OxyCon Game: Anatomy of a Media-made Drug Scare (Long Version)
In early January, Time Magazine was the first major media outlet in America to report on the growing abuse of a synthetic opiod prescription painkiller named OxyContin. According to the story, the drug was "so popular and addictive" that it was generating "a blizzard of a crime wave" in several "pockets of the nation." While the article admitted that it "has been hailed as a miracle" by legitimate users, it added that OxyContin pills were nicknamed "killers" in some areas due to the rapidly escalating toll of overdose deaths allegedly associated with its illicit use.
These two themes, that OxyContin is an ultra-powerful narcotic coveted by junkies for its uniquely intense high, and that it is responsible for scores if not hundreds of fatalities -- the specific numbers would vary widely -- were to be repeated ad nauseum in a spate of succeeding media accounts. Indeed, readers didn't know it at the time, but the Time piece was only the opening salvo in a sustained journalistic campaign -- conducted over the angry protests of pain specialists and their patients -- which has, in a space of a few short months, irredeemably stained the public image of a medication previously acknowledged as a major breakthrough in the treatment of long-term, intense pain.
Now for a more recent example. "Pain Pills Blamed for Rash of Deaths" was filed by an Associated Press reporter on May 1, and was published in the Orlando Sentinel and many other newspapers. To illustrate the "deadly dangers of OxyContin," it opens with the tale of the tragic end of a Palm Beach County teenager who died Easter weekend from "an overdose of the synthetic morphine," the fourteenth Oxy (as it's more commonly nicknamed) victim in that county alone.
Unfortunately, the story failed to reveal that the young man had a history of substance abuse, and had stolen the pills from his mother. And it didn't report that, according to one of the young man's relatives, he had ingested the OxyContin in conjunction with an unknown quantity of alcohol and Xanax, another powerful prescription drug. And if Palm Beach County is anything like the other places where a substantial number of fatal OxyContin overdoses have been touted in the media, almost all of the 14 claimed deaths were due to "polypharmacy," or the mixture of two or more drugs, often including such potent illegal substances as heroin or cocaine, but this too was not deemed worthy of inclusion in the piece.
And finally we come to Cleveland, Ohio, where the Plain Dealer took its first stab at the OxyContin story on Feb. 10. "Abuse of prescription painkiller spreading: Overdoses are believed to have killed dozens," claimed that OxyContin was responsible nationally for a rash of thefts, burglaries and other crimes and to have killed more than 100 overdose victims, fifty-nine in Kentucky alone. Even more alarmingly, the article opened with a scary recounting of a pharmacy holdup there. A masked man wielding a firearm specifically demanded the store's entire supply of OxyContin. Oddly, the man apparently ignored the host of other morphine-analogue drugs behind the counter, many of which also contained oxycodone, OxyContin's active ingredient, and others of which were actually far more potent and much easier to abuse.
On Feb. 16, six days later, a pharmacy in a Cleveland suburb was robbed. As in the story, a masked man wielding a firearm specifically demanded the store's entire supply of OxyContin. And in this case too the perpetrator was uninterested in the plethora of other powerful narcotics stocked on the dispensary's shelves; he escaped with more than 1,100 OxyContin pills of varying doses.
Could not the Plain Dealer story have prompted some local addict (or entrepreneur) to replicate the act? When you add in the fact that to that point the Cleveland cops had only handled a handful of OxyContin related cases in the previous year, none involving a pharmacy stick-up (out of more than 11,000 drug busts), it's difficult to think otherwise.
As the above examples imply, the media has jumped to the conclusion, on the basis of exaggeration, omission, and the scantiest of evidence, that OxyContin has become America's newest and most serious drug problem. In fact, in the last four months reporting on OxyContin abuse has become a national media craze, with often sensational, fear-mongering stories appearing in hundreds of publications from Newsweek to small town newspapers in rural Midwestern hinterlands.
"The 'poor man's heroin'" U.S. News described the drug. "Prescription Painkiller Gains Status as Thrill Pill" claimed the Indianapolis Star, while the Cincinnati Enquirer called it the "'Heroin of the Midwest;' Traffickers' and Abusers' First Choice." But none could match the Port St. Lucie News, which called it the "New Crack" and touted its "Herion-Like High" in the same headline. Except perhaps the TV reporting -- particularly on local news broadcasts -- where reporters seemed embarrassingly eager to sacrifice truth and objectivity on the altar of ratings.
Taken together, all of these stories (and countless others) have misleadingly and preemptively proclaimed a major epidemic of OxyContin abuse -- it is said to now be "the street drug of choice" in many cities -- and trumped up the threat it poses to public safety. Rather than just covering a danger, they appear to be causing it, advertising to the addicted the existence of a new drug with abuse potential, and how to get it and use it.
Which is bad enough. What's worse, the media hype is creating a panic that makes doctors and legitimate users needlessly afraid of utilizing an important advance in the treatment of pain.
THE DUKES OF HAZARD
OxyContin was an instant hit with doctors when first introduced in December 1995. Hailed by pain management specialists as a wonder drug, the oxycodone-based formulation was considered a major advance in the medical profession's expanding effort to battle the debilitating effects of severe, debilitating, chronic pain. As the good news spread sales of the drug mushroomed, rising from $40 million in 1996 to more than $1 billion last year, outstripping even medications as popular as Viagra.
And the drug was a godsend for a bevy of patients who were not finding relief for their pain from other medications. "Without OxyContin I wouldn't be able to get out of bed in the morning, much less hold down a fill-time job," says Tracey Jordan of Houston, Texas, who suffers from three degenerative disks in her back. Prior to going on it in August 2000 she took a host of other medications, but they "were just too harsh, and didn't really take care of my pain."
Media accounts were correspondingly glowing, though relatively few in number. For instance, in a September 1996 article Oxy was said to be enjoying "a groundswell of international support" at the annual meeting of the International Association of the Study of Pain (IASP), as members touted it as "an excellent opiod for moderate to severe pain."
Then, about 18 months ago, some cases involving the illegal use of the drug surfaced in rural Maine, but the situation failed to draw any media attention outside the immediate area. Soon after, the drug's popularity began to rise in rural Appalachia, especially parts of western Virginia, eastern Kentucky, West Virginia and southern Ohio (in and around Cincinnati). If claims of epidemic levels of abuse are true anywhere, it's here, says Ashland, KY pain specialist, Dr. Shelley Freimark. "In this area right now it is a severe problem," she states.
This can largely be chalked up to the fact that the usual street drugs are simply not as readily available in these rural outposts, says Dr. Phil Fisher, head of the Appalachian Pain Foundation (APF), a group formed last year by pain doctors devoted to educating the medical community and public about the uses and benefits of OxyContin: "this is an isolated area where it's hard for people to get real street drugs. By and large, OxyContin is not a street drug in most places."
Also, demographic and economic conditions in Appalachia have contributed to an established, long-term problem with prescription drug abuse in the region. In general, the population is older, Fisher says, and many suffer from chronic illnesses and debilitating diseases born of years working in the mines, increasing both the number of addicts and the availability of such drugs.
Still, outside of the region this development went largely ignored by the press at first. Part of the problem was that the media lacked a "hook," some spectacular news event around which to build their coverage of OxyContin. But that all changed on February 6 with "Operation Oxyfest 2001": more than 100 Kentucky cops fanned out in "the largest drug raids in state history." Sweeping a five county area, they netted 207 dealers and users.
Within days, the OxyContin "epidemic" was national news, turning small town cops into minor celebrities. For example, Detective Roger Hall of the Harlan County Sheriff's Department had the distinction of being quoted in two separate AP articles printed in scores of papers, despite the fact his claim that abusers "will kick a bag of cocaine aside to get to the Oxy" failed to make the absolutely fundamental distinction between nervous system depressants like OxyContin and stimulants like cocaine -- addicts of one are usually not addicted to the other.
Naturally, politicians weren't shy about chasing the free publicity either. With the heightened press interest, they convened a series of press conferences and public meetings in order to maximize press coverage of their efforts, such as on March 1 when Virginia Attorney General Mark Earley convened a major "summit" on the Oxy epidemic which included high ranking officials from five states. Not to be outdone by his neighbors, Kentucky governor Paul Patton, who had already proclaimed a "near epidemic" in his own state, announced the creation of the state-wide OxyContin task force, comprised of officials from 15 separate agencies.
Coverage built until April 9, the day Newsweek's cover screamed "Painkillers." Inside, the popular newsmagazine's writers penned two articles, one on the rising tide of prescription drug abuse in general and the other, titled "How One Town Got Hooked," on events in Hazard, KY, the town said to be at the center of the epidemic.
With the raids' success, and the massive press coverage they engendered, the existence of an Oxy epidemic became an integral part of the cultural zeitgeist, one which the press rapidly nationalized. After the wave of Kentucky stories by the big boys, the major urban newspapers in the East and Midwest assigned reporters to look for indications of a rising tide of abuse in their own localities. Unsurprisingly, they found what they were looking for.
DYING FOR A FIX
Many of the media's "thrill pill" stories have been centered on widely disseminated and divergent claims that OxyContin has been responsible for a shocking number of overdose deaths. Just how many is an open question. The numbers vary from paper to paper, and are at best unverifiable, at worst wildly inflated. Some of the published figures appear only once, in a single article, and leave no clue as to their origins. Others are widely spread; most papers across the country claim that the drug has been responsible for more than 120 deaths, 59 since February 2000 in eastern Kentucky alone.
Repeated across the country, that latter originated in early February with public statements from Joseph Famularo, the U.S. Attorney for the Eastern District of Kentucky, who used it to justify the eight month investigation leading to Operation Oxyfest. In Virginia, the second hardest hit state, Attorney General Mark Earley struck next, claiming 32 deaths in southwestern Virginia since 1997, later revised upwards to 39 by Assistant Medical Examiner William Massello
The press responded to these announcements with a flurry of further stories. But none of those accounts, which repeatedly asserted these contentions of a fast-rising death toll in bold, large-type headlines and gut-punching story leads, bothered to ask how solid the numbers were and what they meant. If they had, they might have been a little more circumspect in their reporting.
"That figure was given to us by local law enforcement," says Wanda Roberts, U.S. Attorney Famularo's spokeswoman, about the 59 alleged Kentucky deaths. That it was generated by the same police officials who used it to justify Operation Oxyfest does not appear to trouble Ms. Roberts, though when asked she declines to confirm the figure as accurate.
The search for the truth leads to David W. Jones, executive director of the Kentucky State Medical Examiner's Office. He asserts that "as far as deaths go, I've heard different numbers in different places at different times; I have no idea where these people are getting their facts and figures." While he stresses that not every drug-related death is necessarily reported to his office, according to his data there were 27 oxycodone-related deaths in the entire state in 2000.
Of course at first glance 27 deaths over 12 months in a single state -- even one at ground zero in the spread of OxyContin abuse -- appears to support the implication that there has been an explosion in the number of drug abusers in Kentucky due solely to the devastating impact of this single drug. But Jones parses the numbers further.
Two of the 27 victims, he explains, were found to have traces of both oxycodone and alcohol in their bodies, with death caused by their interaction. What's more, 23 others evinced traces of a head-spinning multiplicity of other drugs in their systems, including highly potent prescription painkillers such as Dilaudid as well as powerful illegal drugs like heroin. In the final analysis, Jones reveals, only two of the 27 fatalities can be shown to have been due to the effects of oxycodone alone -- not just two in eastern Kentucky, two in the entire state.
As for Virginia, medical examiner Massello became notably tightlipped when asked for further details about his cases, though he did admit that a "significant number" of victims had multiple drugs in their bodies. J. David Haddox, senior medical director at Purdue Pharma, which is required by law to report any information about adverse drug reactions to the Food and Drug Administration (FDA), says his people haven't had any better luck in evincing answers: "I don't quite understand how they can report the information to the newspapers but can't explain it to us."
Then there's the fact that most accounts don't bother to mention that oxycodone is the opiod agent in around 40 separate brand-name prescription medications besides OxyContin. While it is the strongest oxycodone formulation available, nonetheless there is absolutely no way of telling, Jones explains, whether an oxycodone-related fatality was due to OxyContin or one of these other medicines.
Other jurisdictions report similar findings. In Blair County, PA, which encompasses the city of Altoona, the county coroner has collected data which shows that of the 7 oxycodone-related deaths in her jurisdiction in the last five-plus years, six involved the presence of multiple drugs, often including heroin, and one was a suicide.
In fact, not everyone who dies from an oxycodone overdose does so accidentally. For the long-suffering, often terminal patients who comprise the vanguard of legitimate OxyContin users, suicide by opiate overdose often seems like a painless way to escape a life of terrific suffering. Yet such suicide cases are often lumped in with accidental overdoses, making the already inflated Oxy death numbers appear even greater.
Even when the deaths can be reliably confirmed, for the most part they do not point to a vast increase in the overall number of prescription drug abusers. Rather, the evidence of multiple-drug usage implies that a substantial majority of OxyContin abusers are long-standing drug addicts who have either switched to Oxy from other prescription or illegal drugs, or alternately, who take it occasionally as a substitute for other more preferable drugs which may be in short supply in areas such as rural Kentucky.
"Most of these people have been abusing prescription drugs for awhile, and have just switched over to OxyContin," says Kentucky state representative Jack Coleman, a legislative expert on prescription drug abuse and a member of the recently formed state OxyContin task force. "The problem is not particularly the abuse of OxyContin," he adds, "it's with prescription drug abuse in general."
His view is echoed by Dr. Karla Berkholz, board member of the American Academy of Family Physicians, who says that "6 to 7 percent of the American population uses illicit substances, and that number has held pretty steady over time."
EPIDEMIC IN A TEAPOT
The truth is, fear-mongering newspaper and television reports notwithstanding, Oxy abuse isn't much of a problem in most cities, especially compared to illegal drugs. Take Philadelphia as an example. Local papers began reporting a surge in OxyContin abuse in late February and March; the Inquirer described it as a "flash epidemic," while the Bucks County Courier Times claimed that the misuse had cost 20 lives in less than a year. In truth, however, the entire "epidemic" apparently ground to a halt with the arrest of a single person, an allegedly crooked doctor named Richard Paolino, who was said to have written about 1,250 prescriptions (though many of these were for Xanax rather than Oxy) between November 2000 and his arrest in early March.
Moreover, in the Philly area there were 20 hospitalizations, not deaths, involving OxyContin, says Gary Gambardella, the Bucks County deputy district attorney charged with prosecuting Paolino; to his knowledge, there were only 6 oxycodone-related deaths, and he could not say how many of those involved polypharmacy. Even more extraordinary, in the month after the doctor's arrest Gambardella was unaware of even a single further OxyContin-related incident in his jurisdiction. In light of this, even if all of Paolino's scrips were illegitimate, and were all for Oxy, 1,250 prescriptions in a four month period in a city of 4 million -- which does suffer a serious heroin and cocaine problem -- does not make for much of an "epidemic."
In Cleveland, the Plain Dealer in early April ran a front page story which claimed OxyContin abuse was sweeping across NE Ohio with the "vengeance" of crack cocaine. Yet Lt. Sharon MacKay of the Cleveland police contends that "OxyContin hasn't been much of a problem in the city of Cleveland. Some other prescription drugs are a much bigger problem around here, like Vicodan."
And the Plain Dealer wasn't the only Cleveland media outlet pushing the OxyContin scare. Take the April 16 11 p.m. report on ABC affiliate WEWS 5, which was riddled with fear-inducing claims: since the drug began "booming on the black market" the number of "holdups at pharmacies have grown to such a large extent" -- at the time there had been two in the region, the one previously mentioned and an abortive attempt outside of Akron -- that area pharmacists were now "living in fear." However, in a random check of 15 Cleveland-area pharmacies, not one pharmacist contacted reported even a single case of people attempting to pass bogus or suspicious prescriptions, much less a robbery. Nor did any admit to "living in fear."
And while levels of Oxy abuse do appear to be rising in some urban areas, particularly in the East and Midwest, that growth seems to follow rather than precede the heavy attention devoted to the phenomenon by major metropolitan dailies, leading to the strong suspicion that the overblown reports are largely responsible for the rise.
Confirmation of this came from a Cleveland heroin dealer, who said in mid-April that he "never heard of the stuff until about a month ago, when one of my customers asked me about it. He showed me an article in the paper that talked about how everyone wanted to get hold of this shit, so I did a little checking and found some available."
In Cincinnati, the Enquirer has undoubtedly led the nation's newspapers in the volume of OxyContin coverage. On February 7 (the day after Operation Oxyfest in nearby Kentucky), it labeled Oxy "the heroin of the Midwest" and claimed it had made "a leap in popularity unlike anything police have seen in years." Arrests were "soaring," the paper bragged -- the Cincy fuzz had nailed 32 Oxy heads and seized more than 13,000 doses of the medication in 2000.
Of course, the Enquirer saw no need to contextualize the problem. One phone call reveals that over the same period Cincinnati's finest made 12,049 drug busts, making Oxy accountable for less than three-tenths of one percent of the city's drug problem. And more than 8,800 grams of powder and rock cocaine were seized there last year, equivalent to at least 130,000 "doses" of coke; while exact heroin-seizure numbers were unavailable, heroin use tend to run a close second to cocaine in most cities. Given numbers like these, it seems safe to say that heroin remains the "heroin of the Midwest."
If the Oxy epidemic isn't what it's made out to be in these cities, then how bad is the situation really across the country? The most relevant data come from the Drug Abuse Warning Network (DAWN) compiled by the federal government, which tracks drug-related emergency room visits across the country.
The most recent DAWN figures do show a 72 percent increase in the number of oxycodone-derived ER incidents, from 3,060 in the first half of 1999 to 5,261 in the equivalent period in 2000, but that's still tiny compared to many other drugs. During the same period there were more than 18 cocaine and 15 heroin-related visits for each one involving oxycodone. Indeed, there were almost twice as many hydrocodone-based incidents -- hydrocodone is the narcotic ingredient in a number of opiates including Vicodan -- as oxycodone-linked ones. Then, when one factors in that OxyContin accounts for only about 25 percent of the oxycodone consumed annually, one can't help but entertain some serious doubts about just how large the much ballyhooed Oxy epidemic actually is.
And there are other reasons why the increase is not as significant as it might first appear. For one, the increase in ER visits was largely predictable and unsurprising since legitimate use of OxyContin rose by a similar amount, argues Dr. Fisher. argues Vicodan poses a much more serious prescription drug problem, since illegal usage of it as a percentage of total sales is rising much faster than with oxycodone: "compared to it Oxy only accounts for 10 percent of the cases but gets 90 percent of the attention."
OLD WINE, NEW BOTTLES
So if the OxyContin abuse phenomenon isn't nearly as bad as it's made out to be, why so much media attention?
For one thing, OxyContin is new, and the media are constantly in search of something different, unusual or unknown with which to titillate its audience. "The media are thrill-seekers looking for the next big ratings turn-on," contends nationally recognized media critic Norman Solomon. "You know they're embarked on an intellectually dishonest course when 18 people on a new drug becomes much more important than tobacco, which results in 700,000 deaths a year."
Also, ironically, media crazes touting the arrival of some apparently new, dangerous drug whose unchecked spread surely spells the doom of Western civilization is as old as the hills. Dr. June Dahl, professor of pharmacology at the University of Wisconsin Medical School and president of the American Alliance of Cancer Pain Initiatives, likens the current spate of "ultimately exaggerated" Oxy stories to the 1930s era film Reefer Madness, with its laughably over-the-top rendering of the evils of marijuana use. And in the more recent past, a number of other "new" drugs have received similar treatment from the press.
At the beginning of the last decade it was "ice." A smokable form of speed, which a slew of print articles and television reports touted as "the crack of the 90s." Apparently too expensive and difficult to manufacture, ice never attained the exalted heights media prognosticators prematurely accorded it.
Much of the problem with the way drug abuse is reported stems from the advent of the openly declared War on Drugs in the early 1980s, when the media signed on as a full partner in the government's effort to demonize drug use and stigmatize users. "The media presented the drug problem as a war of the holy people against the depraved people, and we haven't gone far past that moralizing tone unfortunately" says Solomon.
And there's a racial dimension to this coverage as well. Though contradicted by statistics compiled by the federal government, the public perception persists that heroin and crack are ghetto drugs abused by poor people of color. That affects almost every aspect of the drug war, from public policy choices to legislative decisions to law enforcement tactics, and to media choices. Could it be we don't see 15 heroin stories for every Oxy one because prescription drug abuse is known to be primarily a white, middle-class phenomenon?
Oxycodone, it turns out, is probably the whitest drug of all. DAWN also breaks down abuse figures by race. In general whites accounted for 65 percent of medical examiner's reports for all drugs combined, but a whopping 87.4 percent of those for oxycodone, the highest proportion of mentions among the 14-odd drugs reported at least 100 times. By way of comparison, whites accounted for only about 60 percent of the heroin mentions.
"The whole drug issue is fraught with almost totally unacknowledged class and racial aspects," argues Solomon. "It's a big reason we have such racially driven disparities in the prosecutions and penalties associated with different drugs."
THE REAL VICTIMS
All of the media hype, complete with gripping headlines and fear-generating content, is provoking feelings of anger and derision from growing numbers of medical professionals who specialize in chronic pain management. For years, this area of medical treatment was largely ignored or underemphasized by most physicians, says Dr. Dahl of the National Alliance of Cancer Pain Initiatives. "Historically, there have been a lot of inaccurate preconceptions and over-sensitivity about opiod analgesics and other narcotics, which has kept them from being used as much as they should."
Now, the flurry of accounts surrounding Oxy has not only stalled progress in this area, but has sent the treatment of chronic pain reeling backwards into ignorance and fear.
As the media flurry has heightened, the Drug Enforcement Agency (DEA) has begun to take action against Purdue and the doctors who prescribe OxyContin. In early May, in a first for the agency -- it had never before fixed its sights on a single prescription drug -- it began to pressure Purdue into discontinuing all marketing of OxyContin to general practitioners, who comprise the vast majority of doctors.
So far Purdue has resisted the DEA effort, much to the relief of pain experts. "It's a ridiculous idea," snorts Dr. Barry Cole of the American Academy of Pain Management. "There are only 7,000 pain doctors in the entire country, not nearly enough to treat everyone who needs this medication." However, Purdue has temporarily halted shipments of the largest 160mg size pills, introduced two years ago for the treatment of terminal cancer patients.
In addition, the DEA has publicly announced that it is launching a crackdown on "over-prescribing" physicians. One doctor in southern Virginia recently reported that 30 minutes after a visit from a Purdue sales representative, local DEA agents descended on his office to question him about what the rep had told him and whether he intended to prescribe the drug to any of his patients.
In light of such developments, more and more doctors are becoming leery of prescribing OxyContin though thousands of patients desperately need the medication, as even the Washington Post admitted in May 2 story. One doctor in St. Charles, Virginia has even begun a petition drive to pressure Purdue into withdrawing the drug from the market.
"As a pain specialist, my job is to take care of the worst of the worst cases," Dr. Fisher says, "but now I'm seeing run-of-the-mill patients whose doctors are afraid that they'll be prosecuted for prescribing OxyContin, or that they're somehow being duped and the drugs they prescribe will end up on the street."
In addition, the negative media attention is not only making it more difficult for legitimate patients to get the medicine they need, it is making them afraid of taking it when it is prescribed to them. "I'm treating two little old preacher's wives," Fisher relates. "Both are afraid of getting addicted, and one is sure someone's going to break into her home to get her supply of the drug."
All of this is not to say that the problem of Oxy abuse is not growing in some American cities, such as Cleveland, Cincinnati, and Philadelphia. Media accounts notwithstanding, however, it is still abused far less than some other prescription drugs. And in many of these instances a substantial portion of the blame for that rise is due to the media, whose prominent, sensationalized, fear-mongering coverage of the pharmaceutical to a large extent creates and drives the burgeoning demand for the drug. Thus the February Cleveland pharmacy robbery.
And given this sort of almost ludicrously hyperbolic coverage, was it not just a matter of time before another pharmacy was robbed of its supply of OxyContin? That's exactly what happened. On Sunday, April 22 a second pharmacy in the Cleveland suburbs was robbed; again, the robber zeroed in only on the Oxy, ignoring the treasure-trove of other opiates stocked behind the counter.