*Substance Abuse Treatment*

ADVISORY

*News for the Treatment Field*

April 2006

Volume 5

Issue 1

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Substance Abuse and Mental Health Services Administration

Center for Substance Abuse Treatment

www.samhsa.gov

OxyContin^®^:

Prescription Drug Abuse---2006 Revision

From the CSAT Director

by H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

The media have issued numerous reports about the apparent increase in
OxyContin® abuse and addiction. Some of these reports include the
following:

-   In Madison, Wisconsin, a task force reported a dramatic increase in
    OxyContin cases since 2003. Most OxyContin making its way onto the
    streets of Madison and nearby communities was believed to have been
    stolen from local pharmacies.^1^

-   The police chief in Billerica, Massachusetts, reported a "dramatic
    increase in OxyContin abuse."^2^

-   The distribution of OxyContin in Virginia was reported to be well
    above the national average. In the counties of far southwest
    Virginia, where the hard physical labor of coal mining and farming
    leads to a higher incidence of injuries, OxyContin prescriptions
    were generally 500 percent above the national average.^3^

-   Sixty-nine percent of police chiefs and sheriffs said they have
    witnessed an increase in the abuse of painkillers such as OxyContin.
    The areas most affected are eastern Kentucky, New Orleans, southern
    Maine, Philadelphia, southwestern Pennsylvania, southwestern
    Virginia, Cincinnati, and Phoenix.^4^

These reports may reflect some of your experiences: We know many of you
are treating clients addicted to OxyContin.

OxyContin has been heralded as a miracle drug that allows patients with
chronic pain to resume a normal life. It has also been called
pharmaceutical heroin and is thought to have been responsible for a
number of deaths and robberies in areas where its abuse has been
reported. Patients who legitimately use OxyContin fear that the
continuing controversy will mean tighter restrictions on the medication.
Those who abuse OxyContin reportedly go to great lengths---legal or
illegal---to obtain the powerful drug.

At the Center for Substance Abuse Treatment (CSAT), we are not
interested in fueling the controversy about the use or abuse of
OxyContin. As the Federal Government's focal point for addiction
treatment information, CSAT is instead interested in helping
professionals on the front line of substance abuse treatment by
providing you with the facts about OxyContin, its use and abuse, and how
to treat individuals who present at your treatment facility with
OxyContin concerns. Perhaps these individuals are taking medically
prescribed OxyContin to manage pain and are concerned about their
physical dependence on the medication. Perhaps you are faced with a
young adult who thought that OxyContin was a "safe" recreational drug
because, after all, doctors prescribe it. Possibly changes in the
availability or quality of illicit opioid drugs in your community have
led to abuse of and addiction to OxyContin.

Whatever the reason, OxyContin is being abused, and people are becoming
addicted. And in many instances, these people are young adults unaware
of the dangers of OxyContin. Many of these individuals mix OxyContin
with alcohol and drugs, and the result is all too often tragic.

Abuse of prescription drugs is not a new phenomenon. You have
undoubtedly heard about abuse of Percocet^®^, hydrocodone, and a host of
other medications. What sets OxyContin abuse apart is the potency of the
drug. Treatment providers in affected areas say that they were
unprepared for the speed with which an OxyContin "epidemic" developed in
their communities.

We at CSAT want to make sure that you are prepared if OxyContin abuse
becomes a problem in your community. This revised issue of the original
*Substance Abuse Treatment Advisory* on OxyContin will help prepare you
by

-   Answering frequently asked questions about OxyContin

-   Providing you with general information about semisynthetic opioids
    and their addiction potential

-   Summarizing evidence-based protocols for treatment

-   Providing you with resources for further information

For more information about OxyContin abuse and treatment, see our
resource boxes and end of this document. Feel free to copy the
information in the *Substance Abuse Treatment Advisory* and share it
with colleagues so that they, too, can have the most current information
about this critically important topic.

OxyContin^®^ Frequently Asked Questions

Q: What is OxyContin?

A: OxyContin is a semisynthetic opioid analgesic prescribed for chronic
or long-lasting pain. The medication's active ingredient is oxycodone,
which is also found in drugs like Percodan^®^ and Tylox^®^. However,
OxyContin contains between 10 and 80 milligrams (mg) of oxycodone in a
timed-release tablet. Painkillers such as Tylox contain 5 mg of
oxycodone and often require repeated doses to bring about pain relief
because they lack the timed-release formulation.

Q: How is OxyContin used?

A: OxyContin, also referred to as "Oxy," "O.C.," and "Oxycotton" on the
street, is legitimately prescribed as a timed-release tablet, providing
as many as 12 hours of relief from chronic pain. It is often prescribed
for cancer patients or those with chronic, long-lasting back pain. The
benefit of the medication to people who suffer from chronic pain is that
they generally need to take the pill only twice a day, whereas a dosage
of another medication would require more frequent use to control the
pain. The goal of chronic pain treatment is to decrease pain and improve
function.

Q: How is OxyContin abused?

A: People who abuse OxyContin either crush the tablet and ingest or
snort it or dilute it in water and inject it. Crushing or diluting the
tablet disarms the timed-release action of the medication and causes a
quick, powerful high. Those who abuse OxyContin have compared this
feeling to the euphoria they experience when taking heroin. In fact, in
some areas, the use of heroin is overshadowed by the abuse of OxyContin.

Purdue Pharma, OxyContin's manufacturer, has taken steps to reduce the
potential for abuse of OxyContin and other pain medications. Its Web
site lists the following initiatives: funding educational programs to
teach healthcare professionals how to assess and treat patients
suffering from pain, providing prescribers with tamper-proof
prescription pads, developing and distributing more than 1 million
brochures to pharmacists and healthcare professionals to help educate
them about medication diversion, working with healthcare and law
enforcement officials to address prescription drug abuse, and endorsing
the development of State and national prescription drug monitoring
programs to detect diversion. In addition, the company is attempting to
research and develop other pain management products that will be more
resistant to abuse and diversion. The company estimates that it will
take significant time for such products to be brought to market. For
more information, visit Purdue Pharma's Web site at www.purduepharma.com
or call the company at 203--588--8069.

Q: How does OxyContin abuse differ from abuse of other pain
prescriptions?

A: Abuse of prescription pain medications is not new. Two primary
factors, however, set OxyContin abuse apart from other prescription drug
abuse. First, OxyContin is a powerful drug that contains a much larger
amount of the active ingredient, oxycodone, than other prescription pain
relievers. By crushing the tablet and either ingesting or snorting it,
or by injecting diluted OxyContin, people who abuse the opioid feel its
powerful effects in a short time, rather than over a 12-hour span.
Second, great profits can be made in the illegal sale of OxyContin. A
40-mg pill costs approximately \$4 by prescription, yet it may sell for
\$20 to \$40 on the street, depending on the area of the country in
which the drug is sold.^5^

OxyContin can be comparatively inexpensive if it is legitimately
prescribed and if its cost is covered by insurance. However, the
National Drug Intelligence Center reports that people who abuse
OxyContin may use heroin if their insurance will no longer pay for their
OxyContin prescription because heroin is less expensive than OxyContin
that is purchased illegally.^6^

Q: Why are so many crimes reportedly associated with OxyContin abuse?

A: Many reports of OxyContin abuse have occurred in rural areas that
have housed labor-intensive industries, such as logging or coal mining.
These industries are often located in economically depressed areas, as
well. Therefore, people for whom the drug may have been legitimately
prescribed may be tempted to sell their prescriptions for profit.
Substance abuse treatment providers say that the addiction is so strong
that people will go to great lengths to get the drug, including robbing
pharmacies and writing false prescriptions.

Q: What is the likelihood that a person for whom OxyContin is prescribed
will become addicted?

A: Most people who take OxyContin as prescribed do not become addicted.
The National Institute on Drug Abuse reports: "Long-term use \[of
opioids\] can lead to physical dependence---the body adapts to the
presence of the substance and withdrawal symptoms occur if use is
reduced abruptly. This can also include tolerance, which means that
higher doses of a medication must be taken to obtain the same initial
effects. . . . Studies have shown that properly managed medical use of
opioid analgesic compounds is safe and rarely causes addiction. Taken
exactly as prescribed, opioids can be used to manage pain
effectively."^7^

One review found, "A multitude of studies indicate that the rate of
opioid addiction in populations of chronic pain sufferers is similar to
the rate of opioid addiction within the general population, falling in
the range of 1 to 2 percent or less."^8^

In short, most individuals who are prescribed OxyContin, or any other
opioid, will not become addicted, although they may become dependent on
the drug and will need to be withdrawn by a qualified physician.
Individuals who are taking the drug as prescribed should continue to do
so, as long as they and their physician agree that taking the drug is a
medically appropriate way for them to manage pain.

Q: How can I determine whether a person who uses OxyContin is dependent
on rather than addicted to OxyContin?

A: When pain patients take an opioid analgesic as directed, or to the
point where their pain is adequately controlled, it is not abuse or
addiction. Abuse occurs when patients take more than is needed for pain
control, especially if they take it to get high. Patients who take their
medication in a manner that grossly differs from a physician's
directions are probably abusing that drug.

If a patient continues to seek excessive pain medication after pain
management is achieved, the patient may be addicted. Addiction is
characterized by the repeated, compulsive use of a substance despite
adverse social, psychological, and/or physical consequences. Addiction
is often (but not always) accompanied by physical dependence, withdrawal
syndrome, and tolerance. Physical dependence is defined as a physiologic
state of adaptation to a substance. The absence of this substance
produces symptoms and signs of withdrawal. Withdrawal syndrome is often
characterized by overactivity of the physiological functions that were
suppressed by the drug and/or depression of the functions that were
stimulated by the drug. Opioids often cause sleepiness, calmness, and
constipation, so opioid withdrawal often includes insomnia, anxiety, and
diarrhea.

Pain patients, however, may sometimes develop a physical dependence
during treatment with opioids. This is not an addiction. A gradual
decrease of the medication dose over time, as the pain is resolving,
brings the former pain patient to a drug-free state without any craving
for repeated doses of the drug. This is the difference between the
patient treated for pain who was formerly dependent and has now been
withdrawn from medication and the patient who is opioid addicted: The
patient addicted to diverted pharmaceutical opioids continues to have a
severe and uncontrollable craving that almost always leads to eventual
relapse in the absence of adequate treatment. This uncontrollable
craving for another "rush" of the drug differentiates the patient who is
"detoxified" but opioid addicted from the former pain patient.
Theoretically, a person who abuses opioids might develop a physical
dependence but obtain treatment in the first few months of abuse, before
becoming addicted. In this case, supervised withdrawal (detoxification)
followed by a few months of abstinence-oriented treatment might be
sufficient for the patient who is not addicted who abuses opioids. If,
however, this patient subsequently relapses to opioid abuse, then that
behavior would support a diagnosis of opioid addiction. If the patient
has several relapses to opioid abuse, he or she will require long-term
treatment for the opioid addiction. (See the section titled Treatment
and Detoxification Protocols to learn more about treatment options.)

Q: I work at a facility that does not use medication-assisted treatment.
What treatment should I provide to individuals addicted to or dependent
on OxyContin?

A: The majority of U.S. treatment facilities do not offer
medication-assisted treatment. However, because of the strength of
OxyContin and its powerful addiction potential, medical complications
may be increased by quickly withdrawing individuals from the drug.
Premature withdrawal may cause individuals to seek heroin, and the
quality of that heroin will not be known. In addition, these
individuals, if injecting heroin, may also expose themselves to HIV and
hepatitis. Most people addicted to OxyContin need medication-assisted
treatment. Even if individuals have been taking OxyContin legitimately
to manage pain, they should not stop taking the drug all at once.
Instead, their dosages should be tapered down until medication is no
longer needed. If you work in a drug-free or abstinence-based treatment
facility, it is important to refer patients to facilities where they can
receive appropriate treatment. (See SAMHSA Resources.)

Treatment and Detoxification Protocols

OxyContin^®^ is a powerful drug that contains a much larger amount of
the active ingredient, oxycodone, than other prescription opioid pain
relievers. Whereas most people who take OxyContin as prescribed do not
become addicted, those who abuse their pain medication or obtain it
illegally may find themselves becoming rapidly dependent on, if not
addicted to, the drug.

Two types of treatment have been documented as most effective for opioid
addiction. One is a long-term, residential, therapeutic community type
of treatment, and the other is long-term, medication-assisted outpatient
treatment. Clinical trials using medications to treat opioid addiction
have generally included subjects addicted to diverted pharmaceutical
opioids as well as to illicit heroin. Therefore, there is no medical
reason to suppose that the patient addicted to diverted pharmaceutical
opioids is any less likely to benefit from medication-assisted treatment
than the patient addicted to heroin.

Some patients who are opioid addicted who have very good social supports
may occasionally be able to benefit from antagonist treatment with
naltrexone. This treatment works best if the patient is highly motivated
to participate in treatment and has undergone adequate detoxification
from the opioid of abuse. Most patients who are opioid addicted in
outpatient therapy, however, do best with medication that is either an
agonist or a partial agonist. Methadone is the agonist medication most
commonly prescribed for opioid addiction treatment in this country.
Buprenorphine is the only partial agonist approved by the Food and Drug
Administration for opioid addiction treatment.

The guidelines for treating OxyContin addiction or dependence are
basically no different than the guidelines the Center for Substance
Abuse Treatment (CSAT) uses for treating addiction to or dependence on
*any* opioid. However, because OxyContin contains higher dose levels of
opioid than are typically found in other oxycodone-containing pain
medications, higher dosages of methadone or buprenorphine may be needed
to appropriately treat patients who abuse OxyContin.

Methadone or buprenorphine may be used for OxyContin addiction treatment
or, for that matter, treatment for addiction to any other opioid,
including the semisynthetic opioids. Medication-assisted treatment for
prescription opioid abuse is not a new treatment approach. For instance,
in 2002, Alaska estimated that 15,000 people abused prescription opioids
in the State and that most patients receiving methadone were not
addicted to heroin. In addition, a significant percentage of patients in
publicly supported methadone programs were not being treated for heroin
addiction but for abuse of semisynthetic opioids (e.g., hydrocodone).
The Substance Abuse and Mental Health Services Administration (SAMHSA)
Drug Abuse Warning Network emergency room data show that both oxycodone
and hydrocodone mentions increased dramatically in the United States
between 1995 and 2002.^9^ And when Arkansas opened its first methadone
maintenance clinic in December 1993, the vast majority of its clients
were not admitted for heroin addiction but for semisynthetic opioid
abuse. These individuals had been traveling to other States for
treatment because methadone treatment was not available near their
homes.

Using the criteria above describing the difference between addiction to
and dependence on OxyContin, you may be able to determine whether a
patient requires treatment for opioid addiction. If this is the case,
methadone or buprenorphine may be used for withdrawal. For certain
patient populations, including those with many treatment failures,
methadone or buprenorphine is the treatment of choice.^10^

"As substance abuse treatment professionals, we have the responsibility
for learning as much as we can about OxyContin and then providing
appropriate treatment for people addicted to it. Appropriate treatment
will nearly always involve prescribing methadone, buprenorphine, or, in
some cases, naltrexone," says H. Westley Clark, M.D., J.D., Director of
CSAT. "Programs that do not offer medication-assisted treatment will
need to refer patients who are addicted to OxyContin to programs that
do," he adds.

It is important to assess an individual's eligibility for
medication-assisted treatment with methadone or buprenorphine to
determine whether he or she is eligible for this type of treatment and
whether it would be appropriate. The assessment may take place in a
hospital emergency department, central intake unit, or similar place.
Final assessment of an individual's eligibility for medication-assisted
treatment must be completed by treatment program staff. The preliminary
assessment should include the following areas:^11^

-   Determining the need for emergency care

-   Diagnosing the presence and severity of opioid dependence

-   Determining the extent of alcohol and drug abuse

-   Screening for co-occurring medical and psychiatric conditions

-   Evaluating an individual's living situation, family and social
    problems, and legal problems

". . . we have the responsibility for learning as much as we can about
OxyContin, and then providing appropriate treatment for people who are
addicted to it."

H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

Director, CSAT

Treatment Improvement Protocols (TIPs) and Collateral Products
Addressing Opioid Addiction Treatment

TIP 40 *Clinical Guidelines for the Use of Buprenorphine in the
Treatment of Opioid Addiction* **BKD500**

*Quick Guide for Physicians Based on TIP 40: Clinical Guidelines for the
Use of Buprenorphine in the Treatment of Opioid Addiction* **QGPT40**

*KAP Keys for Physicians Based on TIP 40: Clinical Guidelines for the
Use of Buprenorphine in the Treatment of Opioid Addiction* **KAPT40**

TIP 43 *Medication-Assisted Treatment for Opioid Addiction in Opioid
Treatment Programs* **BKD524**

*Quick Guide for Clinicians Based on TIP 43: Medication-Assisted
Treatment for Opioid Addiction in Opioid Treatment Programs* **QGCT43**

*KAP Keys for Clinicians Based on TIP 43: Medication-Assisted Treatment
for Opioid Addiction in Opioid Treatment Programs* **KAPT43**

SAMHSA Resources

To find a substance abuse treatment facility near you, visit the
Substance Abuse Treatment Facility Locator at
www.findtreatment.samhsa.gov. Call the Substance Abuse and Mental Health
Services Administration Substance Abuse Treatment Hotline at
800--662--HELP for substance abuse treatment referral information.

For More Information About Treatment for Opioid Addiction

Sign up for SAMHSA's Information Mailing System (SIMS) to receive
information about the following topics:

-   Grant announcements

-   Funding opportunities such as competitive contract announcements

-   Prevention materials and publications

-   Treatment- and provider-oriented materials and publications

-   Research findings and reports

-   Announcements of available research data sets

-   Policy announcements and materials

To sign up for this free service, use one of the following methods to
contact SIMS:

**Web:** http://sims.health.org

**Mail:** SAMHSA's National Clearinghouse for Alcohol and Drug
Information (NCADI)

Attn: Mailing List Manager

P.O. Box 2345

Rockville, MD 20847--2345

**Phone:** 800--729--6686

**Fax:** 301--468--6433

Attn: Mailing List Manager

Three Ways To Obtain Free Copies of All CSAT Products:

1\. Call SAMHSA's NCADI at 800--729--6686; TDD (hearing impaired)
800--487--4889

2\. Visit NCADI's Web site, www.ncadi.samhsa.gov

3\. Access TIPs on line at www.kap.samhsa.gov

*Substance Abuse Treatment Advisory*

*Substance Abuse Treatment Advisory*---published on an as-needed basis
for treatment providers---was written and produced under contract number
270-04-7049 by the Knowledge Application Program (KAP), a Joint Venture
of JBS International, Inc., and The CDM Group, Inc., for the Center for
Substance Abuse Treatment, Substance Abuse and Mental Health Services
Administration (SAMHSA), U.S. Department of Health and Human Services
(HHS). The content of this publication does not necessarily reflect the
views or policies of SAMHSA or HHS.

**Public Domain Notice:** All material in this report is in the public
domain and may be reproduced or copied without permission; citation of
the source is appreciated. However, this publication may not be
reproduced or distributed for a fee without the specific, written
authorization of the Office of Communications, SAMHSA, HHS.

**Electronic Access and Copies of Publication:** This publication can be
accessed electronically through the Internet at www.kap.samhsa.gov.
Additional free print copies can be ordered from SAMHSA's National
Clearinghouse for Alcohol and Drug Information at 800--729--6686.

**Recommended Citation:** Center for Substance Abuse Treatment.
"OxyContin®: Prescription Drug Abuse---2006 Revision." *Substance Abuse
Treatment Advisory*, Volume 5, Issue 1. Rockville, MD: Substance Abuse
and Mental Health Services Administration, April 2006.

DHHS Publication No. (SMA) 06-4138

Substance Abuse and Mental Health Services Administration

Printed 2006

Notes

1\. WISC-TV. *OxyContin:* *The Good, The Bad, The Deadly*. Broadcast
transcript. Madison, WI: WISC-TV, February 14, 2006.
www.channel3000.com/health/7013912/detail.html \[accessed March 2,
2006\].

2\. Crane, J.P. Drug use by young raises flag. *The Boston Globe*,
February 5, 2006.
www.boston.com/news/local/articles/2006/02/05/drug_use_by_young_raises_flag
\[accessed March 2, 2006\].

3\. Hammack, L. Painkiller prescriptions up significantly in region.
*The Roanoke Times*, March 28, 2004.
www.roanoke.com/roatimes/news/story164817.html \[accessed March 2,
2006\].

4\. Reuters. Powerful painkillers fueling U.S. crime rate. Redmond, WA:
MSNBC.com., March 10, 2005. www.msnbc.msn.com/id/7141313 \[accessed
March 2, 2006\].

5\. National Drug Intelligence Center. *Intelligence Bulletin: OxyContin
Diversion, Availability, and Abuse*. Johnstown, PA: National Drug
Intelligence Center, U.S. Department of Justice, August 2004.
www.usdoj.gov/ndic/pubs10/10550/10550p.pdf \[accessed March 3, 2006\].

6\. National Drug Intelligence Center. Pharmaceuticals. In: *National
Drug Threat Assessment 2004*. Johnstown, PA: National Drug Intelligence
Center, U.S. Department of Justice, April 2004.
www.usdoj.gov/ndic/pubs8/8731/8731p.pdf \[accessed March 3, 2006\].

7\. National Institute on Drug Abuse (NIDA). *NIDA Infofacts:
Prescription Pain and Other Medications*. Washington, DC: NIDA, National
Institutes of Health, 2005. www.drugabuse.gov/infofacts/PainMed.html
\[accessed March 3, 2006\].

8\. Fisher, F.B. Interpretation of "aberrant" drug-related behaviors.
*Journal of American Physicians and Surgeons* 9(1):25--28, 2004.

9\. Substance Abuse and Mental Health Services Administration (SAMHSA).
*Emergency Department Trends From the Drug Abuse Warning Network: Final
Estimates 1995--2002.* DAWN Series D-24. DHHS Publication No. (SMA)
03-3780. Rockville, MD: SAMHSA, 2003.
dawninfo.samhsa.gov/old_dawn/pubs_94_02/edpubs/2002final \[accessed
March 2, 2006\].

10\. Center for Substance Abuse Treatment. *Detoxification and Substance
Abuse Treatment*. Treatment Improvement Protocol (TIP) Series 45. DHHS
Publication No. (SMA) 06-4131. Rockville, MD: Substance Abuse and Mental
Health Services Administration, 2006.

11\. Center for Substance Abuse Treatment. Initial screening, admission
procedures, and assessment techniques. In: *Medication-Assisted
Treatment for Opioid Addiction in Opioid Treatment Programs*. Treatment
Improvement Protocol (TIP) Series 43. DHHS Publication No. (SMA)
05-4048. Rockville, MD: Substance Abuse and Mental Health Services
Administration, 2005, pp. 43--61.