ADVISORY Breaking News for the Treatment Field

OxyContin®:
April 2001, Volume 1, Issue 1

Prescription Drug Abuse

OxyContin® Frequently
Asked Questions From the CSAT Director
by H. Westley Clark, M.D., J.D., M.P.H., CAS, FASAM

Q: What Is OxyContin? Recently, the media have issued numerous reports

about the apparent increase in OxyContin® abuse
A: OxyContin is a semisynthetic opioid analgesic and addiction. These reports have included the
prescribed for chronic or long-lasting pain. The following:
medication’s active ingredient is oxycodone, which
is also found in drugs like Percodan and Tylox. • An alliance of hospitals in the greater Cincinnati
However, OxyContin contains between 10 and area has restricted the use of OxyContin to can-
160 milligrams of oxycodone in a timed-release cer patients, although exceptions will be granted.
tablet. Painkillers such as Tylox contain 5 milligrams The new policy calls for using other pain med-
of oxycodone and often require repeated doses to ications with less potential for abuse.1
bring about pain relief because they lack the timed- • A treatment facility in southwest Virginia
release formulation. received Federal and State approval to provide
methadone treatment in December 1999.
Q: How Is OxyContin Used? Halfway through the licensure process, staff
began receiving telephone calls from people
A: OxyContin, also referred to as “Oxy,” “O.C.,” seeking information about OxyContin addiction.
and “killer” on the street, is legitimately prescribed Recently, 80 percent of the 290 people in this
as a timed-release tablet, providing as many as 12 outpatient treatment program named OxyContin
hours of relief from chronic pain. It is often as their primary drug of abuse.2
prescribed for cancer patients or those with chronic,
long-lasting back pain. The benefit of the • Pharmacies and homes in some rural areas have
medication to chronic pain sufferers is that they been robbed by individuals seeking OxyContin. 3
generally need to take the pill only twice a day, • Maine, one of the first States to report the
whereas a dosage of another medication would increase in OxyContin abuse, is the second
require more frequent use to control the pain. The largest consumer of OxyContin in the United
goal of chronic pain treatment is to decrease pain States.4
and improve function.
These reports may reflect some of your own experi-
ences: We know many of you are actually treating
...continued on page 4 patients addicted to OxyContin.

...continued on page 3

continued on reverse...
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Center for Substance Abuse Treatment
www.samhsa.gov
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OxyContin ® is a powerful drug that contains a much larger amount of the active ingredient, oxycodone, than other
prescription opiate pain relievers. While 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 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 will be any less likely to benefit from medication-assisted treatment
than the patient addicted to heroin.
Some opioid-addicted patients with very good social supports may occasionally be able to benefit from antagonist
maintenance with naltrexone. This treatment works best if the patient is highly motivated to participate in treatment and
has been adequately detoxed from the opioid of abuse. Most opioid-addicted patients in outpatient therapy, however, will
do best with medication that is either
an agonist or a partial agonist.
CSAT Advisory Methadone and levo alpha acetyl-
Editor: Edwin M. Craft, Dr. P.H., LCPC, Center for Substance Abuse Treatment methadol (LAAM) are the two agonist
medications currently approved for
Managing Editor: Cheryl L. Serra, Johnson, Bassin & Shaw, Inc.
addiction treatment in this country.
Associate Editor: Liz Zylwitis, Johnson, Bassin & Shaw, Inc.
Presently there is no partial agonist
Design and Layout: Sharon Hodgson, Johnson, Bassin & Shaw, Inc. approved by the Food and Drug
For further information or to request information about the CSAT Advisory, please Administration (FDA) for use in
contact Edwin M. Craft, Editor, at [email protected]. narcotic treatment, although
buprenorphine holds great promise.
The CSAT Advisory was written and produced by the Center for Substance Abuse
Treatment’s (CSAT’s) Knowledge Application Program (KAP), a Joint Venture of The guidelines for treating OxyContin
Johnson, Bassin & Shaw, Inc., and The CDM Group, Inc. CSAT is a center within the addiction or dependency are basically
Substance Abuse and Mental Health Services Administration (SAMHSA), U.S.
no different than the guidelines the
Department of Health and Human Services (DHHS). This publication was produced
under contract number 270–99–7072. Center for Substance Abuse Treatment
(CSAT) uses for treating addiction or
A fully referenced version of the CSAT Advisory is available on CSAT’s Web site: dependency to ANY opioid. There is
www.samhsa.gov/csat/csat.htm. Feel free to reproduce additional copies or reference
one important thing to remember,
this publication; citation of the source is appreciated. The CSAT Advisory is designed
to relay information that has significant and immediate impact on patients seeking
however: Because OxyContin contains
alcohol or substance abuse treatment. The publication will be distributed to alcohol or higher dose levels of opioid than are
substance abuse treatment providers and other interested individuals on an as-needed typically found in other oxycodone-
basis. containing pain medications, higher
Suggested citation for the CSAT Advisory: Center for Substance Abuse Treatment. ...continued on page 6
OxyContin®: Prescription Drug Abuse. CSAT Advisory. Volume 1, Issue 1, April 2001.

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From the Director

...continued from front cover

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 recent controversy will mean tighter restrictions
on the drug. Abusers will 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 tak-
ing medically prescribed OxyContin to manage pain and are concerned about their physical dependence on the medication.
Perhaps you will be faced with a young adult who thought that OxyContin was a “safe” recreational drug because, after all, doc-
tors 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 abusers are
young adults unaware of the dangers of OxyContin. Many of these individuals mix OxyContin with alcohol and other 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, however, is the potency of the drug. Treatment providers in
affected areas say that they were unprepared for the speed with which an OxyContin “epidemic” has 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 first
issue of the CSAT Advisory will 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 a referral source for further information: www.samhsa.gov
• Introducing you to our Substance Abuse Treatment Facility Locator, an online database that can assist you in
making referrals to treatment facilities.
For more information about OxyContin abuse and treatment, please see our resources boxes on pages 5 and 7, and the back
cover. Please also feel free to copy any of the articles in the CSAT Advisory and share them with colleagues so that they, too,
may have the most current information about this critically important topic. n

Notes
1. Bonfield, Tim, “OxyContin users wary of backlash,” Cincinnati Enquirer , February 26, 2001, retrieved March 2, 2001, from the World Wide Web,
www.enquirer.com/editions/2001/02/26/loc_oxycontin_users_wary.html.
2. Tina Renee Bullins, CEO, Life Center of Galax, interview by Cheryl Serra, March 2, 2001.
3. Roch, Timothy, “The potent perils of a miracle drug.” Time, February 28, 2001.
4. Ibid.

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OxyContin Frequently Asked Questions

...continued from front cover

Q: How Is OxyContin Abused? made in the illegal sale of OxyContin. A 40-milligram pill
costs approximately $4 by prescription, yet it may sell for
A: OxyContin abusers either crush the tablet and ingest $20 to $40 on the street, depending on the area of the
or snort it or dilute it in water and inject it. Crushing or
country in which the drug is sold.1
diluting the tablet disarms the timed-release action of the
medication and causes a quick, powerful high. Abusers OxyContin can be comparatively inexpensive if it is
have compared this feeling to the euphoria they experience legitimately prescribed and if its cost is covered by
when taking heroin. In fact, in some areas, the use of insurance. However, the National Drug Intelligence Center
heroin is overshadowed by the abuse of OxyContin. reports that OxyContin abusers may use heroin if their
insurance will no longer pay for their OxyContin
Purdue Pharma, OxyContin’s manufacturer, has taken prescription, because heroin is less expensive than
steps to reduce the potential for abuse of the medication.
OxyContin that is purchased illegally. 2
Its Web site lists the following initiatives aimed at curbing
the illicit use of OxyContin: providing physicians with
tamper-proof prescription pads, developing and Q: Why Are So Many Crimes Reportedly Associated
distributing more than 400,000 brochures to send to With OxyContin Abuse?
pharmacists and healthcare professionals to help educate A: Many reports of OxyContin abuse have occurred in
them about how to prevent diversion, working with rural areas that have housed labor-intensive industries,
healthcare and law enforcement officials to address the such as logging or coal mining. These industries are often
problem of prescription drug abuse, and helping to fund a located in economically depressed areas, as well.
study of the best practices in Prescription Monitoring Therefore, people for whom the drug may have been
Programs. In addition, the company is attempting to legitimately prescribed may be tempted to sell their
research and develop other pain management products that prescriptions for profit. Substance abuse treatment
will be more resistant to abuse and diversion. The providers say that the addiction is so strong that people
company estimates that it will take significant time for will go to great lengths to get the drug, including robbing
such products to be brought to market. For more pharmacies and writing false prescriptions.
information, visit Purdue Pharma’s Web site at
www.purduepharma.com or call them at 203–588–8069.
Q: What Is the Likelihood That a Person for Whom
OxyContin Is Prescribed Will Become Addicted?
Q: How Does OxyContin Abuse Differ From Abuse
of Other Pain Prescriptions? A: Most people who take OxyContin as prescribed do not
become addicted. The National Institute on Drug Abuse
A: Abuse of prescription pain medications is not new. (NIDA) reports: “With prolonged use of opiates and
Two primary factors, however, set OxyContin abuse apart opioids, individuals become tolerant…require larger doses,
from other prescription drug abuse. First, OxyContin is a and can become physically dependent on the drugs....
powerful drug that contains a much larger amount of the Studies indicate that most patients who receive opioids for
active ingredient, oxycodone, than other prescription pain pain, even those undergoing long-term therapy, do not
relievers. By crushing the tablet and either ingesting or become addicted to these drugs.”3
snorting it, or by injecting diluted OxyContin, abusers feel
the powerful effects of the opioid in a short time, rather One NIDA-sponsored study found that “only four out of
than over a 12-hour span. Second, great profits are to be more than 12,000 patients who were given opioids for

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OxyContin Frequently Asked Questions

acute pain actually became addicted to the drugs…. addiction. A gradual decrease of the medication dose over
In a study of 38 chronic pain patients, most of whom time, as the pain is resolving, brings the former pain patient
received opioids for 4 to 7 years, only 2 patients actually to a drug-free state without any craving for repeated doses
became addicted, and both had a history of drug abuse.”4 of the drug. This is the difference between the formerly
dependent pain patient who has now been withdrawn from
In short, most individuals who are prescribed OxyContin, or
medication and the opioid-addicted patient: The patient
any other opioid, will not become addicted, although they
addicted to diverted pharmaceutical opioids continues to
may become dependent on the drug and will need to be
have a severe and uncontrollable craving that almost always
withdrawn by a qualified physician. Individuals who are
leads to eventual relapse in the absence of adequate
taking the drug as prescribed should continue to do so, as
treatment. It is this uncontrollable craving for another “rush”
long as they and their physician agree that taking the drug is
of the drug that differentiates the “detoxified” but opioid-
a medically appropriate way for them to manage pain.
addicted patient from the former pain patient. Theoretically,
an opioid abuser might develop a physical dependence, but
Q: How Can I Determine Whether a User Is obtain treatment in the first few months of abuse, before
Dependent on Rather Than Addicted to OxyContin? becoming addicted. In this case, supervised withdrawal
(detoxification) followed by a few months of abstinence-
A: When pain patients take a narcotic analgesic as
oriented treatment might be sufficient for the nonaddicted
directed, or to the point where their pain is adequately
patient who abuses opioids. If, however, this patient
controlled, it is not abuse or addiction. Abuse occurs when
patients take more than is needed for pain control, especially ...continued on page 6
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. Treatment Improvement
If a patient continues to seek excessive pain medication after Protocols (TIPs) Addressing
pain management is achieved, the patient may be addicted. Opioid Addiction Treatment
Addiction is characterized by the repeated, compulsive use
of a substance despite adverse social, psychologic, and/or TIP 1 State Methadone Treatment Guidelines
physical consequences. Addiction is often (but not always) BKD98
accompanied by physical dependence, withdrawal
syndrome, and tolerance. Physical dependence is defined as TIP 19 Detoxification From Alcohol and
a physiologic state of adaptation to a substance. The absence Other Drugs BKD172
of this substance produces symptoms and signs of
withdrawal. Withdrawal syndrome is often characterized by TIP 20 Matching Treatment to Patient Needs
overactivity of the physiologic functions that were in Opioid Substitution Therapy
suppressed by the drug and/or depression of the functions BKD168
that were stimulated by the drug. Opioids often cause
sleepiness, calmness, and constipation, so opioid withdrawal TIP 22 LAAM in the Treatment of Opiate
often includes insomnia, anxiety, and diarrhea. Addiction BKD170
Pain patients, however, may sometimes develop a physical See back cover for ordering information.
dependence during treatment with opioids. This is not an

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OxyContin Frequently Asked Treatment and Detoxification

Questions Protocols
...continued from page 5 ...continued from page 2

subsequently relapses to opioid abuse, then that would dosages of methadone may be needed to appropriately
support a diagnosis of opioid addiction. After several treat patients who abuse OxyContin.
relapses to opioid abuse, it becomes clear that a patient will
require long-term treatment for the opioid addiction. Methadone or LAAM may be used for OxyContin
(Please see the section of this CSAT Advisory titled addiction treatment or, for that matter, treatment for
Treatment and Detoxification Protocols on page 2 to learn addiction to any other opioid, including the semi-
more about treatment options.) synthetic opioids. This is not a new treatment
approach. For instance, Alaska estimates that there
Q: I Work at a Facility That Does Not Use are 15,000 prescription opioid abusers in the State
Medication-Assisted Treatment. What Treatment and that most methadone patients are not heroin-
Should I Provide to Individuals Addicted to or addicted individuals. In addition, a significant
Dependent on OxyContin? percentage of patients in publicly supported
methadone programs were not being treated for
A: The majority of U.S. treatment facilities do not heroin addiction but for abuse of semisynthetic
offer medication-assisted treatment. However, due to the opioids (e.g., hydrocodone).The Substance Abuse and
strength of OxyContin and its powerful addiction Mental Health Services Administration Drug Abuse
potential, medical complications may be increased by
Warning Network emergency room data show that
quickly withdrawing individuals from the drug.
both oxycodone and hydrocodone mentions increased
Premature withdrawal may cause individuals to seek
heroin, and the quality of that heroin will not be known. dramatically between 1990 and 1999. 1 And when
In addition, these individuals, if injecting heroin, may Arkansas opened its first methadone maintenance
also expose themselves to HIV and hepatitis. Most clinic in December 1993, the vast majority of its
people addicted to OxyContin need medication-assisted clients were not admitted for heroin addiction, but
treatment. Even if individuals have been taking for semisynthetic opioid abuse. These individuals
OxyContin legitimately to manage pain, they should not had been traveling to other States because methadone
stop taking the drug all at once. Instead, their dosages treatment was not available near their homes.
should be tapered down until medication is no longer Using the criteria on page 5 of this CSAT Advisory
needed. If you work in a drug-free or abstinence-based
describing the difference between addiction to and
treatment facility, it is important to refer patients to
dependence on OxyContin, you may be able to
facilities where they can receive appropriate treatment.
(See SAMHSA Resources, page 7.) n determine if a patient requires treatment for opioid
addiction. If this is the case, methadone may be used
for withdrawal. For certain patient populations,
Notes including those with many treatment failures,
1. National Drug Intelligence Center, “Information Bulletin: OxyContin methadone is the treatment of choice.2
Diversion and Abuse,” retrieved March 7, 2001, from the World Wide
Web, www.usdoj.gov/ndic/pubs/651/index.htm. “As substance abuse treatment professionals, we have
2. Ibid.
3. National Institute on Drug Abuse, “Pain Medications: 13553,” retrieved the responsibility for learning as much as we can about
February 15, 2001, from the World Wide Web, 165.112.78.61/Infofax/ OxyContin, and then providing appropriate treatment
PainMed.html.
4. Ibid.
for people addicted to it. Appropriate treatment will

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nearly always involve prescribing methadone, or in some cases, LAAM,” says H. Westley Clark, M.D., J.D., Director
of the Center for Substance Abuse Treatment. “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 LAAM to
determine if an individual is eligible for this type of treatment and if 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:
“...we have the responsibility for
• Determining the need for emergency care learning as much as we can
• Diagnosing the presence and severity of about OxyContin,
opioid dependence and then providing appropriate
treatment for people who are
• Determining the extent of alcohol and drug
abuse
addicted to it.”
• Screening for comorbid medical and H. Westley Clark, M.D., J.D.,
psychiatric conditions Director, CSAT

• Evaluating an individual’s living situation, family and social problems, and legal problems.3 n

SAMHSA Resources
To find a substance abuse treatment
facility near you, see the Substance
Abuse Treatment Facility Locator on the
Notes
drop-down menu titled “CSAT Data
1. Sowder, Barbara, and Beschner, George, “Heroin Use in the United States: A
Working Paper” (unpublished), The CDM Group.
Resources” on CSAT’s Web site,
www.samhsa.gov/centers/csat/csat.html .
2. Center for Substance Abuse Treatment (CSAT), Detoxification From Alcohol and
Other Drugs, Treatment Improvement Protocol (TIP) Series, Number 19, DHHS Call the CSAT Substance Abuse
Pub. No. (SMA) 00–3404, Rockville, MD: CSAT, pp. 22 and 23, 2000. Treatment Hotline at 1–800–662–HELP
3. CSAT, Matching Treatment to Patient Needs in Opioid Substitution Therapy, TIP for substance abuse treatment referral
19, DHHS Pub. No. (SMA) 95–3049, Rockville, MD: CSAT, pp. 17 and 18, information.
1995.

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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: sims.health.org/Admins/default.asp
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

There Are Three Ways To Obtain Free Copies of All TIP Products

1. Call SAMHSA’s NCADI at 800–729–6686; TDD (hearing impaired) 800–487–4889.

2. Visit NCADI’s Web site, www.samhsa.gov/centers/clearinghouse/clearinghouses.html.

3. Access TIPs online at SAMHSA’s Web site, www.samhsa.gov/csat/csat.htm.

DHHS Publication No. (SMA) 02–3636

NCADI Publication No. MS726
Substance Abuse and Mental Health Services Administration
Printed 2001
Reprinted 2002