Was CBC's the fifth estate attack on Oxycontin the whole story?

This is an important additional note posted Feb. 3, 2019. Please read first.

An update on the role of opioids in the management of chronic pain of nonmalignant origin: The fact that opioids can improve the key outcomes in selected patients with chronic nonmalignant pain should not be ignored. A whole range of very serious long-term risks and consequences are, however, beginning to emerge, such as addiction, tolerance, OIH, cognitive disorders, and suppression of the immune and reproductive systems. Much more research is needed regarding the long-term consequences of opioid therapy.
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The Myth of Drug-Induced Addition. Source: Parliament of Canada

Sunday night the fifth estate looked into addiction problems associated with OxyContin, one of the most popular pain relief medications in Canada. The CBC program had a singular point of view: Oxycontin is a highly addictive, potentially deadly narcotic, over prescribed by doctors influenced by the drug manufacturer's erroneous claims of safety.

No big argument there, but is the fifth estate giving us the whole story? As a simple blogger writing from home, it is impossible for me to say. That said, I'm well into my 60s and worked for more than three decades in the media. I saw a lot of one sided stories and learned that many media stories making it into the top ten list had good hooks and played well at first, but, in the end, had little staying power. A lot of drug related stories fall into this slot: Think of the crack babies scare.

W. Joseph Campbell writes: "As I note in my latest book, Getting It Wrong, the crack baby scare was a media-driven myth based more on anecdote than solid, sustained research." It turned out to be, as the New York Times put it in 2009, “the epidemic that wasn’t.' "

My years spent closely working with reporters have left me suspicious of one sided stories. Canadians, the CBC tells us, will ingest possibly 10 million grams of oxycodone, the active ingredient in OxyContin, for pain relief in 2012. That's a lot of oxycodone. With numbers like these, surely there must be something good to be said.

On the growing Oxycontin problem, Campbell quotes the words of a lawyer-politician, the Florida attorney general, who said: "I’m scared to death this will become the crack-baby epidemic." Which, of course, proved to be mostly an epidemic of media hype.

A little more googling turned up this positive story from Karen L. Simon:

I suffered for 20 years with an arthritic hip while being miss-diagnosed with Fibromyalgia. I finally got a doctor who cared enough to order a plain hip x-ray and I was able to get hip replacement surgery.

After the operation, my surgeon said that the femur head was half gone. Without pain medication there is no way I could have had any, I repeat, any kind of life. I was on pain medication for 20 years and went off with no withdrawal symptoms.

Your continued reports on pain medicine abuse simply make it harder for chronic pain patients to get adequate pain medicine. Believe me that if you suffered from pain 24/7, you would require medication. Please, please report on some other better subject.

Ms. Simon is not alone in singing the praises of Oxycontin. Very little searching will turn up hundreds of positive testimonials. What I found very interesting in Simon's story was she claimed to have used pain medication for 20 years without suffering severe withdrawal. Is this possible? The short answer is: Yes.

Let me quote Richard Pacheco of the Harvard Law School, who as a third year law student he wrote a paper on the use and misuse of OxyContin.

"The physical dependence associated with some drugs can be treated by gradually reducing the dosages of the medication to the point where a patient is drug-free and has no withdrawal symptoms or craving"

You may believe Pacheco or not, but be aware that media scare stories to the contrary there are many who agree with Pacheco. And, of course, many who do not.

Still, there are areas of agreement, right? For instance, OxyContin is highly addictive. Some of my quoted sources claimed OxyContin pills when crushed and then snorted or swallowed resulted in  almost immediate addiction, much like heroin. Crush it, snort it, and be left immediately needing to do it again and again. Bing, bang, boom and the addictive boom engulfs the unsuspecting user.

I've read this claim before and alarm bells went off. Immediate addiction, an interesting concept seeing that addiction involves a recurrent failure of control and a continuation of a behaviour with significant destructive consequences. 

It is a lot like reporting something is the first annual. If something has only been done once, it cannot be annual. Many "annual" events fail to be held again and many folk taking "immediately addicting" drugs do not develop an ongoing pattern of abuse.

I can hear the protests to this line of reasoning already. Fine. But a reporter has an obligation to report the whole story and the whole story is that many do not believe in "immediate addiction."

Terms like addiction, dependence, withdrawal are not the neat, clear cut descriptive words many in the media would like us to believe. Read the following from the American Psychiatric Association (APA) discussion of an entry in the upcoming fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM).

"The term dependence is misleading, because people confuse it with addiction, when in fact the tolerance and withdrawal patients experience are very normal responses to prescribed medications that affect the central nervous system," said Charles O’Brien, M.D., Ph.D., chair of the Substance-Related Disorders Work Group. “On the other hand, addiction is compulsive drug seeking behavior which is quite different. We hope that this new classification will help end this wide-spread misunderstanding."

I don't think the media understand that there is a large group of people who would argue that dependence, tolerance and withdrawal are all very normal responses to oxycodone based pain relievers.

One person, claiming to be a legal user of OxyContin, wrote on the Net:

"To keep this within limits I will not get detailed on the benefits of Oxycontin. As you can read on the other forums it works. I take 80mg 3x a day and it works great. Been on it for 5 years now and liver test done last month was excellent.

I am tired of the bad rap this medicine gets though. There are even sites devoted to its removal by people who have lost loved ones who abused the drug. While I feel for these people, no one told anyone abuse this wonderful drug. When taken properly this medicine works excellent with little to no side effects.

It is said that you become dependent on this medicine but it is meant for long term and a good doctor will bring you down properly. So withdrawals should be minimum. This is a true wonder drug."

Let's give the last words to W. Joseph Campbell writing one of his Media Myth Alert posts.

(There is) a tendency among journalists "to neglect or disregard the tentativeness that characterizes serious scientific and biomedical research, and to reach for certainty and definitiveness that are not often found in preliminary findings."

Journalists pushed too hard on thin, preliminary, and sketchy data, and extrapolated rather extravagantly from small numbers of anecdotes. It’s a pattern that tends to repeat itself, as journalists fail to take lessons from misreported drug scares of the past.

"What reporters need to do,” the inestimable media critic Jack Shafer has written, "is challenge their sources in criminal justice, medicine, drug treatment, legislatures, and the user community when they make assertions of fact."

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Some years have passed since writing the above post. I was wrong. This story has legs. In February of this year, 2018, Reuters reported OxyContin maker Purdue Pharma LP slashed its sales force in half and would stop promoting opioids to physicians. This after widespread criticism of the ways that drug-makers marketed potentially addictive painkillers.

Read: The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy. 

I still question the reporting on the opioid crisis but there does seem to be enough blame to go around. Producers, like Purdue, have been forced by the courts to accept some responsibility. Users have always had to shoulder some blame.

But the days of the media slipping by unscathed may be coming to an end. CBC Radio reported, "the media perpetuated the notion that Oxycontin was the problem, the (Canadian) government reacted, Oxycontin was pulled from the market, and the supply was throttled.

"But drug markets are complicated and the notion that a supply line can be simply cut off without something else emerging to take its place is naive." Hence, the appearance of fentanyl and carfentanil. According to Dan Werb, the role of the media is to provide context. The media must dig beneath the surface. Link: Media Coverage Is Making the Opioid Crisis Worse.

Think of Portugal and its unique approach to the universal drug problem. Read: Portugal’s radical drugs policy is working. Why hasn’t the world copied it? This is an in-depth report from The Guardian. We need more stories like this.

According to the article, one critical change was the shift in language. Junkies became known more broadly, more sympathetically, and more accurately, as "people who use drugs" or "people with addiction disorders". This was crucial. In North America we still brand folk as junkies. Maybe there's a story here for the fifth estate.
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Some interesting links:

What Percentage of Chronic Nonmalignant Pain Patients Exposed to Chronic Opioid Analgesic Therapy Develop Abuse/Addiction and/or Aberrant Drug-Related Behaviors? A Structured Evidence-Based Review (Answer: a very small percentage of patients at 3.27%)

Addiction to opioids in chronic pain patients: A literature review (Findings: the prevalence of addiction varied from 0% up to 50% in chronic non‐malignant pain patients, and from 0% to 7.7% in cancer patients depending of the subpopulation studied and the criteria used.)

Most Drug Overdose Deaths from Nonprescription Opioids (This seems to contradict a lot of other posted information but...) The claim is made that the opioid overdose increase had little to do with prescription painkillers such as oxycodone or hydrocodone.
  
Long-term opioid management for chronic noncancer pain. Reviewed 26 studies with 27 treatment groups with a total enrollment of 4893 participants. Serious adverse events, including iatrogenic opioid addiction, were rare. One caveat: This study is almost a decade old.

But all studies are not positive: A Review of Potential Adverse Effects of Long-Term Opioid Therapy: A Practitioner’s Guide.

• Increasing numbers of deaths are due to opioid overdose among patients prescribed long-term opioid therapy to manage chronic pain.
• Opioid therapy can adversely affect respiratory, gastrointestinal, musculoskeletal, cardiovascular, immune, endocrine, and central nervous systems.
• The higher the daily dose of prescribed opioid, the higher the risk of overdose and other significant problems such as fractures, addiction, intestinal blockages, and sedation.
• Physicians and patients are encouraged to weigh the full spectrum of medical risks against a realistic assessment of observed benefits for pain.

Yes, this is a complicated story. It is too bad that, for the most part, the media hates complicated stories.