OXYCODONE

OFFICIAL NAMES: Endocet, Endocodone, Endodan, M-Oxy, OxyContin, OxyFast, OxyIR, Percocet, Percodan, Percodan-Demi, Percolone, Roxicet, Roxicodone, Roxilox, Roxiprin, Tylox

STREET NAMES: Hillbilly heroin, poor man's heroin, oxy, oxies, oxycotton, OCs, killers, oxycons, percs (or perks), pink spoons.

DRUG CLASSIFICATIONS: Schedule II, narcotic analgesic

OVERVIEW

Oxycodone is a semi-synthetic prescription drug with pain-relieving properties similar to those of morphine and codeine. Although commonly known as an opioid analgesic, it is also known as a narcotic analgesic. The drug's ability to relieve moderate to severe pain makes it a good choice for the treatment of many painful conditions, including back pain and headache as well as pain due to cancer and some dental procedures.

Oxycodone is derived from thebaine, one of more than 20 components known as alkaloids (including morphine and codeine) found in opium. In addition to being a primary component of oxycodone, thebaine also is a main ingredient of hydrocodone and hydromorphone, two other prescription painkillers.

History

Long before thebaine was identified and synthesized from opium poppies for use as a pain killer, ancient peoples were using opium to induce euphoria and even to stimulate creativity.

Historically, opium was an important crop as far back as 3400 b.c., when it was referred to as Hul Gil, or the joy plant. The milky liquid from the poppy seeds was dried to produce the powerful opium powder. As a commodity, the opium trade flourished in Egypt during the reigns of Thutmose IV, Akhenton, and the boy king Tutankhamen.

The first medicinal use of opium is credited to Hippocrates, the Greek physician known as the "father of medicine." In addition to using opium to relieve pain, Hippocrates advocated its use for treating internal diseases and some so-called women's diseases. Later, the famous physician Paracelsus mixed opium with citrus juice and gold essence and prescribed the compound for use as a pain remedy he called laudenum. In the late 1600s, the English apothecary (the equivalent of today's pharmacist) Thomas Sydenham introduced his own laudenum compound by mixing opium with sherry wine and herbs. The resulting medication, in the form of pills, was used to treat a variety of painful conditions.

Oxycodone was first developed in Germany in 1916 and marketed under the brand name Eukodal. The first documented medical reports of striking "euphoric highs" in patients taking the drug surfaced in the 1920s. Those reports also included warnings about the apparent habit-forming nature of the drug. In the United States, oxycodone was approved by the Food and Drug Administration (FDA) in 1976. Various formulations followed, including drugs that combined oxycodone with either aspirin or acetaminophen.

Evidence suggests that oxycodone has the ability to lock onto a special cell receptor found primarily in the brain, spinal cord, and intestines. When the drug connects to the receptors in the spinal cord, it causes the nerves that are sending pain signals to be temporarily blocked. Similarly, when the drug connects to the receptors in the brain, it causes an overall sense of well-being and relaxation. However, when the drug connects to the receptors in the intestines, the result is often constipation.

Opioids are praised by pain experts for their effectiveness in treating chronic pain because the drugs directly affect the way the body perceives pain. When properly administered in adequate, appropriate doses, opioids such as oxycodone can allow people with chronic pain from arthritis, back problems, cancer, and severe pain syndromes to lead more normal lives.

Pain experts have learned that patients who take opioid drugs for long periods of time will build up a physical tolerance and may need higher and higher dosages to achieve adequate pain relief. Unfortunately, physical dependence is sometimes confused with addiction, and patients may be denied appropriate medication by a doctor who cannot tell the difference between physical dependence and psychological addiction. One way to look at it, according to some pain experts, is that the drugs should be used when they improve a person's functioning (i.e., allow for better overall functioning than what they could achieve without medication).

When drugs interfere with patients' functioning rather than help them cope with daily activities in the face of severe pain, the line between physical dependence and addiction may have been crossed. According to the Center for Substance Abuse Treatment (CSAT), addiction "is characterized by the repeated, compulsive use of a substance despite adverse social, psychological, and/or physical consequences."

That fear of giving pain medication because patients might become addicted, what some experts refer to as opiophobia, is unjustified in most cases in which pain medications are needed for proper treatment. Research sponsored by the National Institute on Drug Abuse suggests that most patients will not become addicted when taking opioids. When used properly, the drugs can be tapered or decreased slowly as pain improves. This careful weaning from the drug eliminates the physical dependence and avoids the withdrawal problems that would occur if the person "went cold turkey" and stopped taking the drug too suddenly.

Surprisingly, studies show pain caused by cancer or other terminal disease is often undertreated. Even though the World Health Organization has shown that more than 90% of such pain can be effectively controlled with good pain management, patients who need relief the most are often among those least likely to receive it. In a 1998 study published in the Journal of the American Medical Association, researchers found that 26% of elderly cancer patients living in a nursing home who experienced daily pain did not receive a painkiller. People older than age 85 were more likely than those in other age groups to receive no pain medication at all. The oldest patients were also less likely than those ages 65 to 74 to receive strong pain medications such as opioids, despite the fact that they experienced pain daily.

One additional reason some physicians may knowingly undertreat pain is fear of being prosecuted for over-prescribing certain drugs. In one survey conducted in the early 1990s, more than half of physicians admitted to reducing the dose of opioids they prescribe or switching a patient to a non-opioid pain drug out of concern they might be investigated or even fined by their state medical board for over-prescribing.

For years the leading drug used to treat chronic pain was short-acting opioids. However, in 1995 a new long-acting form of oxycodone became available. The drug, known as OxyContin, has quickly become the preferred medication for chronic back pain and cancer pain, among other conditions, because it has fewer side effects and lasts longer than other similar painkillers.

OxyContin's sustained release activity means that a steady stream of medication is released into the bloodstream over a 12-hour period. This allows users to sleep through the night without waking to take more pain pills. It also means there is little or no breakthrough pain, as often occurs with shorter-acting pain medications, because the relief lasts until the next dose is taken.

While many doctors and patients consider OxyContin a wonder drug, it has become a controversial and highly abused substance in many parts of the United States that previously had experienced little or no drug problems. Some have gone so far as to call it "pharmaceutical heroin." Within just a few years of its introduction, OxyContin became the source of many news stories as a large number of people, from celebrities to housewives, developed an OxyContin habit. Physicians and health care providers in some affected areas found themselves unprepared for the speed with which an epidemic of OxyContin abuse developed in their communities. The problem is so bad that pharmacies in some areas have chosen not to even stock the drug anymore for safety reasons, and the Drug Enforcement Administration (DEA) created a special national strategy for dealing with the OxyContin problem.

Although abuse of prescription painkillers is nothing new, OxyContin distinguishes itself by being more powerful than other prescription painkillers. OxyContin contains between 10 and 160 mg of oxycodone, whereas other oxycodone-containing drugs such as Tylox contain only 5 mg. The higher dose of oxycodone makes OxyContin attractive to abusers who crush the pills and either snort or inject the oxycodone for a powerful high. This controversy has created difficulties for patients who rely on OxyContin for pain relief and for the doctors who prescribe it.

Selling OxyContin prescriptions has become big business. According to a report from the Center for Sub-stance Abuse Treatment (CSAT), one 40-mg pill costs about $4 by prescription, but the same pill can go for $20 to $40 on the street, depending on the area of the country. This led to some people in economically depressed areas selling their legitimate prescriptions for profit. In West Virginia, OxyContin earned the nicknames "hill-billy heroin" and "poor man's heroin," as abuse of the drug—and crime related to its use—increased rapidly among residents of Appalachia, historically one of the poorest areas of the country.

Robberies and prescription forging, as well as the activities of unscrupulous doctors seeking to make big profits, also contributed substantially to the problem of OxyContin abuse. From early 2000 through the summer of 2001, at least 700 thefts from pharmacies involving OxyContin were reported, according to the DEA's Office of Diversion Control. States with the highest rates of OxyContin-related theft included Pennsylvania, Florida, Ohio, and Kentucky. Other states that reported a high number of OxyContin crimes included Maine, Massachusetts, Virginia, and California.

CHEMICAL/ORGANIC COMPOSITION

Oxycodone is available alone or in combination with either acetaminophen or aspirin. Its chemical structure is most closely related to codeine, but it has strong painkilling effects equal to those of morphine.

Types of prescription oxycodone

Oral preparations of oxycodone include immediate-release pills, controlled-release pills, and a liquid solution. The immediate-release pills, as their name implies, get the drug into the bloodstream faster than other formulations. Within about 15 minutes of taking immediate-release oxycodone, the drug's analgesic effects take hold. Pain is lessened and the user experiences a feeling of drowsiness and/or well-being.

The controlled-release formulations, on the other hand, prolong the release of oxycodone from the tablet for several hours. These pills have a special protective outer coating that makes them harder to digest, so that the oxycodone inside can be released slowly over a period of about 12 hours. That means the pills are capable of providing relief that lasts twice as long, allowing users to obtain the same effect they would get from taking an immediate-release tablet once every six hours.

For patients with severe pain, one additional advantage of newer controlled-release formulations such as OxyContin is that they contain a much larger amount of oxycodone than the other prescription painkillers that contain some oxycodone.

Oxycodone with aspirin

Like oxycodone, oxycodone with aspirin is used to treat moderate to severe pain. The aspirin provides additional pain relief and anti-inflammatory properties not found in oxycodone alone. For some types of pain, these medications may be a better choice than oxycodone alone, particularly if pain is accompanied by significant inflammation, swelling, and stiffness. The aspirin component also may be especially beneficial if pain is accompanied by fever.

Pain relief usually begins within 30 minutes of taking oral oxycodone with aspirin. The drug achieves its peak effect within about 90 minutes and lasts for three to four hours.

Oxycodone with acetaminophen

Like oxycodone with aspirin, oxycodone with acetaminophen combines a powerful pain reliever with an additional pain reliever and a fever-reducer. However, unlike aspirin, it does not have anti-inflammatory properties, so it may not be the best medication if a patient's pain is accompanied by inflammation, swelling, and stiffness.

Pain relief usually begins within 30 minutes of taking oxycodone with acetaminophen. The drug achieves its peak effect within about 90 minutes and lasts three to four hours.

INGESTION METHODS

Most of the oxycodone drugs—which include the drug alone or in combination with aspirin or acetaminophen—are available in tablet form. For patients who have trouble swallowing or who cannot take the tablet form for other reasons, the drug is available in a highly concentrated flavored liquid solution. The appropriate dose of the liquid is measured into a dropper either by a nurse or by the patient. Often, the liquid may be added to semi-soft foods such as applesauce or pudding to help disguise its bitter taste. Those who use liquid formulations of oxycodone should be aware that some of them may contain alcohol.

The growing problem of OxyContin abuse has revealed a new and highly dangerous ingestion method. Abusers of the drug crush, chew, or break the pills apart to remove the outer coating. With normal use, the coating serves the purpose of allowing the oxycodone inside the pills to be released slowly over 12 hours. By removing it, abusers can snort the oxycodone powder, or dilute it and inject it, which produces a fast and potentially deadly high.

THERAPEUTIC USE

The primary therapeutic use of oxycodone is to relieve moderate to severe pain. However, the drug also is used before or during dental extractions and other surgery both to relieve pain and to improve the effectiveness of certain anesthesia drugs.

Chronic back pain is a common reason many people use oxycodone or other opioids. The drugs can provide enough relief so that people with unbearable back pain can work and carry on with other daily activities. People may also use the drugs to obtain relief from chronic pain syndromes. Although the term is vague, chronic pain syndrome can refer to any muscle, joint, or body pain that is debilitating to the patient, and is long-lasting or recurs frequently. One example of a patient who would fit into this category is someone who had a serious car or motorcycle accident that left him or her with chronic pain for months or years after the incident. Another example might be a woman who has experienced years of chronic pelvic pain whose cause is not known. For most of these patients, oxycodone is not used on a daily or even a weekly basis. Rather, a prescription is written with instructions to use oxycodone on an as-needed basis, and patients only take the pills when the pain becomes intolerable or interferes with their daily lives.

Another therapeutic use of oxycodone is to relieve the pain of chronic moderate to severe osteoarthritis, arthritis that results from degeneration of cartilage and/or bone in a joint. In a study of patients who had been experiencing osteoarthritis pain for at least one year, controlled-release oxycodone was more effective than a placebo in relieving the pain. The researchers suggested in their report that although opioid analgesics are strong medicines, they might be worthwhile for patients with osteoarthritis who do not get adequate pain relief from other types of pain medication.

Oxycodone also can be helpful to people with diabetes or AIDS who have a painful condition known as peripheral neuropathy. The condition causes burning pain and tingling in the hands, feet, and toes. Over time, the pain worsens and can lead to difficulty sleeping, walking, and performing other normal daily activities.

The decision to give oxycodone or one of the combination drugs consisting of oxycodone and acetaminophen or oxycodone and aspirin may be based on a number of factors. If a person has significant inflammation in addition to pain, for example, an acetaminophen-oxycodone combination drug such as Endocet, Percocet, Roxicet, Roxilox, or Tylox may be the best option. If fever is present in addition to pain, an aspirin-oxycodone combination drug such as Percodan, Percodan-Demi, or Roxiprin may be the most effective treatment. If chronic, uncontrolled pain is the main problem, however, a long-acting oxycodone drug such as OxyContin that controls pain effectively for 12-hour periods may be best. Doctors who treat cancer patients say that Oxy-Contin is one of the most powerful treatments available to relieve patients of treating crippling pain, and unlike morphine, OxyContin does not cause frightening side effects, such as hallucinations, in long-term users.

USAGE TRENDS

Scope and severity

National surveys have shown that abuse of prescription drugs is on the rise in the United States. Compared with the 1980s, when fewer than 500,000 people took a prescription drug for a nonmedical reason each year, the number of people who engaged in this behavior increased 181% from 1990 to 1998 for pain relievers alone.

In a Consensus Development Conference statement published in late 1997, the National Institutes of Health (NIH) estimated that approximately 600,000 people in the United States are opiate-dependent, meaning they use an opiate drug daily or on a frequent basis.

The DEA says oxycodone and hydrocodone are among the most abused of the prescription painkillers. An increasing number of people who abuse these drugs are requiring medical attention because of side effects, overdose, and other issues that arise when the drugs are used for reasons other than their intended purpose. Statistics compiled by the Drug Abuse Warning Network (DAWN) indicate that oxycodone-related visits to hospital emergency departments are increasing steadily. In 2000, the number of such visits was 10,825 per year, more than double the 5,211 visits reported just two years earlier.

The number of prescriptions written for oxycodone combination drugs increased slightly during the period from 1996–2000. However, the DEA's Diversion Control Program found that the number of prescriptions written for oxycodone-only drugs such as OxyContin was 14 times higher during the same time period.

According to a national study undertaken by the DEA, 803 deaths in 31 states in 2000 and 2001 were related to use of oxycodone and another 179 deaths were likely related to oxycodone. Of the 803 total deaths related to the drug, 117 were linked specifically to OxyContin. The study was undertaken in the form of letters sent to 775 medical examiners (MEs). The MEs were asked to supply autopsy reports, blood, and drug test results, and to investigate reports on all deaths caused by or associated with use of oxycodone.

Age, ethnic, and gender trends

NIDA data from 1999 show an estimated four million Americans over age 12 were using prescription pain relievers, sedatives, and stimulants for nonmedical reasons. Nearly 50% of those were first-time users. For the most part, young people appear to be the leading new and first-time users, according to data from the National Household Survey on Drug Abuse (1999). The most dramatic increase in new users of prescription drugs for nonmedical reasons occurred among 12-to 25-year-olds. The same data show that nonmedical use of two pain relievers—oxycodone with aspirin (Percodan) and hydrocodone (Vicodin)—is increasing among college students.

NIDA statistics also indicate that adolescent girls are abusing prescriptions more than ever before and are engaging in illicit drug use to a greater extent than their male peers. Opioids are the prescription drugs most likely to be abused by young people, followed by central nervous system depressants such as Valium and Xanax, and stimulants such as Ritalin.

Among adults, some studies suggest that women are more likely than men to be prescribed the more highly abused drugs, including painkillers and anti-anxiety medications. In fact, some studies have shown that women may be as much as 48% more likely than men to be given these drugs. The studies also indicate, according to NIDA, that women and men who use prescription opioids run an equal risk of becoming addicted. Women run a much higher risk than men of becoming addicted to other drugs, though, particularly sedatives, anti-anxiety medications, and hypnotic drugs such as sleeping pills.

Pain is a common problem in the elderly, and many elderly people are prescribed painkillers. A report from the American Geriatrics Society found that about one-fourth to one-half of all elderly people not living in nursing homes report pain-related problems, and one in five people over age 65 take painkillers one or more times each week. As many as three in five elderly people have taken prescription pain medication for more than six months. In nursing homes or other care facilities, as many as 80% of elderly patients report some type of pain.

Misuse of prescription drugs, including painkillers, is common among elderly people. However, unlike with younger people, when elderly people misuse or abuse prescriptions it is more likely to be accidental or unintentional. Since the body's ability to metabolize, or break down, many medications decreases with age, elderly people usually are prescribed lower doses of potent drugs than younger persons are.

Another group that is potentially at increased risk for abuse of painkillers is doctors, nurses, pharmacists, anesthesiologists, dentists, veterinarians, and others who work in health care. It may be easier for people working in environments where drugs are kept or dispensed to either steal pills or forge prescriptions for themselves or others.

People who abuse prescription drugs may escape detection for years because they have learned how to "beat the system" and obtain prescriptions by visiting different doctors and claiming a different ailment at each place. In addition, some doctors may have trouble saying no to patients asking for prescription pain medication for fear that the patients may truly be in pain. Meanwhile, others simply do not realize they are being tricked by patients with a serious drug problem. The Substance Abuse and Mental Health Services Administration (SAMSHA) began a major training program in 2000 to help doctors, nurses, and others spot signs of drug abuse in patients. If they know how to recognize the signs, health professionals can then talk to patients about the problem and refer them for appropriate treatment.

MENTAL EFFECTS

Because oxycodone may cause drowsiness and/or dizziness, people taking oxycodone-containing drugs should use caution when driving, operating machinery, or performing any other type of work that requires being alert and responsive. For the most part, the effect of oxycodone on mood is a mellow one. Most people feel an improved sense of well-being while taking the drug. In contrast, when people stop taking oxycodone suddenly, they may notice significant shifts in their moods and experience anxiety, restlessness, and insomnia.

Some researchers believe the mood-elevating properties of oxycodone make it a reasonable treatment for depression in certain individuals, although that use of the drug is not yet common. The most likely to benefit from this type of therapy are people with major depression whose illness has not been successfully controlled with standard antidepressant medications. Careful, close monitoring is essential since, unlike antidepressant drugs, oxycodone does cause side effects and poses a risk of addiction.

PHYSIOLOGICAL EFFECTS

Opioid analgesics such as oxycodone act directly on the central nervous system by stimulating opioid receptors in the brain. This action affects how the pain is perceived and can alter the user's emotional response to the pain.

Oxycodone is absorbed by the liver, skeletal muscles, intestinal tract, spleen, lungs, and central nervous system. The drug is broken down in the liver and passes out of the body via the kidney into urine.

Oxycodone's effects on the central nervous system produce pain relief, euphoria, and slowed breathing. It also decreases the activity of the intestinal tract, often leading to constipation. To combat this, patients are advised to drink six to eight full glasses of water per day and increase the amount of dietary fiber they eat.

Other side effects of oxycodone can include: nausea, dizziness, vomiting, itchy skin, weakness, and headache. Oxycodone should not be given to patients

who have significant breathing problems such as asthma, emphysema, or chronic lung disease, or patients with intestinal abnormalities or blockages.

Harmful side effects

Taking more than the recommended dose of oxycodone can lead to serious health problems including convulsions, coma, or even death.

The Food and Drug Administration (FDA) has placed oxycodone in pregnancy category B because although some studies in animals show an increase in birth defects and other problems, there is no evidence that taking oxycodone when pregnant causes birth defects in people. However, it is possible for the infants of mothers who took the drug during pregnancy to be born with addiction and withdrawal symptoms, as well as breathing difficulties resulting from the drug's effect of slowing down respiration. The Physician's Desk Reference advises that oxycodone only be given to pregnant women if the benefits significantly outweigh potential risks to both the mother and her fetus.

Similarly, caution is advised for women who are breastfeeding, as oxycodone may pass through the breast milk in large enough quantities to cause addiction, withdrawal, and breathing problems in a nursing infant. Women should be sure to tell their doctors they are breastfeeding if they are in need of a strong prescription pain medication such as oxycodone.

Oxycodone also should be used cautiously by people who have a head injury or have abnormally increased pressure in the brain, or by people who have had convulsions or seizures.

People with the following medical conditions also should avoid taking oxycodone or any oxycodone-combination drug:

• kidney disease
• liver disease
• underactive thyroid (hypothyroidism)
• enlarged prostate
• Addison's disease (a disease of the adrenal glands)
• colitis
• gallbladder disease or gallstones

Long-term health effects

The greatest long-term effect on health from oxycodone is addiction. NIDA warns that people who are addicted are at increased risk of overdose and death.

Oxycodone can be addictive when taken in dosages higher than those prescribed by a doctor or when taken for nonmedical purposes (i.e., recreational drug use). For these reasons, people with a prior history of other drug abuse may be advised not to take oxycodone.

REACTIONS WITH OTHER DRUGS OR SUBSTANCES

Oxycodone is a strong prescription analgesic and, as such, it is not advisable to take oxycodone in combination with any other pain medications, including common over-the-counter pain relievers like Tylenol or Advil. If oxycodone taken as prescribed does not relieve the pain adequately, the patient's doctor can adjust the dose or substitute a stronger drug.

Because oxycodone may intensify the effects of other drugs that cause drowsiness, it should not be taken with antidepressants, antihistamines, anti-anxiety drugs, seizure medications, sedatives, sleeping pills, or muscle relaxants, except under the supervision of a doctor. Patients who may be prescribed oxycodone should tell their doctor if they are taking any of these medications.

Similarly, alcohol should be avoided when taking oxycodone. It, too, increases feelings of drowsiness and can cause dizziness when combined with oxycodone. Avoiding alcohol is especially important when taking pain-relievers containing oxycodone and acetaminophen, as studies have shown that liver damage can occur when even relatively small amounts of alcohol are combined with acetaminophen. A current or past history of alcohol or drug abuse should be carefully considered before oxycodone is prescribed.

When taking an acetaminophen-containing oxycodone drug, it is also important to pay attention to the acetaminophen content in other medications, such as over-the-counter cough or cold remedies. The maximum daily recommended amount of acetaminophen for the average adult should not exceed 4 g per day or 4,000 mg per day.

TREATMENT AND REHABILITATION

Addiction to prescription painkillers is a major reason people are admitted to drug rehabilitation centers. In the early part of the twentieth century, however, treatment for addiction to opiates was actually self-administered. Private doctors would prescribe narcotics for opiate addicts, but that practice was soon outlawed, and local governments and communities established formal morphine clinics. By the 1920s, these clinics too were closed and opiate addicts were jailed or treated, usually unsuccessfully, in public health hospitals.

In the 1960s, the emergence of a new drug lifestyle among young people led to increases in opiate addiction as well as deaths from overdose. This growing problem resulted in researchers looking for newer, more effective approaches to treating opiate dependence.

There is some evidence that addiction behaviors may be genetic; in other words, some people who take prescription pain medication may become addicted because of an inherited tendency. However, genetic predisposition is likely to be only partially to blame. Environmental factors, underlying mental illness, and history of known addictions to alcohol or drugs are other factors that contribute to compulsive or addictive drug use.

When a person stops taking, or sharply reduces, the daily amount of oxycodone, severe withdrawal symptoms may occur. These symptoms are similar to those seen in people experiencing morphine withdrawal. To avoid this problem, pain experts slowly reduce the amount of drug the person takes each day.

Withdrawal symptoms can be quite uncomfortable when they do occur, but they are not life-threatening. Typical withdrawal symptoms may begin with yawning, restlessness, insomnia, goose flesh (commonly called goose bumps), and anxiety. Within a few hours symptoms worsen, and may include stomach pain, diarrhea, nausea, vomiting, muscle aches and pain, fevers, sweating, and runny nose and eyes. Symptoms usually begin within six to eight hours of the last dose of short-acting oxycodone, and 24 to 48 hours after the last dose of long-acting oxycodone (such as OxyContin).

One of two common treatment approaches is to combat withdrawal symptoms by treating them with appropriate medications. A drug commonly used in withdrawal treatment is clonidine, a medication most often used to lower blood pressure. For people going through withdrawal, clonidine may help lessen some symptoms. A variety of other drugs also may be used to deal with symptom-specific complaints. Examples include ibuprofen for headaches, muscle, joint, or bone pain, and mild tranquilizers to combat anxiety and/or insomnia.

Withdrawal may also be treated by replacing the drug of abuse with methadone, a long-acting opiate that does not usually produce the heightened sense of wellbeing characteristic of a drug high. Methadone is typically given every four to six hours under close supervision. The patient's reactions are monitored and the dosages of methadone are slowly decreased until withdrawal symptoms disappear. Methadone withdrawal usually takes about three weeks. Most methadone withdrawals are conducted in hospitals or residential facilities on an in-patient basis, rather than in methadone maintenance programs, which are outpatient programs in which patients who are unwilling to stop using opiates receive methadone as a legal, long-term substitute.

Some experts recommend a newer option for withdrawal known as rapid opiate detoxification (ROD). This method is typically carried out in a hospital or private treatment facility, and as its name implies, it is faster than some of the more conventional methods. In some cases, withdrawal treatment with ROD can be completed in just a few days. Compared with conventional withdrawal treatment, ROD also has been found to cause less physical discomfort. Even more recently, some researchers have investigated an even faster method called ultra-rapid opiate detoxification (UROD), in which the patient goes through withdrawal while asleep under anesthesia. The entire process takes four to seven hours.

Patients undergoing ROD or UROD are given clonidine plus a drug called naltrexone, which blocks opiate receptors and makes withdrawal signs and symptoms occur more rapidly. This method is still considered experimental.

PERSONAL AND SOCIAL CONSEQUENCES

The majority of people who use narcotic pain relievers do so safely and appropriately without becoming addicted. Despite widely held assumptions that increased prescribing of these drugs will lead to increased abuse, recent studies suggest this is not the case.

Patients with chronic pain or who suffer from pain syndromes are sometimes labeled as "weak" or "dependent" because they need prescription pain medication on a daily or as-needed basis. Unfortunately, such labeling might make people who truly need strong prescription pain relief too ashamed or embarrassed to ask for it.

People who do become addicted to oxycodone or other opiates face many personal and social obstacles, including difficulty obtaining or maintaining a steady job. As a result, addicts who do not get the help they need to stop using prescription drugs may end up having to rely on public assistance.

Since the early 1990s the prevalence of human immunodeficiency virus (HIV), hepatitis B and C viruses, and tuberculosis among people who inject opiate drugs has increased dramatically. The annual number of opiate-related emergency room visits has increased dramatically and the number of people who die each year as a result of abusing opiates has nearly doubled in recent years, further underscoring the human, economic, and societal costs of opiate addiction.

LEGAL CONSEQUENCES

Dependence on opiates has long been associated with increased crime and illegal activities. According to data presented at a National Institutes of Health conference in 1997, more than one-quarter of the inmates in state and federal prisons in 1993 were incarcerated for drug-related offenses. Among federal prison inmates, the largest group were those serving drug-related sentences.

In a survey of opiate-dependent people, stealing was the most common illegal activity associated with trying to obtain more of the drug. In addition to improving health and preventing future health problems, one of the goals of treating people addicted to opiates such as oxycodone is to reduce the amount of associated crime and its impact on society.

Federal guidelines, regulations, and penalties

Oxycodone is a Schedule II controlled substance, which is subject to the Controlled Substances Act (CSA) of 1970. The CSA was enacted to control and limit use and distribution of drugs that have a high potential for abuse, including oxycodone, codeine, and morphine. Listing a drug as a controlled substance is not intended to interfere with the way doctors practice medicine or the availability of that drug for patients who may need it for legitimate medical reasons.

The DEA is considered the "watchdog" in charge of enforcing the CSA, but its authority over doctors and how they prescribe controlled substances for medical purposes is limited. This arrangement is intended to protect doctors—such as those who treat patients with terminal cancer—who might come under suspicion for frequently prescribing large quantities of controlled substances. Doctors who prescribe any drug listed as a controlled substance must be registered with the DEA for tracking and monitoring purposes. Hospitals and pharmacies also must register with the DEA. By registering, the doctor, pharmacy, or hospital is given a number that must be used each time a controlled substance is ordered. Any individual or facility that has been issued a DEA registration number is legally obligated to keep detailed records regarding how, when, and to whom the drug was dispensed.

For the most part, the DEA is on the lookout for doctors who are prescribing controlled substances illegally to people who have no medical need for them. Pharmacists and manufacturers of controlled substances are also monitored for suspected abuse of the CSA. Anyone who dispenses controlled substances and is found to be in violation of the CSA faces fines, imprisonment, or both.

Some states have enacted their own laws regarding controlled substances, and have placed legal limits on dosages and the total number of pills that can be prescribed within a specific time period. Some doctors argue that this type of regulation requires patients who take large quantities of pain medication to obtain more frequent prescriptions, thus putting patients at risk of having refills delayed and or encountering problems with their insurance company.

See also Cocaine; Heroin; Morphine; Opium

RESOURCES

Books

Booth, Martin. Opium: A History. New York: St. Martin's Press,1996.

Periodicals

Armengol, Robert. "Other Victims of OxyContin Abuse." Courier Times (Bucks County, Pa.) August 5, 2001.

Chernin, Tammy. "Painkillers and Pill Popping." Drug Topics(August 6, 2001).

Kalb, Claudia. "Playing With Painkillers." Newsweek (April 9,2001).

Other

Congressional Testimony. Statement of Asa Hutchinson, Administrator, Drug Enforcement Administration before the House Committee on Appropriations. December 11, 2001. <http://www.usdoj.gov/dea/pubs/testimony.htm>.

Neer, Katherine. "How OxyContin Works." Marshall Brain's How Stuff Works. 2002. (April 18, 2002). <http://www.howstuffworks.com/OxyContin.htm>.

U.S. Food and Drug Administration. Center for Drug Evaluation and Research. "OxyContin: Questions and Answers." <http://www.fda.gov/cder/drug/infopage/OxyContin/OxyContin-qa.htm>.

Organizations

National Clearinghouse for Alcohol and Drug Information (NCADI), P.O. Box 2345, Rockville, MD, USA, 20847-2345,(800) 729-6686, webmaster@health.org, <http://www.health.org>.

National Drug Intelligence Center (NDIC), 319 Washington Street, 5th Floor, Johnstown, PA, USA, 15901-1622, (814) 532-4601, (814) 532-4690, cmbwebmgr@ndic.osis.gov, <http://www.usdoj.gov/ndic/>.

National Institute on Drug Abuse (NIDA), National Institutes of Health, 6001 Executive Boulevard, Room 5213, Bethesda, MD, USA, 20892-9561, (301) 443-1124, (888) 644-6432, information@lists.nida.nih.gov, <http://www.nida.nih.gov>.

Substance Abuse and Mental Health Services Administration (SAMHSA)/Center for Substance Abuse Treatment (CSAT), 5600 Fishers Lane, Rockville, MD, USA, 20857, (301) 443-8956, info@samhsa.gov, <http://www.samhsa.gov>.

Laura A. McKeown