black beauties, gorilla pills, footballs, and …cicero.wustl.edu/skip/publications/partner_pubs/7...

1ROWN, DEMBO, LEUKEFELD © 2009 BY THE JOURNAL OF DRUG ISSUES

BLACK BEAUTIES, GORILLA PILLS, FOOTBALLS,

AND HILLBILLY HEROIN : SOME REFLECTIONS ONPRESCRIPTION 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 twocenturies, research into the abuse and diversion ofthese drugs has been relativelyrecent. The first general population survey to document the abuse ofprescriptionmedications occurred in 1970, and subsequent studies demonstrated that theabuse and diversion of amphetamines, opioids, and sedatives has continuedto be widespread. During the 1980s and much of the 1990s, prescription drugabuse took a back seat to other more pressing concerns : ifreebasei and powdercocaine, the cocaine wars, crack and sex-for-crack exchanges, rising rates ofdrug-related street crime, and HIV/AIDS among injection and non-injection drug users.However, recent surveys suggest that the current outbreak of prescription drugabuse began during the early to mid-1990s. Although the abuse and diversion ofprescription drugs was clearly an evolving problem, what seemed to galvanize theattention of the media, the government, and the public at large was OxyContin''Currently, there is no question that the problems of prescription drug abuse anddiversion continue to grow. Why this is so, however, is open to speculation .Perhaps the reason lies in the increasing numbers ofprescription drugs that arebeing legally marketed. Or perhaps . the popularity ofprescription drugs is rooted inthe beliefs that they are more acceptable, less dangerous, and less subject to legalconsequences than are illicit drugs .

James A. Inciardi, Ph .D., is the Co-Director of the Center for Drug and Alcohol Studies at theUniversity of Delaware, and is the author of more than 450 articles, chapters, and books in the areasof 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 ofMedicine, has a 40-year long interest in two aspects of substance abuse : the neurobiological andneuroendocrinological substrates of tolerance and dependence ; and studies in humans directed at theabuse of prescription opioid analgesics.

INCIARDI, CICERO

INTRODUCTION

If anything has been learned about the drug problem in the United States, it isthat 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 emergeand then disappear from the American drug scene. Still others are rediscovered,reinvented, revitalized, repackaged, recycled, and become permanent parts of thelandscape . As new drugs of abuse become visible, concomitant media and politicalfeeding frenzies call for a strengthening of the "war on drugs ." There was heroinin the 1950s; marijuana, amphetamines (black beauties), and LSD in the 1960s ;Quaaludes ® , barbiturates (gorilla pills), and PCP in the 1970s; and crack and otherforms of cocaine in the 1980s and 1990s . And then came Vicodin®, OxyContin®(hillbilly heroin), and Xanax ® (footballs), which gained attention during the latter1990s 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 18thcentury with Thomas Dover, a student of British physician Thomas Sydenham,considered the "father" of clinical medicine, and strong advocate of the use ofopium for the treatment of disease . Following in the path of his mentor, Doverdeveloped a form of medicinal opium . Known as Dover's Powder, it containedone ounce each of opium, ipecac (the dried roots of a tropical creeping plant), andlicorice, combined with saltpeter, tartar, and wine . Dover's Powder was introducedin 1709 and soon made its way to America, where it remained one of the mostwidely 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 attractionof Dover's Powder was in the euphoric and anesthetic properties of opium . Theintroduction of Dover's Powder apparently started a trend . By the latter part ofthe eighteenth century, similar patent medicines containing opium were readilyavailable 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 thebackdrop 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 emergedduring the late 1960s and early 1970s, with much of it coming from the work ofthe late Carl D . Chambers, who at the time was Director of Research for the NewYork State Narcotic Addiction Control Commission . Although few members ofthe newer generations of drug abuse researchers are likely to know him, or even

1 02 JOURNAL OF DRUG ISSUES

REFLECTIONS ON PRESCRIPTION DRUG ABUSE

be familiar with his contributions, in many ways he was a pioneer-aand innovator in the field of substance abuse research . Years befNational Household Survey on Drug Abuse was launched, for exampldesigned and fielded the first general population survey of drug abuse,in New York, and it paved the way for National Institute on Drug AbuNational Household and Monitoring the Future studies . Chambersgeneral population survey was the first to empirically document thatdrug abuse and diversion were problems that needed to be addressed1971) .

Chambers' subsequent work focused on the abuse and diversion ofdrugs : pentazocine (Talwin®), propoxyphene (Darvon®), ambarbiturate-sedatives, and methadone . Not surprisingly, he made a 1along the way. First there were the pharmaceutical companies whose cwriting about (Chambers, Inciardi, Petersen, Siegal, & White, 1987) .Third National Conference on Methadone Treatment in New York Ca number of the methadone maintenance matriarchs and patriarchsentire two-hour session to Chambers' work, endlessly castigating hinintroduced such terms as "supplementation," "cheating," and "diversimethadone literature . Supplementation referred to increasing the maintof methadone to get high ; cheating referred to abusing cocaine during Itherapy; diversion referred to a patient's participation in more than on(program and selling the excess on the street (Chambers & Brill, 1973Taylor, & 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 amplthe 1970s led to increased focus on the prescription drug problem, andbody of scientific literature began to develop, yet it was Chambers wlit all going.

During the 1980s and much of the 1990s, however, prescription druga back seat to other more pressing concerns . "Freebase" and powder cmajor concerns, with the attendant cocaine wars in Florida, Latin AmelCaribbean instigated by Colombia's Medellin and Cali cartels . In innchouses across the nation, crack and the sex-for-crack exchanges appea1993). Rates of drug-related street crime rose as did the violence ass(drug gang wars over control of emerging crack markets . The occurreiAIDS among injection drug and crack users became a concern and wasearly attempts to understand the phenomenon and develop effective sc

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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 emergerppear from the American drug scene . Still others are rediscovered,evitalized, repackaged, recycled, and become permanent parts of thes new drugs of abuse become visible, concomitant media and political.ies call for a strengthening of the "war on drugs ." There was heroinmarijuana, amphetamines (black beauties), and LSD in the 1960s ;

barbiturates (gorilla pills), and PCP in the 1970s ; and crack and otheraine in the 1980s and 1990s. And then came Vicodin®, OxyContin®)in), and Xanax® (footballs), which gained attention during the latteropening years of the twenty-first century. But where did it all begin?

prescription drugs, perhaps it goes back to the early part of the 18thThomas Dover, a student of British physician Thomas Sydenham,ie "father" of clinical medicine, and strong advocate of the use ofe .. treatment of disease. Following in the path of his mentor, Doverform of medicinal opium . Known as Dover's Powder, it containedch of opium, ipecac (the dried roots of a tropical creeping plant), andbined with saltpeter, tartar, and wine . Dover's Powder was introducedsoon made its way to America, where it remained one of the mostopium preparations for almost two centuries (Inciardi, 2008 ; Souhami,i Pellens 1928 ) .opium had been a popular narcotic for thousands of years, the attractionowder was in the euphoric and anesthetic properties of opium . Theof Dover's Powder apparently started a trend . By the latter part ofh 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 maillens, 1928) . This patent medicine industry eventually provided thethe 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 of3. Chambers, who at the time was Director of Research for the Newarcotic Addiction Control Commission. Although few members ofierations of drug abuse researchers are likely to know him, or even

JOURNAL OF DRUG ISSUES

be familiar with his contributions, in many ways he was a pioneer-a trailblazer-and innovator in the field of substance abuse research . Years before the firstNational Household Survey on Drug Abuse was launched, for example, Chambersdesigned and fielded the first general population survey of drug abuse . It was donein New York, and it paved the way for National Institute on Drug Abuse's (NIDA)National Household and Monitoring the Future studies . Chambers' New Yorkgeneral population survey was the first to empirically document that prescriptiondrug abuse and diversion were problems that needed to be addressed (Chambers,1971) .

Chambers' subsequent work focused on the abuse and diversion of prescriptiondrugs: pentazocine (Talwin®), propoxyphene (Darvon®), amphetamines,barbiturate-sedatives, and methadone . Not surprisingly, he made a few enemiesalong the way. First there were the pharmaceutical companies whose drugs he waswriting about (Chambers, Inciardi, Petersen, Siegal, & White, 1987) . Then, at theThird National Conference on Methadone Treatment in New York City in 1970,a number of the methadone maintenance matriarchs and patriarchs devoted anentire two-hour session to Chambers' work, endlessly castigating him for havingintroduced such terms as "supplementation," "cheating," and "diversion" into themethadone literature . Supplementation referred to increasing the maintenance doseof methadone to get high ; cheating referred to abusing cocaine during maintenancetherapy; diversion referred to a patient's participation in more than one methadoneprogram 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, wouldfollow in his footsteps : Jim Inciardi, Dave Petersen, Dick Stephens, and the lateHarvey Siegal. The near-epidemic abuse of methaqualone and the amphetamines inthe 1970s led to increased focus on the prescription drug problem, and a significantbody of scientific literature began to develop, yet it was Chambers who really gotit all going .

During the 1980s and much of the 1990s, however, prescription drug abuse tooka back seat to other more pressing concerns . "Freebase" and powder cocaine weremajor concerns, with the attendant cocaine wars in Florida, Latin America, and theCaribbean instigated by Colombia's Medellin and Cali cartels . In inner-city crackhouses 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 withdrug 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 byearly attempts to understand the phenomenon and develop effective science-based

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interventions . During those years, little attention could be focused on prescriptiondrug abuse .

RECENT TRENDS AND ACCOMPLISHMENTS

In 1994, with little fanfare and for the most part unknown to researchers in thedrug field, Ortho-McNeil Pharmaceutical funded what turned out to be the longestand most expensive.drug abuse research study to date (excluding, of course, theannual National Household and Monitoring the Future surveys) . The focus wasUltram® (tramadol HC1), an opioid-like analgesic, which had just been approvedby the Food and Drug Administration (FDA) as a nonscheduled drug underthe Controlled Substances Act. The nonscheduled status was contingent on thedevelopment and implementation of a comprehensive postmarketing surveillanceprogram by an Independent Steering Committee external to Ortho-McNeil, chargedwith monitoring abuse and recommending scheduling if necessary . The programwas composed of a variety of studies, including : (a) a nationwide network of some400 key informants in the drug field who participated in a quarterly survey, reportingtheir observations of any abuse of Ultram®; (b) a quarterly survey of diversioninvestigators recruited from police departments and regulatory agencies in all 50states ; (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 patientswho had been prescribed Ultram® for noncancer pain . In addition, in locales wherethe abuse of Ultram® was suspected, citywide and statewide physician educationprograms and other interventions were developed . For more than 10 years, theIndependent Steering Committee met monthly to review the data and to makerecommendations to Ortho-McNeil and the FDA . Ultimately, the postmarketingsurveillance effort documented that although there was indeed abuse and diversionof 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 beenimplemented, researchers, clinicians, and government observers began noticingthat prescription drugs were being more widely prescribed and abused (Compton& Volkow, 2006 ; Zacny et al., 2003) . A study conducted by the National Center onAddiction and Substance Abuse at Columbia University, for example, found thatfrom 1992 to 2002, opioid prescriptions increased by 222%, codeine prescriptionsincreased by 12%, fentanyl by 1,106%, hydrocodone by 376%, meperidine by66%, hydromorphone by 107%, methadone by 1,597%, morphine by 279%, andoxycodone by 380% (The National Center on Addiction and Substance Abuseat Columbia University, 2005) . For the period 1995 through 1997, the DrugEnforcement Administration's Automation of Reports and Consolidated Orders

104 JOURNAL OF DRUG ISSUES


System (ARCOS), which measures the retail distribution of pain medicgrams, found substantial increases in the medicinal use of morphine (ifentanyl (1,168%), oxycodone (23%), and hydromorphone (19%) . Substhe period of 1997 to 1 2001 demonstrated increases in the retail distriloxycodone (up--348%), morphine (49%), and fentanyl (151%) (JoranslRyan, K.M., & Gilson, A.M. et al ., 2000 ; Novak, S ., Nemeth, WC ., Laws2004). One could argue that these increases served as a catalyst for the iiabuse, dependence, and diversion of prescription opioids .

At the same time, national data suggested that the abuse of manyprescription drugs had been escalating since the early to mid-1990s . TheSurvey of Drug Use and Health found that the numbers of new nonmediof prescription opioids (primarily products containing codeine, hydrocodoxycodone) 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 (SAbuse and Mental Health Services Administration, 2005) . In additionfrom the Drug Abuse Warning Network indicated that abuse-related endepartment (ED) visits involving narcotic analgesics increased by 15 :1995 through 2002, and during the same period, abuse-related ED visits ibenzodiazepines increased by 41 % (Substance Abuse and Mental HealthAdministration, & Office of Applied Studies, 2004a, 2004b) . Similar iwere reflected in data on drug abuse treatment admissions .

Although the abuse and diversion of prescription drugs was clearly anproblem, OxyContin® galvanized the attention of the media, the governnthe public at large . When the drug was first introduced in 1996, it was hrbreakthrough 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 quiteAbuse of OxyContin® first surfaced in rural Maine, soon spreading alongcoast and Ohio Valley, and then into rural Appalachia . Communities inVirginia, eastern Kentucky, West Virginia, and southern Ohio were e ;hard hit, and a number of factors characteristic of these areas seemed towith the apparent high rates of abuse (Inciardi & Goode, 2003) . Aspecculture in northern Maine and rural Appalachia are markedly different frcin other parts of the country. Many of the communities are quite small andoften situated in the mountains and "hollers" (small crevice-like mountand valleys), a considerable distance from major towns and highways . Asmany of the usual street drugs are simply not available . Instead, locals nwith resources already on hand, like prescription drugs. Isolation limits opamenities and entertainment, a major contrast to the distractions of mete

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1tions . During those years, little attention could be focused on prescriptionise .

TRENDS AND ACCOMPLISHMENTS

)94, with little fanfare and for the most part unknown to researchers in theEd, Ortho-McNeil Pharmaceutical funded what turned out to be the longestit expensive drug abuse research study to date (excluding, of course, thenational Household and Monitoring the Future surveys) . The focus was' (tramadol HC1), an opioid-like analgesic, which had just been approvedFood and Drug Administration (FDA) as a nonscheduled drug undertrolled Substances Act. The nonscheduled status was contingent on thement and implementation of a comprehensive postmarketing surveillanceI by an Independent Steering Committee external to Ortho-McNeil, charged-nitoring abuse and recommending scheduling if necessary . The programiposed of a variety of studies, including: (a) a nationwide network of someinformants in the drug field who participated in a quarterly survey, reportingnervations of any abuse of Ultram ®; (b) a quarterly survey of diversionitors recruited from police departments and regulatory agencies in all 50~) an in-depth study of impaired health professionals in four states ; andlow-up study of almost 90,000 interviews with over 11,000 pain patients. been prescribed Ultram® for noncancer pain . In addition, in locales wheree of Ultram® was suspected, citywide and statewide physician education.s and other interventions were developed . For more than 10 years, thedent Steering Committee met monthly to review the data and to makeendations to Ortho-McNeil and the FDA. Ultimately, the postmarketing.nce effort documented that although there was indeed abuse and diversionn® , 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 beenanted, researchers, clinicians, and government observers began noticingcription drugs were being more widely prescribed and abused (Comptonw, 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 prescriptionsd by 12%, fentanyl by 1,106%, hydrocodone by 376%, meperidine bydromorphone by 107%, methadone by 1,597%, morphine by 279%, andne by 380% (The National Center on Addiction and Substance Abusenbia University, 2005) . For the period 1995 through 1997, the Drugnent Administration's Automation of Reports and Consolidated Orders


System (ARCOS), which measures the retail distribution of pain medications ingrams, 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 ofoxycodone (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 increasingabuse, dependence, and diversion of prescription opioids .

At the same time, national data suggested that the abuse of many differentprescription drugs had been escalating since the early to mid-1990s . The NationalSurvey of Drug Use and Health found that the numbers of new nonmedical usersof prescription opioids (primarily products containing codeine, hydrocodone, andoxycodone) increased from 600,000 in 1990 to over 2 .4 million in 2004, markingit as the drug category with the largest number of new users in 2004 (SubstanceAbuse and Mental Health Services Administration, 2005) . In addition, reportsfrom the Drug Abuse Warning Network indicated that abuse-related emergencydepartment (ED) visits involving narcotic analgesics increased by 153% from1995 through 2002, and during the same period, abuse-related ED visits involvingbenzodiazepines increased by 41% (Substance Abuse and Mental Health ServicesAdministration, & Office of Applied Studies, 2004a, 2004b) . Similar increaseswere reflected in data on drug abuse treatment admissions .

Although the abuse and diversion of prescription drugs was clearly an evolvingproblem, OxyContin® galvanized the attention of the media, the government, andthe public at large . When the drug was first introduced in 1996, it was hailed as abreakthrough in pain management . The medication is unique in that its time-releaseformula allows patients to enjoy continuous, long-term relief from moderate tosevere 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 eastcoast and Ohio Valley, and then into rural Appalachia . Communities in westernVirginia, eastern Kentucky, West Virginia, and southern Ohio were especiallyhard hit, and a number of factors characteristic of these areas seemed to correlatewith the apparent high rates of abuse (Inciardi & Goode, 2003) . Aspects of theculture in northern Maine and rural Appalachia are markedly different from thosein 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 densand 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 duewith resources already on hand, like prescription drugs . Isolation limits options foramenities and entertainment, a major contrast to the distractions of metropolitan

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INCIARDI, CICERO

areas. Many substance abuse treatment patients in these rural areas have told theircounselors that they started using drugs because of boredom. Many start abusingdrugs quite young, as well .

In addition, many adults in these rural areas tend to suffer from chronicillnesses and pain syndromes, born out of hard lives of manual labor in perilousprofessions : coal mining, logging, fishing, and other blue-collar industries thatoften result in debilitating injuries . As a result, a disproportionately high segmentof the population lives on strong painkillers . Use of pain pills evolves into a kindof coping mechanism, and the practice of self-medication becomes a way of lifefor many. As such, the use of narcotic analgesics has become normalized andintegrated 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 onlyabout the properties of the drug, but also about: (a) how to compromise its time-release mechanism, (b) the tactics of diversion that people were using to obtain thedrug (including Medicaid fraud), and (c) the concerns of the medical professionabout the potential for abusing the drug . In addition, numerous examples of allegedOxyContin®-related crimes were described in detail. A smattering of news articlesfollowed in other parts of the nation, and in May, 2000, the Boston Globe becamethe first major daily to focus on OxyContin® (Meier, 2003) . After that, OxyContin®became a national media event, and the escalating rates of prescription drug abuseand diversion were more fully recognized .

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 themany frivolous, flaky, foolish, and downright absurd approaches to drug policythat have been put forward, from not only our political leaders, but from a few ofour colleagues and peers as well . There are far too many examples, but perhapsa 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 LadyNancy Reagan, the idea was to discourage children from recreational drug use(and violence and drinking and premarital sex) by offering a variety of ways ofsaying "No!" In theory, it was a laudable goal . The campaign made its way intopopular American culture as several television sitcoms of the period, includingPunky Brewster and Diff'rent Strokes, produced_ episodes centered around thecampaign. Then in 1987 La Toya Jackson became the spokesperson for "Just SayNo." She even recorded a song entitled "Just Say No ." In the end, however, thecampaign became the subject of satire and ridicule (Elliott, 1993) . Moreover, it


I


was ineffective, but did anyone really think that the solution to theabuse could be reduced to a snappy catch phrase? But it gets worse .

Enter Bob Dole, the Republican Senator from Kansas . History tellwas a war hero, an effective politician, and in later years a capable anytelevision commercial protagonist for both Viagra ® and Dunkin' Donutdrug policy realm, something was missing . During his campaign for thlagainst incumbent Bill Clinton in 1996, Senator Dole searched arouncatch phrase of his own. Cognizant of the attention garnered by Nani"Just Say No" crusade and the commercial success of Nike's "Just DoDole came up with "Just Don't Do It" as his message to Americanrecreational drug use . Most everyone realized that it was rather urClinton won the election with an Electoral College landslide (379 1Dole moved on to Viagra®, Dunkin' Donuts, and Saturday Night Live

At about the same time, researchers at the University of MiamMedicine received seed funding from NIDA to develop a concept call(Model of Drug Use Spread) . The purpose of MODUS was to deteexisting data and policies what factors contributed to the drug abuparticularly in Latin American nations . Science-based solutions for reabuse would be developed from these data. In theory, it was a good ismore than a year's effort, the resulting solutions were amateurish and silexample, some of the suggested remedies for solving the drug problc(a) arrest drug traffickers ; (b) keep drugs away from youth ; (c) malavailable to drug abusers ; (d) strengthen anti-drug legislation ; aieconomic alternatives to poppy and coca cultivation (Health ServicCenter, 1996) . In 2006, it would appear that the Maryland Attorneymodeled his solutions to the prescription drug problem after MOD1made similar recommendations : (a) strengthen laws relating to the diprescription drugs ; (b) increase coordination among law enforcemeand (c) regulate the online pharmaceutical industry (Kunkle, 2005) .

Shifting to more serious considerations, there is no question that theprescription drug abuse and diversion continue to grow . The most recSurvey 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 surveysame conclusion. Moreover, ED visits involving the abuse or misuse ofdrugs increased by 21% from 2004 to 2005 (Substance Abuse and MServices Administration, 2008 ; Johnston, L. D., O'Malley, P. M., Ba(& Schulenberg, J. E., 2007). There were about 600,000 cases in 200`

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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 chronicand 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 kindg mechanism, and the practice of self-medication becomes a way of lifey. As such, the use of narcotic analgesics has become normalized andd 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 onlyproperties of the drug, but also about : (a) how to compromise its time-

iechanism, (b) the tactics of diversion that people were using to obtain the:luding Medicaid fraud), and (c) the concerns of the medical professionpotential 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 becamenajor daily to focus on OxyContin® (Meier, 2003) . After that, OxyContin®i national media event, and the escalating rates of prescription drug abusersion were more fully recognized .

ODDITIES, ECCENTRICITIES, AND MISCONCEPTIONS : SOME REFLECTIONS ON THEESENT, AND FUTURE

le most powerful nation in the world, we are continuously amazed by thevolous, flaky, foolish, and downright absurd approaches to drug policybeen put forward, from not only our political leaders, but from a few ofagues and peers as well. There are far too many examples, but perhaps11 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 Ladyeagan, the idea was to discourage children from recreational drug useence 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 intokmerican culture as several television sitcoms of the period, includingrewster and Diff'rent Strokes, produced episodes centered around thei. Then in 1987 La Toya Jackson became the spokesperson for "Just Sayeven 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 drugabuse could be reduced to a snappy catch phrase? But it gets worse .

Enter Bob Dole, the Republican Senator from Kansas . History tells us that hewas a war hero, an effective politician, and in later years a capable and believabletelevision commercial protagonist for both Viagra ® and Dunkin' Donuts. But in thedrug policy realm, something was missing . During his campaign for the presidencyagainst incumbent Bill Clinton in 1996, Senator Dole searched around for a niftycatch 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 aboutrecreational drug use . Most everyone realized that it was rather unconvincing .Clinton won the election with an Electoral College landslide (379 to 159), andDole moved on to Viagra®, Dunkin' Donuts, and Saturday Night Live .

At about the same time, researchers at the University of Miami School ofMedicine received seed funding from NIDA to develop a concept called MODUS(Model of Drug Use Spread) . The purpose of MODUS was to determine fromexisting data and policies what factors contributed to the drug abuse problem,particularly in Latin American nations . Science-based solutions for reducing drugabuse would be developed from these data. In theory, it was a good idea, but aftermore than a year's effort, the resulting solutions were amateurish and simplistic . Forexample, some of the suggested remedies for solving the drug problem included :(a) arrest drug traffickers ; (b) keep drugs away from youth ; (c) make treatmentavailable to drug abusers ; (d) strengthen anti-drug legislation ; and (e) offereconomic alternatives to poppy and coca cultivation (Health Services ResearchCenter, 1996) . In 2006, it would appear that the Maryland Attorney General hadmodeled his solutions to the prescription drug problem after MODUS when hemade similar recommendations: (a) strengthen laws relating to the distribution ofprescription 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 ofprescription drug abuse and diversion continue to grow . The most recent NationalSurvey on Drug Use and Health documented that U.S. household residents aremore likely to report the nonmedical use of prescription opioids than any illicitdrug, other than marijuana . The 2006 Monitoring the Future survey reached thesame conclusion . Moreover, ED visits involving the abuse or misuse of prescriptiondrugs increased by 21 % from 2004 to 2005 (Substance Abuse and Mental HealthServices 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

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many as for heroin and cocaine combined (Substance Abuse and Mental HealthServices Administration, & Office of Applied Studies, 2005) .Although the reasons behind this are open to speculation, two things are indeedapparent. First, the number and variety of prescription drugs have increasedsignificantly in recent years, which is a positive trend for patients in legitimateneed of care . At the same time, however, it has been repeatedly documented thatavailability seems to invariably create demand for drugs with a high potentialfor abuse. Second, prescription drugs are popular among abusers because theyare considered to be more acceptable, less dangerous, easier to rationalize, andless subject to legal consequences than are illicit drugs . These phenomena tendto support the contention that fads and fashions in both the preferences in, andpatterns of, drug abuse appear to be continually shifting and changing . The currenttrend would appear to be prescription drugs .

One of the big mysteries about the prescription drug problem appears to bewhere the drugs are coming from, that is, "diversion." Specifically, diversioninvolves the unlawful channeling of regulated pharmaceuticals from legal sourcesto the illicit marketplace, and this can occur along all points in the drug deliveryprocess : from the original manufacturing site, the wholesale distributor, thephysician's office, the retail pharmacy, or the patient . Diversion, however, hasbeen the focus of only minimal study, and ideas on the sources of illegal suppliesof prescription drugs vary. Federal agencies maintain that diverted drugs enterthe illegal market primarily through "doctor shoppers," inappropriate prescribingpractices by physicians, and improper dispensing by pharmacists . Given this belief,the major solution suggested has been the creation of prescription monitoringprograms, which enable pharmacists and drug control agencies to detect "scriptdocs" who write prescriptions for a fee, as well as "doctor shoppers" who go fromphysician to physician and from pharmacy to pharmacy to obtain multiple suppliesof prescription drugs . Federal authorities have also identified Internet salesas a major source of diversion . Correspondingly, in 2005 the authors surveyeddiversion investigators in 300 police and regulatory agencies across the nation asto their perceptions of the primary sources of diversion . Interestingly, almost three-fourths of the survey participants considered drug abusers posing as patients to bethe major source of diversion through doctor shopping and prescription theft andforgery (Inciardi et al ., 2007) . At the same time, only 3% considered the Internetto be a significant source of prescription drugs . By contrast, the 2005 NationalSurvey on Drug Use and Health found that among individuals ages 12 and olderwho reported abusing prescription opioids in the last year, 72 .3% had obtained thedrugs from friends or relatives, 18 .5% had obtained them from a physician, andless than 1 % reported that they were getting the drugs from the Internet (Substance



Abuse and Mental Health Services Administration, & Office of Applil2006). One of the questions that these findings suggest is: Where are therelatives getting the drugs? Are they sharing their legitimate supplies,giving away pills that should have been discarded? Are the friends or rcdoctor shoppers who ate visiting multiple physicians, or forging prescrilthey getting the drugs from street dealers, and if so, where are the dealertheir supplies? Moreover, our research suggests that dealers are a majoprescription 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 pdistributors, hospitals and clinics, treatment programs, or any other 1organization where controlled substances are stored . When losses occrobberies, burglaries, shoplifting, or employee theft, the Drug EiAdministration (DEA) requires that its Form 106 (Report of TheftControlled Substances) be filed . Although the Form 106 data are notabulated and published, what has been released suggests the potentialof losses. From 2001 to 2003, some 563,677 "standard dosage units" of(1 methadone dosage unit in DEA terminology = 10 mg) were repoior 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 Adm2005). Moreover, a request by the University of Wisconsin under the IInformation Act found a total of 12,894 theft and loss incidents reportfrom 2000 to 2003 in 22 Eastern states, involving some 28 million doszcontrolled substances (Joranson & Gilson, 2005) . These data suggest tIquantities of prescription opioids are being stolen prior to being prescri

Residential burglary also should be studied . Millions of residentialoccur in the United States each year, and evidence suggests that prescrilare a major target in a significant portion of these crimes (Inciardi etIn scores of focus groups and in-depth interviews conducted with hdrug-involved offenders, active street drug users, and recovering addicpast decade, participants agreed that the four items typically sought inburglaries are cash, jewelry, guns, and prescription drugs . Studies coithe Department of Justice and by independent researchers as well asreports support this contention (Inciardi et al ., 2007) .

Are residential burglaries and pharmacy losses the major sources ofstreet dealers? Perhaps, but our research with prescription drug abusersto script doctors, illegal sales in small pharmacies, acquaintances whpersonal prescriptions, sex workers' clients, disability patients, Medicaid

FALL 2009

for heroin and cocaine combined (Substance Abuse and Mental HealthAdministration, & Office of Applied Studies, 2005) .h the reasons behind this are open to speculation, two things are indeedt. First, the number and variety of prescription drugs have increasedmtly in recent years, which is a positive trend for patients in legitimatecare. At the same time, however, it has been repeatedly documented thatlity seems to invariably create demand for drugs with a high potentiale. Second, prescription drugs are popular among abusers because theyidered to be more acceptable, less dangerous, easier to rationalize, andject to legal consequences than are illicit drugs . These phenomena tendin the contention that fads and fashions in both the preferences in, andof, drug abuse appear to be continually shifting and changing . The currentuld appear to be prescription drugs .ff the big mysteries about the prescription drug problem appears to bere drugs are coming from, that is, "diversion." Specifically, diversionthe unlawful channeling of regulated pharmaceuticals from legal sourcesicit marketplace, and this can occur along all points in the drug deliveryfrom the original manufacturing site, the wholesale distributor, thei's office, the retail pharmacy, or the patient . Diversion, however, hasfocus of only minimal study, and ideas on the sources of illegal suppliesiption drugs vary. Federal agencies maintain that diverted drugs enter1 market primarily through "doctor shoppers," inappropriate prescribingby 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 "scripto write prescriptions for a fee, as well as "doctor shoppers" who go fromto physician and from pharmacy to pharmacy to obtain multiple suppliesiption drugs. Federal authorities have also identified Internet sales)r source of diversion . Correspondingly, in 2005 the authors surveyedinvestigators in 300 police and regulatory agencies across the nation asrceptions of the primary sources of diversion . Interestingly, almost three-'the survey participants considered drug abusers posing as patients to besource of diversion through doctor shopping and prescription theft andnciardi et al ., 2007). At the same time, only 3% considered the Internetgnificant source of prescription drugs . By contrast, the 2005 National. Drug Use and Health found that among individuals ages 12 and olderted abusing prescription opioids in the last year, 72 .3% had obtained thea 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 andrelatives getting the drugs? Are they sharing their legitimate supplies, or are theygiving away pills that should have been discarded? Are the friends or relatives thedoctor shoppers who are visiting multiple physicians, or forging prescriptions? Arethey getting the drugs from street dealers, and if so, where are the dealers obtainingtheir supplies? Moreover, our research suggests that dealers are a major source ofprescription 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 ororganization where controlled substances are stored . When losses occur throughrobberies, burglaries, shoplifting, or employee theft, the Drug EnforcementAdministration (DEA) requires that its Form 106 (Report of Theft or Loss ofControlled Substances) be filed. Although the Form 106 data are not routinelytabulated and published, what has been released suggests the potential magnitudeof 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 lostor stolen, and almost all were through illegal means. From January 2000 to June2003, the DEA reported that almost 1 .4 million tablets of OxyContin® were lost orstolen through 2,494 separate incidents (U.S . Drug Enforcement Administration,2005). Moreover, a request by the University of Wisconsin under the Freedom ofInformation Act found a total of 12,894 theft and loss incidents reported to DEAfrom 2000 to 2003 in 22 Eastern states, involving some 28 million dosage units ofcontrolled substances (Joranson & Gilson, 2005) . These data suggest that massivequantities of prescription opioids are being stolen prior to being prescribed .

Residential burglary also should be studied . Millions of residential burglariesoccur in the United States each year, and evidence suggests that prescription drugsare 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 ofdrug-involved offenders, active street drug users, and recovering addicts over thepast decade, participants agreed that the four items typically sought in residentialburglaries are cash, jewelry, guns, and prescription drugs . Studies conducted bythe Department of Justice and by independent researchers as well as newspaperreports support this contention (Inciardi et al ., 2007) .

Are residential burglaries and pharmacy losses the major sources of supply forstreet dealers? Perhaps, but our research with prescription drug abusers also pointsto script doctors, illegal sales in small pharmacies, acquaintances who sell theirpersonal prescriptions, sex workers' clients, disability patients, Medicaid recipients,

FALL 2009 109

INCIARDI, CICERO

and personal prescriptions intended for the treatment for drug dependence ormental illness. All of this suggests that focused research is needed targeting the"black box" of diversion . This also suggests that prescription monitoring programsare likely intercepting only a segment of those individuals diverting prescriptiondrugs .

As a final point, a number of other approaches may help us to better understandand address the problems of prescription drug abuse and diversion :

1 . The data on prescription drug losses sent to the DEA on Form 106 are notreadily available. Data for Form 106 can be obtained under the Freedomof Information Act, but what is typically received is incomplete . To garnera better idea of the extent and geographical distribution of losses ofcontrolled substances, funding should be allocated to the DEA for betterarchiving and analysis of Form 106 data .

2. The Federal Bureau of Investigation's (FBI) Uniform Crime ReportingSystem has been collecting and publishing nationwide data on crime forgenerations . However, in the areas of larceny/theft and burglary, no dataare collected on what is actually stolen . The FBI's crime reporting systemshould be revised to collect more relevant information on burglaries andother thefts .

3. For a number of years, segments of the pharmaceutical industry, atthe request of the FDA, have been supporting postmarketing and riskmanagement programs to determine the nature and extent of the abuse anddiversion of specific controlled substances (Cicero et al., 2007 ; Katz et al .,2007) . The FDA's requirement for postmarketing surveillance should beexpanded to include all controlled substances with a potential for abuse-both new and old-and both branded and generic varieties . In addition,when a continuing problem of abuse becomes apparent with a given drugin a specific locale, the FDA and industry should share the burden ofdetermining 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 andSymptom Management, 31, 465-476 .

1 1 0 JOURNAL OF DRUG ISSUES


Chambers, C.D .1971 An assessment of drug use in the general population . Albany, i

Narcotic Addiction Control Commission .Chambers, C.D ., & Brill, L. (Eds .)1973 Methadone: Experiences and issues. New York: Behavioral PuChambers, 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., SchSenay, E.C ., & Woody, G.E .1999 A postmarking surveillance program to monitor Ultram, (trama

hydrochloride) Abuse in the United States . Drug and AlcoholDependence, 57, 7-22 .

Cicero, T.J ., Dart, R.C ., Inciardi, J.A ., Woody, G.E., Schnoll, S ., & Mui2007 The development of a comprehensive risk management prograi

prescription opioid analgesics : Researched abuse, diversion andaddiction-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 Dej81, 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 ., SewWoody, G.E .2006 The diversion of Ultram, Ultracet, and generic tramadol . Jourr

Addictive Diseases, 25(2), 53-58 .

FALL 2009

:rsonal prescriptions intended for the treatment for drug dependence orillness. All of this suggests that focused research is needed targeting thebox" of diversion. This also suggests that prescription monitoring programs;ly intercepting only a segment of those individuals diverting prescription

i final point, a number of other approaches may help us to better understandtress the problems of prescription drug abuse and diversion :

The data on prescription drug losses sent to the DEA on Form 106 are notreadily available. Data for Form 106 can be obtained under the Freedomof Information Act, but what is typically received is incomplete . To garnera better idea of the extent and geographical distribution of losses ofcontrolled substances, funding should be allocated to the DEA for betterarchiving and analysis of Form 106 data .The Federal Bureau of Investigation's (FBI) Uniform Crime ReportingSystem has been collecting and publishing nationwide data on crime forgenerations . However, in the areas of larceny/theft and burglary, no dataare collected on what is actually stolen . The FBI's crime reporting systemshould be revised to collect more relevant information on burglaries and)ther thefts .?or a number of years ; segments of the pharmaceutical industry, athe request of the FDA, have been supporting postmarketing and risknanagement programs to determine the nature and extent of the abuse andliversion 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 drugi a specific locale, the FDA and industry should share the burden ofetermining the exact nature of the problem and provide interventions,here appropriate.

S

?.H., 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, andidrocodone in patients with chronic pain. Journal of Pain. and'mptom Management, 31, 465-476 .


I

Chambers, C.D .1971 An assessment of drug use in the general population. Albany, NY :

Narcotic Addiction Control Commission .Chambers, C .D., & Brill, L. (Eds .)1973 Methadone: Experiences and issues . New York: Behavioral Publications .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 .

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 AlcoholDependence, 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 andaddiction-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 .

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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 .

Joranson, D.E., & Gilson, A.M .2005 Drug crime is a source of abused pain medications in the United States .

Journal of Pain and Symptom Management, 30(4), 299-301 .Joranson, D.E ., Ryan, K.M., Gilson, A.M., et al .2000 Trends in medical use and abuse of opioid analgesics . JAMA, 283(13) :

1710-1714 .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,J., & Lande, S.D .2007 Foundations of opioid risk management . Clinical Journal of Pain, 23,

103-118 .Kunkle, F.2005 Attorney General targets prescription drug abuse . The Washington

Post, p . T03, October 6 .Meier, B .2003 Pain killer: A "wonder" drug's trail of addiction and death . Emmaus,

PA: Rodale Press .Novak, S., Nemeth, WC ., & Lawson, K.A .2004 Trends in medical use and abuse of sustained-release opioid analgesics :

A revisit . Pain Medicine, 5(1), 59-65 .Ordway, Renee2000 Narcotics abuse on rise, pharmaceutical drug fraud, misuse worry

officials . Bangor Daily News: Bangor, Maine (April 6) .Ratner, M . (Ed .) .1993 Crack pipe as pimp : An ethnographic investigation of sex for-crack

exchanges . NY: Lexington Books .Souhami, D .2001 Selkirk's Island. New York: Harcourt .



Substance Abuse and Mental Health Services Administration2008 Results from the 2007 National Survey on Drug Use and Health :

National Findings (Office of Applied Studies, NSDUH SeriesH-34, DHHS Publication No . SMA 08-4343) . Rockville, MD .

Substance Abuse_ and Mental Health Services Administration, & Office ofStudies2004a Benzodiazepines in Drug Abuse-Related Emergency Department

1995-2002. The DAWN Report. Accessed from http ://dawninfo . sgov/old dawn/pubs 94 02/shortreports/files/DAWN_tdr _benzo :

Substance Abuse and Mental Health Services Administration, & Office ofStudies2004b Narcotic Analgesics, 2002 Update . The DAWN Report. Accessec

http ://oas.samhsa.gov/2k4analgesics.pdf.Substance Abuse and Mental Health Services Administration, & Office ofStudies .2005 Results from the 2004 National Survey on Drug Use and Health :

National Findings . (Office of Applied Studies, NSDUH Series HDHHS Publication No. SMA 05-4062) . Rockville, MD : Office oApplied Studies .

Substance Abuse and Mental Health Services Administration, & Office o :Studies .2006 Results from the 2005 National Survey on Drug Use and Health :

National findings . Retrieved February 26, 2007, from http://oas . :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 L2005 Under the counter: The diversion and abuse of controlled prescri

drugs in the U.S. New York: Columbia University .U. S. Drug Enforcement Administration1997 ARCOS 2 - Report 7: U.S . Summary of Retail Drug Purchases r

period: 1/01/1997-12/31/1997 : U.S. Department of Justice .U. S . Drug Enforcement Administration1998 ARCOS 2 - Report 7: U.S. Summary of Retail Drug Purchases r

period: 1/01/1998-12/31/1998 : U.S. Department of Justice .U. S. Drug Enforcement Administration1999 ARCOS 2 - Report 7 : U.S. Summary of Retail Drug Purchases r

period: 1/01/1999-12/31/1999 : U.S. Department of Justice .

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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 cluband 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: Overviewof 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 .Reneelarcotics abuse on rise, pharmaceutical drug fraud, misuse worryfcials. Bangor Daily News: Bangor, Maine (April 6) .L (Ed .) .:rack pipe as pimp: An ethnographic investigation of sex-for-crackrchanges . NY: Lexington Books .D.olkirks Island. New York: Harcourt .


Substance Abuse and Mental Health Services Administration2008 Results from the 2007 National Survey on Drug Use and Health :

National Findings (Office of Applied Studies, NSDUH SeriesH-34, DHHS Publication No . SMA 08-4343) . Rockville, MD .

Substance Abuse and Mental Health Services Administration, & Office of AppliedStudies2004a 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.

Substance Abuse and Mental Health Services Administration, & Office of AppliedStudies2004b Narcotic Analgesics, 2002 Update . The DAWN Report. Accessed from

http://oas.samhsa.gov/2k4analgesics .pdf.Substance Abuse and Mental Health Services Administration, & Office of AppliedStudies .2005 Results from the 2004 National Survey on Drug Use and Health :

National Findings . (Office of Applied Studies, NSDUH Series H-28,DHHS Publication No. SMA 05-4062) . Rockville, MD : Office ofApplied Studies .

Substance Abuse and Mental Health Services Administration, & Office of AppliedStudies .2006 Results from the 2005 National Survey on Drug Use and Health :

National findings . Retrieved February 26, 2007, from http://oas.samhsa .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 University2005 Under the counter : The diversion and abuse of controlled prescription

drugs in the U.S. New York: Columbia University .U. S. Drug Enforcement Administration1997 ARCOS 2 - Report 7 : U.S . Summary of Retail Drug Purchases reporting

period: 1/01/1997-12/31/1997 : U.S . Department of Justice .U. S. Drug Enforcement Administration1998 ARCOS 2 - Report 7 : U.S. Summary of Retail Drug Purchases reporting

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period: 1/01/1999-12/31/1999 : U.S. Department of Justice .

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period: 1/01/2001-12/31/2001 : U.S . Department of Justice .U.S. Drug Enforcement Administration2005 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 Administration2005 OxyContin® theft & loss incidents : January 2000 through June 2003 .

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Zacny, J., Bigelow, G., Compton, P., Foley, K., Iguchi, M., & Sannerud, C .2003 College on problems of drug dependence taskforce on prescription

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© 2009 BY THE JOURNAL OF DRUG ISSUES

THE NEUROBIOLOGY OF ADDICTION : WHERE WEBEEN AND WHERE WE ARE GOING

GEORGE F. KOOB, ERIC J. SIMON

A number of dramatic breakthroughs in the neurobiology of addicoccurred in the past 40 years. Two domains will be highlighted: the netof addiction and the molecular biology of addiction targets. The neursubstrates for the reinforcing effects of drugs of abuse have been largelboth at the initial site of action and in the circuitry involved . In humsstudies, decreases in dopaminergic function have been identified as a k(of addiction, lending support for research on the role of dopamine in addicnovel areas currently are emerging : the role of deficits in frontal cortex fchanges in the brain neurocircuitry that convey long-term vulnerability to rethe role of nondopaminergic systems in the neuroadaptations associatdevelopment of drug dependence. Parallel to these functional changesmajor advances in our understanding of the molecular biology of ad(greatest contribution has been in the understanding of the molecular mof opioid action. This paper reviews the major developments in our unaof the molecular biology of the endogenous opioid system and the use oto advance our knowledge of the function and regulation of opioid recendorphins.

THE PAST AND THE PRESENT

A number of dramatic breakthroughs in the neurobiology of addicoccurred in the past 40 years with the support of the National InstituteAbuse (NIDA) . Two domains will be highlighted here : the neurocircuitry of

George F. Koob, Ph.D., is Professor and Chairman of the Committee on the NeurobiologyDisorders at The Scripps Research Institute and Adjunct Professor in the Departments ofand . Psychiatry and the Skaggs School of Pharmacy and Pharmaceutical Sciences at thof California, San Diego . He specializes on the neurobiology and theoretical constructs oftion, reward, and stress . Dr. Eric J. Simon is Professor of Psychiatry and PharmacologyUniversity Medical Center. Dr. Simon's laboratory has done pioneering research on the meof narcotic analgesics . In 1973 his laboratory, and others, discovered the opiate receptorsHe and his collaborators have continued to work on opiate receptors and endogenous opiand have published 250 papers in excellent journals . He coined the widely used term "enc

black beauties, gorilla pills, footballs, and …cicero.wustl.edu/skip/publications/partner_pubs/7...

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