Anthony DiTullio would pop a painkiller in his mouth, but not just swallow it, as intended. He would chew it for 30 minutes, grinding through its protective coating and waxy unpleasantness, because the only pain he was treating was addiction.
The pill was OxyContin, a painkiller that its manufacturer, Purdue Pharma, said deters abuse by being difficult to chew or liquefy into forms that give addicts stronger highs, orally or through injection. Since adding these features to its original and widely abused OxyContin in 2010, the company has likened the pill to a virtual seatbelt to restrain the epidemic of prescription drug abuse in the US.
However, as thousands of addicts still find ways to abuse OxyContin and similar painkillers, called abuse-deterrent formulations, some experts caution that the protections are misunderstood and could mislead both users and prescribers into thinking that the underlying medications are less addictive.
Because abuse-deterrent formulations are relatively new, preliminary data on their public-health implications is limited. Several studies, some sponsored by Purdue, have found that abuse of OxyContin specifically has decreased after its protections were added. Other reports confirmed those findings, but also found that many abusers simply moved on to other opioids, as well as heroin, leaving the overall effect on drug abuse open for debate.
Abuse-deterrent painkillers’ limitations were recently underscored when more than 150 residents of southern Indiana contracted HIV, the virus that causes AIDS, by sharing needles they used to inject Opana, a drug once marketed as resistant to being liquefied for injection.
“I would definitely say that OxyContin is harder to abuse than it used to be — it was a pain in the neck,” said DiTullio, 35, who successfully addressed his addiction at a drug-abuse treatment facility and now operates an auto body shop in Keene, New Hampshire. However, he added: “No matter what they do, there’s always going to be a way for people to get whatever they want in their system.”
Nearly 2 million people in the US either abused or were dependent on opioid painkillers in 2013, with 16,000 people dying from overdoses, according to the US Centers for Disease Control and Prevention.
Three new painkillers were approved last year by the US Food and Drug Administration to be marketed as having abuse-deterrent properties. Pfizer’s Embeda and Purdue’s Targiniq release naloxone when crushed to counteract the euphoria experienced through snorting or injection. Purdue’s Hysingla, like OxyContin, is difficult to chew or liquefy.
Support for such protections has grown to the point that the agency was roundly criticized in 2013 for going against its advisory committee’s recommendation in approving a new painkiller, Zohydro, without deterrent features. (Its manufacturer, Zogenix, has since pursued adding them.) Some lawmakers have pushed for legislation to make the branded drugs cheaper or require that generic versions of older painkillers include abuse-deterrent features.
Even though technologies can hinder tampering with painkiller pills, the active ingredients in abuse-deterrent drugs provide the same high and remain just as addictive as in regular formulations. Research indicates that the majority of people who abuse or become dependent on prescription opioids do so not by altering the pills, but by swallowing them whole.
So even if doctors move toward OxyContin and newer abuse-deterrent formulations, which is roundly supported, many misunderstand the persistent risks, said doctor G Caleb Alexander, a codirector of the Center for Drug Safety and Effectiveness at the Johns Hopkins Bloomberg School of Public Health.
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