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How Much Does It Hurt?

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An anti-Zohydro rally at the Massachusetts State House on April 29.  

As a result, Americans consume 80 percent of the global opioid supply. “In most of Europe, it isn’t like physicians don’t prescribe opioids,” says Michael Von Korff of the Seattle-based Group Health Research Institute. “But they do it very cautiously, very selectively, and at low doses, and they don’t seem to be having the same problems we’re having here.”

The dramatic American embrace of painkillers in some ways begins with the distinction between acute and chronic pain. The former refers to the sudden, intense, and usually short-lived pain associated with a discrete event—surgery, a broken arm, getting your wisdom teeth pulled; it’s the kind of pain that typically requires a short course of painkilling medication, and virtually no one in the medical community disputes the utility of opioid drugs in this setting. Chronic pain, however, is an alternative universe of torment; if pain is, as C. S. Lewis once said, God’s megaphone, then chronic pain is a megaphone with a different kind of volume knob—incapacitating, demoralizing, life-altering. Among the more common causes are lower-back pain, migraine headaches, osteoarthritis, and fibromyalgia, a diffuse form of musculoskeletal pain, as well as cancer. As one patient told the FDA when it was considering Zohydro, his pain became so intense that “I told my doctor, ‘Either find me a tall building to jump off or something to help me with my pain.’ ”

But pain is very difficult to quantify for both subjective and psychological reasons. There’s no objective instrument to measure pain; patients typically rate their own (usually on a scale of zero to ten), but there is clearly a psychological component to its perception because, as FDA officials have pointed out, upwards of 40 percent of patients who take part in clinical trials report pain relief when given a sugar pill. For a long time, doctors shied away from using opioid painkillers for chronic pain, fearing the long-term side effects. In 1986, two doctors then at Memorial Sloan-Kettering Cancer Center, Russell Portenoy and Kathleen Foley, reported in the journal Pain that long-term opioid use in several dozen chronic-pain patients provided “safe, salutary, and more humane” treatment for non-cancer pain; the majority of patients said they achieved satisfactory pain relief, and the researchers reported very little risk of addiction (two patients out of 38, both with a prior history of drug abuse). It was the avatar of a message that would gain strength in the 1990s: Doctors were being excessively cautious about the use of narcotic painkillers, especially in cancer patients facing end-stage disease. A new, derogatory word trickled into the medical vocabulary: opiophobic.

In 1996, Purdue Pharma introduced OxyContin, an extended-release version of oxycodone for chronic-pain patients; it contained up to 80 milligrams of oxycodone (Zohydro contains up to 50 milligrams of hydrocodone, which many physicians believe is less potent and addictive than oxycodone). In marketing its product, Purdue deliberately downplayed the risk of addiction. Purdue Frederick Co. (part of the pharmaceutical company) and three company executives would later admit to federal charges of “falsely claiming that OxyContin was less addictive, less subject to abuse, and less likely to cause withdrawal symptoms than other pain medication.” (The company agreed to pay a staggering $634 million fine.)

That part about it being less addictive? Not quite true. “An opioid is an opioid is an opioid,” says Lewis Nelson, an NYU professor and attending physician in the emergency medical department at Bellevue hospital. “Heroin is illegal; oxycodone, hydrocodone, hydromorphone are all just legal versions of the illegal drug heroin from an end-user’s perspective.” And in part because of the ready availability of opioid painkillers, the National Institute on Drug Abuse estimates that 1.9 million Americans have become addicted to prescription painkillers.

In November 2011, the Centers for Disease Control and Prevention confirmed an “epidemic” with damning statistics showing that rates of opioid prescription, addiction, and fatal overdose rose virtually in lockstep since the late 1990s. “By 2010,” the CDC reported, “enough [opioid painkillers] were sold to medicate every American adult with a typical dose of 5-mg. of hydrocodone every four hours for one month.”

If there was a modest bright spot, it was that Purdue Pharma introduced a tamper-resistant formulation of OxyContin in August 2010; anyone trying to crush the pills to abuse the drug would end up with a gooey, uninjectible gel. Such measures seemed to discourage drug abusers from using the long-acting painkiller with its big payload of narcotic: A 2012 report in the New England Journal of Medicine documented a dramatic decline in OxyContin use among drug abusers after the change. But the report also detected an early hint of an ominous trend. Hooked on opioids, drug abusers began to move on to a cheaper and more plentiful alternative: heroin.


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