The OxyContin crisis: problematisation and responsibilisation strategies in addiction, pain, and general medicine journals

Health Care Provider Utilization of Prescription Monitoring Programs: A Systematic Review and Meta-Analysis

OBJECTIVE

To synthesize the literature on the proportion of health care providers who access and use prescription monitoring program data in their practice, as well as associated barriers to the use of such data.

DESIGN

We performed a systematic review using a standard systematic review method with meta-analysis and qualitative meta-summary. We included full-published peer-reviewed reports of study data, as well as theses and dissertations.

METHODS

We identified relevant quantitative and qualitative studies. We synthesized outcomes related to prescription monitoring program data use (i.e., ever used, frequency of use). We pooled the proportion of health care providers who had ever used prescription monitoring program data by using random effects models, and we used meta-summary methodology to identify prescription monitoring program use barriers.

RESULTS

Fifty-three studies were included in our review, all from the United States. Of these, 46 reported on prescription monitoring program use and 32 reported on barriers. The pooled proportion of health care providers who had ever used prescription monitoring program data was 0.57 (95% confidence interval: 0.48-0.66). Common barriers to prescription monitoring program data use included time constraints and administrative burdens, low perceived value of prescription monitoring program data, and problems with prescription monitoring program system usability.

CONCLUSIONS

Our study found that health care providers underutilize prescription monitoring program data and that many barriers exist to prescription monitoring program data use.

'Potential issues of morbidity, toxicity and dependence': Problematizing the up-scheduling of over-the-counter codeine in Australia

Until February of 2018, Australians were able to purchase low-dose codeine products (LDCPs) over-the-counter from pharmacies. In 2017, following review and public consultation, Australia's therapeutic drug regulator rescheduled LDCPs to prescription-only, in line with other higher-dose codeine and opioid products. In this article, we draw on Bacchi's 'what's the problem represented to be' approach to 'work backwards', analysing this 'solution' and the particular 'problematisation' of codeine it produces and relies on. We analyse the 'final decision and reasons for decisions' document, which outlines the consultation and decision-making process leading to the rescheduling of LDCPs. We contend that abuse and dependence of codeine by people with chronic pain is the 'problem' constituted by the decision to reschedule LDCP. We consider the ethical and political implications of this problematisation. First, we argue that this problematisation limits the ways the LDCP consumption, particularly by people with chronic pain, can be understood. This problematisation effaces the multiple reasons people with chronic pain may consume LDCPs long term and works to naturalise notions of 'misuse'. We next argue that notions of the 'legitimate patient' and the 'illegitimate consumer' or 'abuser' are in different ways positioned as primarily responsible for managing their health. From here we argue that the problematisation of LDCPs in Australia produces codeine as the sole agent of harm in ways that background wider harm-producing social arrangements. Our analysis also suggests that the 'problem' of LDCPs unreflexively reinforces medical authoring and expertise as the primary solution. Finally, we suggest that the use of LDCPs in Australia could instead be re-problematised as an issue of 'chronic health mismanagement'. Responses to this problematisation would require a reorientation away from attempts to reduce accessibility such as up-scheduling to significantly more focus on long-term healthcare engagement for people consuming LDCPs to manage chronic health issues.

OxyContin in Ontario: the multiple materialities of prescription painkillers

BACKGROUND

In the past decade, OxyContin diversion and misusehave been firmly established in Ontarian public discourse as serious problems requiring major intervention.This article contextualizes and theorizesthe processes through which the marketing of the prescription opioid and its subsequent problematization occurred. Theanalysis refuses the impossible choice between the 'deserving pain patient' and the 'undeserving addict,' between the war on pain and the war on drugs, and between a notion of OxyContin as either miracle panacea or destructive poison. Rather than falling in step with these binaries, OxyContinis theorized across them, or multiply, with the aim of moving beyond established moral and theoretical registers for exploring embodied consumption.

METHODS

This discursive study is based on a broad range of texts collected between 2009-2013: Hansard reports from the Legislative Assembly of Ontario; newspaper, magazine, and internet coverage of OxyContin; and policy documents, research reports, and position papers and news releases produced by government agencies, advocacy organizations, professional bodies, think tanks, tribal councils, and law enforcement agencies.

RESULTS

Pharmaceutical industry and state actors have attempted to dualistically parse disparate materializations of OxyContin, a tactic that intensified as media pressure helped produce the notion of a public health crisis and, implicitly, a crisis of welfare dependence. By focusing on the (impossible) task of stratifying proper from improper use, the drug's advocatessought to secure the integrity of opioid painkillers and to protect their materialization as vehicles for maintaining a body that is normal, stable, and in control, as opposed to a body of excess that threatens to expose the consumerist logic of contemporary medicine.

CONCLUSION

Attempts to contain the multiplicity of OxyContin result in the further entrenchment of privatized and individualized approaches to pain and painkilling and serve to undermine rather than secure public health and safety.

Abuse potential, pharmacokinetics, pharmacodynamics, and safety of intranasally administered crushed oxycodone HCl abuse-deterrent controlled-release tablets in recreational opioid users

The objective of this study was to evaluate abuse potential, pharmacokinetics, pharmacodynamics, and safety of intranasally administered, crushed reformulated OxyContin® (oxycodone HCl controlled-release) tablets (ORF), relative to crushed original OxyContin® (OC), oxycodone powder (Oxy API), and OC placebo. This randomized, double-blind, positive- and placebo-controlled crossover study enrolled healthy, adult, nonphysically dependent recreational opioid users with recent history of intranasal drug abuse (N = 27). Active treatments contained oxycodone (30 mg). Pharmacokinetics, pharmacodynamics (e.g., Overall Drug Liking [ODL], Take Drug Again [TDA], and High Visual Analog Scales [VAS]; Subjective Drug Value [SDV]; pupillometry; intranasal irritation), and safety (e.g., adverse events, vital signs, laboratory tests) were assessed to 24 hours postdose. Crushed ORF administration yielded reduced oxycodone Cmax and increased Tmax versus crushed OC and Oxy API. Peak effects for pharmacodynamic measures were delayed with ORF (1-2 hours) versus OC and Oxy API (0.5-1 hour). ODL, TDA, High VAS, and SDV Emax values were significantly lower (P ≤ .05) and some intranasal irritation ratings were greater for ORF versus OC and Oxy API. No significant or unexpected safety findings were observed. Compared with OC and Oxy API, intranasally administered ORF was associated with lower and delayed peak plasma concentrations, decreased drug-liking, and decreased intranasal tolerability. This suggests that ORF has a decreased potential for intranasal oxycodone abuse. There were no significant or unexpected safety findings. As is true for all abuse potential studies, epidemiological or other appropriate post-marketing studies are required to assess the impact of the reduction in intranasal oxycodone abuse potential observed in the present study on real-world patterns of ORF misuse, abuse, and diversion.