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Official websites use. Share sensitive information only on official, secure websites. I focus on issues surrounding the promotion and marketing of controlled drugs and their regulatory oversight. Compared with noncontrolled drugs, controlled drugs, with their potential for abuse and diversion, pose different public health risks when they are overpromoted and highly prescribed. An in-depth analysis of the promotion and marketing of OxyContin illustrates some of the associated issues. Modifications of the promotion and marketing of controlled drugs by the pharmaceutical industry and an enhanced capacity of the Food and Drug Administration to regulate and monitor such promotion can have a positive impact on the public health. An in-depth analysis of the promotion and marketing of OxyContin Purdue Pharma, Stamford, CT , a sustained-release oxycodone preparation, illustrates some of the key issues. When Purdue Pharma introduced OxyContin in , it was aggressively marketed and highly promoted. Under current regulations, the Food and Drug Administration FDA is limited in its oversight of the marketing and promotion of controlled drugs. However, fundamental changes in the promotion and marketing of controlled drugs by the pharmaceutical industry, and an enhanced capacity of the FDA to regulate and monitor such promotion, can positively affect public health. OxyContin's commercial success did not depend on the merits of the drug compared with other available opioid preparations. The Medical Letter on Drugs and Therapeutics concluded in that oxycodone offered no advantage over appropriate doses of other potent opioids. The promotion and marketing of OxyContin occurred during a recent trend in the liberalization of the use of opioids in the treatment of pain, particularly for chronic non—cancer-related pain. From to , Purdue conducted more than 40 national pain-management and speaker-training conferences at resorts in Florida, Arizona, and California. More than physicians, pharmacists, and nurses attended these all-expenses-paid symposia, where they were recruited and trained for Purdue's national speaker bureau. Through these profiles, a drug company can identify the highest and lowest prescribers of particular drugs in a single zip code, county, state, or the entire country. Unfortunately, this same database would also identify which physicians were simply the most frequent prescribers of opioids and, in some cases, the least discriminate prescribers. A lucrative bonus system encouraged sales representatives to increase sales of OxyContin in their territories, resulting in a large number of visits to physicians with high rates of opioid prescriptions, as well as a multifaceted information campaign aimed at them. From to , Purdue increased its internal sales force from sales representatives to , and its total physician call list from approximately 33 to 44 to approximately 70 to 94 physicians. By , when the program was ended, approximately 34 coupons had been redeemed nationally. Purdue promoted among primary care physicians a more liberal use of opioids, particularly sustained-release opioids. Primary care physicians began to use more of the increasingly popular OxyContin; by , nearly half of all physicians prescribing OxyContin were primary care physicians. Prospective, randomized, controlled trials lasting at least 4 weeks that evaluated the use of opioids for chronic, non—cancer-related pain showed statistically significant but small to modest improvement in pain relief, with no consistent improvement in physical functioning. In the long-term use of opioids for chronic non—cancer-related pain, the proven analgesic efficacy must be weighed against the following potential problems and risks: well-known opioid side effects, including respiratory depression, sedation, constipation, and nausea; inconsistent improvement in functioning; opioid-induced hyperalgesia; adverse hormonal and immune effects of long-term opioid treatment; a high incidence of prescription opioid abuse behaviors; and an ill-defined and unclarified risk of iatrogenic addiction. A consistent feature in the promotion and marketing of OxyContin was a systematic effort to minimize the risk of addiction in the use of opioids for the treatment of chronic non—cancer-related pain. One of the most critical issues regarding the use of opioids in the treatment of chronic non—cancer-related pain is the potential of iatrogenic addiction. Both of these studies, although shedding some light on the risk of addiction for acute pain, do not help establish the risk of iatrogenic addiction when opioids are used daily for a prolonged time in treating chronic pain. There are a number of studies, however, that demonstrate that in the treatment of chronic non—cancer-related pain with opioids, there is a high incidence of prescription drug abuse. Prescription drug abuse in a substantial minority of chronic-pain patients has been demonstrated in studies by Fishbain et al. Misrepresenting the risk of addiction proved costly for Purdue. Although research demonstrated that OxyContin was comparable in efficacy and safety to other available opioids, 11 , 63 marketing catapulted OxyContin to blockbuster drug status. The remarkable commercial success of OxyContin, however, was stained by increasing rates of abuse and addiction. Drug abusers learned how to simply crush the controlled-release tablet and swallow, inhale, or inject the high-potency opioid for an intense morphinelike high. Purdue's own MS Contin had been abused in the late s in a fashion similar to how OxyContin was later to be; by , MS Contin had become the most abused prescription opioid in one major metropolitan area. Opioid prescribing has had significant geographical variations. In some areas, such as Maine, West Virginia, eastern Kentucky, southwestern Virginia, and Alabama, from through , hydrocodone and non-OxyContin oxycodone were being prescribed 2. By , these same areas had become high OxyContin-prescribing areas—up to 5 to 6 times higher than the national average in some counties Table 1. In West Virginia, the first methadone maintenance treatment program opened in August , largely in response to the increasing number of people with OxyContin dependence. By October , West Virginia had 7 methadone maintenance treatment clinics with patients in treatment M. In southwestern Virginia, the first methadone maintenance treatment program opened in March , and within 3 years it had admissions E. Data are for the counties or independent cities with the highest quantities of opioids in grams prescribed in each of the 3 states. With increasing diversion and abuse, opioid-related overdoses escalated. The high availability of OxyContin in these 5 regions seemed to be a simple correlate of its abuse, diversion, and addiction. With the growing availability of OxyContin prescriptions, the once-regional problem began to spread nationally. The increasing OxyContin abuse problem was an integral part of the escalating national prescription opioid abuse problem. Liberalization of the use of opioids, particularly for the treatment of chronic non—cancer-related pain, increased the availability of all opioids as well as their abuse. In terms of illicit drug abuse, prescription opioids are now ahead of cocaine and heroin and second only to marijuana. Under the Food, Drug, and Cosmetics Act and implementing regulations, the FDA regulates the advertising and promotion of prescription drugs and is responsible for ensuring that prescription drug advertising and promotion are truthful, balanced, and accurately communicated. There is no distinction in the act between controlled and noncontrolled drugs regarding the oversight of promotional activities. Although regulations require that all promotional materials for prescription drugs be submitted to the FDA for review when the materials are initially disseminated or used, it is generally not required that these materials be approved by the FDA prior to their use. The FDA has a limited number of staff for overseeing the enormous amount of promotional materials. In , for example, 39 FDA staff members were responsible for reviewing roughly 34 pieces of promotional materials. In , Purdue distributed 15 copies of an OxyContin video to physicians without submitting it to the FDA for review, an oversight later acknowledged by Purdue. After its review, the FDA concluded that the video minimized the risks from OxyContin and made unsubstantiated claims regarding its benefits to patients. In July , to reflect the available scientific evidence, the label was modified to state that data were not available for establishing the true incidence of addiction in chronic-pain patients. The labeling also deleted the original statement that the delayed absorption of OxyContin was believed to reduce the abuse liability of the drug. OxyContin appears to be as efficacious and safe as other available opioids and as oxycodone taken 4 times daily. Compared with noncontrolled drugs, controlled drugs, with their potential for abuse and diversion, pose different public health risks when overpromoted and highly prescribed. Several marketing practices appear to be especially questionable. The extraordinary amount of money spent in promoting a sustained-release opioid was unprecedented. During OxyContin's first 6 years on the market, Purdue spent approximately 6 to 12 times more on promoting it than the company had spent on promoting MS Contin, or than Janssen Pharmaceutical Products LP had spent on Duragesic, one of OxyContin's competitors. Although there are no available data for evaluating the promotional effect of free starter coupons for controlled drugs, it seems likely that the over- and misprescribing of a controlled drug are encouraged by such promotional programs and the public health would be well served by eliminating them. The use of prescriber profiling data to influence prescribing and improve sales is imbedded in pharmaceutical detailing. Very little data are publicly available for understanding to what extent this marketing practice boosts sales. Regulations eliminating this marketing tool might decrease some potential overprescribing of controlled drugs. The public health would be better protected if the FDA reviewed all advertising and promotional materials as well as associated educational materials—for their truthfulness, accuracy, balance, and scientific validity— before dissemination. Such a change would require a considerable increase in FDA support, staffing, and funding from what is currently available. Public monies spent on the front end of the problem could prevent another such tragedy. The pharmaceutical industry's role and influence in medical education is problematic. Particularly with controlled drugs, the potential for blurring marketing and education carries a much higher public health risk than with uncontrolled drugs. At least in the area of controlled drugs, with their high potential for abuse and diversion, public health would best be served by severing the pharmaceutical industry's direct role and influence in medical education. Marketing and promotion by the pharmaceutical industry have considerably amplified the prescription sales and availability of opioids. A number of factors have contributed to the marked growth of opioid abuse in the United States, but one factor is certainly the much increased availability of prescription opioids. As a library, NLM provides access to scientific literature. Am J Public Health. Accepted May 9. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

Predictors of opioid misuse in patients with chronic pain: a prospective cohort study

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Heroin addiction is a severe condition affecting the brain and body, leading to various physical and psychological symptoms. Understanding the nature of heroin and the science behind addiction is crucial for recognising its signs and symptoms in Salen. Get in touch. Heroin, also known as diacetylmorphine, is a semi-synthetic opioid derived from morphine. Opioids include prescription pain relievers, synthetic opioids, and heroin. Heroin and other opioids bind to opioid receptors in the brain, producing pain relief and feelings of euphoria and relaxation. Opioid addiction is characterised by a strong, often uncontrollable, urge to use the drug. Individuals may continue using heroin despite negative consequences to their health, relationships, and daily life. Physical dependence can develop quickly, leading to withdrawal symptoms when not using the drug. This cycle of addiction can be challenging to break without professional help in Salen. Heroin addiction affects the brain's reward system, which is involved in regulating mood, emotion, and behaviour. When heroin enters the brain, it binds to opioid receptors, triggering the release of dopamine, a neurotransmitter associated with pleasure and reward. Repeated use of heroin changes the way the brain functions. These changes can lead to a shift in behaviour, where obtaining and using heroin becomes the primary focus. The brain's ability to produce natural dopamine decreases, making it difficult to feel pleasure from everyday activities in Salen. This alteration in brain chemistry also affects decision-making, impulse control, and stress responses. As a result, individuals may engage in risky behaviours, neglect responsibilities, and struggle with mental health problems like anxiety and depression. Identifying heroin use involves looking for specific signs and symptoms. Physical symptoms often include constricted pupils, drowsiness, and weight loss. 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Three stages generally mark this process: early withdrawal, peak withdrawal, and late withdrawal. Early Withdrawal: Starts within hours after the last dose with symptoms like anxiety and sweating. Peak Withdrawal: Occurs around 72 hours in, with the most intense symptoms such as nausea, vomiting, diarrhoea, and severe cravings. Late Withdrawal: Eases over the next week but can include lingering symptoms such as mood swings and fatigue. Heroin withdrawal produces both physical and psychological symptoms, often making the process challenging. Common symptoms include:. Medication-assisted treatment MAT plays a pivotal role in heroin detox and withdrawal. MAT involves using certain medications to help manage cravings and withdrawal symptoms. Methadone: A long-acting opioid that helps reduce cravings and withdrawal without producing a high. Buprenorphine: Partial opioid agonist that eases symptoms and reduces the risk of misuse. 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