Reprinted from the Gainesville Sun Article "Tough on Pain" by Diane Chun

Lorraine Horton lost her 17-year-old son, Justin, to an overdose of OxyContin on Easter weekend. He and two friends had swallowed three pills each. It was enough to kill Justin.

Now, the West Palm Beach mother wants the drug taken off pharmacy shelves, saying it's too easily stolen or inappropriately prescribed.

And that scares High Springs resident Robin Caballero, because OxyContin has given her back her life.

"It's most unfortunate that a young boy died, but he wasn't taking something that was prescribed for him. He shouldn't have had it," she said.

"It's terrible, but now his mother is trying to have this drug taken off the market. And that's not fair to people who need it."

Oxycodone hydrochloride, the active ingredient in OxyContin, is a synthetic chemical that is a close chemical relative of codeine, morphine and heroin. Its effects are also much the same - relief of pain, which is what doctors prescribe it for, and euphoria, which is what its illegal users seek.

Now patients who live with chronic pain, like Caballero, are becoming apprehensive. If the illegal trade in OxyContin leads to more stringent controls on its use and makes doctors more reluctant to prescribe it, they are afraid they may be unable to continue to lead lives that are close to normal and largely pain-free.

Caballero, 46, was disabled in a 1985 car accident that left her with degenerative disk disease. She had emergency back surgery, after which her health slowly declined.

"I suffered for many years, until I started taking OxyContin. That changed my life forever," she said.

She saw several doctors who she said were reluctant to help her deal with her pain.

"I couldn't walk for quite a long time and was told I wouldn't walk again," she said.

In 1993, she became a patient of Dr. Siegfried Schmidt, a clinical associate professor in the University of Florida's department of community health and family medicine. As a family physician with a special interest in pain management, he sees many patients with chronic pain.

Caballero was one of them. Previous spinal surgeries had left her with chronic, disabling pain and the need to use a wheelchair, Schmidt said.

"With chronic pain-sufferers, their whole life starts to become pain," he said. "The only way to break the cycle is to treat the pain. In some cases, treatment works, and Robin's is one of those cases."

Schmidt adds, "As physicians, we have a responsibility to see these people and examine them closely. If they have an intractable pain condition, opioids such as OxyContin are a legal medicine to treat them with. They would have to sign a contract, but it's a case of providing good medicines for the right reasons.

"Our goal is for these patients to be able to live a life above their pain. Some can do that without anything, but another large group cannot.

"The problem with pain is it is very objective," he added. "Everybody feels pain differently. But society has ethical reasons not to deny people's pain."

For many, pain is a constant

How do you measure pain? One must do studies, see patients frequently and monitor how functional they are, Schmidt said.

"I always say, 'If the doctor doesn't believe you are in pain, you should go to someone else,' " he said.

"A lot of people don't understand the nature of chronic pain because you can't see it. With acute pain, you see someone slumped over. Maybe they've got bandages or an arm in a cast. But if you have chronic pain, you look somewhat normal, but you live with pain every day. It has a physical effect, and it certainly has an effect on the psyche."

Caballero has been prescribed OxyContin for more than 18 months. She takes an 80-milligram dose every 12 hours, two pills a day, with a "reserve" of 40-milligram pills for the really bad days.

"I don't have to look at the clock every four or six hours to be out of pain. I can function without being groggy. I'm able to drive. I can walk without my cane. I can do normal things that I cannot do without it," said the former competitive swimmer, diver and American Airlines employee who is now on disability.

Pain management often needed

Dr. Robert Guskiewicz is an assistant professor of anesthesiology and director of the pain management program at Shands at the University of Florida. The interventional center helps patients manage chronic pain and sees more than 4,000 people a year, he said, for pain after spinal surgery, continued lower back pain, chronic pain syndrome and other medical conditions, such as cancer or AIDS.

OxyContin has served many of these patients well, he said, because the drug is slowly absorbed and lasts longer.

"There have been studies that show that in individuals with chronic pain, their reflexes, their cognitive abilities and their lifestyle in general can be improved. Many are able to return to work on a full-time or near full-time basis," he said.

Guskiewicz said addiction to OxyContin is not a problem if the drug is prescribed properly, but patients can develop a tolerance. The addiction is related to pleasure, the other to a continued need to control their pain.

He does see a growing reticence among private physicians to prescribe the drug, and said some may refer patients to the Shands program, where their pain and treatment can be closely monitored.

He says that representatives for Purdue Pharma L.P. of Stamford, Conn., which makes OxyContin, have been in close contact with physicians working in pain management at Shands.

"They understand the black mark that recent abuses have posted against their drug," he said.

According to the market research firm Scott-Levin, OxyContin was prescribed 5.5 million times last year, generating sales of more than $1 billion for Purdue Pharma. It was first approved by the Food and Drug Administration in 1996.

Abuse rare in legitimate uses

Should there be changes in how, or how often, OxyContin is prescribed for pain control?

"We mull through this all the time," Guskiewicz said. "It's a relatively new drug. We take as many safeguards as possible, but those who are determined to abuse it may slip through the system. And in this sense, it's difficult to single out OxyContin alone."

Legitimate pain patients may become dependent on OxyContin, but can gradually come off the drug under a physician's care. Addiction is rare - one study by the National Institute on Drug Abuse found that it happened to only four of more than 1,200 patients who were prescribed opium-based drugs.

The real danger comes when OxyContin goes from the medicine cabinet to the streets.

"Addiction comes when you begin to seek out the drug for a high or a kick," Schmidt said.

Florida medical examiners reported that overdoses of oxycodone and hydrocodone killed 152 people statewide in the final six months of 2000. That compares with 129 deaths attributed to cocaine and 25 tied to ecstasy in the same time period.

Jim Heins, assistant director of public affairs for Purdue Pharma, addressed concerns over misuse.

"We don't think we should limit access to those who have a legitimate use for OxyContin," Heins said. "Limiting its use to certified pain specialists, of which there are 3,000 in the United States, means most of the 50 million people with chronic pain will go without treatment."

The company also is worried that doctors' concern about potential abuse and fear of regulatory oversight will change medical practice with regard to OxyContin.

"Drug abuse is setting health policy, and that's wrong," Heins said, "but we do have to take steps about the dangers of abusing prescription drugs."

As a physician on the front lines in the war against chronic pain, Schmidt is certain of his position.

"Anything that endangers the ability to get appropriate pain management is the real danger," he said.