The OxyContin epidemic and crime panic in rural Kentucky.

OxyContin (trade name), an oxycodone drug, was approved by the Food and Drug Administration (FDA) in 1995 and first marketed in 1996 by Purdue Pharma of Stamford, Connecticut (U.S.A.). Among the most powerful analgesics currently manufactured, OxyContin is a synthetic opioid. Opioid drugs (which include opium, heroin, morphine, codeine, hydrocodone, and oxycodone) are produced from the opium poppy. Opiate agonists, such as OxyContin, provide pain relief by acting on opioid receptors in the brain and the spinal cord and directly on tissue (OxyContin Diversion and Abuse 2002). OxyContin is a single-entity product unlike most oxycodone drugs (e.g., Percodan and Percocet), which typically contain aspirin or acetaminophen. A marked improvement, OxyContin reportedly is 16 times more powerful than similar narcotics (Sappenfield 2001). Designed as an orally administered, time-release analgesic, OxyContin provides significant and sustained pain relief and, due to its addictive propensity, is listed as a Schedule II narcotic (i.e., drugs approved for medical use that have a high potential for abuse) under the Controlled Substances Act.

OxyContin abuse

OxyContin abuse was first noted in Maryland, the eastern part of rural Maine, eastern Ohio, the rust-belt areas of Pennsylvania, and the southern Appalachian region of West Virginia, Virginia, and Kentucky. During the year 2000, the 10 states with the highest OxyContin prescription rates (per 100,000 population) and those with problems of abuse were, in descending order: West Virginia, Alaska, Delaware, New Hampshire, Florida, Kentucky, Pennsylvania, Maine, Rhode Island and Connecticut (Hutchinson 2001). West Virginia, particularly its southern region, and southeastern Kentucky have long histories of pharmaceutical abuse (DEA Briefs and Background 2002).

As prescriptions dramatically increased, concerns were raised about this new drug that was sweeping across some communities. The apprehensions, galvanized by citizens' complaints, increases in drug-related arrests, politicians' dire warnings, and newspapers' headlines, soon took an all too familiar shape--a new drug-abuse epidemic fueling myriad social problems. As is shown in the remainder of this paper, OxyContin use increased markedly after its introduction. OxyContin-related problems likewise increased. In some locales, OxyContin likely was connected to some increases in index crimes. But, similar to marijuana, opium, LSD, crack, and MDMA, OxyContin also has been the subject of drug panics. The politics of drug panics, often involving people with good intentions, politicians, newsmakers, and moral entrepreneurs, produce their own unintended dysfunctions and uninformed public policies (see, e.g., Duster 1970; Reinarman and Levine 1989; Humphries 1993; Jenkins 1999; Presdee 2000). These drugs' use, their pharmacological effects, and their relationships to crime have been socially constructed and, in public dialogues, often bear little resemblance to empirical reality. As is shown in this paper detailing the growth of OxyContin use, crime-related increases either have not occurred or have been greatly mischaracterized or exaggerated by both public and private sector officials.

OxyContin abuse has been made possible largely by its diversion. OxyContin is illegally acquired with fraudulent prescriptions; through illegal sales; by pharmacy theft and doctor shopping; from loosely organized rings of individuals diverting and then selling it; and by way of foreign diversion and smuggling into the U.S. (often via the Internet). When OxyContin abuse dramatically increased, authorities in Pennsylvania, Florida, Ohio, Kentucky, and Georgia reported swelling numbers of pharmacy robberies, burglaries, and theft to get OxyContin (OxyContin: Pharmaceutical Diversion 2002). Some individuals have been known to acquire OxyContin from parents and grandparents or to buy it from elderly patients who hold valid prescriptions (Sappenfield 2001). OxyContin's black market price is about one dollar per milligram (Dangers of OxyContin 2001; Addressing OxyContin Abuse 2001).

During the late 1990s, OxyContin became the stuff of frequent front-page news stories. News articles consistently increased in number from no stories from its introduction in 1996 through 1999 to 17 in 2000, to 404 in 2001, and declining to 247 in 2003 (Lexis-Nexis search by keyword "OxyContin"). News coverage and the campaigns of public and private sector officials fueled a moral panic about a new drug of abuse (Goode and Ben-Yehuda 1994). Their panic may have resulted from the sheer number of new OxyContin prescriptions, which in and of itself may have been negatively and sensationally interpreted and reported.

There are various methods of abusing OxyContin. In some cases tablets are crushed and snorted. In others, the powder is diluted and intravenously injected. A less often used delivery style is to peel off the outer coating and chew the tablets (Sullivan 2001). These abuse techniques result in the sudden absorption of the analgesic rather than as designed--slowly and continuously over several hours. Not surprisingly, overdoses and deaths have occurred, although the exact number is unknown. OxyContin-related overdose deaths are difficult to disaggregate, and the actual number likely will never be known with any degree of certainty. This is due in part to poly-drug use, in some cases OxyContin mixed with alcohol and in others OxyContin with depressants. Furthermore, data do not distinguish accidental deaths from suicides.

Conflicting estimates, however, have been published by the media and various office holders. For example, in September 2003, the New York Times reported that OxyContin was blamed for 500 to 1,000 deaths per year. Yet an article from March in The Journal of Analytical Toxicology examined records of 919 oxycodone-related deaths in 23 states across three years. In only 12 cases OxyContin alone was found. The remaining deaths were due to an overdose of oxycodone or poly-drug use. Almost all the victims had at least three other drugs in their systems, with alcohol, Valium and cocaine comprising the bulk. The conclusion, in the Journal, was that these deaths occurred in drug-abusing individuals. OxyContin, it was discovered, was rarely the sole cause of death (Satel 2003).

National data consistently indicate, however, increases in the number of new pharmaceutical abusers (but not solely oxycodone) and narcotic-related emergency incidents. During the 1980s, the National Household Survey on Drug Abuse reported generally fewer than 500,000 people yearly who first used prescription drugs for non-medical purposes. By 1998, the number of first-time users was at 1.6 million persons. Since then, persons reporting at least one non-medical use of OxyContin have increased from 221,000 in 1999 to 1,900,000 in 2002 (National Survey on Drug Use and Health 2003). Federal data indicate that emergency room visits involving oxycodone increased with the introduction of OxyContin. Between 1990 and 1996, emergency room treatment of oxycodone remained stable. After 1996, when OxyContin was first marketed, the number of oxycodone-related emergency room visits skyrocketed from 100 in 1996 to nearly 15,000 in 2002 (Clines and Meier 2001; Emergency Department Trends 2003). Nonetheless, emergency rooms that treat drug-related emergencies report that oxycodone (there is no separate category for OxyContin) is mentioned by patients in less than one percent of all cases (viz., 0.95%). Oxycodone ranks 18th, with alcohol first, acetaminophen sixth, and ibuprofen 13th in frequency of mentions (see Table 1). Although OxyContin use and its connection to drug-related emergencies have increased, oxycodone products evidently remain far less widely used than rhetoric often suggests.

OxyContin diversion and containment

Illegal acts by doctors and pharmacists are the primary means of diverting narcotics, some of which are illicitly sold. Some narcotics users "doctor shop" to find physicians who write prescriptions; in some cases they find multiple doctors to write multiple prescriptions. In some regions of the United States (and particularly in southern Appalachia), "pain clinics" are the primary source of OxyContin prescriptions (many of which result in illegal diversion). But over-prescribing remains the single most common source for OxyContin (and for other oxycodone and hydrocodone narcotics) (Johnson 2003a; OxyContin: Pharmaceutical Diversion 2002).

Because of this, medical providers have been prosecuted. For example, a Florida physician who overprescribed OxyContin, and whom prosecutors likened to a drug dealer, was convicted on four counts of manslaughter, five counts of unlawful delivery of a controlled substance, and racketeering. The Drug Enforcement Administration (DEA) spokesperson in the case claimed the conviction should "send a very strong message to the medical community that they treat these very potent drugs ... with respect." Similar charges against other medical doctors have been filed in California and Kentucky. In Virginia, a retired physician was held under house arrest allegedly for overprescribing OxyContin. In Canada, doctors' licenses have been suspended for trafficking in oxycodone. Some concerns have been raised within the medical community that authorities have become overly aggressive at containing even legitimate OxyContin use ("Panhandle doctor's OxyContin conviction to send message").

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