Gram for gram, people in the United States consume more narcotic medications than any other nation worldwide, a factor some experts say is driving an epidemic of pain-pill abuse.
"We've gotten too used to popping pills in this country," said Dr. Andrew Kolodny, chief of psychiatry at Maimonides Medical Center in Brooklyn. "There are other ways to deal with pain."
But doctors who treat chronic-pain patients contend the drugs are vital to managing intractable pain.
"These medications are very helpful for a subset of chronic-pain patients," said Dr. Lynn Webster of the American Academy of Pain Medicine. "They are not a panacea. But some patients respond very well and we need to have these medications available."
In the United States, about one in every 20 people age 12 and older -- 12 million people -- say they've used prescription painkillers nonmedically, according to the National Survey on Drug Use and Health.
The Centers for Disease Control and Prevention estimates 5,500 people start prescription painkiller abuse every day in this country. The agency also estimates 40 people die daily nationwide of prescription drug overdoses.
Kolodny, president of Physicians for Responsible Opioid Prescribing, traces the problem to unprecedented amounts of prescription narcotics in the pharmaceutical supply chain.
The International Narcotics Control Board, a division of the United Nations, estimates global pharmaceutical companies produce more than 75 tons a year of oxycodone, compared with 11.5 tons in 1999. More than 80 percent of the worldwide oxycodone supply is consumed in the United States, according to board estimates.
Kolodny contends there's no reason Americans should consume most of the world's oxycodone as well as the lion's share of many other major narcotic medications.
Doc: Public health crisis
Hydrocodone is the most widely prescribed drug in the United States, according to the CDC. In December, the international narcotics board estimated U.S. demand for hydrocodone to be about 27.4 million grams annually compared with 3,237 grams for Britain, France, Germany and Italy combined. A typical dose is about 5 milligrams.
Doctors who treat patients in pain, meanwhile, are concerned pressure is mounting against narcotic medications.
Webster said critics too often overstate the degree to which people are addicted.
"I am not sure I would use the word epidemic," he said. "There is a public health crisis, but not an epidemic."
Webster criticized the CDC, which declared an epidemic of pain-pill abuse, saying patients prescribed narcotic pain pills need them.
Yet, prescription painkillers can be as addictive as their chemical cousin heroin -- and they are purer because they're made in world-class labs, experts say.
"These drugs are very, very active in the brain," said Dr. Stephen Dewey, director of behavioral and molecular neuroimaging at the Feinstein Institute for Medical Research in Manhasset.
Dewey uses sophisticated imaging technology to trace the destructive path drug abuse causes in the brain. He has found that narcotics of all kind can damage vast populations of cells and alter human behavior as a consequence.
"As a rule of thumb, if you're in pain the addictive liability of these drugs is very low," Dewey said. "But more and more people are taking them in the absence of pain when their addictive liability is very high. And because of that, they get hooked very quickly."
Hydrocodone, oxycodone and oxymorphone are the key prescription drugs of abuse, data from the CDC show.
Taken as an intact pill, any of the drugs can extinguish pain when dispersed in micro-quantities over several hours.
Once pulverized into a fine powder and sniffed; crushed to destroy time-release features and ingested; or, liquefied and injected, they become black-market commodities that act within minutes.
Physical dependence can occur rapidly -- within days -- when the pill casing is broken, Dewey said. Weight, age and genetics, he added, govern how fast full-blown addiction occurs, and teen users are highly vulnerable to addiction.
Cravings for euphoria
All narcotic medications are members of the opioid drug class, Dewey said.
When abused, prescription-grade narcotics produce the same effect as heroin and are converted into morphine in the brain.
The morphine flood switches on key proteins -- opiate receptors -- which modulate the body's pleasure and reward system, Dewey said. Thousands of the receptors pervade the brain, spinal cord, intestines and respiratory system.
The drugs also trigger a copious flow of dopamine, causing the hallmark rush of euphoria, another characteristic of heroin addiction.
Dr. Rita Goldstein, a neuroscientist at Brookhaven National Laboratory, noted virtually all misused narcotics become addictive because of the body's unbridled cravings for euphoria.
"All of the drugs of abuse increase the release of dopamine," Goldstein said. "So the more of the drug you take, the more of a dopamine response you get, and the more dopamine, the greater the high."
Dewey said as addiction takes hold, opioid drugs begin altering cells in the brain's orbital frontal cortex, the region "that makes us think before we act."
The inability to perceive danger, to recognize a need for sustenance over drug consumption, and to act responsibly typify opioid addiction, he said.
Dr. Rick Terenzi, chief of North Shore University Hospital's drug treatment and education center, said more than half the children and teens he has counseled for prescription painkiller use report getting the drugs from home, usually from the family medicine cabinet.
"When you look at the number of pain relievers that are prescribed or available," Terenzi said, "and the number of people who have access to pharmaceutically pure opioids, then you start getting an idea about the scope of this problem."