Pubdate: Sun, 29 Jul 2001
Source: New York Times (NY)
Copyright: 2001 The New York Times Company
Section: Magazine
Author: Paul Tough
Bookmark: (Oxycontin)


Paula is taking me on a driving tour of Man, the tiny West Virginia town 
where she has spent her entire life. Because I don't know my way around the 
hollows and gullies and creeks that carve through these hills, Paula is at 
the wheel.

And because Paula isn't a morning person, we've set out on our tour at 

It's dark; the only illumination comes from our headlights cutting through 
the mist that rolls down from the hills.

The tour Paula is leading isn't sanctioned by the local chamber of 
commerce; there are no stops at Civil War plaques or scenic vistas.

It's a pillhead tour: an addict's-eye view of the radical changes that a 
single prescription drug, called OxyContin, has brought to the town of Man. 
OxyContin abuse started in remote communities like this one more than two 
years ago; more recently, it has spread beyond its origins in Appalachia 
and rural Maine to affect cities and suburbs across the eastern United 
States. I came to Man to try to understand how America's latest drug 
problem started, to see its roots and trace how it has spread.

"That's my best friend's trailer right there," Paula says, pointing out a 
comfortable-looking single-wide across the creek. "She's somebody that you 
couldn't look at and know she was an oxy addict. She was a cheerleader in 
junior high. She's married. You can't just look at somebody and tell."

A few years ago, Paula says, Man was like any small town in America: you 
could buy a variety of illegal drugs, as long as you knew the right person 
to talk to. Pot was big; there was occasionally some cocaine around and a 
few pills for recreational use. Fads would come and go. But these days, she 
says, the only drug for sale in Man is OxyContin, a narcotic painkiller 
that users crush -- to disable its patented time-release mechanism -- and 
then snort or inject for a powerful and immediate opiate high. Legally, 
it's sold only by prescription for the treatment of chronic pain. In 
practice it's available just about everywhere around here, immediately, for 
cash. The going rate is a dollar a milligram, or $40 for a 40-milligram pill.

Paula is a thoughtful, good-natured 24-year-old with wispy blond hair, 
serious eyes and faded jeans.

She's fidgety; as she drives with one hand, she's rummaging through her 
handbag with the other, looking for her pack of Marlboro Lights. She finds 
them, removes one and stabs the dashboard lighter. "I'll show you some 
places over here," she says, as she turns her car off the main road, over a 
short bridge and down into a rough indentation that holds a couple dozen 
trailers and prefab homes. "This is Green Valley. We just call it the valley.

It's a pretty good neighborhood," she says, then interrupts herself. "Well, 
except that's a dealer there."

She points to a trailer with a Chevy pickup out front and a light burning 
inside. I crane my neck to get a look at a real-life drug den, but the tour 
has already moved on. Paula is pointing out a trailer on the other side of 
the road: "That's a small-time dealer there, nothing big," she says. Then 
she points to another one, and then another: "That's a dealer. . . . That's 
a small-time dealer. . . . That's a dealer. . . . Her son's a dealer, but I 
don't know if he lives there. . . . He uses, that boy in there. . . . They 
use really, really big."

We're driving slowly around the circular dirt road that is the only path 
through Green Valley. The neighborhood doesn't feel dangerous -- no 
graffiti, no pit bulls, no broken bottles lying around.

Still, Paula is pointing out criminal activity in every second home, 
peering through the front windshield and gesturing left and right: "They 
used to deal, too, but they don't no more. . . . They deal. . . . There's 
some dealers up through there, one or two, nothing big. . . . This boy that 
lives here deals. . . . They deal, in that trailer there."

The first time Paula did an oxy (as she calls the pills), in the summer of 
1999, it didn't do much for her. "That first 10-milligram pill, I didn't 
really feel nothing off it," she says. "But the second time I did it, I did 
two 20's, and I was high." She liked the effect. "When you get that oxy 
buzz," she says, "it's a great feeling.

You're happy.

Your body don't hurt. Nothing can bring you down. It's a high to where you 
don't have to think about nothing.

All your troubles go away. You just feel like everything is lifted off your 

What Paula calls "that oxy buzz" comes from OxyContin's only active 
ingredient: oxycodone, an opioid, or synthetic opiate, developed in a 
German laboratory in 1916. Chemically, it is a close relative of every 
other opium derivative and synthetic: heroin, morphine, codeine, fentanyl, 
methadone. The narcotic effects that Paula is describing are the exact same 
ones that have drawn people to opiates for centuries.

And just as every opiate does, oxycodone creates a physical dependence in 
most of its users and a powerful addiction in some of them. "At first you 
do them to get high," Paula says, "and then after you're addicted to them 
you don't do them to get high; you do them to survive. You do them to feel 
normal." At her peak, she says, she was snorting four or five 80-milligram 
pills a day.

The earliest reported cases of Oxycontin abuse were in rural Maine, 
rust-belt counties in western Pennsylvania and eastern Ohio and the 
Appalachian areas of Virginia, West Virginia and Kentucky. The problem 
traveled through these regions, as friends told friends and the word spread 
from town to town, county to county, up and down the Appalachians. There 
are a few defining characteristics that the first affected regions share: 
they're home to large populations of disabled and chronically ill people 
who are in need of pain relief; they're marked by high unemployment and a 
lack of economic opportunity; they're remote, far from the network of 
Interstates and metropolises through which heroin and cocaine travel; and 
they're areas where prescription drugs have been abused -- though in much 
smaller numbers -- in the past. "There's always been a certain degree of 
prescription drug abuse in this area," says Art Van Zee, a physician in Lee 
County, Va., "but there's never been anything like this. This is something 
that is very different and very new, and we don't understand all the 
reasons why. This is not just people who have long-term substance-abuse 

In our region this is young teenagers, 13- and 14-year-olds, experimenting 
with recreational drug use and rapidly becoming addicted.

Tens of thousands of opioid addicts are being created out there."

In Man, Paula said, it was like OxyContin came out of nowhere.

One day no one had heard of oxys, and a month later, the pills had become a 
way of life for hundreds of locals.

It became so easy to buy OxyContin in and around Man, Paula said, that 
until recently, she never really thought about the fact that everyone 
involved was breaking the law. "Buying pills never seemed illegal," she 
said. "It just didn't feel like it was wrong." There aren't lookouts 
involved, or secret passwords or elaborate drop sites: when Paula wants to 
buy an OxyContin pill, she simply drives to a dealer's house and knocks on 
the front door in broad daylight.

If she knows the dealer well enough, she'll go on in and snort the pill 
there, just to be neighborly. If not, she'll hand over the cash, put the 
pill in her pocket and drive away. Sometimes she'll be the only person 
there; other times, there will be a dozen cars lined up out front.

The dealers have the benefit of a captive market: OxyContin, like any 
opioid, is very difficult to quit abusing.

And given the pill's ubiquity here in Man, and the fact that the nearest 
rehab clinic is two hours away, this is an unusually hard place to quit 
using it. Nonetheless, Paula is trying. Six months ago, she and her best 
friend decided they were going to quit cold turkey.

They took a couple of days off work, locked themselves in her friend's 
trailer and started to detox. "That was the worst three days of my life," 
Paula said. "Honestly, I prayed to God to let me die. That's how bad it is. 
Your stomach hurts, you get really bad headaches, you get diarrhea. You 
want to throw up. You get really depressed.

If you can get past the third day or the fourth day, you're pretty much 
fine, but most people don't make it." Paula and her friend didn't make it: 
at the end of the third day, they went out and got a pill.

A few months ago, OxyContin abuse was considered a regional problem, 
labeled "hillbilly heroin" and confined to areas far from the nation's 
population centers. This year, though, abuse of OxyContin has started to 
move away from its backwoods origins and into metropolitan areas on the 
East Coast, into the Deep South and parts of the Southwest and into 
suburban communities throughout the Eastern United States. In Miami-Dade 
County, there have been 11 overdose deaths so far this year in which 
oxycodone was the probable cause, according to the county medical examiner.

There have been 11 more in Philadelphia, according to the medical examiner 

Police in Bridgeport, Conn., arrested a local doctor in July for 
prescribing tens of thousands of OxyContin tablets to patients, often, they 
say, without any medical examination at all. And in the suburbs of Boston, 
police say more than a dozen pharmacies have been held up by a gang of 
young men wearing baseball caps and bandannas, looking for OxyContin.

n many ways, the spread of Oxycontin abuse closely resembles another recent 
drug epidemic.

In the early 1990's, the Medellin and Cali cartels controlled cocaine and 
heroin distribution in the United States. Cocaine was selling well, but 
there was a marketing problem with heroin: it could only be injected, and 
many people, even frequent drug abusers, are reluctant to stick needles in 
their arms.

The Colombians' solution to this problem was to increase the purity of the 
heroin they were bringing into the United States until it was potent enough 
to snort.

They were then able to use their existing cocaine-trafficking network in 
the Eastern United States to get heroin onto the street in powder form. 
Cocaine users, who were used to the idea of buying and snorting a white 
powder, experimented and became addicted.

As their tolerance increased, these new heroin snorters overcame their 
aversion to needles and soon turned into heroin injectors. , doing the most 
damage when it enters a community of people who don't think of themselves 
as serious drug users.; 'At the moment,' one pain specialist says the 
attitude is that if one housewife in Alabama becomes addicted, then the 
drug must be pullled and the company shut down.'

Similarly, there were plenty of oxycodone users in Appalachia before 
OxyContin came along.

Many of the OxyContin addicts I spoke to in Kentucky and West Virginia used 
to snort or chew a mild oxycodone-based painkiller called Tylox. They said 
they found the pills somewhat euphoric and not very addictive -- each Tylox 
contains just 5 milligrams of oxycodone, along with 500 milligrams of 
acetaminophen. When OxyContin arrived on the scene, in pills containing 20, 
40 and 80 milligrams of oxycodone, it marked a jump in purity similar to 
that of early-90's heroin -- and again, casual users started snorting, and 
then shooting, a powerful opioid.

Although heroin and OxyContin have a similar unhappy effect on the lives of 
people addicted to them, there is a critical and simple difference between 
the two: heroin is illegal; OxyContin, when used as directed, is legal.

More than that: the pill is government-approved. It is made by Purdue 
Pharma, a successful and well-regarded pharmaceutical company headquartered 
in Stamford, Conn. It is prescribed to a million patients for the treatment 
of chronic pain, and it is closely regulated at every stage of its 
manufacture and distribution by the Food and Drug Administration and the 
Drug Enforcement Administration.

This fact has meant a major conceptual shift for law-enforcement officials, 
who are used to combating narcotics produced by international drug lords, 
not international corporations. Terry Woodworth, the deputy director of the 
D.E.A.'s office of diversion control, says the spread of OxyContin has 
posed a challenge to the D.E.A.'s traditional methods: "Instead of using 
the normal law-enforcement techniques -- like going to the source and 
attempting to eradicate or destroy the criminal organization producing the 
drug and immobilize its distribution networks and seize all its assets -- 
you have a very different situation in a legitimate industry, in that your 
manufacture and distribution is legal."

Scott Walker, the director of Layne House, a drug treatment facility in 
Prestonsburg, Ky., puts it more concisely: "You don't have the Coast Guard 
chasing OxyContin ships," he says. "This isn't something you can stop at 
the border. It's growing from within."

Part of what makes the spread of OxyContin abuse so difficult to track, let 
alone to stop, is that the drug moves not physically but conceptually. When 
crack cocaine spread from the big cities on either coast toward the center 
of the country, it traveled gradually, along Interstates, city by city. 
OxyContin abuse pops up suddenly, in unexpected locations: Kenai, Alaska; 
Tucson; West Palm Beach, Fla. At the Gateway Rehabilitation Center in 
Aliquippa, Pa., a suburb of Pittsburgh, Jay, a recovering OxyContin addict 
and a former small-time dealer, offered an explanation for OxyContin's 
sudden geographical shifts. "It's the idea that passes on," he told me. 
"That's how it spreads.

There aren't mules running the drug across the country. It's dealt by word 
of mouth.

I call a friend in Colorado and explain it to him: 'Hey, I've got this 
crazy pill, an OC 80, an OC 40. You've got to go to the doctor and get it. 
Tell him your back hurts."'

Jay is 26, a college graduate and former nurse.

He started doing oxys in 1999, and his consumption quickly rose to 240 
milligrams a day. He was clean when we met and trying to stay that way. But 
when he talked about the drug's potential as a small business, he couldn't 
help getting excited. "I could go to California or Las Vegas and say, 'Hey, 
I was getting OC's prescribed to me in Pennsylvania; I'm going to get them 
in Las Vegas,"' he said. "And then if I wanted to sell them, I could sell 
them there.

I'd start out and sell them for 10 bucks apiece.

Get people hooked on them, then sell them for 50 bucks apiece.

It's experienced word of mouth.

I've experienced the drug, therefore I know how to describe it to you."

Unlike heroin, Jay explained, OxyContin doesn't require investment or 
muscle or manpower to move across the country.

OxyContin abuse is a a contagious idea -- a meme, if you will. Because 
OxyContin, the medicine, is readily available in pharmacies everywhere, all 
it takes to bring OxyContin, the drug, to a new place is a persuasive 
talker like Jay. A powerful recreational narcotic can now travel halfway 
across the country in the course of a phone call.

n order to understand the particular dilemma of OxyContin, you need to 
understand the long-fought war among doctors over pain and addiction.

For centuries, opium and its derivatives have been considered a 
double-edged sword -- the most effective painkiller on earth and also the 
most addictive substance. For most of the 20th century, opiates were 
considered too dangerous to use in all but the most critical pain 
treatments. The assumption was that their medical use would inevitably lead 
to addiction.

In the late 1980's, for the first time, public and medical opinion began to 
swing decisively in the other direction.

Patient advocates and pharmaceutical companies, bolstered by studies 
showing that there were vast numbers of cancer patients whose pain was 
being undertreated, encouraged the medical community to rethink its 
approach to opioids, especially in the management of cancer pain. Their 
campaign was persuasive. Between 1990 and 1994, morphine consumption in the 
United States rose by 75 percent, and in 1994, the Department of Health and 
Human Services issued new clinical guidelines encouraging the use of 
opioids in the treatment of cancer pain.

Purdue Pharma was a leading player in the pro-opioid campaign.

The company contributed generously to patient-advocacy organizations, 
including the American Pain Foundation, the National Foundation for the 
Treatment of Pain and the American Chronic Pain Association, and underwrote 
dozens of scientific studies on the effectiveness of opioids in the 
treatment of pain. In 1985, the company began marketing MS Contin, a 
time-release morphine pill that was used to treat cancer pain. As attitudes 
on opioids shifted, Purdue began to promote MS Contin for noncancer pain as 

Dr. Russell Portenoy is chairman of pain medicine and palliative care at 
Beth Israel Medical Center in New York City, and the co-author of a 
groundbreaking 1986 study that supported the long-term use of opioids to 
treat noncancer pain. "Between 1986 and 1997, within the community of pain 
specialists, there was increasing attention on the role of opioids," 
Portenoy says, "but there was relatively little diffusion of that idea to 
family doctors and other nonspecialists." That began to change, Portenoy 
says, with the F.D.A.'s approval of OxyContin in 1995. "There was a sea 
change that occurred with the release of this drug," Portenoy says. For the 
first time, general practitioners began to prescribe strong, long-acting 
opioids to treat chronic noncancer pain. Portenoy says the change was due 
to four factors that came together at about the same time. "The reasons 
were partly cultural -- the attitudes of the medical and regulatory 
communities had been gradually shifting for a decade.

They were partly medical -- studies had been coming out showing that 
patients with low back pain, chronic headaches and neuropathic pain might 
benefit from long-term opioid therapy. They were partly pharmacological -- 
OxyContin made it easier and more convenient for patients to receive 
long-term opioid therapy.

And they were finally related to marketing, because Purdue Pharma was the 
first company to advertise an opioid pill to general practitioners in 
mainstream medical journals."

In addition to those doctor-directed ads in magazines like The Journal of 
the American Medical Association, the company began an innovative 
indirect-marketing campaign just before OxyContin's release.

Because of F.D.A. regulations on the marketing of narcotics, the company 
was unable to use direct-to-consumer advertising, as other pharmaceutical 
companies were beginning to do for antidepressants and prescription allergy 
medications. So Purdue decided to concentrate on what they call "nonbranded 
education." Just as Nike advertises the concept of sports instead of shoes, 
so Purdue would market the concept of pain relief to consumers, but not 
OxyContin. In 1994, the company launched Partners Against Pain, a 
public-education program that at first concentrated on cancer pain and 
later expanded to include other forms of long-term pain. Through videos, 
patient pain journals and an elaborate Web site, Purdue promoted three 
ideas to doctors and patients: that pain was much more widespread than had 
previously been thought; that it was treatable; and that in many cases it 
could, and should, be treated with opioids. Partners Against Pain didn't 
promote OxyContin specifically; the company's marketers knew that simply 
expanding the total market would also increase their bottom line.

OxyContin was seen by many doctors as the solution to the long rift between 
pain specialists and addiction specialists. Purdue Pharma believed that 
OxyContin's time-release function would mean a much lower risk of addiction 
than other opioid medications. According to a principle known as the "rate 
hypothesis," the rate at which an opioid enters the brain determines its 
euphoric effect, and also its addiction potential.

This is why injecting a narcotic produces a more powerful high, and 
addiction risk, than snorting it or swallowing it. Because OxyContin, taken 
whole, provides a steady flow of oxycodone over an extended period, the 
high it produces is diminished, as is the risk of addiction.

Before OxyContin, narcotic painkillers were prescribed mostly by 
oncologists and pain specialists. Purdue believed that OxyContin's 
time-release safeguards made it appropriate for use by a much broader array 
of medical professionals. The company began promoting OxyContin to family 
doctors and local pharmacists nationwide through a network of hundreds of 
field reps who emphasized, in their office visits, the idea that OxyContin 
presented a lower addiction risk than other opioid medicines.

Over the next few years, sales of OxyContin exploded.

OxyContin prescriptions have more or less doubled in number each year since 
its release; the company's revenues from the pill jumped to $1.14 billion 
in 2000 from $55 million in 1996. Last year, doctors wrote more than six 
and a half million OxyContin prescriptions, and OxyContin ranked as the 
18th best-selling prescription drug in the country (as measured by retail 
sales) and the No. 1 opioid painkiller. The company grew along with its 
main product's sales; between 1998 and 2000, the Purdue work force expanded 
to nearly 3,000 employees from 1,600.

Purdue's attempt to expand the opioid marketplace beyond cancer patients 
was also remarkably successful. Five years ago, cancer patients were still 
the main market for long-acting opioids, but oncologists accounted for only 
3 percent of the OxyContin prescribed last year. The largest single group 
of OxyContin prescribers is now family physicians, who account for 21 
percent of the total.

According to Portenoy, this change in the number and kinds of doctors 
prescribing OxyContin is fundamentally linked to the spread of OxyContin 
abuse. "It's not the drug, per se," Portenoy says. "It's rapidly expanding 
access, plus the reality of doctors prescribing it who may not have the 
skill set required to prescribe it responsibly."

Purdue's field reps were the first wave of OxyContin apostles, spreading 
word of the pill's effectiveness door to door -- doctor by doctor, 
pharmacist by pharmacist. But Purdue's officially sanctioned word-of-mouth 
marketing campaign was followed by another, unsanctioned one. This time the 
news was that the miracle pill had an Achilles' heel, that its time-release 
matrix could be eliminated completely in a matter of seconds by the simple 
act of crushing the pill with a spoon, a lighter, even a thumbnail, and 
that the resulting powder, when snorted or mixed with water and injected, 
produced a very potent high. The apostles this time were not Purdue's field 
reps but casual drug abusers throughout the Eastern United States. And just 
like Purdue's, their marketing campaign was enormously successful.

n a steel-mill suburb northwest of Pittsburgh, the leader of the second 
wave of OxyContin apostles was Curt, a young man who in 1998, at the age of 
23, found himself kicked out of the Air Force and living back in his 
hometown. He worked the midnight shift running cranes at the mill, and he 
dealt a little marijuana during the day. He was part of a "drug community," 
as he calls it, 20 or so people who worked together, hung out together, 
went to parties and concerts and smoked a lot of pot. Every couple of 
months someone would land a prescription for Percocet or Vicodin, and 
they'd sell the pills to friends for $5 apiece, a cheap and mild high.

In April 1999, someone in his circle was prescribed OxyContin. Curt assumed 
that it was just like any other pain pill. "Everybody thought at first that 
they were like a Percocet," Curt says. "Nobody understood how many 
milligrams were really in these things.

People were selling them like an expensive Percocet" -- for $10, in other 
words, instead of $5 -- and swallowing them whole.

At a party, Curt figured out the trick of crushing the pill and snorting 
the powder, and he quickly spread the word. "I showed a lot of people," 
Curt says. "At first they were like, 'You're crazy.' But then they'd do it, 
and that would be it. People tell me now, Yeah, you're the one who showed 
me how to snort this thing."

Oxys quickly became very popular in Curt's circle of friends, and Curt 
found a comfortable niche for himself between supply and demand. "I knew 
people all over the county that were getting prescriptions," he says. 
"They'd call me and say, I'm getting OC's now and I want to get rid of 
them. They knew there was money there, but they didn't know who to sell to. 
They usually gave me a heck of a deal. I'd get them all for maybe $10" per 
40-milligram pill. "I'd sell them for $20, so for every one I sold, I made 
one. And then I'd give them their money and the next month I'd get their 
scrip again." At that rate, he could make $900 off a 90-pill bottle.

But he wasn't in it for the profit; he was in it for the pills. "I didn't 
need money," he explains. "I worked at the mill. I was always doing it just 
for the free drugs."

Before long, he had 10 people giving him their pills to sell, mostly women 
in their 30's and 40's on welfare or disability. (Patients on Medicaid pay 
just a dollar for a $250 OxyContin prescription.) "It's so weird the people 
that got into this," Curt says. "Some of them were innocent mothers.

I had one that was in her 60's. She never did drugs.

She'd sell every last one of her pills, and it would pay for all her other 
medication." Curt would keep careful track of which day of the month each 
of his suppliers filled her prescription. "A lot of times I would drive 
them to the pharmacy," he says. "I'd always get a couple of pills for that."

One of the most valuable -and closely guarded -- resources in the local 
OxyContin economy was a doctor who was willing to write an OxyContin 
prescription without asking too many questions. "It's a slow process, 
breaking a doctor in," Curt explains. "You've got to know how to work him. 
I'd say: 'I can't take the Vicodins and the Percocets because they're 
hurting my stomach.

Do they have anything that's, like, time released?' The doctor goes, 'Oh, 
you know what, they've got this new stuff called OxyContin.' And I'd say: 
'Oh, yeah? Wow, how's that work?"' Some local doctors, Curt says, knew 
exactly what was going on, but they needed the business. One started 
handing out monthlong OxyContin prescriptions every two weeks.

On the demand end, Curt had between 25 and 50 steady customers. "I had a 
cell phone at that time, so I was doing a lot of driving," he says. "People 
would gather at their houses, and they'd bring all their friends over, 10 
of them that'd use it. They'd all gather when they knew I was coming, 
because they wanted the pill immediately."

Curt has been in recovery for a few months now; since he got out of rehab, 
he's been cut off from almost all his old friends, and he fills his spare 
time fixing up his sister's house, fishing and reading up on psychology, 
which he plans to begin studying this fall. He's a man of boundless energy 
and focus, and he has taken to the 12-step process with an unusual 
intensity; in his first 60 days clean, he told me, he attended 138 
Narcotics Anonymous meetings.

That same energy served him well back in his oxy days, when he was cutting 
steel at the mill all night and driving around making pickups and 
deliveries all day. The pills themselves, he says, helped him keep going. 
"I could go get two hours of sleep, wake up, do a pill and continue on from 
there," he says.

It was only a couple of months after OxyContin arrived in town that Curt 
and most of his customers realized they were addicted.

At first, they were happy just to take a pill whenever one was around, for 
fun, but soon they found themselves experiencing severe withdrawal symptoms 
if they didn't have a pill every day. Everyone's tolerance built up quickly 
- -- one week they were able to get by on a 20 a day, the next week they'd 
need a 40, and a couple of weeks later, it had to be an 80. "No one knew 
what was going on," Curt says. "These are a bunch of pot smokers, drinkers, 
just mellow people.

This drug just took us by storm.

A whole community, at least a hundred people I know around here. They're 
all into the addiction.

These are guys I used to smoke pot with and drink beer with in the woods.

I grew up with them all, having parties and that. And now there's not one 
of them -- not one of them -- that don't use pills."

urdue Pharma wasn't aware of significant problems with OxyContin abuse 
until April 2000, when a front-page article in The Bangor Daily News, 
claiming that OxyContin "is quickly becoming the recreational drug of 
choice in Maine," landed on the desk of Purdue's senior medical director, 
Dr. J. David Haddox. In the summer of 2000, the company formed a response 
team, made up of medical personnel, public relations specialists and two of 
the company's top executives, which has guided the company's OxyContin 
campaign ever since.

It's fair to say that in public relations terms, Purdue's reaction to the 
OxyContin problem has been less than successful. As recently as six months 
ago, the company had a considerable supply of good will in the media, the 
government and the affected communities; it is now facing 12 separate 
potential class-action suits from former patients, as well as one from the 
attorney general of West Virginia; formerly sympathetic community leaders 
in Appalachia and Maine have grown increasingly skeptical of the company's 
approach; and in separate Congressional testimony, Attorney General John 
Ashcroft called OxyContin a "very, very dangerous drug," and Donnie 
Marshall, then head of the D.E.A., said in May that unless he received 
"more cooperation" from Purdue, he was "seriously considering rolling back 
the quotas that D.E.A. sets . . . to the 1996 level," which would have 
meant a 95 percent cut in production.

Purdue's P.R. problems seem rooted in the company's deep-seated belief in 
the inherent safety of and public need for its product.

It is an article of faith for the company that illegal traffic in its drug 
is the work of "bad guys" and "professionals," in Haddox's words.

In fact, Purdue says that its internal data indicate that the levels of 
OxyContin abuse in the country are no greater than expected. "We have had 
increased numbers in the last year or so," I was told by Robert Reder, 
Purdue's vice president of medical affairs and worldwide drug safety, "but 
our estimation is that they're commensurate with the distribution of the 
drug." The abuse situation, according to Reder's numbers, is normal. 
(Government statistics indicate that as of 1999, 221,000 Americans had 
abused OxyContin.) The real victims, the company says, are their 
"legitimate patients," who would be denied OxyContin if its distribution 
were restricted.

In March, Purdue announced a 10-point plan to combat OxyContin abuse.

The plan includes tamper-resistant prescription pads for doctors, 
antidiversion brochures and educational seminars for doctors and 
pharmacists in affected areas, an initiative to combat smuggling of 
OxyContin from Mexico and Canada and a donation of $100,000 to a Virginia 
group for a study of prescription-monitoring programs.

To Purdue, the plan is generous and well focused; to people in the 
communities where abuse is widespread, it seems like a way for the company 
to avoid the real problem.

I spoke several times this spring and summer to Debbie Trent, a 
professional counselor in Gilbert, W. Va., who runs the local antidrug 
community group called STOP (Strong Through Our Plan). In our first 
conversation, she was scrupulously cautious and polite when she spoke about 
Purdue Pharma, saying, "I don't want STOP to be seen as fighting 
OxyContin." During STOP's first few months, Haddox addressed her group twice.

When we spoke in April, though, Trent told me that she had come to believe 
that the company's 10-point plan was addressing the wrong problems -- 
prescription fraud and international smuggling, for example, when what 
Gilbert really needed was a way to get immediate treatment for its many 
addicts. "I read about the tamper-proof prescription pads and I think, Give 
me a break!" she said. "That seems like such a little thing.

It seems so minute in comparison to the scope of the problem.

It's almost intentionally missing the point.

Rather than prescription pads, I would like to see something done in rehab, 
something where they're making an effort to help these folks get better."

Similar sentiments were expressed in Maine in July, when Purdue announced 
its latest solution to the OxyContin problem: a $100,000 grant to start a 
"mini-M.B.A." program in high schools.

This fall, Purdue will send 20 teachers from some of the most affected 
counties in Appalachia and Maine to New York for training by the National 
Foundation for Teaching Entrepreneurship. When they return to their 
schools, they will teach students how to formulate a business plan and 
invest in the stock market. The idea is to "provide these kids with a sense 
of hope," according to a Purdue spokesperson. A Maine school administrator 
was quoted in The Boston Globe asking why the company "wouldn't have come 
up here and asked us what we want"; if anyone had, she said, she would have 
asked for money for the treatment of addicts rather than entrepreneurial 

Again and again, Purdue has apparently been blindsided by criticism.

At a news conference in Alabama attended by parents whose teenage children 
had died from OxyContin overdoses, Gov. Don Siegelman interrupted a Purdue 
doctor who was going point by point through Purdue's 10-point plan. "I find 
this very offensive, and I want you to stop," he said as the doctor stood 
open-mouthed in front of the television cameras. "We've had enough public 
relations and enough sugar-coating of this issue and quite frankly, as 
governor, I am fed up." In March, Haddox had what he thought was a cordial 
and cooperative meeting with Attorney General Darrell V. McGraw of West 
Virginia to discuss the company's plan to combat drug abuse.

Less than three months later, McGraw filed a lawsuit against Purdue, 
charging the company with "highly coercive and inappropriate tactics to 
attempt to get physicians and pharmacists to prescribe OxyContin and to 
fill prescriptions for OxyContin, often when it was not called for," and 
seeking millions of dollars in compensation for state medical costs.

In the meantime, the lack of co-ordination between Purdue and the 
government agencies that regulate it has had serious repercussions in 
affected communities, as local police, small-town mayors and individual 
doctors and pharmacies have been forced to make up their own policies on 
the fly. Six states -- Florida, Maine, Vermont, West Virginia, Ohio and 
South Carolina -- have introduced regulations making it harder for Medicaid 
recipients to receive OxyContin. After the recent spate of pharmacy 
robberies near Boston, dozens of drug stores in Massachusetts pulled 
OxyContin from their shelves -- only to be ordered by the state pharmacy 
board to begin carrying the drug again.

In the small town of Pulaski, Va., the police have instituted a program in 
which patients picking up OxyContin prescriptions from local pharmacies 
must give their fingerprints, a development that has alarmed civil 
liberties advocates.

Doctors in many states, sometimes fearing reprisals from the D.E.A., have 
refused to prescribe OxyContin even to patients clearly in need.

Purdue's executives see the company as an unwitting victim of criminal 
activity -- not unlike Johnson & Johnson in 1982, when seven people were 
killed by Extra-Strength Tylenol tablets that had been laced with cyanide. 
The company's critics prefer to compare Purdue to tobacco companies and 
handgun manufacturers, who are increasingly likely to be found liable for 
deaths caused by their products.

Clearly, the company failed to anticipate the growing chorus of public 
sentiment against it. And as OxyContin incidents move closer to Washington 
and New York, pressure may increase on the D.E.A. and the F.D.A. to take 
regulatory action against Purdue.

hen I returned to the Gateway rehabilitation Center outside Pittsburgh 
earlier this month, I got a clearer sense of the way in which OxyContin is 
taking hold in urban and suburban America. I also learned about an 
unexpected secondary effect of OxyContin abuse: in cities like Pittsburgh, 
the crackdown on OxyContin is resulting in a sharp rise in heroin abuse.

I sat for an afternoon in a glassed-in conference room, looking out on 
Gateway's parking lot and groomed grounds, and talked with Andy and B., two 
addicts and former low-level dealers.

Before trying OxyContin, they had used their share of recreational drugs, 
but they didn't consider themselves part of a hard-core drug community.

Aside from the track marks on his arms, B., 21, looked like every 
disaffected college kid in America. He was a professional sloucher, dressed 
in an orange T-shirt, Army shorts and sneakers, with a mop of brown hair. 
Andy wore a sparse goatee, a hooded Ecko sweatshirt and a baseball cap with 
a Japanese character on it. I asked him what it meant, and he said he 
didn't know.

B. began using OxyContin in 1998, when a friend told him about the pills.

He soon started dealing to support his habit, buying pills from a dozen or 
so people and then selling them from his apartment to friends and friends 
of friends. His sources were all legitimate pain patients, sick with 
cancer, carpal tunnel syndrome, lupus or chronic back problems.

But, as B. explained, they would often supplement their OxyContin 
prescriptions with something weaker and cheaper, like Vicodin, then sell 
the OxyContin and struggle through the month on Vicodin. "Some of them were 
old sick ladies who've never done drugs," B. said. "They didn't understand 
what oxy can do to people.

They just knew they were getting $20 for each pill -- $1,800 a month off 
something they can do without.

They just wanted that money."

Andy laughed. "Old people are supposed to keep young people off drugs," he 

B. described for me the casual feel of his drug deals.

For the first several months that he was selling OxyContin, he said, 
everything was friendly when he'd go to pick up pills from his suppliers. 
"Most of them would say, 'Hi, honey, come on in.' You go into their house 
and sit down and have something to drink and talk for a while and see how 
their family's doing, and they see how mine's doing.

They were nice people.

I don't think they think of themselves as drug dealers." Nonetheless, B. 
said, his suppliers kept most of the profits; he'd generally buy their 
pills for $20 apiece and then sell them for $25.

About six months ago, B. said, as the police and news media began to sound 
the alarm about OxyContin abuse, local doctors grew anxious.

Many switched their patients to harder-to-abuse fentanyl patches and 
morphine, and B. lost most of his connections. The supply dried up, prices 
rose and people started ripping each other off.

A friend told him that shooting heroin was just like shooting OxyContin, 
only cheaper.

He'd never imagined that he might take heroin, but the expense of OxyContin 
was killing him. "I was spending a hundred bucks a day on oxy," B. said. 
"That's why I switched to heroin.

You get really high off two bags, which is 30 bucks a day. That's a big 

Andy agreed.

It took him only a month and a half to go from using OxyContin for the 
first time to shooting heroin, he said. "I've always said that I'd never 
ever touch heroin.

But then oxys came along and that's the same thing, just cleaner.

And that got me into shooting dope. If I'd never touched OxyContin, I 
wouldn't have done heroin."

In Pittsburgh and its suburbs, Andy and B.'s stories aren't unique. 
Gateway's doctors report a sharp increase in admissions of young heroin 
addicts who started out on OxyContin. "Ninety percent of my friends that 
were addicted to oxys are now addicted to heroin," B. said. "I know 
probably 30 or 40 heroin IV drug users now because of OxyContin."

OxyContin entered the lives of casual drug users as a Trojan horse, 
disguised as something it is not. It has never become a popular drug among 
existing heroin or crack addicts, who already have a cheaper and at least 
as intoxicating mechanism for getting high. OxyContin does the most damage 
when it enters a community of casual drug users -- Curt's pot smokers and 
beer drinkers -- who think of pain pills as just another interesting 
diversion for a Saturday night.

In networks like Curt's or Paula's, before OxyContin, no one ever did 
heroin or crack; those were seen as an entirely different category of drug: 
something that will take over your life.

When you hold it in your hand, an OxyContin pill doesn't seem any different 
than a Tylox or a Percocet or any of the mild narcotic preparations that 
have for years seeped out of the pharmaceutical pipeline and into the lives 
of casual drug users.

What B. and Andy and Paula and Curt failed to realize is that despite 
appearances, OxyContin actually belongs on the other side of the drug 
divide; it might look like a casual Saturday-night drug, but it's a 
take-over-your-life drug. Rehab centers across the country are filling up 
with young people who discovered that fact too late.

To Art Van Zee, the doctor who has seen his small community in western 
Virginia "devastated" by OxyContin abuse, the answer to the crisis is to 
take OxyContin off the market.

Van Zee is circulating a petition asking the F.D.A. and Purdue to withdraw 
the pill until a safer formulation can be found. "The bottom line is, 
there's much more harm being created by this drug being available than 
good," he says. "There are very good medicines available that are equally 

We can certainly meet people's pain needs without OxyContin."

But for many people, "drug communities" like Curt's are not worthy of a 
whole lot of official sympathy or regulatory concern -- especially not when 
their interests are considered next to those of patients in pain, who are 
using OxyContin the way it is meant to be used and whose lives have been 
improved as a result.

For doctors who have seen their patients transformed by OxyContin, there is 
something mystifying, even infuriating, about the suggestion that it should 
be withdrawn or even restricted, just because a bunch of kids in Kentucky 
didn't know what they were snorting.

"There is no question that increasing opioid consumption for legitimate 
medical purposes is going to lead to some increase in the rates of 
addiction," Portenoy of Beth Israel says. "But the fact is, the trade-off 
is worth it. At the moment, the attitude is that if one housewife in 
Alabama becomes addicted, then the drug must be pulled and the company shut 
down. But we're talking about millions of people whose lives can be brought 
back from total disability by the proper use of opioids.

Any actions taken by law enforcement or the regulatory community that 
increase the stigma associated with these drugs, or increase the fear of 
physicians in prescribing these drugs, is going to exacerbate an already 
terrible condition and hurt patients."

The 10th point in Purdue Pharma's 10-point plan to reduce OxyContin abuse 
is reformulation. The company says that it is spending millions of dollars 
to create a new version of OxyContin, or perhaps a whole new medication, 
that would have all the benefits of OxyContin and none of its dangers.

Of all the initiatives under way, this is the one that has received the 
most attention and created the most hope in Appalachia and other affected 

In some interviews, Purdue's representatives sound downright enthusiastic 
about this idea. Earlier this month, they put a price tag -- $50 million -- 
on the project for the first time. But when pressed, Haddox admits that 
what Purdue's scientists are looking for is a "holy grail," a drug that 
will activate the receptors in the brain that control pain relief and leave 
alone those that control euphoria.

And this isn't a new initiative, it turns out, but one that the company has 
been working on for many years.

Scientists and doctors as far back as Hippocrates have tried to find a way 
to separate the benefits of opiates from their dangers.

There are often suggestions from Purdue that this reformulation may take "a 
few years"; it's also entirely possible that it will never happen.

Opioids, including OxyContin, may remain the double-edged sword they have 
always been. And regulators may simply decide to accept a certain amount of 
unintentional damage in the treatment of pain, and leave local police 
chiefs and drug counselors -- as well as individual addicts -- to find 
solutions to the OxyContin problem on their own.

Paul Tough is an editor for The Times Magazine.
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