"The current statistic is that about 16,000 people a year die of overdoses involving prescription narcotics.... It's a huge problem. The number of people dying from these drugs is second only to the number of people that die in car accidents," he ls Fresh Air 's Terry Gross.
And there was a lot of suffering as a result of that. In the '80s there was a realization that these drugs could be used successfully on cancer patients and terminally ill patients. And then in the mid-1990s there was really a revolution that took place. There was a study done here in New York by a pain expert who found that if I gave these same drugs to people with non-cancer pain, common pain like back pain, arthritis, facial pain, that it appeared that they also weren't getting addicted.
And that opened the door to the widespread medical use of drugs that had previously been reserved for cancer patients into the general patient population.
GROSS: So one of the first places it caught on was in Appalachia because of work-related pain problems? Is that what you're saying?
GROSS: It makes me wonder, though, maybe the people who became dependent on drugs were the people who didn't respond to other forms of therapy like physical therapy, or maybe they were in more severe pain than the other people who were able to return to work, and consequently stayed on drugs longer.
MEIER: Well, the person that sort of first sounded the alarm about this was a doctor in Boston, her name is Jane Ballantyne, and she was the head of pain treatment at Massachusetts General. And in 2003, I mean she accepted that these drugs were beneficial. She was a soldier in this war on pain, and as she kind of walked around Massachusetts General, she started seeing things that caught her attention.
"All you needed to do was to crush it, chew it, grind it down," Meier says, "and basically the entire narcotic pain load that was contained within the drug was released immediay, which is why it was powerful high and such an addictive drug when it was abused that way.".
Meier's previous book, Pain Killer, was published in 2003. He explains that for patients, part of the danger when it comes to the long-term medical use of painkillers like OxyContin comes from the body's ability to develop a tolerance for it.
MEIER: That's possible, but we don't know that because the way our medical system is set up right now is that we really don't finance the treatment of these chronic pain conditions through alternative means. If you look at data from other countries where there is more aggressive use of alternative pain treatments, what you'll see is that in many cases people recover far more quickly from chronic pain conditions when they're given alternative forms of treatments than when they're given opioids.
MEIER: Absoluy. I mean you got a huge hit at one time. And you know, to people who had never tried it before, it was extraordinarily dangerous as well, because that big hit could actually kill you from an overdose. So people in areas like Appalachia and Maine, where there was a large-scale use of painkillers for work-related problems, et cetera, started catching on to that there was this really great new drug on the street if this is the way I'd like to get high.
MEIER: Correct. I mean I had a doctor who I greatly respect mention to me that, you know, we thought the big problem with these drugs was addiction. What we didn't realize is that people who take them would opt out of life. And, you know, you see it across the spectrum. One of the more startling things is in the area of workplace injuries. I mean things like back strains are very common problems.
That doesn't mean, however, that Meier is unilaterally opposed to these narcotics.
GROSS: If you're just joining us, we're talking about pain medicine, particularly various forms of oxycodone. My guest is Barry Meier. He's a New York Times reporter who covers the intersection of business, medicine and public health. He's the author of a new New York Times e-book, which is called "A World of Hurt: Fixing Pain Medicine's Biggest Mistake." It's his second book about painkillers.
The dilemma here is that companies have legitimate commercial interests, and that is to make sure these drugs are available for patients, and that became the drumbeat to which the patient groups marched as well, and so it became very focused on changing state laws or deterring any effort that might limit the availability of these drugs to patients, rather on the issue of whether these drugs were actually beneficial to the patients who were taking them.
MEIER: Sure, that's correct. I mean basically in the 1980s or '70s, drugs like morphine were not widely used in this country because of fears of addiction related to them. And as a result of that, a lot of people at their end of their lives, be it cancer sufferers or people who were dying, were denied these drugs.
But what folks have discovered is that the more patients that - you know, workers who are treated with these drugs for back strain, the longer and longer and longer they stay away from work. In fact, we've kind of created kind of a legion of chronically unemployed people who are dependent on these drugs.
And that led her to start studying animal tests involved in these drugs and basically began to lead her to question whether these drugs were really beneficial for many patients in the long term.
On the rise of pill mills.
"The first person who sounded the alarm about this was a doctor in Boston. Her name is Jane Ballantyne, and she was the head of pain treatment at Massachusetts General. In 2003 she had accepted that these drugs were beneficial. She was a soldier in this war on pain, and as she kind of walked around Mass General, she started seeing things that caught her attention. For example, chronic pain patients who were given these drugs started improving. They would improve for a while, and suddenly their improvement would stop. Their pain would return. They would lose function, or the improvement in function they had achieved would be lost, and she began to wonder why this was going on. That led her to start studying animal tests involving these drugs, and basically began to lead her to question whether these drugs were really beneficial for patients in the long term.".
MEIER: There is no question that these drugs are extremely beneficial. They're valuable, vital drugs. And there should be no hesitation in their use after conditions like surgery or accidents or cancer treatment or end-of-life use. One does not want to turn the clock back to the limitations of these drugs in certain medical treatments.
And so what happens then is a steady escalation in dosage, and it can keep going and going and going and going and going, to the point where after a year or two of treatment, you are on extremely high levels of these drugs, and the higher level you take these drugs at, the more potential side effects that can occur.
MEIER: Oh, absoluy. The company that makes OxyContin, Purdue Pharma, launched what was an innovative and huge campaign to introduce drugs that had previously used for cancer treatment into general pain. That involved training hundreds of doctors to go out and speak to their medical colleagues about the benefits of these drugs.
GROSS: I think it's good to have cautionary advice, but there's times when you really need a painkiller.
This is FRESH AIR. I'm Terry Gross. Prescription painkillers have become the most widely used drugs in America. My guest Barry Meier has been investigating painkillers for more than 10 years. He's a reporter for the New York Times who covers the intersection of business, medicine and public health. His new e-book, "A World of Hurt," was published today.
"I had a doctor who I greatly respect who said, 'We thought the great problem with these drugs is addiction. What we didn't realize that the people who take them would opt out of life.' And you see it across the spectrum: One of the more startling things is in the area of workplace injuries; things like back strains are very common problems. But what folks have discovered is the more patients — workers — who are treated with these drugs for back strain, the longer and longer and longer they stay away from work. In fact, we've kind of created a legion of chronically unemployed people who are dependent on these drugs.".
And most importantly, the FDA allowed them to make an unusual claim, and that is that because OxyContin was a time-release drug, it would be less prone to causing addiction and less attractive to people who abuse drugs. So this became part of what was a steady drumbeat that was sounded not only by the company but by many leading pain experts, that in fact with this drug we had what was really a unique new weapon to deal with an age-old problem.
So OxyContin also has an underground history. How did it start catching on as a high?
GROSS: And one of the side effects you write about is basically disengaging from life.
MEIER: Correct. All you needed to do was to crush it, chew it, grind it down, and basically the entire narcotic pain load that was contained within the drug was released immediay, which is why it was such a powerful high and such an addictive drug when it was abused that way.
BARRY MEIER: Sure. OxyContin is basically a time-release form of a narcotic called oxycodone. It's in the same class of drugs as morphine, codeine. They're basically all natural or synthetic variations of the - from the poppy seed. What made OxyContin so unique is that it was a pure version of the drug. It wasn't mixed with aspirin or acetaminophen the way it's found in other narcotic painkillers like Percocet.
GROSS: What were some of the early problems that pain specialists started reporting?
On widespread use of OxyContin in Appalachia.
So you had people who became addicted to it through its medical use, and increasingly we're seeing evidence that patients become dependent upon it. We're seeing consequences where people's hormonal balance is basically being affected and their production of sexual hormones is being decreased, which is leading to lethargy.
GROSS: So I don't want to unnecessarily scare people about using painkillers when they come out of surgery or when they've been in a terrible accident. So would you just address that? I mean... MEIER: Absoluy.
GROSS:... a bigger hit at one time.
GROSS: And as you explained before, the advantage of crushing it is that it was a time-release capsule, and if you crushed it, all of the opiate would be released at once. So you'd get... MEIER: Correct.
And it also - in many of these areas you have doctors who are generalists, you know, they're not specialists. So most folks are going to a general practitioner, a family doctor, and when they were told that OxyContin was a less abusable drug than drugs that had preceded it, they said great, this sounds like a good thing for my patients. So they, you know, they started prescribing it very heavily.
For example, chronic pain patients who were given these drugs started improving. They would improve for a while, and suddenly their improvement would stop. Their pain would return, they would lose function, or the improvement in function they had achieved would be lost, and she began to wonder why this was going on.
And it was in a time-release form, so the drug was supposed to - you take it, and you are supposed to get pain relief for about 12 hours or so.
We're seeing a variety of ill effects that are being produced by the long-term medical use of these drugs as opposed to their abuse.
And it kind of ran like wildfire. It really started catching on in 1999, and by 2001 it was all over much of the Eastern United States and then spread across the country.
"If you look at the atlas of how drugs are prescribed in different parts of the country, there usually is a pretty straight correlation between the use of narcotic painkillers and areas where you have physical labor jobs, like mining, farming, logging — where people get a lot of back problems and muscle injuries and things of that nature. In many of these areas you have doctors who are generalists; they're not specialists. So most folks are going to a general practitioner — a family doctor — and when they were told that OxyContin was a less abusable drug than drugs that had preceded it, they said, 'Great. This sounds like a good thing for my patients.' So they started prescribing it very heavily.".
So whatever controversy there was at the point of introduction, it was kind of quickly swept aside by economic forces, and these drugs, OxyContin in particular, were very quickly and widely accepted by many, many doctors.
GROSS: You've been writing about how medical and social attitudes toward opiate painkillers keep shifting. You write a lot about the war on pain, which started, what, in the '80s, where attitudes shifted to be more open to the long-term use of opioids in the treatment of pain. This actually started with cancer and with people who were, you know, terminally ill and sought pain relief. Let's start there.
GROSS: But people who wanted to use it to get high found a way around that.
Meier explains how, in its initial form, OxyContin was designed as a time-released version of oxycodone — meant to ease pain for many hours at a time without interruption. It became a street drug when people looking to get high found a way to get around the time-release design of the pill.
On the side-effect of becoming disengaged from life.
GROSS: Did the manufacturer of OxyContin do anything to promote the long-term use of the drug for pain patients who didn't have cancer, people with back pain and nerve damage?
MEIER: It's a very common thing, and it's sort of part and parcel of using these drugs. Essentially, unlike many other types of medications, where you can sort of be prescribed a dosage and stay on that dosage for a long time, your body adapts to these drugs. And when your body adapts to these drugs, which is the situation called tolerance, essentially you require more of the drug to get the same killing effect.
MEIER: There was - you know, if you look at sort of the atlas, if you will, of how drugs are prescribed around the country, what types of drugs are prescribed in different parts of the country, there usually is a pretty straight correlation between the use of narcotic painkillers in areas where you have physical labor, jobs like mining, farming, logging, where people get a lot of back problems and muscle injuries and things of that nature.
"Unlike many other types of medications where you can be prescribed a dosage and stay on that dosage for a long time," Meier says, "your body adapts to these drugs. ", you require more of the to get the same... effect. And what happens is a steady escalation in dosage, and it can keep going and going and going and going to the point where, after a year or two of treatment, you are on extremely high levels of these drugs.".
MEIER: Well, it started catching on pretty soon after it appeared on the street. This is going back about a decade ago or so. And people that abuse drugs are very clever in finding ways of abusing whatever new drug comes onto the market, and it was quickly discovered that OxyContin could be crushed and snorted or chewed.
GROSS: And what some doctors started finding, you write, is that patients would become tolerant of the drug. They would develop a tolerance and require increased doses. Does that frequently happen?
And it sort of became the hottest drug on the street.
Meier's new e-book, A World of Hurt: Fixing Pain Medicine's Biggest Mistake, is published by The New York Times Co. and explores opiate painkillers and the consequences of long-term use. He focuses in particular on OxyContin — how it came to be prescribed for chronic pain, what the consequences have been, and how it became a street drug.
MEIER: There was some controversy. You know, prior to that there had been other approaches to treating pain, sometimes successfully, sometimes unsuccessfully. It basically involved, you know, physical therapy, behavioral therapy. Pain is a very, very complex condition, particularly chronic pain. And what happened was that with the introduction of what seemed to be kind of a wonder drug, insurers shifted to basically paying only for drugs, much as they did when antidepressants replaced psychotherapy.
GROSS: You write about how pharmaceutical companies who manufacture painkillers have actually funded medical and patient pain groups. Would you describe the funding and the relationship of the pharmaceutical companies to these groups?
"There is no question that these drugs are extremely beneficial," he ls Gross. "They are valuable, vital drugs. There should be no hesitation in their use after conditions like surgery, or accidents, or cancer treatment or end-of-life use.... he question becomes: How effective are these drugs in long-term treatment of chronic pain?".
"The company that produces OxyContin — Purdue Pharma — launched... an innovative and huge campaign to introduce drugs that had previously been used for cancer treatment into general pain. That involved training hundreds of doctors to go out and speak to their medical colleagues about the benefits of these drugs and, most importantly, the FDA allowed Purdue to make an unusual claim... that because OxyContin was a time-release drug it would be less prone to causing addiction and less attractive to people who abuse drugs. This became part of a steady drumbeat that was sounded by not only the company, but by leading pain experts — that, in fact, with this drug we had what was really a unique new weapon to deal with an age-old problem.".
MEIER: Sure, these types of arrangements are found throughout medicine, where you have drug companies funding patient or advocacy groups that represent a particular disease or particular interest that they have. This in the area of use of opioids became very, very well-funded with the launch of OxyContin and continued for about a decade or so.
It's about high-dose opioid painkillers and the consequences that come with long-term use. It focuses especially on OxyContin, how it came to be prescribed for chronic pain, and what the consequences have been. It also examines how Oxy became a street drug. Meier's previous book, published in 2003, is called "Painkiller.".
The question becomes how effective are these drugs in the long-term treatment of chronic pain, and the dilemma that we're facing now, after an experiment that began 15 years ago, is we really don't know that answer. And what we're seeing the longer these drugs are being used are consequences from their long-term use that weren't envisioned when this experiment began. (BREAK).
On the promotion of OxyContin for chronic pain relief.
GROSS: When OxyContin started entering the realm of medical use for long-term chronic pain, like back problems and nerve pain, was it controversial within the medical field?
"You basically had these pain clinics doctors that supposedly specialized in treating pain. These, in fact, were doctors who had no experience in treating pain. These are essentially clinics where you could walk in and the doctor would say, 'How do you feel?' 'I'm in pain. I think OxyContin would work for me.' And the doctor would write your prescription. You would pay cash for the appointment, and the cycle would start. And these... proliferated throughout the U.S." Transcript TERRY GROSS, HOST:
Prescription painkillers are among the most widely used drugs in America. In the decade since New York Times reporter Barry Meier began investigating their use and abuse, he says he has seen the number of people dying from overdoses quadruple — an increase Meier calls "staggering.".
On the first signs of problems with OxyContin.Oxycontin pain relief