A masked man walked into a Fort Wayne, Ind., drugstore early one Saturday morning, approached the pharmacy counter and, realizing it was closed, left. An hour later, wearing the same mask, he entered the store across the street, handed the pharmacist a list of drugs scrawled on a napkin and threatened to kill the pharmacist if he didn't get them, police say.
Police were waiting, having been notified by employees of the first account. As the suspect dashed from the store, prescription painkillers clutched in his hand, a police officer caught him.
The June 2 incident was the 11th pharmacy robbery in Fort Wayne this year, an unusually high number for this city of 250,000 people, police spokeswoman Raquel Foster said. In almost every case, the robbers asked specifically for Opana, the trade name for oxymorphone, a powerful prescription painkiller.
"A few years ago, it was OxyContin. Now it's Opana," Foster said. "These people are desperate to get it."
Prescription drug abuse is the nation's fastest-growing drug problem, the White House Office on National Drug Policy says. The Centers for Disease Control and Prevention has classified the misuse of these powerful painkillers as an epidemic, with 1.3 million emergency room visits in 2010, a 115% increase since 2004. Overdose deaths on opioid pain relievers surpassed deaths from heroin and cocaine for the first time in 2008.
This rise of Opana abuse illustrates the adaptability of drug addicts and the never-ending challenge facing law enforcement authorities, addiction specialists and pharmaceutical companies. Just when they think they have curbed abuse and stopped trafficking of one drug, another fills the void. Opana's dangerous new popularity arose when OxyContin's manufacturer changed its formula to deter users from crushing, breaking or dissolving the pill so it could be snorted or injected to achieve a high.
"It's almost like a game of Whac-A-Mole. You get a handle on OxyContin; they switch to Opana," said Jeffrey Reynolds, executive director of the Long Island Council on Alcoholism and Drug Dependence in Mineola, N.Y. "My guess is it will be something new tomorrow."
As a new, harder-to-abuse Opana formulation replaces the old formula, police and addiction experts expect heroin to fill that void.
"They will adapt the same way drug traffickers or criminals will adapt to a new law. They are going to find a way to satisfy their addiction," said DEA Special Agent Gary Boggs of the Office of Diversion Control. "When they either can't get those particular pharmaceuticals or can't afford them, they now gravitate to heroin."
For years, drug abusers favored an extended-release version of OxyContin, a narcotic painkiller, for a powerful high. Over the past decade, its abuse was so prevalent that the drug became a household name.
Drug abusers could crush or dissolve the pill's time-release coating to get the full punch of the opioid oxycodone. But Purdue Pharma, OxyContin's manufacturer, reformulated it in August 2010, making it nearly impossible to crush, dissolve and inject. By the beginning of 2011, more than 95% of prescriptions were being filled with reformulated OxyContin, Purdue spokesman James Heins said.
Though people could still abuse the drug by taking larger quantities, some addicts craved the injectable high.
As the supply of the old formulation dwindled, panicked drug abusers flooded Internet chat rooms in attempts to find ways to outsmart the new technology, from pounding it with hammers to soaking it in acid, said Sgt. John McGuire, head of the prescription drug diversion unit at the Louisville Metro Police Department.
"At first, people tried to defeat it," McGuire said. "Then, Opana started to pop up like crazy."
Opana ER, an extended-release painkiller containing oxymorphone, came on the market in 2006. Endo Pharmaceuticals, the manufacturer, completed development of a crush-resistant pill in 2010 but did not get approval from the Food and Drug Administration (FDA) until late last year, said Endo senior vice president Blaine Davis.
On June 14, the FDA moved the old Opana formulation to its list of discontinued drugs. Davis said he doesn't know how much remains on the market.
Meanwhile, the Opana problem grew swiftly and sharply, particularly in several states where prescription drug abuse is deeply ingrained:
•Nassau County, N.Y., issued a health alert in 2011 when the New York City suburb saw the first signs of an alarming spike in Opana use. Medicaid data for the county showed prescriptions for extended-release Opana had increased 45% in six months. Since then, Reynolds said, the problem has worsened. "Opana has emerged as the key drug of choice," said Reynolds, who estimates that 80% of the 600 people who seek help each month from the Long Island Council use Opana.
•A DEA intelligence briefing noted increases in Opana uses in Pennsylvania, including Philadelphia, and Delaware. In New Castle, Del., the DEA said, drug users had switched from uncrushable OxyContin to the crushable oxymorphone "for ease of use," pushing the price for a 40 mg tablet to $65. A tablet costs $4 to $8 when purchased legitimately at a pharmacy.
•In Ohio, authorities in Akron, Cincinnati and Athens noted surges in Opana as a replacement for OxyContin, the state's Substance Abuse Monitoring Network reported earlier this year. One unnamed drug abuser in Youngstown told network monitors "no one wants the new oxys now that (Purdue) change the makeup of them," the Ohio Substance Abuse Monitoring Network noted in its January surveillance report. Opana 40 mg tablets sell for $60 to $70 each, outpacing the once-popular old formulation OxyContin, which now sells for at least $1 a milligram, the report said. The less popular new formulation of OxyContin 40 mg sells for $20 to $30, the report said.
The spike is particularly pronounced in Kentucky. In 2010, toxicology tests identified oxymorphone, the key ingredient in Opana, in 2% of the state's overdose cases, said Van Ingram, executive director of the Kentucky Office of Drug Control Policy. By 2011, oxymorphone was present in the blood of 23% of overdose victims.
The numbers so alarmed Ingram that he asked the CDC to do an epidemiological study to pinpoint where the drug was coming from and why use had increased. Ingram is waiting to hear from the CDC, which did not respond to a request for comment.
Ingram fears the problem will get worse this year. "I don't think we've hit the apex yet," he said. "We're just now seeing how big this is."
Abuse, then the overdoses
A similar switch happened in Indiana, where the pill problem began a decade ago with hydrocodone - known by trade names Vicodin and Lortab - and then to oxycodone, said Sgt. Jerry Goodin of the Indiana State Police.
"When OxyContin changed, the drug abusers looked for a different thing. Opana emerged immediately," Goodin said. "Seems like every time we get a handle on something, another evil pops its head up."
Soon after Opana came on the scene, the overdoses began, Goodin said. "When you abuse it and manipulate it and do all the things you're not supposed to do, it turns deadly."
Oxycodone abuse was well established in Scott County, Ind., when Sheriff Dan McClain took office in January 2011. He expected more of the same. Instead, the small-town sheriff in the sparsely populated county of 24,000 people in southeast Indiana confronted a rash of Opana overdoses.
"We were starting to see it emerge and surpass OxyContin early that year," McClain said.
Last year, 19 people in the tiny county died of overdoses, the majority on Opana in combination with alcohol and other drugs, Scott County Coroner Kevin Collins said. This year, 13 people have died from drug overdoses, he said.
McClain said in some cases the people purchased the drugs from elderly people with legitimate prescriptions who sold the drugs to supplement their Social Security income. Others bought the drugs from drug dealers who traveled to out-of-state "pill mills" - clinics where doctors perform cursory examinations on people with dubious injuries and prescribe large quantities of the pills, he said.
The number of overdose deaths is unusually high for the county and has pushed the number of coroner's cases from an average of 28 a year to 39 in the first six months of 2012. The coroner must investigate all unattended or suspicious deaths, he said.
Collins, who has been coroner or deputy coroner for 27 years, said he won't seek office again this year. The overdoses - mostly of people ages 18 to 30 - weigh heavily on him.
"It's depressing. It's still somebody's son or brother or dad," he said. "They got hooked on this crap, and it takes their lives."
Lori Croasdell, coordinator for the Coalition to Eliminate Abuse of Substances in Scott County and a member of the Governor's Commission for a Drug-Free Indiana, said she sees signs of an Opana shortage that might be the result of the new formulation. Pharmacists report that desperate addicts call to ask whether the old formulation is in stock, she said.
"People are going to find something else," Croasdell said.
When a production snafu caused a nationwide shortage of Opana earlier this year, the price in Louisville soared from $65 for a 40 mg pill to $185, McGuire said. "That is a crazy amount of money. For a heavy abuser who will give up anything in his life to make sure he gets that pill, there's no way one will get them through the day."
The price spike sparked a surge in heroin use, which might foreshadow what will happen when the supply of old Opana dries up, McGuire said.
Indiana's Goodin agrees. "We're battling that uptick like we're battling everything else. We've got a war on our hands. We're fighting it every day."
The shortages drive crime as people steal the drugs or steal other things to get money to buy drugs, he said.
A desperate cycle
The man charged with the Fort Wayne drug store robbery - 36-year-old Aaron McAtee - has struggled since his teens with a drug addiction that began with cocaine and progressed to painkillers, according to his wife, April. Court records show McAtee has been in and out of prison for forgery, cocaine possession and other drug convictions. His court-appointed public defender, Michelle Kraus, declined to comment while the case is underway.
April McAtee said Opana and other prescription narcotics sell for high prices on the street. "You could snort a piece of Opana and you're high like you're on heroin. Because of that, the street usage went up big time," she said.
McAtee, who has pleaded not guilty, was released from prison Feb. 8 after serving two years for forgery. His wife said he forged payroll checks to get money to buy drugs. After his release, he stayed drug-free for 16 weeks, but relapsed the night before the alleged robbery, she said.
"He doesn't need to be locked in prison with a bunch of criminals," she said. "He needs medical help."