black beauties, gorilla pills, footballs

Transcription

1ROWN, DEMBO, LEUKEFELD
© 2009 BY THE JOURNAL OF DRUG ISSUES
BLACK
BEAUTIES,
GORILLA
PILLS,
FOOTBALLS,
AND HILLBILLY
HEROIN : SOME REFLECTIONS ON
PRESCRIPTION
DRUG
ABUSE
AND
DIVERSION
RESEARCH OVER THE PAST 40 YEARS
JAMES A . INCIARDI, THEODORE J . CICERO
Although the problem of prescription drug abuse has endured for well over two
centuries, research into the abuse and diversion of these drugs has been relatively
recent. The first general population survey to document the abuse of prescription
medications occurred in 1970, and subsequent studies demonstrated that the
abuse and diversion of amphetamines, opioids, and sedatives has continued
to be widespread. During the 1980s and much of the 1990s, prescription drug
abuse took a back seat to other more pressing concerns : ifreebasei and powder
cocaine, the cocaine wars, crack and sex-for-crack exchanges, rising rates of drugrelated street crime, and HIV/AIDS among injection and non-injection drug users.
However, recent surveys suggest that the current outbreak of prescription drug
abuse began during the early to mid-1990s . Although the abuse and diversion of
prescription drugs was clearly an evolving problem, what seemed to galvanize the
attention of the media, the government, and the public at large was OxyContin''
Currently, there is no question that the problems of prescription drug abuse and
diversion continue to grow. Why this is so, however, is open to speculation .
Perhaps the reason lies in the increasing numbers of prescription drugs that are
being legally marketed. Or perhaps . the popularity of prescription drugs is rooted in
the beliefs that they are more acceptable, less dangerous, and less subject to legal
consequences than are illicit drugs .
James A. Inciardi, Ph .D ., is the Co-Director of the Center for Drug and Alcohol Studies at the
University of Delaware, and is the author of more than 450 articles, chapters, and books in the areas
of substance abuse, criminology, criminal justice, history, folklore, public policy, HIV/AIDS, medicine,
and law. Theodore J. Cicero, Ph .D ., a Professor in Psychiatry at Washington University School of
Medicine, has a 40-year long interest in two aspects of substance abuse : the neurobiological and
neuroendocrinological substrates of tolerance and dependence ; and studies in humans directed at the
abuse of prescription opioid analgesics.
INCIARDI, CICERO
REFLECTIONS ON PRESCRIPTION DRUG ABUSE
INTRODUCTION
be familiar with his contributions, in many ways he was a pioneer-a
and innovator in the field of substance abuse research . Years bef
National Household Survey on Drug Abuse was launched, for exampl
designed and fielded the first general population survey of drug abuse,
in New York, and it paved the way for National Institute on Drug Abu
National Household and Monitoring the Future studies . Chambers
general population survey was the first to empirically document that
drug abuse and diversion were problems that needed to be addressed
1971) .
Chambers' subsequent work focused on the abuse and diversion of
drugs : pentazocine (Talwin®), propoxyphene (Darvon®), am
barbiturate-sedatives, and methadone . Not surprisingly, he made a 1
along the way . First there were the pharmaceutical companies whose c
writing about (Chambers, Inciardi, Petersen, Siegal, & White, 1987) .
Third National Conference on Methadone Treatment in New York C
a number of the methadone maintenance matriarchs and patriarchs
entire two-hour session to Chambers' work, endlessly castigating hin
introduced such terms as "supplementation," "cheating," and "diversi
methadone literature . Supplementation referred to increasing the maint
of methadone to get high ; cheating referred to abusing cocaine during I
therapy; diversion referred to a patient's participation in more than on(
program and selling the excess on the street (Chambers & Brill, 1973
Taylor, & Moffett, 1972) .
Chambers also mentored a number of researchers who, to some e,,
follow in his footsteps : Jim Inciardi, Dave Petersen, Dick Stephens,
Harvey Siegal. The near-epidemic abuse of methaqualone and the ampl
the 1970s led to increased focus on the prescription drug problem, and
body of scientific literature began to develop, yet it was Chambers wl
it all going.
During the 1980s and much of the 1990s, however, prescription drug
a back seat to other more pressing concerns . "Freebase" and powder c
major concerns, with the attendant cocaine wars in Florida, Latin Amel
Caribbean instigated by Colombia's Medellin and Cali cartels . In innc
houses across the nation, crack and the sex-for-crack exchanges appea
1993) . Rates of drug-related street crime rose as did the violence ass(
drug gang wars over control of emerging crack markets . The occurrei
AIDS among injection drug and crack users became a concern and was
early attempts to understand the phenomenon and develop effective sc
If anything has been learned about the drug problem in the United States, it is
that patterns of drug-taking and drug-seeking are continually shifting and changing .
Fads and fashions in the drugs of abuse seem to come and go . Drugs of choice emerge
and then disappear from the American drug scene. Still others are rediscovered,
reinvented, revitalized, repackaged, recycled, and become permanent parts of the
landscape . As new drugs of abuse become visible, concomitant media and political
feeding frenzies call for a strengthening of the "war on drugs ." There was heroin
in the 1950s ; marijuana, amphetamines (black beauties), and LSD in the 1960s ;
Quaaludes ®, barbiturates (gorilla pills), and PCP in the 1970s ; and crack and other
forms of cocaine in the 1980s and 1990s . And then came Vicodin®, OxyContin®
(hillbilly heroin), and Xanax ® (footballs), which gained attention during the latter
1990s and the opening years of the twenty-first century . But where did it all begin?
With the prescription drugs, perhaps it goes back to the early part of the 18th
century with Thomas Dover, a student of British physician Thomas Sydenham,
considered the "father" of clinical medicine, and strong advocate of the use of
opium for the treatment of disease . Following in the path of his mentor, Dover
developed a form of medicinal opium . Known as Dover's Powder, it contained
one ounce each of opium, ipecac (the dried roots of a tropical creeping plant), and
licorice, combined with saltpeter, tartar, and wine . Dover's Powder was introduced
in 1709 and soon made its way to America, where it remained one of the most
widely used opium preparations for almost two centuries (Inciardi, 2008 ; Souhami,
2001 ; Terry & Pellens 1928 ) .
Although opium had been a popular narcotic for thousands of years, the attraction
of Dover's Powder was in the euphoric and anesthetic properties of opium . The
introduction of Dover's Powder apparently started a trend . By the latter part of
the eighteenth century, similar patent medicines containing opium were readily
available throughout urban and rural America. They were sold in pharmacies,
grocery and general stores, at traveling medicine shows, and through the mail
(Terry & Pellens, 1928) . This patent medicine industry eventually provided the
backdrop for the abuse of prescription drugs and other pharmaceuticals (Inciardi,
2008) .
THE EARLY DAYS
Our introduction to the study of prescription drug abuse and diversion emerged
during the late 1960s and early 1970s, with much of it coming from the work of
the late Carl D . Chambers, who at the time was Director of Research for the New
York State Narcotic Addiction Control Commission . Although few members of
the newer generations of drug abuse researchers are likely to know him, or even
1 02
JOURNAL OF DRUG ISSUES
FALL 2009
tg has been learned about the drug problem in the United States, it is
:)f drug-taking and drug-seeking are continually shifting and changing .
Lions in the drugs of abuse seem to come and go . Drugs of choice emerge
rppear from the American drug scene . Still others are rediscovered,
evitalized, repackaged, recycled, and become permanent parts of the
s new drugs of abuse become visible, concomitant media and political
.ies call for a strengthening of the "war on drugs ." There was heroin
marijuana, amphetamines (black beauties), and LSD in the 1960s ;
barbiturates (gorilla pills), and PCP in the 1970s ; and crack and other
aine in the 1980s and 1990s . And then came Vicodin ®, OxyContin®
)in), and Xanax ® (footballs), which gained attention during the latter
opening years of the twenty-first century . But where did it all begin?
prescription drugs, perhaps it goes back to the early part of the 18th
Thomas Dover, a student of British physician Thomas Sydenham,
ie "father" of clinical medicine, and strong advocate of the use of
e.. treatment of disease . Following in the path of his mentor, Dover
form of medicinal opium . Known as Dover's Powder, it contained
ch of opium, ipecac (the dried roots of a tropical creeping plant), and
bined with saltpeter, tartar, and wine . Dover's Powder was introduced
soon made its way to America, where it remained one of the most
opium preparations for almost two centuries (Inciardi, 2008 ; Souhami,
i Pellens 1928 ).
opium had been a popular narcotic for thousands of years, the attraction
owder was in the euphoric and anesthetic properties of opium . The
of Dover's Powder apparently started a trend . By the latter part of
h century, similar patent medicines containing opium were readily
)ughout urban and rural America . They were sold in pharmacies,
general stores, at traveling medicine shows, and through the mail
lens, 1928) . This patent medicine industry eventually provided the
the abuse of prescription drugs and other pharmaceuticals (Inciardi,
YS
luction to the study of prescription drug abuse and diversion emerged
:e 1960s and early 1970s, with much of it coming from the work of
3 . Chambers, who at the time was Director of Research for the New
arcotic Addiction Control Commission . Although few members of
ierations of drug abuse researchers are likely to know him, or even
be familiar with his contributions, in many ways he was a pioneer-a trailblazerand innovator in the field of substance abuse research . Years before the first
National Household Survey on Drug Abuse was launched, for example, Chambers
designed and fielded the first general population survey of drug abuse . It was done
in New York, and it paved the way for National Institute on Drug Abuse's (NIDA)
National Household and Monitoring the Future studies . Chambers' New York
general population survey was the first to empirically document that prescription
drug abuse and diversion were problems that needed to be addressed (Chambers,
1971) .
Chambers' subsequent work focused on the abuse and diversion of prescription
drugs : pentazocine (Talwin®), propoxyphene (Darvon®), amphetamines,
barbiturate-sedatives, and methadone . Not surprisingly, he made a few enemies
along the way. First there were the pharmaceutical companies whose drugs he was
writing about (Chambers, Inciardi, Petersen, Siegal, & White, 1987) . Then, at the
Third National Conference on Methadone Treatment in New York City in 1970,
a number of the methadone maintenance matriarchs and patriarchs devoted an
entire two-hour session to Chambers' work, endlessly castigating him for having
introduced such terms as "supplementation," "cheating," and "diversion" into the
methadone literature . Supplementation referred to increasing the maintenance dose
of methadone to get high ; cheating referred to abusing cocaine during maintenance
therapy ; diversion referred to a patient's participation in more than one methadone
program and selling the excess on the street (Chambers & Brill, 1973 ; Chambers,
Taylor, & Moffett, 1972) .
Chambers also mentored a number of researchers who, to some extent, would
follow in his footsteps : Jim Inciardi, Dave Petersen, Dick Stephens, and the late
Harvey Siegal . The near-epidemic abuse of methaqualone and the amphetamines in
the 1970s led to increased focus on the prescription drug problem, and a significant
body of scientific literature began to develop, yet it was Chambers who really got
it all going .
During the 1980s and much of the 1990s, however, prescription drug abuse took
a back seat to other more pressing concerns . "Freebase" and powder cocaine were
major concerns, with the attendant cocaine wars in Florida, Latin America, and the
Caribbean instigated by Colombia's Medellin and Cali cartels . In inner-city crack
houses across the nation, crack and the sex-for-crack exchanges appeared (Ratner,
1993) . Rates of drug-related street crime rose as did the violence associated with
drug gang wars over control of emerging crack markets . The occurrence of HIV/
AIDS among injection drug and crack users became a concern and was followed by
early attempts to understand the phenomenon and develop effective science-based
FALL 2009
103
INCIARDI, CICERO
interventions . During those years, little attention could be focused on prescription
drug abuse .
System (ARCOS), which measures the retail distribution of pain medic
grams, found substantial increases in the medicinal use of morphine (i
fentanyl (1,168%), oxycodone (23%), and hydromorphone (19%) . Subs
the period of 1997 to 1 2001 demonstrated increases in the retail distril
oxycodone (up--348%), morphine (49%), and fentanyl (151%) (Joransl
Ryan, K.M., & Gilson, A.M . et al ., 2000 ; Novak, S ., Nemeth, WC ., Laws
2004) . One could argue that these increases served as a catalyst for the ii
abuse, dependence, and diversion of prescription opioids .
At the same time, national data suggested that the abuse of many
prescription drugs had been escalating since the early to mid-1990s . The
Survey of Drug Use and Health found that the numbers of new nonmedi
of prescription opioids (primarily products containing codeine, hydrocod
oxycodone) increased from 600,000 in 1990 to over 2 .4 million in 2004,
it as the drug category with the largest number of new users in 2004 (S
Abuse and Mental Health Services Administration, 2005) . In addition
from the Drug Abuse Warning Network indicated that abuse-related en
department (ED) visits involving narcotic analgesics increased by 15 :
1995 through 2002, and during the same period, abuse-related ED visits i
benzodiazepines increased by 41 % (Substance Abuse and Mental Health
Administration, & Office of Applied Studies, 2004a, 2004b) . Similar i
were reflected in data on drug abuse treatment admissions .
Although the abuse and diversion of prescription drugs was clearly an
problem, OxyContin® galvanized the attention of the media, the governn
the public at large . When the drug was first introduced in 1996, it was hr
breakthrough in pain management . The medication is unique in that its tim~
formula allows patients to enjoy continuous, long-term relief from mo,
severe pain, but the honeymoon period for the drug turned out to be quite
Abuse of OxyContin® first surfaced in rural Maine, soon spreading along
coast and Ohio Valley, and then into rural Appalachia . Communities in
Virginia, eastern Kentucky, West Virginia, and southern Ohio were e ;
hard hit, and a number of factors characteristic of these areas seemed to
with the apparent high rates of abuse (Inciardi & Goode, 2003) . Aspec
culture in northern Maine and rural Appalachia are markedly different frc
in other parts of the country . Many of the communities are quite small and
often situated in the mountains and "hollers" (small crevice-like mount
and valleys), a considerable distance from major towns and highways . As
many of the usual street drugs are simply not available . Instead, locals n
with resources already on hand, like prescription drugs . Isolation limits op
amenities and entertainment, a major contrast to the distractions of mete
RECENT TRENDS AND ACCOMPLISHMENTS
In 1994, with little fanfare and for the most part unknown to researchers in the
drug field, Ortho-McNeil Pharmaceutical funded what turned out to be the longest
and most expensive .drug abuse research study to date (excluding, of course, the
annual National Household and Monitoring the Future surveys) . The focus was
Ultram® (tramadol HC1), an opioid-like analgesic, which had just been approved
by the Food and Drug Administration (FDA) as a nonscheduled drug under
the Controlled Substances Act. The nonscheduled status was contingent on the
development and implementation of a comprehensive postmarketing surveillance
program by an Independent Steering Committee external to Ortho-McNeil, charged
with monitoring abuse and recommending scheduling if necessary . The program
was composed of a variety of studies, including : (a) a nationwide network of some
400 key informants in the drug field who participated in a quarterly survey, reporting
their observations of any abuse of Ultram®; (b) a quarterly survey of diversion
investigators recruited from police departments and regulatory agencies in all 50
states ; (c) an in-depth study of impaired health professionals in four states ; and
(d) a follow-up study of almost 90,000 interviews with over 11,000 pain patients
who had been prescribed Ultram ® for noncancer pain . In addition, in locales where
the abuse of Ultram® was suspected, citywide and statewide physician education
programs and other interventions were developed . For more than 10 years, the
Independent Steering Committee met monthly to review the data and to make
recommendations to Ortho-McNeil and the FDA . Ultimately, the postmarketing
surveillance effort documented that although there was indeed abuse and diversion
of Ultram®, both occurred at a relatively low rate (Adams et al ., 2006 ; Cicero et al .,
1999; Inciardi et al ., 2006) .
Not long after the postmarketing surveillance study of Ultram® had been
implemented, researchers, clinicians, and government observers began noticing
that prescription drugs were being more widely prescribed and abused (Compton
& Volkow, 2006 ; Zacny et al., 2003) . A study conducted by the National Center on
Addiction and Substance Abuse at Columbia University, for example, found that
from 1992 to 2002, opioid prescriptions increased by 222%, codeine prescriptions
increased by 12%, fentanyl by 1,106%, hydrocodone by 376%, meperidine by
66%, hydromorphone by 107%, methadone by 1,597%, morphine by 279%, and
oxycodone by 380% (The National Center on Addiction and Substance Abuse
at Columbia University, 2005) . For the period 1995 through 1997, the Drug
Enforcement Administration's Automation of Reports and Consolidated Orders
104
FALL 2009
1tions . During those years, little attention could be focused on prescription
ise .
TRENDS AND ACCOMPLISHMENTS
)94, with little fanfare and for the most part unknown to researchers in the
Ed, Ortho-McNeil Pharmaceutical funded what turned out to be the longest
it expensive drug abuse research study to date (excluding, of course, the
national Household and Monitoring the Future surveys) . The focus was
' (tramadol HC1), an opioid-like analgesic, which had just been approved
Food and Drug Administration (FDA) as a nonscheduled drug under
trolled Substances Act . The nonscheduled status was contingent on the
ment and implementation of a comprehensive postmarketing surveillance
I by an Independent Steering Committee external to Ortho-McNeil, charged
-nitoring abuse and recommending scheduling if necessary . The program
iposed of a variety of studies, including : (a) a nationwide network of some
informants in the drug field who participated in a quarterly survey, reporting
nervations of any abuse of Ultram ®; (b) a quarterly survey of diversion
itors recruited from police departments and regulatory agencies in all 50
~) an in-depth study of impaired health professionals in four states ; and
low-up study of almost 90,000 interviews with over 11,000 pain patients
. been prescribed Ultram® for noncancer pain . In addition, in locales where
e of Ultram® was suspected, citywide and statewide physician education
.s and other interventions were developed . For more than 10 years, the
dent Steering Committee met monthly to review the data and to make
endations to Ortho-McNeil and the FDA. Ultimately, the postmarketing
.nce effort documented that although there was indeed abuse and diversion
n®, both occurred at a relatively low rate (Adams et al ., 2006 ; Cicero et al.,
ciardi et al., 2006) .
long after the postmarketing surveillance study of Ultram ® had been
anted, researchers, clinicians, and government observers began noticing
cription drugs were being more widely prescribed and abused (Compton
w, 2006 ; Zacny et al ., 2003) . A study conducted by the National Center on
, n and Substance Abuse at Columbia University, for example, found that
)2 to 2002, opioid prescriptions increased by 222%, codeine prescriptions
d by 12%, fentanyl by 1,106%, hydrocodone by 376%, meperidine by
dromorphone by 107%, methadone by 1,597%, morphine by 279%, and
ne by 380% (The National Center on Addiction and Substance Abuse
nbia University, 2005) . For the period 1995 through 1997, the Drug
nent Administration's Automation of Reports and Consolidated Orders
System (ARCOS), which measures the retail distribution of pain medications in
grams, found substantial increases in the medicinal use of morphine (up 59%),
fentanyl (1,168%), oxycodone (23%), and hydromorphone (19%) . Subsequently,
the period of 1997 to 2001 demonstrated increases in the retail distribution of
oxycodone (up 348%), morphine (49%), and fentanyl (151%) (Joranson, D.E.,
Ryan, K .M., & Gilson, A .M. et al., 2000 ; Novak, S ., Nemeth, W.C., Lawson, K .A.,
2004) . One could argue that these increases served as a catalyst for the increasing
abuse, dependence, and diversion of prescription opioids .
At the same time, national data suggested that the abuse of many different
prescription drugs had been escalating since the early to mid-1990s . The National
Survey of Drug Use and Health found that the numbers of new nonmedical users
of prescription opioids (primarily products containing codeine, hydrocodone, and
oxycodone) increased from 600,000 in 1990 to over 2 .4 million in 2004, marking
it as the drug category with the largest number of new users in 2004 (Substance
Abuse and Mental Health Services Administration, 2005) . In addition, reports
from the Drug Abuse Warning Network indicated that abuse-related emergency
department (ED) visits involving narcotic analgesics increased by 153% from
1995 through 2002, and during the same period, abuse-related ED visits involving
benzodiazepines increased by 41% (Substance Abuse and Mental Health Services
Administration, & Office of Applied Studies, 2004a, 2004b) . Similar increases
were reflected in data on drug abuse treatment admissions .
Although the abuse and diversion of prescription drugs was clearly an evolving
problem, OxyContin® galvanized the attention of the media, the government, and
the public at large . When the drug was first introduced in 1996, it was hailed as a
breakthrough in pain management . The medication is unique in that its time-release
formula allows patients to enjoy continuous, long-term relief from moderate to
severe pain, but the honeymoon period for the drug turned out to be quite brief .
Abuse of OxyContin® first surfaced in rural Maine, soon spreading along the east
coast and Ohio Valley, and then into rural Appalachia . Communities in western
Virginia, eastern Kentucky, West Virginia, and southern Ohio were especially
hard hit, and a number of factors characteristic of these areas seemed to correlate
with the apparent high rates of abuse (Inciardi & Goode, 2003) . Aspects of the
culture in northern Maine and rural Appalachia are markedly different from those
in other parts of the country . Many of the communities are quite small and isolated,
often situated in the mountains and "hollers" (small crevice-like mountain dens
and valleys), a considerable distance from major towns and highways . As a result,
many of the usual street drugs are simply not available . Instead, locals make due
with resources already on hand, like prescription drugs . Isolation limits options for
amenities and entertainment, a major contrast to the distractions of metropolitan
FALL 2009
105
INCIARDI, CICERO
areas . Many substance abuse treatment patients in these rural areas have told their
counselors that they started using drugs because of boredom. Many start abusing
drugs quite young, as well .
In addition, many adults in these rural areas tend to suffer from chronic
illnesses and pain syndromes, born out of hard lives of manual labor in perilous
professions : coal mining, logging, fishing, and other blue-collar industries that
often result in debilitating injuries . As a result, a disproportionately high segment
of the population lives on strong painkillers . Use of pain pills evolves into a kind
of coping mechanism, and the practice of self-medication becomes a way of life
for many . As such, the use of narcotic analgesics has become normalized and
integrated into the local culture (Inciardi & Goode, 2003) .
Media outlets in Maine began reporting on OxyContin ® abuse in early 2000 .
The Bangor Daily News ran several features, which included information not only
about the properties of the drug, but also about : (a) how to compromise its timerelease mechanism, (b) the tactics of diversion that people were using to obtain the
drug (including Medicaid fraud), and (c) the concerns of the medical profession
about the potential for abusing the drug . In addition, numerous examples of alleged
OxyContin®-related crimes were described in detail. A smattering of news articles
followed in other parts of the nation, and in May, 2000, the Boston Globe became
the first major daily to focus on OxyContin ® (Meier, 2003) . After that, OxyContin®
became a national media event, and the escalating rates of prescription drug abuse
and diversion were more fully recognized .
was ineffective, but did anyone really think that the solution to the
abuse could be reduced to a snappy catch phrase? But it gets worse .
Enter Bob Dole, the Republican Senator from Kansas . History tell
was a war hero, an effective politician, and in later years a capable any
television commercial protagonist for both Viagra ® and Dunkin' Donut
drug policy realm, something was missing . During his campaign for thl
against incumbent Bill Clinton in 1996, Senator Dole searched aroun
catch phrase of his own . Cognizant of the attention garnered by Nani
"Just Say No" crusade and the commercial success of Nike's "Just Do
Dole came up with "Just Don't Do It" as his message to American
recreational drug use . Most everyone realized that it was rather ur
Clinton won the election with an Electoral College landslide (379 1
Dole moved on to Viagra®, Dunkin' Donuts, and Saturday Night Live
At about the same time, researchers at the University of Miam
Medicine received seed funding from NIDA to develop a concept call
(Model of Drug Use Spread) . The purpose of MODUS was to dete
existing data and policies what factors contributed to the drug abu
particularly in Latin American nations . Science-based solutions for re
abuse would be developed from these data . In theory, it was a good is
more than a year's effort, the resulting solutions were amateurish and sil
example, some of the suggested remedies for solving the drug problc
(a) arrest drug traffickers ; (b) keep drugs away from youth ; (c) mal
available to drug abusers ; (d) strengthen anti-drug legislation ; ai
economic alternatives to poppy and coca cultivation (Health Servic
Center, 1996) . In 2006, it would appear that the Maryland Attorney
modeled his solutions to the prescription drug problem after MOD1
made similar recommendations : (a) strengthen laws relating to the di
prescription drugs ; (b) increase coordination among law enforceme
and (c) regulate the online pharmaceutical industry (Kunkle, 2005) .
Shifting to more serious considerations, there is no question that the
prescription drug abuse and diversion continue to grow . The most rec
Survey on Drug Use and Health documented that U.S. household 1
more likely to report the nonmedical use of prescription opioids th,
drug, other than marijuana . The 2006 Monitoring the Future survey
same conclusion. Moreover, ED visits involving the abuse or misuse of
drugs increased by 21% from 2004 to 2005 (Substance Abuse and M
Services Administration, 2008 ; Johnston, L . D ., O'Malley, P. M ., Ba(
& Schulenberg, J. E ., 2007) . There were about 600,000 cases in 200`
FOIBLES, ODDITIES, ECCENTRICITIES, AND MISCONCEPTIONS : SOME REFLECTIONS ON THE
PAST, PRESENT, AND FUTURE
For the most powerful nation in the world, we are continuously amazed by the
many frivolous, flaky, foolish, and downright absurd approaches to drug policy
that have been put forward, from not only our political leaders, but from a few of
our colleagues and peers as well . There are far too many examples, but perhaps
a few will get the point across . A good place to start might be the "Just Say No"
media campaign from the 1980's "war on drugs ." Championed by First Lady
Nancy Reagan, the idea was to discourage children from recreational drug use
(and violence and drinking and premarital sex) by offering a variety of ways of
saying "No!" In theory, it was a laudable goal . The campaign made its way into
popular American culture as several television sitcoms of the period, including
Punky Brewster and Diff'rent Strokes, produced_ episodes centered around the
campaign. Then in 1987 La Toya Jackson became the spokesperson for "Just Say
No." She even recorded a song entitled "Just Say No ." In the end, however, the
campaign became the subject of satire and ridicule (Elliott, 1993) . Moreover, it
1 06
I
FALL 2009
any substance abuse treatment patients in these rural areas have told their
)rs that they started using drugs because of boredom . Many start abusing
.ite young, as well.
Idition, many adults in these rural areas tend to suffer from chronic
and pain syndromes, born out of hard lives of manual labor in perilous
)ns : coal mining, logging, fishing, and other blue-collar industries that
,ult in debilitating injuries . As a result, a disproportionately high segment
)pulation lives on strong painkillers . Use of pain pills evolves into a kind
g mechanism, and the practice of self-medication becomes a way of life
y. As such, the use of narcotic analgesics has become normalized and
d into the local culture (Inciardi & Goode, 2003) .
a outlets in Maine began reporting on OxyContin® abuse in early 2000 .
gor Daily News ran several features, which included information not only
properties of the drug, but also about : (a) how to compromise its timeiechanism, (b) the tactics of diversion that people were using to obtain the
:luding Medicaid fraud), and (c) the concerns of the medical profession
potential for abusing the drug . In addition, numerous examples of alleged
tin®-related crimes were described in detail . A smattering of news articles
. in other parts of the nation, and in May, 2000, the Boston Globe became
najor daily to focus on OxyContin ® (Meier, 2003) . After that, OxyContin®
i national media event, and the escalating rates of prescription drug abuse
rsion were more fully recognized .
ODDITIES, ECCENTRICITIES, AND MISCONCEPTIONS : SOME REFLECTIONS ON THE
ESENT, AND FUTURE
le most powerful nation in the world, we are continuously amazed by the
volous, flaky, foolish, and downright absurd approaches to drug policy
been put forward, from not only our political leaders, but from a few of
agues and peers as well. There are far too many examples, but perhaps
11 get the point across . A good place to start might be the "Just Say No"
Lmpaign from the 1980's "war on drugs ." Championed by First Lady
eagan, the idea was to discourage children from recreational drug use
ence and drinking and premarital sex) by offering a variety of ways of
%To!" In theory, it was a laudable goal . The campaign made its way into
kmerican culture as several television sitcoms of the period, including
rewster and Diff'rent Strokes, produced episodes centered around the
i. Then in 1987 La Toya Jackson became the spokesperson for "Just Say
even recorded a song entitled "Just Say No ." In the end, however, the
i became the subject of satire and ridicule (Elliott, 1993) . Moreover, it
was ineffective, but did anyone really think that the solution to the youth drug
abuse could be reduced to a snappy catch phrase? But it gets worse .
Enter Bob Dole, the Republican Senator from Kansas . History tells us that he
was a war hero, an effective politician, and in later years a capable and believable
television commercial protagonist for both Viagra ® and Dunkin' Donuts . But in the
drug policy realm, something was missing . During his campaign for the presidency
against incumbent Bill Clinton in 1996, Senator Dole searched around for a nifty
catch phrase of his own . Cognizant of the attention garnered by Nancy Reagan's
"Just Say No" crusade and the commercial success of Nike's "Just Do It" ad blitz,
Dole came up with "Just Don't Do It" as his message to American youth about
recreational drug use . Most everyone realized that it was rather unconvincing .
Clinton won the election with an Electoral College landslide (379 to 159), and
Dole moved on to Viagra®, Dunkin' Donuts, and Saturday Night Live .
At about the same time, researchers at the University of Miami School of
Medicine received seed funding from NIDA to develop a concept called MODUS
(Model of Drug Use Spread) . The purpose of MODUS was to determine from
existing data and policies what factors contributed to the drug abuse problem,
particularly in Latin American nations . Science-based solutions for reducing drug
abuse would be developed from these data . In theory, it was a good idea, but after
more than a year's effort, the resulting solutions were amateurish and simplistic . For
example, some of the suggested remedies for solving the drug problem included :
(a) arrest drug traffickers ; (b) keep drugs away from youth ; (c) make treatment
available to drug abusers ; (d) strengthen anti-drug legislation ; and (e) offer
economic alternatives to poppy and coca cultivation (Health Services Research
Center, 1996) . In 2006, it would appear that the Maryland Attorney General had
modeled his solutions to the prescription drug problem after MODUS when he
made similar recommendations : (a) strengthen laws relating to the distribution of
prescription drugs ; (b) increase coordination among law enforcement agencies ;
and (c) regulate the online pharmaceutical industry (Kunkle, 2005) .
Shifting to more serious considerations, there is no question that the problems of
prescription drug abuse and diversion continue to grow . The most recent National
Survey on Drug Use and Health documented that U .S. household residents are
more likely to report the nonmedical use of prescription opioids than any illicit
drug, other than marijuana . The 2006 Monitoring the Future survey reached the
same conclusion . Moreover, ED visits involving the abuse or misuse of prescription
drugs increased by 21 % from 2004 to 2005 (Substance Abuse and Mental Health
Services Administration, 2008 ; Johnston, L . D ., O'Malley, P. M ., Bachman, J . G .,
& Schulenberg, J. E ., 2007) . There were about 600,000 cases in 2005-almost as
FALL 2009
107
INCIARDI, CICERO
many as for heroin and cocaine combined (Substance Abuse and Mental Health
Services Administration, & Office of Applied Studies, 2005) .
Although the reasons behind this are open to speculation, two things are indeed
apparent. First, the number and variety of prescription drugs have increased
significantly in recent years, which is a positive trend for patients in legitimate
need of care . At the same time, however, it has been repeatedly documented that
availability seems to invariably create demand for drugs with a high potential
for abuse . Second, prescription drugs are popular among abusers because they
are considered to be more acceptable, less dangerous, easier to rationalize, and
less subject to legal consequences than are illicit drugs . These phenomena tend
to support the contention that fads and fashions in both the preferences in, and
patterns of, drug abuse appear to be continually shifting and changing . The current
trend would appear to be prescription drugs .
One of the big mysteries about the prescription drug problem appears to be
where the drugs are coming from, that is, "diversion ." Specifically, diversion
involves the unlawful channeling of regulated pharmaceuticals from legal sources
to the illicit marketplace, and this can occur along all points in the drug delivery
process : from the original manufacturing site, the wholesale distributor, the
physician's office, the retail pharmacy, or the patient . Diversion, however, has
been the focus of only minimal study, and ideas on the sources of illegal supplies
of prescription drugs vary. Federal agencies maintain that diverted drugs enter
the illegal market primarily through "doctor shoppers," inappropriate prescribing
practices by physicians, and improper dispensing by pharmacists . Given this belief,
the major solution suggested has been the creation of prescription monitoring
programs, which enable pharmacists and drug control agencies to detect "script
docs" who write prescriptions for a fee, as well as "doctor shoppers" who go from
physician to physician and from pharmacy to pharmacy to obtain multiple supplies
of prescription drugs . Federal authorities have also identified Internet sales
as a major source of diversion . Correspondingly, in 2005 the authors surveyed
diversion investigators in 300 police and regulatory agencies across the nation as
to their perceptions of the primary sources of diversion . Interestingly, almost threefourths of the survey participants considered drug abusers posing as patients to be
the major source of diversion through doctor shopping and prescription theft and
forgery (Inciardi et al ., 2007) . At the same time, only 3% considered the Internet
to be a significant source of prescription drugs . By contrast, the 2005 National
Survey on Drug Use and Health found that among individuals ages 12 and older
who reported abusing prescription opioids in the last year, 72 .3% had obtained the
drugs from friends or relatives, 18 .5% had obtained them from a physician, and
less than 1 % reported that they were getting the drugs from the Internet (Substance
Abuse and Mental Health Services Administration, & Office of Applil
2006) . One of the questions that these findings suggest is : Where are the
relatives getting the drugs? Are they sharing their legitimate supplies,
giving away pills that should have been discarded? Are the friends or rc
doctor shoppers who ate visiting multiple physicians, or forging prescril
they getting the drugs from street dealers, and if so, where are the dealer
their supplies? Moreover, our research suggests that dealers are a majo
prescription drugs (Inciardi, Surratt, Kurtz, & Cicero, 2007) . There sec
"black box" that warrants some investigation .
One might begin by looking at losses of prescription drugs from p
distributors, hospitals and clinics, treatment programs, or any other 1
organization where controlled substances are stored . When losses occ
robberies, burglaries, shoplifting, or employee theft, the Drug Ei
Administration (DEA) requires that its Form 106 (Report of Theft
Controlled Substances) be filed . Although the Form 106 data are no
tabulated and published, what has been released suggests the potential
of losses . From 2001 to 2003, some 563,677 "standard dosage units" of
(1 methadone dosage unit in DEA terminology = 10 mg) were repoi
or stolen, and almost all were through illegal means. From January 2(
2003, the DEA reported that almost 1 .4 million tablets of OxyContin® N
stolen through 2,494 separate incidents (U.S. Drug Enforcement Adm
2005) . Moreover, a request by the University of Wisconsin under the I
Information Act found a total of 12,894 theft and loss incidents report
from 2000 to 2003 in 22 Eastern states, involving some 28 million dosz
controlled substances (Joranson & Gilson, 2005) . These data suggest tI
quantities of prescription opioids are being stolen prior to being prescri
Residential burglary also should be studied . Millions of residential
occur in the United States each year, and evidence suggests that prescril
are a major target in a significant portion of these crimes (Inciardi et
In scores of focus groups and in-depth interviews conducted with h
drug-involved offenders, active street drug users, and recovering addic
past decade, participants agreed that the four items typically sought in
burglaries are cash, jewelry, guns, and prescription drugs . Studies coi
the Department of Justice and by independent researchers as well as
reports support this contention (Inciardi et al ., 2007) .
Are residential burglaries and pharmacy losses the major sources of
street dealers? Perhaps, but our research with prescription drug abusers
to script doctors, illegal sales in small pharmacies, acquaintances wh
personal prescriptions, sex workers' clients, disability patients, Medicaid
1 08
FALL 2009
for heroin and cocaine combined (Substance Abuse and Mental Health
Administration, & Office of Applied Studies, 2005) .
h the reasons behind this are open to speculation, two things are indeed
t . First, the number and variety of prescription drugs have increased
mtly in recent years, which is a positive trend for patients in legitimate
care . At the same time, however, it has been repeatedly documented that
lity seems to invariably create demand for drugs with a high potential
e . Second, prescription drugs are popular among abusers because they
idered to be more acceptable, less dangerous, easier to rationalize, and
ject to legal consequences than are illicit drugs . These phenomena tend
in the contention that fads and fashions in both the preferences in, and
of, drug abuse appear to be continually shifting and changing . The current
uld appear to be prescription drugs .
ff the big mysteries about the prescription drug problem appears to be
re drugs are coming from, that is, "diversion ." Specifically, diversion
the unlawful channeling of regulated pharmaceuticals from legal sources
icit marketplace, and this can occur along all points in the drug delivery
from the original manufacturing site, the wholesale distributor, the
i's office, the retail pharmacy, or the patient . Diversion, however, has
focus of only minimal study, and ideas on the sources of illegal supplies
iption drugs vary . Federal agencies maintain that diverted drugs enter
1 market primarily through "doctor shoppers," inappropriate prescribing
by physicians, and improper dispensing by pharmacists . Given this belief,
r solution suggested has been the creation of prescription monitoring
, which enable pharmacists and drug control agencies to detect "script
o write prescriptions for a fee, as well as "doctor shoppers" who go from
to physician and from pharmacy to pharmacy to obtain multiple supplies
iption drugs . Federal authorities have also identified Internet sales
)r source of diversion . Correspondingly, in 2005 the authors surveyed
investigators in 300 police and regulatory agencies across the nation as
rceptions of the primary sources of diversion . Interestingly, almost three'the survey participants considered drug abusers posing as patients to be
source of diversion through doctor shopping and prescription theft and
nciardi et al ., 2007) . At the same time, only 3% considered the Internet
gnificant source of prescription drugs . By contrast, the 2005 National
. Drug Use and Health found that among individuals ages 12 and older
ted abusing prescription opioids in the last year, 72 .3% had obtained the
a friends or relatives, 18 .5% had obtained them from a physician, and
reported that they were getting the drugs from the Internet (Substance
Abuse and Mental Health Services Administration, & Office of Applied Studies,
2006) . One of the questions that these findings suggest is : Where are the friends and
relatives getting the drugs? Are they sharing their legitimate supplies, or are they
giving away pills that should have been discarded? Are the friends or relatives the
doctor shoppers who are visiting multiple physicians, or forging prescriptions? Are
they getting the drugs from street dealers, and if so, where are the dealers obtaining
their supplies? Moreover, our research suggests that dealers are a major source of
prescription drugs (Inciardi, Surratt, Kurtz, & Cicero, 2007) . There seems to be a
"black box" that warrants some investigation .
One might begin by looking at losses of prescription drugs from pharmacies,
distributors, hospitals and clinics, treatment programs, or any other business or
organization where controlled substances are stored . When losses occur through
robberies, burglaries, shoplifting, or employee theft, the Drug Enforcement
Administration (DEA) requires that its Form 106 (Report of Theft or Loss of
Controlled Substances) be filed . Although the Form 106 data are not routinely
tabulated and published, what has been released suggests the potential magnitude
of losses. From 2001 to 2003, some 563,677 "standard dosage units" of methadone
(1 methadone dosage unit in DEA terminology = 10 mg) were reported as lost
or stolen, and almost all were through illegal means . From January 2000 to June
2003, the DEA reported that almost 1 .4 million tablets of OxyContin ® were lost or
stolen through 2,494 separate incidents (U.S. Drug Enforcement Administration,
2005) . Moreover, a request by the University of Wisconsin under the Freedom of
Information Act found a total of 12,894 theft and loss incidents reported to DEA
from 2000 to 2003 in 22 Eastern states, involving some 28 million dosage units of
controlled substances (Joranson & Gilson, 2005) . These data suggest that massive
quantities of prescription opioids are being stolen prior to being prescribed .
Residential burglary also should be studied . Millions of residential burglaries
occur in the United States each year, and evidence suggests that prescription drugs
are a major target in a significant portion of these crimes (Inciardi et al ., 2007) .
In scores of focus groups and in-depth interviews conducted with hundreds of
drug-involved offenders, active street drug users, and recovering addicts over the
past decade, participants agreed that the four items typically sought in residential
burglaries are cash, jewelry, guns, and prescription drugs . Studies conducted by
the Department of Justice and by independent researchers as well as newspaper
reports support this contention (Inciardi et al ., 2007) .
Are residential burglaries and pharmacy losses the major sources of supply for
street dealers? Perhaps, but our research with prescription drug abusers also points
to script doctors, illegal sales in small pharmacies, acquaintances who sell their
personal prescriptions, sex workers' clients, disability patients, Medicaid recipients,
FALL 2009
109
INCIARDI, CICERO
and personal prescriptions intended for the treatment for drug dependence or
mental illness . All of this suggests that focused research is needed targeting the
"black box" of diversion . This also suggests that prescription monitoring programs
are likely intercepting only a segment of those individuals diverting prescription
drugs .
As a final point, a number of other approaches may help us to better understand
and address the problems of prescription drug abuse and diversion :
Chambers, C.D .
An assessment of drug use in the general population . Albany, i
1971
Narcotic Addiction Control Commission .
Chambers, C.D., & Brill, L . (Eds .)
Methadone : Experiences and issues. New York : Behavioral Pu
1973
Chambers, C. D ., Inciardi, J ., Petersen, D . M ., Siegal, H . A ., & White,
1987 Chemical dependencies : patterns, costs, and consequences . At
OH : Ohio University Press .
Chambers, C. D ., Taylor, W. J., & Moffet, A. D .
1972 The incidence of cocaine abuse among methadone maintenanc(
International Journal of the Addictions, 7(3), 427-441 .
Cicero, T .J., Adams, E.H ., Geller, A ., Inciardi, J .A., Munoz, A ., Sch
Senay, E.C ., & Woody, G .E.
1999 A postmarking surveillance program to monitor Ultram, (trama
hydrochloride) Abuse in the United States . Drug and Alcohol
Dependence, 57, 7-22.
Cicero, T.J ., Dart, R.C., Inciardi, J.A., Woody, G.E., Schnoll, S ., & Mui
2007 The development of a comprehensive risk management prograi
prescription opioid analgesics : Researched abuse, diversion and
addiction-related surveillance . Pain Medicine, 8, 157-170 .
Compton, W .M., & Volkow, N .D.
2006 Major increases in opioid analgesic in opioid analgesic abuse ii
United States : Concerns and strategies . Drug and Alcohol Dej
81, 103-107 .
Elliott, J.
1993 Just say nonsense : Nancy Reagan's drug education programs .
Washington Monthly, May .
Health Services Research Center .
1996 MODUS Project : Model of Drug Use Spread . Miami, FL : Uni,
Miami School of Medicine .
Inciardi, J .A.
2008 The war on drugs IV The continuing saga of the mysteries an6
of intoxication, addiction, crime, and public policy . Boston : Al
& Bacon .
Inciardi, J .A., Cicero, T.J., Muiioz, A., Adams, E.H ., Geller, A ., Sew
Woody, G .E.
2006 The diversion of Ultram, Ultracet, and generic tramadol . Jourr
Addictive Diseases, 25(2), 53-58 .
1 . The data on prescription drug losses sent to the DEA on Form 106 are not
readily available . Data for Form 106 can be obtained under the Freedom
of Information Act, but what is typically received is incomplete . To garner
a better idea of the extent and geographical distribution of losses of
controlled substances, funding should be allocated to the DEA for better
archiving and analysis of Form 106 data .
2 . The Federal Bureau of Investigation's (FBI) Uniform Crime Reporting
System has been collecting and publishing nationwide data on crime for
generations . However, in the areas of larceny/theft and burglary, no data
are collected on what is actually stolen . The FBI's crime reporting system
should be revised to collect more relevant information on burglaries and
other thefts .
3 . For a number of years, segments of the pharmaceutical industry, at
the request of the FDA, have been supporting postmarketing and risk
management programs to determine the nature and extent of the abuse and
diversion of specific controlled substances (Cicero et al ., 2007 ; Katz et al.,
2007) . The FDA's requirement for postmarketing surveillance should be
expanded to include all controlled substances with a potential for abuseboth new and old-and both branded and generic varieties . In addition,
when a continuing problem of abuse becomes apparent with a given drug
in a specific locale, the FDA and industry should share the burden of
determining the exact nature of the problem and provide interventions,
where appropriate .
REFERENCES
Adams, E.H., Breiner, S ., Cicero, T.J ., Geller, A ., Inciardi, J .A., Schnoll, S.H .,
Senay, E.C., & Woody, G.E.
2006 A comparison of the abuse liability of tramadol, NSAID's, and
hydrocodone in patients with chronic pain . Journal of Pain and
Symptom Management, 31, 465-476 .
110
FALL 2009
:rsonal prescriptions intended for the treatment for drug dependence or
illness . All of this suggests that focused research is needed targeting the
box" of diversion . This also suggests that prescription monitoring programs
;ly intercepting only a segment of those individuals diverting prescription
Chambers, C.D .
An assessment of drug use in the general population . Albany, NY :
1971
Narcotic Addiction Control Commission .
Chambers, C .D., & Brill, L. (Eds .)
Methadone : Experiences and issues . New York : Behavioral Publications .
1973
Chambers, C . D ., Inciardi, J ., Petersen, D . M ., Siegal, H . A ., & White, O . Z .
1987 Chemical dependencies : patterns, costs, and consequences . Athens,
OH : Ohio University Press .
Chambers, C. D ., Taylor, W. J., & Moffet, A. D .
1972 The incidence of cocaine abuse among methadone maintenance patients .
i final point, a number of other approaches may help us to better understand
tress the problems of prescription drug abuse and diversion :
The data on prescription drug losses sent to the DEA on Form 106 are not
readily available . Data for Form 106 can be obtained under the Freedom
of Information Act, but what is typically received is incomplete . To garner
a better idea of the extent and geographical distribution of losses of
controlled substances, funding should be allocated to the DEA for better
archiving and analysis of Form 106 data .
The Federal Bureau of Investigation's (FBI) Uniform Crime Reporting
System has been collecting and publishing nationwide data on crime for
generations . However, in the areas of larceny/theft and burglary, no data
are collected on what is actually stolen . The FBI's crime reporting system
should be revised to collect more relevant information on burglaries and
)ther thefts .
?or a number of years ; segments of the pharmaceutical industry, at
he request of the FDA, have been supporting postmarketing and risk
nanagement programs to determine the nature and extent of the abuse and
liversion of specific controlled substances (Cicero et al ., 2007 ; Katz et al.,
.007) . The FDA's requirement for postmarketing surveillance should be
:xpanded to include all controlled substances with a potential for abuse,oth new and old-and both branded and generic varieties . In addition,
then a continuing problem of abuse becomes apparent with a given drug
i a specific locale, the FDA and industry should share the burden of
etermining the exact nature of the problem and provide interventions,
here appropriate.
International Journal of the Addictions, 7(3),427-441 .
Cicero, T.J., Adams, E .H ., Geller, A ., Inciardi, J .A ., Munoz, A ., Schnoll, S .H .,
Senay, E.C., & Woody, G .E.
1999 A postmarking surveillance program to monitor Ultram, (tramadol
hydrochloride) Abuse in the United States . Drug and Alcohol
Dependence, 57, .7-22 .
Cicero, T.J., Dart, R.C., Inciardi, J .A., Woody, G.E ., Schnoll, S ., & Munoz, A .
2007 The development of a comprehensive risk management program for
prescription opioid analgesics : Researched abuse, diversion and
addiction-related surveillance . Pain Medicine, 8, 157-170 .
Compton, W.M., & Volkow, N .D .
2006 Major increases in opioid analgesic in opioid analgesic abuse in the
United States : Concerns and strategies . Drug and Alcohol Dependence,
81, 103-107 .
Elliott, J .
1993 Just say nonsense : Nancy Reagan's drug education programs .
Washington Monthly, May.
Health Services Research Center .
1996 MODUS Project : Model of Drug Use Spread . Miami, FL : University of
Miami School of Medicine .
Inciardi, J .A .
2008 The war on drugs IV- The continuing saga of the mysteries and miseries
of intoxication, addiction, crime, and public policy . Boston : Allyn
& Bacon .
Inciardi, J.A ., Cicero, T.J., Mufloz, A ., Adams, E.H., Geller, A., Senay, E.C., &
Woody, G .E.
2006 The diversion of Ultram, Ultracet, and generic tramadol . Journal of
Addictive Diseases, 25(2),53-58 .
S
Breiner, S ., Cicero, T.J., Geller, A ., Inciardi, J.A., Schnoll, S.H .,
& Woody, G.E.
comparison of the abuse liability of tramadol, NSAID's, and
idrocodone in patients with chronic pain . Journal of Pain . and
'mptom Management, 31, 465-476 .
? .H.,
FALL 2009
I
11 1
INCIARDI, CICERO
Inciardi, J . A., & Goode, J . L .
2003 OxyContin and prescription drug abuse . Consumers 'Research, 86(7),
17-21 .
Inciardi, J.A., Surratt, H.L., Kurtz, S.P., & Cicero, T.J.
2007 Mechanisms of prescription drug diversion among drug involved club
and street-based populations . Pain Medicine, 8, 171-183 .
Johnston, L . D ., O'Malley, P. M ., Bachman, J . G ., & Schulenberg, J . E .
2007 Monitoring the Future national results on adolescent drug use : Overview
of key findings, 2006 . (NIH Publication No. 07-6202) . Bethesda,
MD : National Institute on Drug Abuse .
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2005 Drug crime is a source of abused pain medications in the United States .
Journal of Pain and Symptom Management, 30(4), 299-301 .
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2000 Trends in medical use and abuse of opioid analgesics . JAMA, 283(13) :
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Katz, N.P., Adams, E.H ., Benneyan, J .C., Birnbaum, H .G ., Budman, S .H ., Buzzeo,
R.W., Carr, D .B., Cicero, T.J., Gourlay, D ., Inciardi, J.A ., Joranson, D .E., Kesslick,
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period : 1/01/1998-12/31/1998 : U .S. Department of Justice .
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1 12
FALL 2009
J. A ., & Goode, J . L .
OxyContin and prescription drug abuse . Consumers 'Research, 86(7),
17-21 .
J.A ., Surratt, H.L., Kurtz, S .P., & Cicero, T.J.
Mechanisms of prescription drug diversion among drug involved club
and street-based populations . Pain Medicine, 8, 171-183 .
n, L . D ., O'Malley, P. M., Bachman, J . G ., & Schulenberg, J. E .
Monitoring the Future national results on adolescent drug use : Overview
of key findings, 2006 . (NIH Publication No . 07-6202) . Bethesda,
MD : National Institute on Drug Abuse .
i, D.E., & Gilson, A .M.
Drug crime is a source of abused pain medications in the United States .
Journal ofPain and Symptom Management, 30(4), 299-301 .
i, D.E., Ryan, K.M., Gilson, A.M., et al .
Trends in medical use and abuse of opioid analgesics . JAMA, 283(13) :
1710-1714 .
P., Adams, E.H., Benneyan, J .C., Birnbaum, H.G ., Budman, S .H ., Buzzeo,
Lrr, D.B., Cicero, T.J., Gourlay, D ., Inciardi, J.A ., Joranson, D .E., Kesslick,
ide, S .D .
oundations of opioid risk management . Clinical Journal of Pain, 23,
103-118 .
F.
attorney General targets prescription drug abuse . The Washington
'ost, p. T03, October 6 .
'ain killer: A "wonder" drug's trail of addiction and death . Emmaus,
'A: Rodale Press .
., Nemeth, W.C., & Lawson, K.A .
'rends in medical use and abuse of sustained-release opioid analgesics :
i revisit . Pain Medicine, 5(1), 59-65 .
Renee
larcotics abuse on rise, pharmaceutical drug fraud, misuse worry
fcials. Bangor Daily News : Bangor, Maine (April 6) .
L (Ed .) .
:rack pipe as pimp : An ethnographic investigation of sex-for-crack
rchanges . NY: Lexington Books .
D.
olkirks Island. New York : Harcourt .
Substance Abuse and Mental Health Services Administration
National Findings (Office of Applied Studies, NSDUH Series
H-34, DHHS Publication No . SMA 08-4343) . Rockville, MD .
Substance Abuse and Mental Health Services Administration, & Office of Applied
Studies
2004a Benzodiazepines in Drug Abuse-Related Emergency Department Visits :
1995-2002 . The DAWN Report . Accessed from http ://dawninfo .samhsa.
gov/old dawn/pubs 94 02/shortreports/files/DAWN tdr _benzo .pdf.
Studies
2004b Narcotic Analgesics, 2002 Update . The DAWN Report . Accessed from
http ://oas .samhsa .gov/2k4analgesics .pdf.
Studies .
National Findings . (Office of Applied Studies, NSDUH Series H-28,
DHHS Publication No . SMA 05-4062) . Rockville, MD : Office of
Applied Studies .
Studies.
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gov/nsduh/2k5nsduh/2k5results .pdf.
Terry, C . E ., & Pellens, M .
1928 The opium problem . New York : Bureau of Social Hygiene .
The National Center on Addiction and Substance Abuse at Columbia University
2005 Under the counter : The diversion and abuse of controlled prescription
drugs in the U.S. New York : Columbia University .
U. S. Drug Enforcement Administration
1997 ARCOS 2 - Report 7 : U .S . Summary of Retail Drug Purchases reporting
period : 1/01/1997-12/31/1997 : U .S . Department of Justice .
.
Drug
U. S
1998 ARCOS 2 - Report 7 : U .S . Summary of Retail Drug Purchases reporting
period : 1/01/1998-12/31/1998 : U.S. Department of Justice .
.
Drug
U. S
1999 ARCOS 2 - Report 7 : U.S . Summary of Retail Drug Purchases reporting
FALL 2009
1 13
INCIARDI, CICERO
© 2009 BY THE JOURNAL OF DRUG ISSUES
2000 ARCOS 2 - Report 7: U.S . Summary of Retail Drug Purchases reporting
period : 1/01/2000-12/31/2000 : U .S . Department of Justice.
2001 ARCOS 2 - Report 7: U .S. Summary of Retail Drug Purchases reporting
period: 1/01/2001-12/31/2001 : U .S . Department of Justice .
U.S. Drug Enforcement Administration
2005 Drug theft & loss . U.S. Department of Justice . Retrieved January 25,
2005 from, http ://www.aatod.org/pdfs/methadone-theft .pdf.
U.S . Drug Enforcement Administration
2005 OxyContin® theft & loss incidents : January 2000 through June 2003.
U.S. Department of Justice . Retrieved January 25, 2005 from,http ://
www.deadiversion .usdoj.gov/drugs concern/oxycodone/oxylosses_
oct2003_l .pdf.
Zacny, J ., Bigelow, G ., Compton, P., Foley, K., Iguchi, M., & Sannerud, C .
2003 College on problems of drug dependence taskforce on prescription
opioid non-medical use and abuse : Position statement . Drug and Alcohol
Dependence, 69, 215-232 .
THE NEUROBIOLOGY OF ADDICTION : WHERE WE
BEEN AND WHERE WE ARE GOING
GEORGE F. KOOB, ERIC J . SIMON
A number of dramatic breakthroughs in the neurobiology of addic
occurred in the past 40 years. Two domains will be highlighted: the net
of addiction and the molecular biology of addiction targets . The neur
substrates for the reinforcing effects of drugs of abuse have been largel
both at the initial site of action and in the circuitry involved . In hums
studies, decreases in dopaminergic function have been identified as a k(
of addiction, lending support for research on the role of dopamine in addic
novel areas currently are emerging : the role of deficits in frontal cortex f
changes in the brain neurocircuitry that convey long-term vulnerability to re
the role of nondopaminergic systems in the neuroadaptations associat
development of drug dependence . Parallel to these functional changes
major advances in our understanding of the molecular biology of ad(
greatest contribution has been in the understanding of the molecular m
of opioid action. This paper reviews the major developments in our una
of the molecular biology of the endogenous opioid system and the use o
to advance our knowledge of the function and regulation of opioid rec
endorphins.
THE PAST AND THE PRESENT
A number of dramatic breakthroughs in the neurobiology of addic
occurred in the past 40 years with the support of the National Institute
Abuse (NIDA) . Two domains will be highlighted here : the neurocircuitry of
George F. Koob, Ph .D ., is Professor and Chairman of the Committee on the Neurobiology
Disorders at The Scripps Research Institute and Adjunct Professor in the Departments of
and . Psychiatry and the Skaggs School of Pharmacy and Pharmaceutical Sciences at th
of California, San Diego . He specializes on the neurobiology and theoretical constructs of
tion, reward, and stress . Dr. Eric J . Simon is Professor of Psychiatry and Pharmacology
University Medical Center . Dr. Simon's laboratory has done pioneering research on the me
of narcotic analgesics . In 1973 his laboratory, and others, discovered the opiate receptors
He and his collaborators have continued to work on opiate receptors and endogenous opi
and have published 250 papers in excellent journals . He coined the widely used term "enc
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