Oxycontin should be prescribed less often by doctors

Oxycontin is an oral pain medication that contains the single active ingredient oxycodone. Oxycodone is one of the most potent of the oral opiates, and has more euphoric effect than many other opiate analgesics.

Oxycontin is the most notorious prescription drug of abuse in the US, and for good reason. Though marketed as a sustained release medication, as much as 30% of the medication is absorbed immediately and the rest absorbed more slowly from the intestinal tract. This fairly large immediate release portion gives a prominent euphoric response, the desired response to opiates by abusers.

In addition since Oxycontin does not contain acetaminophen (active ingredient in Tylenol) its abuse potential is not limited by toxicity of extremely high doses of acetaminophen. This combination is the major the major attraction for abusers. As a single ingredient formulation it is easily ground into a powder for intranasal use or for injection like heroin.

One of its many street nicknames is “Hillbilly Heroin” because of its popularity in some rural eastern US locations shortly after its release by Purdue Pharma in 1996. If you read the DEA information page on Oxycontin you find that most of the page is related to the abuse of this drug.

The release of Oxycontin in 1996 coincided with a major concern that severe pain was being undertreated routinely by most physicians. End-stage cancer patients, post-op patients, and others often were, and to a lesser degree continue to be under dosed and undertreated for their pain out of fear of addiction and side effects like respiratory depression and death. Medical schools and residency programs strongly encouraged physicians to treat pain more aggressively. These criticisms were valid in many regards, and Oxycontin soon became a popular medication for use in these cases because it is very effective in severe pain.

The problem was that it became even more popular as a drug of abuse. Once doctors became comfortable with using Oxycontin as an effective medication for severe acute postoperative pain and for severe pain associated with terminal illnesses, it was often also used to treat pain of other causes, like acute back pain, fibromyalgia, acute injuries, etc. Some patients quickly became addicted to this medication.

Oxycontin was also often diverted (sold on the street) for overt abuse because its street value is so high. By some reports the street value of Oxycontin is as high as $1 per milligram. It is often prescribed at doses of 20 to 80 mg twice daily, so tricking physicians into prescribing Oxycontin and then selling it on the street became a lucrative business as demand increased.

By obtaining prescriptions from multiple physicians a fraudulent patient who is good at the job can do very nicely financially. Now physicians face the dilemma of trying to treat pain adequately without becoming a supplier of opiates for diversion and overt abuse by patients or family members.

At this time I almost never start patients on Oxycontin. There are other opiates that also work well in appropriate cases, with far lower abuse potential and popularity. In my estimation, far more than half of new patients to a practice requesting Oxycontin are seeking it for diversion or for personal abuse. More Americans die each year from prescription opiate overdose than from herion overdose.

I find it easy to “just say no” to Oxycontin requests.

Edward Pullen is a family physician who blogs at DrPullen.com A medical blog for the informed patient.

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  • BladeDoc

    How about the FDA’s new push to eliminate all narcotic/acetaminophen combinations? It seems their more worried about tylenol overdose that narcotic overdose, right?

  • SarahW

    I don’t care about who misuses it as long as people in pain have access to medicine they need for optimal pain control.

    Hillbillys may have their fun, and what they do has no bearing on what a patient needs.

  • ninguem

    Google “OxyContin Express” and watch the video.

    Let them deal with these obvious pill mills. Then they can deal with the physician with a real medical practice who made an incorrect judgement call about a pain patient.

  • Jadedmd

    I agree with this post. I actually think opiates are overprescribed, especially in the emergency dept

  • http://jillofalltradesmd.blogspot.com/ Jill of All Trades, MD

    Opiate addiction and misuse is a HUGE issue in the public health setting in which i practice, and often a true thorn on my side. I have even gone to the point of calling the DEA and reporting a highly suspicious patient. As physicians, we need to be really careful when prescribing these medications. The DEA does truly follow physicians that they keep on their “radar.” If you do prescribe them on a chronic basis for any particular patient, as a primary care physician, please seek a specialist’s input as your back-up — that’s the best advice i can give. And don’t forget to check up on your patients via a Physician Activity Report (PAR) through the DEA website on ALL your patients you prescribe narcotics for.

  • http://guzzoextempore.com Guzzo

    It’s not the most potent oral opiate, but it surely is the one of the most abused (second to hydrocodone). But, I wouldn’t say physicians should prescribe it less, but maybe prescribe it more appropriately. Some patients respond well to it.

    However, the way the DEA is cracking down on prescription abuse, I wouldn’t want to be in your position having to determine which patients are drug seekers and which are legitimately in pain. I probably would “just say no” too.

  • PL

    Recently, I injured my back… not a big deal, but I was sore for a few days. During this time I attended a family party, where I was offered Percocet, Vicodin and yes, Oxycontin by various of my older relatives, all of whom had large quantities of leftovers from various prescribers (both physicians and dentists). Obviously, none of my relatives are “drug seekers”; my father had only used one of a 20-pill prescription because the Vicodin made him drowsy. None of my relatives are being treated for chronic pain but they certainly had quite a pharmaceutical collection.

    I declined all offers because I was on call (I’m a large animal veterinarian) and never take narcotics because I hate the side effects.

  • Abusers don’t matter

    Jill of all trades, you make a fair case, unintentionally, of removing from physicians the burden of their gatekeeper role to narcotic medications.

    Abusers would could buy what they desire, cheaply, staying far away from you and other health care settings where they interfere with patient care and ruin doctor/patient relationships.

    Meanwhile, normal people who actually want to treat medical problems causing them pain and distress, will still seek expert advice about using pain control medicines, will care about safe doses and minimizing side effects.

    Seems like a win win to me.

  • ninguem

    And prescription drug overdose already beats auto accidents as a cause of death for youth in the Northwest.

    Look at the OxyContin Express movie. The factoid that some 80-plus-percent of the oxycontin prescribed in the USA is prescribed in the state of Florida.

    See their alternative weekly paper in Broward County, the equivalent of the LA Reader, Village Voice, Boston Phoenix. The back pages, classifieds, the usual massage parlor and escort ads are crowded out by “pain clinic” advertisements. Five, ten pages of them. They will also dispense for your “convenience”, and to make sure you don’t happen to run into an honest pharmacist outside the clinic.

    See the narrator taking pictures outside clinics, in strip malls, see the parking lot filled with out-of-state license plates. See the guards chase them off the property. A doctor’s office that needs to hire goons. Chains of pain clinics run by non-physicians who branched out from running brothels and strip joints (literally), finding the marginal docs on the fringe of society, the docs walk out with sacks of paper money.

    There are clinics like that out there, and medical boards spend their time chasing after docs who made a judgement call on one patient’s pain.

  • Yious

    “I have even gone to the point of calling the DEA and reporting a highly suspicious patient.”

    Wow. Is that common in your practice?

    Remind me to never, ever, EVER go anywhere near you then and I have never even taken any sort of major pain meds outside of my period with mono years ago

    The thought of doctors running to the DEA because patients are highly suspicious is just….I mean, shockingly intrusive to the patient if he is telling the doctor things and is now getting turned in

  • http://jillofalltradesmd.blogspot.com/ Jill of All Trades, MD

    Yious, i should have elaborated: it was only AFTER i received the PAR report that described the doctor shopping activity (it lists details of when/where/how many tablets/names of the meds filled). No, calling the DEA is not common in my practice. It was a rare occurrence, and you should know that the report must have been severe enough that I was obligated to call.

  • Yious

    Fair enough. I thought you meant you were suspicious and just decided to go to the DEA.

    I understand the need for extreme cases but I always hope that the doctors keep as much as they can between the patient and them rather then turning them in.

    Of course, if it turns into something that HURTS the doctor, I get it

  • ER Doc

    I work in an ED in an upscale community. It just amazes us the number of older patients (70+) who are on multiple narcotics or come in for overdoses.

    Years ago, when I was in training, we would see patients who were on a number of non-narcotic “pain pills” — an arthritis medication from one provider, headache medication from another, back medicine from a third. These used to be NSAID’s (ibuprofen and such).

    Now the polypharmacy is narcotics.

    We also have a group that reviews frequent users of the ED. When we review our own records as well as other information we have access to (utilization records from Medicaid, for example), it is not uncommon to have people who have seen 20+ providers, use 10+ pharmacies, and have narcotic doses in the hundreds. These are not people who are legitimately getting narcotics, this is clearly “doctor shopping.”

    As providers we are in a difficult position. We want to relieve pain, patients are expecting us to relieve pain, administrations follow customer service ratings closely, and we have to try to tease out who is trying to scam us out of narcotics.

    Not easy….

  • Meg Bressette

    I am a chronic pain patient who uses oxycodone for breakthrough nerve pain. It took a year of various treatments including physical therapy, TENS and other medications to find the combination that keeps my pain at a level 3-4 which is where I can function. I was told by my specialist that this was the best we could hope for with my particular injury and it has been fine by me for over 5 years. My doctors know me (over 15 years as patient) and handle my pain medications every month. The pain medications truly changed my life in a meaningful way – allowing me to function, think, be active. I have no tolerance for people that abuse prescription pain medications as it makes it more difficult for those of us that truly need to use them so I say that doctors should be very judicious in who they prescribe them to but please don’t take them away from those of us who use them responsibly.

  • Anonymous

    I believe all of the medical personnel that commented on this article, including the originator of this article SHOULD read one of Dr. Jennifer Schneider (Pain Management Spec) several books on the TRUE research on opiods.. You are all under-educated in the area of palliative care – keep up doc’s it’s important not to blame your patients – “first do no harm” and that means to the PATIENT! Yes yes there will always be people who try to break the law but you have a responsibility to treat, protect and not to pass judgement on the patient…

  • ER Doc

    I appreciate the comment of the person on the role of narcotics in palliative care. I think most other providers do. We also appreciate that there are people for whom long-term high-dose narcotics are the only way to control pain.

    However, we cannot ignore the other side of the problem. It is a delicate balance and not black and white.

    The fact that widespread use and diversion of narcotics for other-than medical reasons is real.

    Patients who really need the narcotics are hurt by the people who abuse the narcotics. I don’t think that any of the people with whom I work deny the need for large narcotic doses in patients who are receiving palliative care. I can remember a rescription I wrote for a patient in the ED who needed more narcotics for a weekend — the large amount raised more than one eyebrow.

    Having said that, I still see patients daily who use any ruse they can to try to get a narcotic prescription from me. A person who has visited 20+ providers, and is using a dozen pharmacies in 5 counties and has recieved literally thousands of narcotic doses yet doesn’t carry a diagnosis that would require palliative care is either using us to support a habit, a business, or both.

    The palliative care patient and their loved ones who are visiting me in the ED for better pain control need to keep in mind that there is a good chance that I just left an encounter with someone who I had to confront about their known drug abuse who has just sworn at and threatened me.

    I then need to wash my hands (and emotions) and try to help their loved one.

    We’re just trying to do our best in an increasingly difficult environment.

  • Anonymous

    With all due respect – ER Doc this is what you signed on for – both sides of the coin not just the easy stuff! And it is not “an increasingly difficult environment” it has always BEEN a difficult envornment.. It is YOUR JOB – the career you chose to protect the patient and try to help.. if you can’t do that anymore then get out of medicine.. And I don’t suggest that lightly – nor do I suggest it with disrespect.. Have you forgotten? Read the books – honestly you are projecting an unsafe world onto the rest of your patients when you concede that all patients are the same – when there are not two bodies exactly alike… Opiods are safe if the strick rules are followed. Tolerance and addiction is not the only way this has to turn out.. as a matter of fact if you look at the FDA stats you will find that approx. 2-4% of people who have no history of abuse will become abusive with their opiate scripts.. You are probably reacting to the fact the the government is increasingly in your rear view mirror about opiates but not because they help or don’t help the patient… Is that reason to allow people in pain to go untreated? Good Luck – I mean that – But the world is not as bad as you see it!!!

  • Abusers don’t matter

    I think patient care should not include reference to abusers.

    Abusers abuse no matter what, and they will abuse SOMETHING. This population of abusers has never been shown to grow or shrink because of prescribing habits – only the substance the abuser turns to.

    I think the gatekeeping burden is something that ought to go back to turn-of-the-century rules – anyone can go into a pharmacy and get what they please. Persons with sense will use prescribed medicines under a doctor’s orders.