The Dawn of the Oxycontin Era, and Unwitting Addiction

supplemental notes on an earlier post

As is so often the case with matters related to Dope, the era of the Oxycontin epidemic (now superseded by the fentanyl epidemic) was a bit more complicated than a skim of the narrative makes it appear. Oxycodone had been around for decade as Percodan and Percoset, mostly in low-dose form- 5mg or 10mg. Then Purdue found that the patent on its extended-release morphine pill, MS-Contin, was due to expire. Shock horror, it was going generic! (There’s no way to patent morphine itself. The big patent “innovation”in question was formulating it with binders to release it slower when orally ingested.) So the savants of the marketing division replaced the morphine with oxycodone—only slightly less powerful by weight—and put out their newly patented opioid, Oxycontin. This was accompanied by an unprecedented marketing push, based on a published research study that had concluded that opioids are not addictive when prescribed for pain. The study wasn’t bogus; the finding that had been observed decades earlier, and the conclusion was and is valid—up to a point.

The decoupling of opioid use from addiction liability when the drugs are prescribed for chronic severe pain relief was actually noted many years before the study that Purdue used to justify its claims for Oxycontin; I first read about it in the book Drugs And The Mind by Robert DeRopp, published in the 1960s. The pain patients who reported the low incidence of addiction were hospitalized patients with long recovery times, or people dealing with ongoing chronic—often lifelong—pain issues who were often stable and well-functioning, using just enough of the prescribed dose to relieve their otherwise intractable pain while declining to increase the dosage to a level that produced the euphoria that was a feature of higher doses.

The problem was that Purdue’s marketing department took that finding, extracted it out of its original context, and ran with a simplified conclusion that allowed them to justify marketing Oxycontin for a wide range of pain relief. The head of Purdue, Sackler, was already well-known in the industry—not as a pharmacologist, but as the first executive in the business to apply mid-20th century modern advertising and marketing techniques associated with consumer products to patent pharmaceutical drugs, beginning in the 1950s. Sackler came up with catchy brand names for his products; his first brand name inspirations included Valium, Librium, and the anti-ulcer medication Zantac. Sackler also led the way in advertising his brand-name drugs in medical journals, and training his traveling sales staff in persuasion techniques when doing cold calls to doctor’s offices.

All of that marketing focus was finely honed by the time of the rollout of Purdue’s newest product, Oxycontin, in 1995. Two features of Oxycontin distinguished it from earlier oxycodone oral medications like Percodan and Percoset. The first difference is that unlike Percodan, which was formulated with aspirin, and Percocet, which was formulated with acetominaphen (aka Tylenol), Oxycontin was formulated exclusively as an opioid. The compounding of the oxycodone with NSAID nonprescription pain relievers appears to have been intended to serve two purposes: 1) providing some additional pain relief in order to limit the opioid content in each pill; and 2) both aspirin and acetaminophen typically produce nausea and vomiting when ingested in large quantities, acting as an effective check on the number of pills that can be comfortably ingested and thereby working to limit the “abuse potential” of the oxxycodone ingredient. There are methods to separate the NSAIDs from the opioid, technically. But it’s typically difficult to do more than a partial extraction by using ‘household methods’, so someone seeking to remove the NSAIDs is still likely to be ingesting a nauseating quantity if they intend to ingest more than 10-20mg of the oxycodone. This worked to limit the appeal of using “percs” for recreational purposes—particularly for addicts with an opioid tolerance. (Another somewhat more sinister side effect is that unlike opioids, NSAIDs like aspirin and acetaminophen are toxic in large quantities, particularly to the liver and kidneys, especially when ingested with alcohol.) That limitation did not apply to Oxycontin, which had only oxycodone as its active ingredient.

Along with its absence of NSAIDs, Oxycontin’s extended release formula typically provided more active ingredient than percs—up to 160mg per pill. The most commonly prescribed dose was 40mg—4 to 8 times the usual dose of Percodan prescribed for transient acute pain conditions like wisdom teeth removal, or back sprain. But Purdue sales people sold Oxycontin as a formulation that could be used for minor and moderate acute pain, and also recommended that physicians prescribe it liberally, in 7 to 21 day amounts, while implying that the mere presence of even minor pain somehow automatically obviated the liability of becoming addicted to the substance.

The marketing reps sold a lot of Oxycontin that way. And the more familiar pharmacists got with seeing the prescriptions, the more they got used to dispensing it frequently and in large quantities. There was widespread ignorance on the part of both medical care professionals and pharmacists about the inherent properties of opioids; in many medical schools, the problems of pain relief hardly merited more than a couple of class sessions. That divide—between the “straight world” of institutional instruction, licensed pharmacies, and naive medical practitioners, and the clandestine subculture of illicit substance use that had become an endemic American subculture since the mid-1960s—provided the final factor that led to the explosion of Oxycontin use in the late 1990s and 2000s.

The people who understood what they were looking at when they saw the label on a bottle of 40mg oxycodone were the criminalized pariahs of the underground drug scene, particularly the opioid fanciers. They found out very quickly that Oxycontin could be converted to instant release simply by the expedient of chewing the pills.

That said, the vast majority of people who reported becoming addicted to Oxycontin said they had received their first supplies from a physician for a legitimate pain complaint. It isn’t easy to gauge sincerity, but it’s entirely likely that most of those people told the truth. It’s undeniable that many unsuspecting people had no idea what they were getting into with their first use, and they eventually found themselves with an opioid habit. The books on the Oxy epidemic provide some anecdotal cases. The most heart-wrenching one I read is the account found by the tragic protagonist in the book Dopesick. Because as it happens, while Oxycontin was sold as a slow release med delivering a 12-hour period of freedom from pain that allowed the users a full night’s sleep without interruption, even when used as recommended—by swallowing the pill—the extended release was actually more like 8 hours. Furthermore, even if it doesn’t hit all at once, 40mg of Oxycontin still packs a wallop in "drug-naive” users. Opt for taking an extra pill, and the endorphin cascade can be out of this world.

The foundation justifying that level of use—for conditions like ankle sprains, torn ligaments, and tooth extractions—was the Respectability of pharmaceutical prescription. That superstitious awe of Ceremonial Chemistry, the magical rite of a credentialed and licensed practitioner of Medicine waving a pen across a prescription pad. Very few Americans maintain the vigilance known as caveat emptor when a doctor prescribes anything at all for them. Meanwhile, opioid manufacturers all over the country were exhorting their sales staffs with bonuses and seminars on effectively pitching the newly lucrative patent medicines, which in some cases expanded beyond Oxycontin to include products like “slow-release” fentanyl lollipops.

Therein lies the problem with the argument that “legal opioids were the cause of the opioid epidemic”: the real problems related to fraudulent representation of the risks by the drug companies, the naivete of “the straight world”about the nature of opioid drugs. Heroin—only slightly more powerful by weight than oxycontin—was taboo, a contraband product reserved for the criminal monopoly. Schedule I, “no accepted medical use”, although it was considered a legitimate pharmaceutical drug in some other countries, like the United Kingdom. By contrast, oxycontin was sometimes not even recognized as an opioid. In any case, it became the “pain pill” of choice in the late 1990s and early 2000s, widely prescribed by doctors and hence held to be basically “safe.” A misconception fostered and maintained by the misleading soft-soap sales tactics pioneered by the Sacklers at companies like Purdue Pharmaceuticals.

https://prium-evidencebased.blogspot.com/2016/

https://www.npr.org/2025/03/27/nx-s1-5342368/addiction-trump-mental-health-funding?utm_source=firefox-newtab-en-us