A serious medical and social problem
today is under intense media, law enforcement, and regulatory
scrutiny: the misuse and abuse of OxyContin (oxycodone) for
chronic nonmalignant pain. This situation has made the drug
difficult to obtain for many patients with malignant and other types
of intractable chronic pain, and has recently influenced the US Food
and Drug Administration to issue a black box warning to lessen the
chance of inappropriate prescribing of this Schedule II narcotic.[1]
In addition to recent Drug
Enforcement Agency (DEA) autopsy findings of nearly 300 OxyContin
overdose deaths nationally since January 2000,[2] a large
volume of patients with chronic nonmalignant pain have become
dependent or addicted as a result of legitimate prescriptions
written for OxyContin, as well as other opioids.
In a recent case,[2] the
DEA suspended physician narcotic licenses and closed a South
Carolina pain clinic for the excessive prescribing of OxyContin,
although the physicians involved believed they were following
current established standards.
How did this situation occur? In the
first place, certain statements in the narcotic guidelines
established by the Federation of State of Medical Boards[3]
have received insufficient or cursory attention. These include the
recommendations on the importance of psychological and substance
abuse evaluations, the necessity for other treatments depending on
the etiology of the pain and extent of psychosocial impairment, and
the requirement for consultation with or referral to an expert for
comorbid psychiatric disorders.
These are common omissions,
particularly in rural environments, where the OxyContin
problem first originated, and in which psychosocial factors receive
less attention, resulting in fewer numbers of referrals to mental
health providers. Even before OxyContin came on the market,
however, another opioid, hydrocodone, was one of the most widely
abused drugs, particularly in rural areas of the South.[4]
Clearly, the large volume of
prescriptions and chronic use of OxyContin have increased the
supply, availability, and opportunities for every type of abuse,
while also filtering into our schools.[5] Contributing to
this situation has been an attempt to expand the indications for
opioid therapy to the entire spectrum of chronic pain, regardless of
cause.
As a result of an organized
educational and marketing campaign by the manufacturer of
OxyContin and a number of pain societies, the message has spread
that pain is often undertreated in general and that opioids are safe
in most instances and should be prescribed more often for chronic
pain of all types.[6,7] If restricted to patients with
cancer or other forms of intractable peripheral pathology, the use
of opioids would be more acceptable, but the message also was
intended and has been used to justify opioid treatment for many
patients with nonmalignant, nonstructural chronic pain.
Because chronic widespread pain and
psychological distress in the general population are closely
associated,[8] the indications for treatment with opioids
have been expanded to patients with chronic pain of central
affective origin, including those within the wide spectrum of
fibromyalgia, one of the most common rheumatic disorders.
Thus, the indications for opioid
therapy have been extended to this large, heterogeneous group
closely associated with a wide range of psychological distress,
including the affective spectrum disorders.[9] These
vulnerable patients are especially at risk for the dangers of opioid
therapy, especially in rural regions where insufficient attention is
given to pain-generating and amplifying psychosocial factors, in
lieu of a more patient-popular drug-oriented approach.
The current "pain revolution" has
also broadened the use of opioid drugs for chronic pain by focusing
on quantitative criteria such as degrees of pain (a largely
subjective parameter), rather than on etiology. However, the degree
of pain often correlates poorly with objective findings, and
quantitative factors have different levels of significance for the
types of chronic pain common to different specialties, eg, oncology
compared with rheumatology. This broad approach does not account for
the essential distinctions in the biological and psychological
origins of chronic pain subgroups, which are important to understand
in making informed therapeutic decisions.
Furthermore, the appeal to broaden
the indications for opioids has also trivialized possible long-term
adverse consequences, particularly of OxyContin.[6,7]
Consequently, as cited above, a number of pain clinics have formed
for the primary reason of prescribing analgesics, especially opioids,
while at the same time frequently downplaying or disregarding
nonpharmacologic approaches, including psychological testing and
management necessary for a large number of the chronic pain
population.
Thus, the combined effect of
expanding the indications for opioid use and insufficient attention
to guideline recommendations has facilitated the current environment
of OxyContin abuse, which has grown into a major medical,
social, and law enforcement problem in many rural areas, as well as
in an increasing number of metropolitan regions throughout the
country.
In the last several years,
OxyContin abuse has spread and reached epidemic proportions. The
extent of this situation, which often involves generally law-abiding
citizens, was recently reported in special television broadcasts on
both CBS News' 48 Hours (in a segment entitled "Addicted")
and MTV's "True Life: I'm Hooked on OxyContin." Susan Zirinsky,
executive producer of the 48 Hours segment, which aired on
December 12, 2001, states that "the growing addiction to
prescription painkillers is a story that is touching every age
group, and its effects are often devastating."[10]
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