Tuesday, August 3, 2010
Has OxyContin abuse in San Diego County been exaggerated? How do you think authorities should handle cases of prescription drug abuse?
MAUREEN CAVANAUGH (Host): I'm Maureen Cavanaugh, and you're listening to These Days on KPBS. Just last month the name of San Diego County's OxyContin Task Force was changed to the Prescription Drug Task Force. Claims that abuse of OxyContin, a powerful prescription pain killer, was becoming increasingly lethal for young people prompted the formation of the task force last year. But some investigative reporting, most notably by the North County Times and the Voice of San Diego, has cast doubt on that claim. The task force name change and the recent investigations open up some questions about how our drug fighting efforts get their focus. Is law enforcement reacting to a real threat or to scary headlines? Do our efforts to fight drug abuse make sense to people who treat drug abusers? I’d like to welcome my guests. Dr. Sean O'Hara is program director of Addictive Diseases at Alvarado Parkway Institute Behavioral Health Systems and a founding member of the San Diego Oxy Task Force. Dr. O’Hara, welcome to These Days.
DR. SEAN O’HARA (Program Director, Addictive Diseases, Alvarado Parkway Institute Behavioral Health Systems): Good morning, Maureen. Thanks for having me on.
CAVANAUGH: And Dr. Stephen J. Ziegler is an associate professor of Public & Environmental Affairs at Indiana University-Purdue University. Dr. Ziegler, good morning.
DR. STEPHEN ZIEGLER (Associate Professor, Public & Environmental Affairs, Indiana University/Purdue University): Good morning.
CAVANAUGH: We invited the San Diego County Sheriff’s office and the San Diego County District Attorney’s office to join the discussion this morning by sending a representative from the Prescription Drug Task Force but they declined. And we invite our listeners to join the conversation. Has OxyContin abuse in San Diego been exaggerated? How do you think authorities should handle cases of prescription drug abuse? Call us with your questions and your comments. The number is 1-888-895-5727, that’s 1-888-895-KPBS. Dr. Ziegler, let me start with you because you wrote an op-ed article awhile ago that said politicians and the media have led the public to believe that OxyContin abuse is one of the most significant current health threats to the nation. Is it?
DR. ZIEGLER: I don’t think it is. I don’t think OxyContin is. I mean there are other, certainly, problems. OxyContin may be a problem, prescription drug abuse certainly is a problem but it is not as big of a problem compared to the other problems that we face, at least in the health arena. And, certainly, that’s what I address in the op-ed of OxyContin and the need for perspective.
CAVANAUGH: How do you reach that conclusion?
DR. ZIEGLER: Well, we look at the numbers, for example, is that we had these congressional hearings several years ago with these OxyContin hysteria and some of the politicians before Congress were talking about some 200 deaths were linked to OxyContin, not caused but perhaps linked. And it kind of ignored the big elephant in the room which is like the 16,000 to 20,000 people that die every year from NSAID-related supplements and, moreover, more significantly is the 400,000, in excess of 400,000 people to die every year from smoking-related illnesses. So, certainly, 200 deaths there’s something we need to be concerned about and, certainly, prescription drug abuse is something we need to be concerned about. But when we’re talking about it as being the most critical health problem facing America, that’s certainly not the case.
CAVANAUGH: So, Dr. Ziegler, in your opinion, why has OxyContin gotten so much attention?
DR. ZIEGLER: Well, it’s an easy target. Prescription drug abuse is a very complex issue and it’s not – does not have an easy solution. And so we see about – we hear about these deaths that have been linked but, again, going back to what I’d said earlier is that that’s not necessarily cause so there could certainly be other factors but it’s just an easy target.
CAVANAUGH: Now, Dr. Sean O’Hara, let me get you into the conversation. And what is it that led to the formation of San Diego County’s Oxy Task Force?
DR. O'HARA: Well, there were a number of, well-publicized overdose deaths in the San Diego area of young people from – directly related to OxyContin and they happened in a short period of time. And that led to investigation of where they received the drugs from, how they were getting them, and, more importantly, how they were manipulating the drug in the form of taking it, which led to a higher rate of addiction. And from that they started investigating the amount of arrests, the amount of accidents, the amount of emergency room admissions related to the drug and then they decided to put a focus on it. And it’s kind of spread out to the larger arena of prescription drug abuse in general.
CAVANAUGH: And, I’m wondering, Dr. O’Hara, how would you characterize how big a problem that illegal use of prescription drugs like OxyContin is in San Diego?
DR. O'HARA: Well, I completely agree with Dr. Ziegler on the fact that we have greater issues with just cigarette smoking and tobacco-related health issues. They far outweigh that of what we see with prescription drug abuse. However, what we’re seeing is a trend, and the trend is a definite spike and a definite increase in the use of these drugs for nonmedicinal purposes. They’re – these drugs are being taken for recreational purposes or they’re being taken to treat conditions other than what they’re intentionally prescribed for.
CAVANAUGH: We’re taking your calls at 1-888-895-5727 if you’d like to join the conversation about how San Diego is handling prescription drug abuse and whether or not the threat of OxyContin in particular has been exaggerated. Our number once again is 1-888-895-KPBS. Dr. O’Hara, what does – or I don’t know if it’s – the focus has now changed since the title of the task force has changed, but what does the task force do?
DR. O'HARA: Well, you know, education is our biggest tool and awareness when it comes to regards to almost anything within health. So the idea is to educate the public, the school district, parents, the community on, obviously, the risks of addiction, the risks of abuse, and to put a tighter control on the dispensing of these drugs and also look at areas where the drugs are being obtained legally or misused in any capacity.
CAVANAUGH: I’m wondering, Dr. Ziegler, are you seeing similar task forces or similar efforts to address prescription drug abuse or OxyContin abuse in other parts of the country?
DR. ZIEGLER: Well, yes and no. I mean, there’s – because the drug abuse problem is so complex there’s a variety of ways to go about it. And certainly as Dr. O’Hara mentioned, the education part of it is certainly pivotal. It’s a excellent way to start. But we also need to have a concern for balance is that we certainly want to prevent abuse and diversion but at the same time we want to be very cognizant of the need to insure access to those patients who need those prescription drugs. And this is largely, this prescription drug abuse problem, is a public health problem. It’s not entirely a law enforcement problem, and so it would be unfair to expect law enforcement to solve this very complex issue which exists.
CAVANAUGH: Now I want to address this to both of you. I’ll start with you, Dr. O’Hara. We’ve heard, you know, in recent years and both of you have reiterated this, that the abuse of prescription pain medication is widespread in America and not just among teenagers but are we focusing, do you think, too much attention on abuse by young people? And that’s to Dr. O’Hara.
DR. O'HARA: Well, young people are – it’s incredibly important to put a focus on younger people. If they start getting a taste for these powerful drugs early in their lives when their brains are most vulnerable to becoming addicted, they’re developing, at an early age, a lifelong problem which they may or may not be able to overcome. And the idea is, is early prevention, early treatment, across the board for any medical problem is proving to be the most effective for recovery, for resilience and to – for any type of cure. So the focus naturally when we see kids coming in that are getting addicted to these drugs, we want to try and get them off of them early in their lives. People of – who have significant pain problems, and I, of course, agree with Dr. Ziegler on this, I work with pain management. There is definitely a need, an absolutely indispensable need, to use these medications for people who are really sick. If they can’t have pain medications, they can’t heal properly. So I work with pain management and the idea is, is to regulate and dispense, you know, prudently and appropriately and be able to have people have a variety of experiences in working with pain management other than just swallowing a pill. So there’s all sorts of different – pain management is just a huge field of medicine and the idea is, is for people who really need pain medications, yes, dispense appropriately but be able to make sure they’re educated on the problems with addiction and they’re utilizing other means, you know, to overcome pain. And for teenagers and young adults who don’t have pain management problems, who are perhaps anxiety ridden or depressed, they take these powerful drugs, they feel 100% better, not necessarily high or out of control, but just better, these are incredibly reinforcing. They continue to take them and, hence, addiction starts to occur. So a focus on youth, why they take them, and to get them off of them early is very important.
CAVANAUGH: Dr. Ziegler, I’d like your reaction to that and also it’s my understanding that we see high numbers of prescription pain medication or prescription drug abuse in a variety of age groups, isn’t that correct?
DR. ZIEGLER: Yes, but what I think is also important is that – and what is also difficult is to agree on the same definitions. And so when you talk about abuse, how do you define abuse? How do you define misuse? How do you define recreational use? For example, is that if someone has a short-acting opioid they’re prescribed as a result of some broken arm and they don’t have a chronic pain issue and so the arm mends and the problem is resolved and they still have some leftover medication and there’s been some programs trying to prevent diversion about let’s give those pills back, let’s destroy those pills, etcetera. So those are some approaches. But let’s say the person then breaks their leg. I mean, this is all legitimately, we’re assuming. And – or sprains their leg, rather. And they then take that prescription pain medication that they were prescribed originally for the broken arm. Now, of course, that would be technically pharmaceutical diversion and one could say that would be abuse. It’s not necessarily, though, misuse because it’s being used for an appropriate purpose, however not the purpose for which it was prescribed. So it would be improper to use it for that purpose but it teases out some of these differences which exist because a person taking pain medication that is left over, to solve or to help palliate a particular existing problem is distinct from recreational use. And so all of those distinctions are very important and when we try to solve this bigger problem of prescription drug abuse.
CAVANAUGH: I’m wondering, Dr. O’Hara, do we know how often the use of – the unauthorized use of OxyContin leads to addiction?
DR. O'HARA: That’s a very difficult thing to gauge. But here’s a trend that we see in San Diego and in Southern California and I also can say I speak to treatment providers around the country and they share similar views. I refer probably six to ten 17-to-25 year old males a month to long term residential treatment because of opiate dependence, not just OxyContin, opiate dependence. They may start by smoking OxyContin or they may start by a simple Vicodin prescription. What we’re seeing is it breaks out from OxyContin and then all of a sudden heroin gets introduced because they’re smoking the OxyContin, they’ve already smoked marijuana, and all of sudden this brown tar heroin, which is a smokable form of heroin, they start using that and eventually they go from OxyContin to heroin and then they – some of them move to a treatment drug known as Zaboxin and then some of them go on to methadone. So it turns into this big – What we’re seeing is this carousel. They’re just – they’re grabbing at any of the opiates. They start with one and it tends to mushroom into the others. The end result is, is at least just me, a single practitioner, I’m seeing 6 to 10 guys of that age group going into treatment per month and probably 2 to 4 females per month going into long term residential.
CAVANAUGH: We are talking about prescription drug abuse and most especially about OxyContin and San Diego County’s, formerly named, OxyContin Task Force. We’re talking about how big a problem it is and whether or not it’s being addressed correctly here in San Diego and across the nation. We’re taking your calls at 1-888-895-5727. We have to take a short break and when we return, we’ll continue our conversation right here on KPBS.
CAVANAUGH: I'm Maureen Cavanaugh. You're listening to These Days on KPBS. We’re talking about the aims and the effect of San Diego County’s Prescription Drug Task Force, formerly the OxyContin Task Force. And my guests are Dr. Sean O’Hara, who is program director of Addictive Diseases at Alvarado Parkway Institute Behavioral Health Systems. He’s a founding member of the San Diego Oxy Task Force. And Dr. Stephen J. Ziegler is an associate professor of Public & Environmental Affairs at Indiana University-Purdue University. We’re taking your calls at 1-888-895-5727. Let’s start with a call from Sheri in Escondido. Good morning, Sheri, and welcome to These Days.
SHERI (Caller, Escondido): Good morning, and thank you so much. I first want to thank you for addressing this epidemic problem in our society and in our community today. My son Aaron overdosed on OxyContin it’ll be five years October ninth. He was in a coma for three months, I mean, not – for three weeks, almost a month. We were preparing to withdraw care from him and by a miracle he started opening his eyes but that miracle left him with life but a quadriplegic. He can’t talk. He uses his fingers to communicate, one for yes, two for no. And he is an OxyContin victim. And I think it is so important, the work that you guys are doing. And Sean O’Hara, I actually had met Sean O’Hara before when my kids were in high school and he helped treatment for them and he’s a fabulous therapist and I admire all the work that he does.
CAVANAUGH: Sheri, thank…
CAVANAUGH: Yes, go ahead.
SHERI: Oh, go ahead. And Aaron has progressed and made small gains throughout the last four and a half years and now we’re at the point of volunteering with the DEA and we go and talk to schools, particularly the first school that we did a talk and I showed a video at was Poway High, which was where Aaron attended. And we go and do these informational drug talks about OxyContin and pills, you know, trying to educate the parents and the kids that pills kill.
CAVANAUGH: Sheri, thank you so much. Thank you for sharing your story. I really appreciate it. Let’s hear from Greg, calling from University City. Good morning, Greg, and welcome to These Days.
GREG (Caller, University City): Good morning.
GREG: Hi. I’m a university student at University of San Diego Cal – or, University of California San Diego.
GREG: And definitely the most problematic or not problematic but common drug abuse, prescription drug abuse, that I see is with Ritalin and Adderall, very rampant, and people use it as a focusing agent. And I realize that, you know, it falls under the same thing as prescription drug abuse even though it’s not an opioid but I definitely see that the most as being common within college life. And I was wondering if your guest had anything to say on that.
CAVANAUGH: Thank you. Thank you for the call, Greg. I appreciate it. And, Dr. O’Hara, is the fact that the county’s task force name is now changed to Prescription Drug Task Force, does that mean that it’s going to put more of an emphasis on drugs like – on the abuse of drugs like Ritalin?
DR. O'HARA: Well, I can’t speak for that. Clearly, across the board, we look at prescription drugs, how they’re being taken and how they’re being dispensed and how they’re being used. Dr. Ziegler brought up it’s a very broad definition on abuse, misuse, addiction. It’s a complex issue. But I will say that it will be spanning the whole range of prescription drugs, at least being able to try and to control for them better. So…
CAVANAUGH: Right. Dr. O’Hara, I wanted to get your reaction to Dr. Ziegler’s description of what constitutes abuse of a prescription drug or a painkiller like that. Is there, in our laws, a bright line between somebody who is perhaps using a prescription drug in an unauthorized way but for a correct reason as opposed to someone who’s perhaps sitting around at a party and taking it to see what it will do to them?
DR. O'HARA: Well, clearly, that’s a very distinct definition you made right there. My thoughts are is, we just have to look at American culture, actually global culture, but especially American. We have a society that if something’s wrong, you know, what do you take to make it go away instead of looking at the source of where it’s coming from. So I think we need to really reexamine our values and our standards towards how we take care of our health in general. And Dr. Ziegler is right when he says this is a public social health issue. This isn’t so much law enforcement, this is a health issue and our attitudes toward health. So I think if someone’s taking a pain medication or a psychiatric medication, if they’re having it prescribed and they’re being monitored and it’s being dispensed by a doctor and taken as prescribed, then it’s being used within its utility. And if people are taking medications that have a potential for addiction they need to be monitored on it and closely supervised to make sure it doesn’t spill over into abuse and then once it’s reached its capacity to help someone that they’re stepped down off of it. And I don’t think we always do that enough. As far as college kids taking Ritalin, this is almost part of our popular culture nowadays. We see it in books, movies, films, it’s just common culture that if kids feel they need to study more or mac down on their reading or exam preparation, they take Ritalin even without a prescription. And, you know, if people don’t have M.D. after their name, they just shouldn’t be messing around in the medicine cabinet. They don’t know what they’re going to get into.
CAVANAUGH: I want to remind our listeners they can join our conversation at 1-888-895-5727. Dr. Ziegler, are laws against prescription drug abuse, do they draw the kind of line that you did here in your description of using of abuse of prescription drugs for totally recreational use as opposed to perhaps really dealing with some kind of physical pain?
DR. ZIEGLER: Well, we certainly can say so. The example I used is that somebody, you know, breaks their arm and then they use it a month later for another purpose but it was prescribed but obviously for a legitimate purpose. That technically would be illegal though because it was not being used for the purpose it was prescribed and we would consider that pharmaceutical diversion. But by understanding and teasing out the distinctions here between recreational use, misuse, abuse, it can help us in forging solutions to these problems instead of lumping everybody together as perhaps a drug abuser. And we continue to need to focus on this notion of balance, is that there are problems associated with prescription drug abuse and – but also we must realize that there are a lot of patients out there that need opioids and opioids is a legitimate treatment protocol and it’s not something that should be considered to be the option of last resort. It doesn’t have to predominate but, certainly, we cannot ignore its use because it has the ability to improve patient function and reduce pain. And the iatrogenic addiction rate, whenever opioids are used properly absent other things in a patient’s chart, is extremely low, estimates in the area of 3 to 5%. So and I say that because just to balance things out is that if there are some chronic pain patients out there who are taking opioids, they should not fear that, oh, my gosh, I’m taking opioids, that means that it’s ultimately going to lead to addiction, and that’s simply not true.
CAVANAUGH: Dr. Ziegler, I know one of the things that you’ve been concerned about in your writing is that laws against prescribing drugs like OxyContin and so forth sort of spill over into the doctor’s office and some doctors are very hesitant to prescribe what, in your opinion, might be the proper amount of the drug to people who are really suffering.
DR. ZIEGLER: Yes. Yeah, the actual administration, the amount of drugs, you know, the general tendency is to start slow, go low. But every person is different, and you titrate up to what is the appropriate pain relief for that person. But the point that you’re hitting on is that as a result of these drug laws, is that sometimes it could cause some prescribers to be paranoid. Oftentimes, legislators that want to be able to solve this crisis aim at the prescribers without realizing that it’s – prescribers may or may not be certainly a part of the problem but it’s a lot bigger than that. There was a study in 1984 that came out published by Sigler, S-i-g-l-e-r, et al, and it examined the negative impact of drug regulation on the treatment of pain and the short version of it is this, they examined before this new law came into effect concerning triplicate prescription program pads and review, and then they looked at after that law came into effect. And as a result, at this one hospital, opioid prescribing reduced dramatically by 6% – 60% and so physicians would, and prescribers would, move from Schedule II down to Schedule III drugs and others would use Schedule III drugs to OTCs. So obviously they were cognizant of the regulatory environment and the regulatory environment is there to help us try to reduce this diversion, this abuse problem, but also realize that there are unintended side effects from regulation and, certainly, that was the case this particular study had identified.
CAVANAUGH: Now, Dr. O’Hara, do you hear a study like that and say, well, perhaps those opiates were being overprescribed to begin with?
DR. O'HARA: No, you know, I would trust a physician’s ability to recognize pain, where it’s coming from, its severity, and be able to prescribe appropriately and also monitor how many prescriptions are being filled by individual patients. Again, I’m behind Dr. Ziegler on that. I work with pain management. Opiates are indispensable as a form of treatment and doctors should prescribe accordingly. There’s a vast difference between medically managed pain medication versus kids or usually young people melting down an OxyContin into a pipe and smoking it, taking it far beyond. So this is a spectrum. I mean, it – there’s no easy answer to this. There’s this whole spectrum of use versus abuse and addiction. And, you know, just some facts, just some stats just for San Diego County…
DR. O'HARA: …you know, this is right from the coroner’s office. And in 2000, we had a combined amount of 483 overdoses combined, alcohol, drugs and everything. Of those, 228 were directly opiates and it doesn’t specify OxyContin versus heroin, it’s just opiates. In 2005, the combined amount was 691 and of those, 319 were directly opiate type drugs. And then as of just last year, in 2009, we had 764 combined overdoses and of those, 357 were opiate drugs. So, you know, we’ve definitely seen this number go up. And, you know, some of the articles that have been written, everything’s the focus on overdose death. True, that is something we want to avoid at all costs but the real issue is how these drugs are being taken, early onset addiction, and the cost to our society in emergency room admissions, lost productivity, lifelong addiction, the problems that happens within the family, financial losses. These are the bigger issues that go with substance abuse and prescription drug addiction that we need to be looking at, not just focusing in on the amount of people that overdose and die.
CAVANAUGH: Let’s take a call. Susan is calling from San Diego. Good morning, Susan. Welcome to These Days.
SUSAN (Caller, San Diego): Good morning. I wanted to point out something that no one has brought up yet, I haven’t heard. And that is that opioids are a very cheap cure for pain. I’m one of the San Diego’s working poor. I don’t have health insurance and I can’t afford physical therapy and I can’t afford a lot of the advanced pain treatment people that doctors would like to send me to if I have a muscle spasm or I have, you know, some back pain. I simply can’t afford it. And I – But I can afford opioids. They’re $15.00 for a prescription. So, you know, this is a bigger issue, I think. Nobody has addressed this yet.
CAVANAUGH: Dr. O’Hara, I’d like to get your reaction to that.
DR. O'HARA: It’s a very valid point and perspective. Again, education’s our best tool. I would be more than happy to offer numerous interventions that people can start to do for various types of pain and pain problems in conjunction with the use of opiate drugs if that is absolutely necessary and within somebody’s financial abilities. Good pain management utilizes anything and everything at one’s disposal to minimize, alleviate and deal with pain.
CAVANAUGH: Now, Dr. Ziegler, I wonder, since you’ve been looking at this and you’ve been looking at communities across the nation and what kind of laws they’ve enacted and how they’ve formed task forces, and I wonder if you have any ideas about how communities should be fighting prescription drug abuse?
DR. ZIEGLER: Yes, I do, just a few ideas. Number one is that you should begin by defining what the problem is and being as specific as possible and what is its scope? You want to, when you form these task forces, involve multiple stakeholders. You seek out experts so that the wheel is not invented. For example, the University of Wisconsin Pain Policy Studies group devotes all of their efforts towards this so they have actually a website with a great deal of helpful information and to help these communities perhaps come to solutions, come up with some ideas, being cognizant of the possibility of unintended consequences or side effects from these programs that are conducted. And ultimately is that whatever policy or policies result, it should be based on sound research which adhere to the principle of balance, that is to ensure patient access to these pharmaceuticals but not interfere with medical care or contribute to the prescription drug abuse problem.
CAVANAUGH: And, Dr. O’Hara, I wonder, being so close to our Oxy Task Force, anything that you would like to see changed? Or anything that we could do differently that you would support?
DR. O'HARA: Well, there’s a lot of things both in the state of California and the federal government, you know, that are being done now to further regulate these medications, not stop them from being dispensed but just to regulate where they seem to be flagrantly abused by. Again, education’s the most important thing that we can offer people and the general public. Doctors do, whenever they’re prescribing medications, to clearly educate their patients on the risks and the potential for addiction and abuse, and to also get people to realize that physical and mental health just don’t come flying in the window because we wake up in the morning. We have to work on these things, and it’s more than just sometimes eating a pill or, you know, taking some remedy to feel better. We need to look at health from a more holistic point. So I think those kinds of points need to be presented on an ongoing basis so we just have a more informed public and I think that, in and of itself, would make a tremendous difference.
CAVANAUGH: Well, I’d like to thank you both. We are out of time. Dr. Sean O’Hara, thank you.
DR. O'HARA: Thanks for having me on, Maureen.
CAVANAUGH: And Dr. Stephen Ziegler, thanks so much.
DR. ZIEGLER: Thank you.
CAVANAUGH: And if you’d like to comment, we encourage you to go online if we couldn’t take your call on the air, KPBS.org/thesedays. Now, coming up, the director of “A Midsummer Night’s Dream” at La Jolla Playhouse, Christopher Ashley, is here. That’s as These Days continues on KPBS.