreed that after July 2001 it would no longer state that OxyContin was less addictive because it was a slow-release tablet. In fact, in 1998 The Journal of the Canadian Medical Association reported that drug abusers actively sought slow-release pain medication. A related editorial warned that assuming slow-release protected against recreational use would lead to serious problems. [<come on, wrap it up>]

 

OxyContin's nonmedical use [This misleading confusion of outcome and index event is an example of  "Outcome Obfuscation." Properly, Use would be the index event from which a problem Outcome might or might not spring.] has now spread much more widely. [I won't even bother complaining about "Denominator Abuse and the Chilling Effect" and ask for pesky stats like appropriately calculated rates.] The company has changed its description of the drug and has mounted a major public relations campaign to improve its image. Pain experts have apologized for their uncritical advocacy of OxyContin. Yet their early assurances of the 99 percent safety from addiction may, to their regret, have set the stage for a revival of extreme caution among doctors in providing relief to the afflicted. [Bush: "Damn it, a drug abuse problem! The NSAID-poisoning thing will just have to wait you damn complaining, drug seeking arthritics. We're talking National Security here. My God, man, can't you see this is a veritable Epidemic of Prescription Drug Abuse Crisis!? I'll bet those sneaky Iraqis are mixed up in this somehow. <mutter> Hey Rummy, could we say OxyContin is a WMD?"]

 

Long-term administration of pain remedies is facing mounting criticism. A recent review article in The New England Journal of Medicine concluded that "evidence now suggests that prolonged, high-dose opioid therapy may be neither safe nor effective. [Stop the public health presses! The hell with the flu! Broadcast immediately to all federal law enforcement officers: "Medical therapy may not, repeat may not, be effective in all cases. Be careful out there."] Mr. Meier, in spite of difficulties obtaining records [what a guy]  and the considerable time required to scour isolated rural areas [no comment], has given us a rare insight [how I wish that were true] into interactions between government and the pharmaceutical industry -- and the extraordinary impact of their decisions upon our lives.

 

[Vilifying doctors and victimizing patients suffering the most elementary and treatable of all human conditions is not rational public health policy. Maybe we'd do better if we put doctors and public health experts back in charge of what are serious public health problems and take these out of the hands of people who would have us believe in vampires and demons. I don't know what we can do about the eminent journalists of The Times, The Washington Post, The DEA PR Office…]

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Dr. DeLuca's Addiction, Pain, and Public Health Website

Alexander DeLuca, M.D., FASAM.

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Originally posted:  12/19/2003

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