Am J Psychiatry 164:11, November 2007
This article is featured in this month’s AJP Audio.
OxyContin Abuse: Who Are the Users?
Recent epidemiological reports suggest that prescription opiate use has increased
sharply in many parts of the United States (Figure 1) (1–4). There is evidence that the In-
ternet has become a new source of prescription drugs, increasing their availability and
eliminating the need for a prescribing physician. In addition, in response to concerns
about the undertreatment of pain, more opiate painkillers are being prescribed (5). Is
there an epidemic of prescription opiate use? Who are the users of prescription opiates?
Effective prevention, public information, and treatment policies require sound drug
use epidemiological data to ensure that policy making is not hijacked by stories of ce-
lebrity arrests and media-generated hysteria.
In this issue of the Journal, the article by Carise et al. provides some very useful data on
a sample of OxyContin users who have been admitted into a variety of treatment pro-
grams around the United States. The authors
present data from a very valuable drug abuse in-
dicator system, the Drug Evaluation Network Sys-
tem (DENS), established to collect information
on individuals admitted to substance abuse
treatment at selected specialty centers through-
out the United States. The data in DENS are col-
lected using the well-established Addiction
Severity Index. The use of this validated data col-
lection instrument results in data with known va-
lidity and reliability parameters. DENS provides a rich set of timely data, captured and
transmitted electronically at the time of admission, which allows for rapid analysis and
information to policy makers about changes in the characteristics of patients admitted
to the network’s participating treatment agencies. Access to these current data is impor-
tant for the substance abuse monitoring system in the United States.
The data presented by Carise et al. offer some very useful insights into the nature of
the patient population that has entered treatment at a set of treatment centers with
OxyContin as their primary drug of choice. It is clear that many of the people who enter
treatment in these treatment programs for OxyContin abuse/dependence are not naive
individuals with accidental addiction who were introduced to opiate painkillers by their
physicians as reported by the media. The individuals admitted to the treatment organi-
zations participating in DENS are, for the most part, individuals with extensive drug use
histories and involvement in the criminal justice system. Their use of OxyContin as
their current preferred drug is related to the fact that in some parts of the United States
there is easy access to OxyContin (1). Hence, OxyContin use among this group simply
represents a drug preference based primarily on convenience. This is an important
finding and adds a useful perspective to understanding the nature of the drug abuse
problems that are associated with the use of OxyContin.
The sample examined in the Carise et al. study is an important segment of the Oxy-
Contin using population. However, as noted by the authors, the DENS sample is not in-
tended to be a representative sample of the general population. The DENS system col-
lects information about individuals admitted into treatment programs that have
volunteered to participate in the DENS program. As the authors acknowledge, it is not
known how representative the DENS treatment program sample is of the entire addic-
tion treatment system, and as the authors suggest, the programs tend to be generally ur-
ban and suburban, while many of the OxyContin reports have described major prob-
“Many of the people who
programs…are not naive
Am J Psychiatry 164:11, November 2007
lems in rural areas. One predominantly rural state, Maine, has witnessed an increase of
methadone programs in the past 5 years and an increase in annual methadone admis-
sions from 1,158 in 2002 to 1,677 in 2005 (6). It would be of great interest to determine if
this new influx of patients to new methadone programs had the same chronic history of
addiction as reported in the DENS data.
The OxyContin phenomenon has affected a number of states. Figure 1 shows the rate
of admissions reported to the Treatment Episode Data Set (TEDS) of “Other Opiates”
per 100,000 individuals in the population from 1995–2005 for the United States and for
the five states with the highest rates in 2005 (3). The Other Opiate category is defined as
codeine, hydromorphone, morphine, meperidine, opium, oxycodone, and any other
drug with morphine-like effects.
Table 1 shows the percent of individuals admitted with a primary problem with heroin
or other opiates in 2005. Notice that in states that have had a long-standing problem with
heroin (e.g., Massachusetts and Rhode Island), the proportion of first-time admissions is
low—consistent with Carise et al.’s finding that only 22% of the DENS clients had no pre-
vious treatment admissions—while in those states that have developed problems with
abuse of other opiates (including OxyContin) more recently (e.g., Maine and Vermont),
the proportion of first-time admissions for problems with heroin or other opiates is much
higher (7). This may indicate two different groups of users: long-term users, as identified
by Carise et al., and novice users whose introduction into opiate use may be the result of
their exposure to OxyContin.
In addition, as noted by the authors, the substance abuse specialty treatment system
has historically become a place where the most difficult patients are referred and
treated. Large proportions of individuals who walk through the doors of these specialty
clinics are long-term drug users who use multiple drugs, are involved in the criminal
justice system, and have numerous previous treatment episodes. Not surprisingly, Oxy-
FIGURE 1. Rate of Individuals Admitted With Primary Non-Heroin Opiate/Synthetic Usea
aUnited States and top five states (Treatment Episode Data Set, 1995–2005).
TABLE 1. Individuals Admitted Who Were First-Time Treatment Admissions (Treatment Episode
Data Set, 2005)
Rate per 100,000 Population
Am J Psychiatry 164:11, November 2007
Contin users who enter treatment in the specialty care addiction treatment system have
many characteristics in common with others who enter treatment in these clinics.
These data clearly support the view that OxyContin users who access the specialty treat-
ment clinics in the DENS sample are not naive, accidental, first-time users.
However, there is no way of knowing if the OxyContin users who end up under the care
of physicians prescribing buprenorphine in office-based practices have the same char-
acteristics as the DENS sample. It is possible that these naive individuals with accidental
addiction (if they do exist) do not seek treatment at the specialty treatment centers. If in
fact there is a new unique cohort of addicted individuals who have become dependent
on OxyContin as a result of their “accidental” misuse of pain medication, it is highly pos-
sible that these individuals would not seek assistance at the treatment clinics where
chronic, polydrug, criminally involved, previously treated individuals with addiction go
for assistance. The stigma of entering treatment in a specialty clinic (particularly many of
the publicly funded clinics that are often in minority neighborhoods characterized by
poverty) may deter entry into these clinics, especially since from the DENS sample and
previous samples it appears that a majority of OxyContin users are Caucasian.
The question of who are the users of OxyContin is an important one. This is a drug
problem in which the drug supply has emerged from a disturbing new set of sources.
Gaining an accurate picture of who this drug use phenomenon affects is a bit like the
story of the blind men who were asked to touch one part of an elephant and then de-
scribe the entire animal. Each set of drug use data from a specific source offers a de-
tailed description of that particular sample, but it is never clear whether each sample
accurately reflects the nature of other samples. We need a more complete picture of the
entire elephant before we can be sure who has and who has not been affected by the
1. Cicero TJ, Inciardi JA, Munoz A: Trends in abuse of Oxycontin and other opioid analgesics in the United States:
2002–2004. J Pain 2005; 6:662–672
2. Cone EJ, Fant RV, Rohay JM, Caplan YH, Ballina M, Reder RF, Spyker D, Haddox JD: Oxycodone involvement
in drug abuse deaths. J Anal Toxicol 2003; 27:57–67
3. Substance Abuse and Mental Health Services Administration, Office of Applied Studies: Treatment Episode
Data Set (TEDS), 1995–2005. National Admissions to Substance Abuse Treatment Services, DASIS Series: S-37
(DHHS Publication No. [SMA] 07–4234) Rockville, Md, SAMHSA, 2007
4. U.S. General Accounting Office: Prescription Drugs: OxyContin Abuse and Diversion and Efforts to Address
the Problem (GAO-04–110), Washington, DC, U.S. General Accounting Office, 2004 (http://www.fda.gov/cder/
drug/infopage/oxycontin/oxycontinGAOreport.pdf [accessed Aug 2007])
5. Researched Abuse, Diversion, and Addiction-Related Surveillance (RADARS) System: RADARS system presents
at SAMHSA methadone-associated mortality meeting. RADARS System News 2007; 4:1–4
6. Substance Abuse and Mental Health Services Administration, Office of Applied Studies: National Survey of
Substance Abuse Treatment Services (N-SSATS) Profile, Maine 2005. Rockville, Md, SAMHSA, 2006 (http://
wwwdasis.samhsa.gov/webt/state_data/ME05.pdf [accessed July 2007])
7. U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administra-
tion, Office of Applied Studies: Treatment Episode Data Set (TEDS), 1992–2005. Concatenated data (com-
puter file). Prepared by Synectics for Management Decisions, Inc. ICPSR Ed. Ann Arbor, Mich, Inter-university
Consortium for Political and Social Research (producer and distributor) (accessed June 2007)
RICHARD A. RAWSON, PH.D.
Los Angeles, Calif.
JANE MAXWELL, PH.D.
BETH RUTKOWSKI, M.P.H.
Los Angeles, Calif.
Address correspondence and reprint requests to Dr. Rawson, Integrated Substance Abuse Program, University
of California, Los Angeles, 1640 S. Sepulveda Blvd., Ste. 200, Los Angeles, CA 90025; firstname.lastname@example.org
(e-mail). Editorial accepted for publication September 2007 (doi: 10.1176/appi.ajp.2007.07091393).
The authors report no competing interests.