STATS ARTICLES 2004

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The Great OxyContin Correction Controversy
Did Slate correct its way into error?

April 27, 2004
Trevor Butterworth

On March 25, Slate published a story by STATS fellow Maia Szalavitz on the myths surrounding an apparent epidemic of OxyContin abuse. (OxyContin is a sustained release opioid for treating moderate to severe pain.) Szalavitz’s story focused on the errors in the Orlando Sentinel’s coverage of OxyContin and argued that it was part of a wider misrepresentation of prescription pain medication in the media. Her criticism of the Orlando Sentinel was uncontroversial; but she also mentioned the work of New York Times reporter Barry Meier in the course of her discussion.

Meier’s early work for the New York Times detailing the surge in OxyContin abuse has been vigorously disputed. Relying mainly on police and law enforcement as sources (26 out of 29 attributions), Meier and co-writer Francis X. Clines reported (Feb 9, 2001) on figures for OxyContin abuse that were either unreliable or demonstrably false.

For instance, Sandeep Kaushik, then writing for the Cleveland Free Times, won a Cleveland Press Club Award for his article .OxyCon Job: The Media-Made OxyContin Drug Scare (May 2-8, 2001),. Which demolished figures cited by law enforcement in the media. For instance, in Kentucky, one of the states that the Times depicted as being in the throes of widespread OxyContin abuse, the executive director of the Kentucky State Medical Examiner’s Office told Kaushik, .I have no idea where these people are getting their facts and figures.. Only two people in the entire state could reliably be said to have died from oxycodone abuse, the active ingredient in OxyContin and other painkillers. The other deaths all resulted from a cocktail of illegal drugs, painkillers and stimulants, including cocaine and heroin.

Even more controversial was Meier’s scoop for the New York Times (October 28, 2001) on the Drug Enforcement Administration’s (DEA) investigation into the links between overdose deaths and OxyContin. The DEA study, the first of its kind the agency had ever undertaken, showed that far more people were apparently dying from OxyContin than had been estimated, and led to the agency aggressively pursuing and prosecuting doctors it suspected of running .pill mills. But when the DEA presented its findings to officials from Purdue Pharma and the Food and Drug Administration, they, as Meier would later recount in chapter 10 of his 2003 book .Pain Killer, dismissed the findings as unscientific.

In a subsequent investigation by the General Accounting Office (OxyContin Abuse and Diversion and Efforts to Address the Problem,. Dec. 2003), the DEA agreed that its data on abuse and diversion were not .reliable, comprehensive, or timely. And then, finally, a major study of drug abuse deaths in the March 2003 edition of the peer-reviewed Journal of Analytical Toxicology (JAT) showed that just 1.3 percent resulted solely from OxyContin. (It’s worth noting that the New York Times did not report the JAT study. And in covering the GAO report (Jan. 23, 2004), the Times did not mention that the DEA conceded that its data on abuse and diversion were unreliable, or indeed report any of the GAO.s conclusions that presented the FDA and Purdue Pharma in a favorable light. The Times focused solely on Purdue.s failure to gain prior approval for a marketing video from the FDA, and action taken on two marketing violations.)

Szalavitz’s article was 1,493 words long, of which about ten percent applied to Meier.s reporting for the New York Times. Szalavitz addressed what she argued was the misleading nature of a Nov. 25, 2003 article by Meier on accidental addiction in pain patients, and how the New York Times public editor believed Meier should not have been allowed to write the piece due to bias. On April 5, Slate posted a 294-word correction after Meier complained to the online publication in a three-page letter about inaccuracies in Szalavitz.s column that pertained to him and to one other piece of data.

Szalavitz has been a freelance writer for 15 years, and has written about medical and drug issues for many leading news organizations. She is co-author of .Recovery Options: The Complete Guide: How You and Your Loved Ones Can Understand And Treat Alcohol and Other Drug Problems(with Joseph Volpicelli). She also went through a period of addiction in the late 1980s.

A year ago, STATS named Szalavitz a fellow, with responsibility to write about media coverage of health and drug issues. As her editor, I have been highly satisfied with her work for STATS and have received no complaints about it. The assignment for Slate was between Szalavitz and Slate, and received no editorial or other input from STATS. We linked to it on our web site when it was published.

However, since the size of the correction provoked discussion on Jim Romenesko’s site at the Poynter Institute, and since a dispute over the accuracy of the correction was covered by the Washington Post’s media reporter Howard Kurtz, STATS decided to conduct its own investigation into the seriousness of error claimed by Slate. Szalavitz had no input into STATS analysis other than to respond to requests for drafts and sources.

Correction Number One

What Szalavitz wrote:
If the Orlando Sentinel were the only news organization to run massively misleading stories on OxyContin, the misinformation could be chalked up to error. But the first substantive column by the New York Times. Ombudsman Daniel Okrent also dealt with OxyContin bias, albeit of a different sort. Okrent wrote that the paper shouldn’t have allowed Times writer Barry Meier, author of the anti-OxyContin book Pain Killer, to cover the drug in an article in its Science section.

Slate’s correction:
This article incorrectly states that the Dec. 21, 2003, column by New York Times Public Editor Daniel Okrent “dealt with Oxycontin bias” in the journalism of Times reporter Barry Meier. Instead, Okrent’s column asked whether allowing Meier to write on narcotic painkillers soon after the publication of his book (Pain Killer) on the same topic posed “a .conflict of interest” Okrent concluded there was no conflict of interest.

Analysis
Szalavitz makes it sound as if Okrent wrote that Meier should not have been allowed to write about OxyContin because he was biased. That is not what Okrent wrote in his column. Okrent wrote that, after investigating complaints from Purdue Pharma about Meier’s coverage, he believed:

Meier.s reporting was generally accurate and fair, even if the way some of the pieces were played –placement, headline, frequency, etc – sometimes seemed the work of an especially ferocious terrier that had gotten its teeth into someone.s ankle…

In other words, Okrent concluded that there was no bias. But he also concluded that in the interest of the paper, Meier should not have written about OxyContin due to the appearance of a conflict of interest:

Even if Barry Meier was not going to see dollars pouring in from writing about OxyContin, and even if he was the Times reporter who knew the most about oxycodone-based painkilling medication, and even if Udell’s demand was perceived as a disingenuous effort to intimidate the paper into altering its coverage.

Despite all this, there did exist the appearance of a conflict.

A newspaper shouldn’t take a reporter off a running story because of complaints from subjects if it doesn’t find the complaints valid. But neither should a newspaper automatically defend this principle when it is neither material nor mission-critical. Meier had not been covering Purdue Pharma or OxyContin for 18 months, and the paper and its readers could have been well served on the Limbaugh piece by one of the reporters currently on the beat. Certainly the paper’s reputation could have been served by removing even the slightest hint of conflict. Assistant managing editor Siegal acknowledges that giving Meier the go-ahead – which Meier properly sought under The Times’s own rules and procedures – was “probably a mistake.”

Conclusion
Szalavitz errs in suggesting that Okrent concluded that Meier was biased. In the early drafts of the article, she gave a more accurate account:

In the first substantive column by the New York Times’ ombudsman also dealt with Oxycontin bias: admitting that, at least for appearances’s sake, the paper shouldn’t have allowed reporter Barry Meier, who wrote an anti-Oxycontin book, to cover the drug in its science pages.

The phrase was removed during editing, and Szalavitz was responsible for accepting the final edit. Slate’s conclusion that Okrent found no conflict of interest is incomplete without noting that he found the appearance of a conflict of interest that warranted Meier’s removal from the story.

Correction Number Two

What Szalavitz wrote:
Meier’s article claimed that researchers now believe that “accidental” addiction is more common than previously thought, never mind the fact that there has been no new research suggesting this since OxyContin was introduced in 1995, only increased pressure from law-enforcement agents.

Slate’s correction:
The column also mischaracterized Meier.s reporting on the prevalence of “accidental” addiction among patients receiving OxyContin prescriptions for pain. Meier’s Nov. 25, 2003, article did not claim that “accidental addiction is more common than previously thought” His article states only that “much remains unknown” about the risk of iatrogenic (or “accidental”) addiction.

What Meier wrote:
The reassessment of narcotic risk [of drugs such as Oxycontin] comes at a time of skyrocketing rates of misuse and abuse of such drugs. Medical experts agree that most pain patients can successfully use narcotics without consequences. But the same experts also say that much remains unknown about the number or types of chronic pain sufferers who will become addicted as a result of medical care, or “iatrogenically” addicted.

Analysis
Meier covered a lot of ground in his Feb 5, 2003 piece. But for Slate to leave readers with the impression that he concluded only that “much remains unknown” about accidental addiction is misleading. A large section of Meier’s article argued that pain management advocates and drug companies “inaccurately portrayed science” to show that there was minimal risk from using opiates to treat medium-term and chronic pain. As a result they underestimated the likelihood of abuse and addiction.

For example, Meier writes that “advocates of increased narcotics” misstated the results of a study at the Diamond Headache Clinic in a way that, according to Dr. Diamond, “clearly underplays the risks.” And he cites a published letter from a pain management expert, Dr. Steven D. Passik, admitting, “In our zeal to improve access to opioids and relieve patient pain suffering, pain specialists have under stated the problem.”

Conclusion
The thrust of Meier’s argument is not simply that the risks of accidental addiction are unknown, but that they have been represented in a manner that understates their extent. One may debate whether Meier’s argument that the risks are understated is equivalent to arguing that accidental addiction is more common than believed. But it is hardly a factual error demanding correction.

Correction Number 3

What Szalavitz wrote:
If the Orlando Sentinel were the only news organization to run massively misleading stories on OxyContin, the misinformation could be chalked up to error. But the first substantive column by the New York Times’ Ombudsman Daniel Okrent also dealt with OxyContin bias, albeit of a different sort. Okrent wrote that the paper shouldn’t have allowed Times writer Barry Meier, author of the anti-OxyContin book Pain Killer, to cover the drug in an article in its “Science” section. Meier’s article claimed that researchers now believe that “accidental” addiction is more common than previously thought – never mind the fact that there has been no new research suggesting this since OxyContin was introduced in 1995, only increased pressure from law-enforcement agents.

Slate correction:
The column inaccurately and unfairly compares Meier’s article .The Delicate Balance of Pain and Addiction. (Nov. 25, 2003), and a five-part series on the dangers of OxyContin published in the Orlando Sentinel (Oct. 19-23, 2003), for which the Sentinel ran a lengthy correction on Feb. 5, 2004. The Slate column should not have compared the two as Meier’s article contained no factual errors.

Analysis
Doris Bloodsworth’s series for the Orlando Sentinel claimed, among other things, that a clueless doctor had destroyed a pain victim’s life as a result of accidental addiction to OxyContin, and that accidental addiction was a widespread phenomenon.

Meier’s Nov. 25, 2003 story deals with the underestimated narcotic risk for pain patients within the context of “skyrocketing” rates of abuse and misuse of opioids.

Thematically, both writers are in the same ballpark, so it cannot be “inaccurate” to compare them simply because Bloodsworth made factual errors and Meier didn’t. The act of comparison is one of evaluation, not one of fact. Szalavitz did not write that Meier made the same factual errors as the Orlando Sentinel series made, nor did she say that Meier’s piece was misleading in the same way as the Sentinel’s series. She said only that both were “massively misleading.”

If there is an error at issue here, it concerns the question of whether it was unfair to say that Meier’s piece was massively misleading. As noted in correction two, Meier argued that pain management advocates and drug companies systematically underestimated the risk of accidental addiction among pain patients. Given the implication is that there is more accidental addiction among pain patients than commonly thought, then the claim is misleading.

Virtually every medical authority to consider the problem of iatrogenic addiction from opioids, concludes that it is very small, or very rare, or minimal. Such authorities include the U.S. Department of Health and Human Services, the National Academy of Science’s Institute of Medicine, the National Institute of Drug Abuse, the World Health Organization, and the American Medical Association.

But what about Meier’s quotation from a letter to a medical journal by Dr. Steven D. Passik, one of the nation’s top experts on pain treatment, which appears to show that the medical community has “understated the problem.” The passage comes from the May 2001 issue of the Journal of Pain and Symptom Management:

In our zeal to improve access to opioids and relieve patient suffering, pain specialists have understated the problem, drawing faulty conclusions from very limited data. In effect, we have told primary care doctors and other prescribers that the risk was so low that they could essentially ignore the possibility of addiction.

But Passik writes in the same letter that the key issue was that doctors should look out for indications that patients may be disposed towards addiction when treating for pain:

The problem is not a specific drug, but rather the base rate of addiction in the United States and the increasing availability of this medication. With 6 to 15% of the US population having a drug problem, any highly available opioid will be sought by this proportionately small fraction of the population, which actually represents millions of substance abusers. Because 6- 15% of the US population abuses drugs, the history of pain management is marked by the undertreatment of the other 84 to 94% of the population, and we do not want to go back to the bad old days.

And

The problem is neither OxyContin nor the growing use of opioids in pain management. The problem is poor assessment and monitoring, and a shortage of settings that can treat pain and bring the needed amount of structure to bear when appropriate. This issue defies the oversimplification that has been ever present in the historical dialogue about opioids. In the end, members of the pain management community are going to have to lead the way of making sure that stories of abuse and diversion of OxyContin do not get caught up in a firestorm of histrionic rumor mongering. Rumors about prescription opioid abuse make for lurid and unfounded tales that have all the appeal of tabloid television and will ultimately do pain experts and their patients much harm.

Dr. Passik told STATS that Meier’s selective quotation had “misportrayed” his position in the letter, which he said was meant only for professionals in the pain management field. He said he was merely trying “to tone down the rhetoric” on both sides of the OxyContin abuse debate, pointing out that the risk from abuse was neither zero nor huge. But Passik stressed that toning down the rhetoric didn’t mean stopping pain treatment.

Dr. Passik also said that in an interview with Meier, he had tried to “set him straight” on the problem of pain treatment and abuse, but that Meier appeared to be only interested in one side of the story. Where there is “a lot of gray,” said Passik, Meier “sees only black and white.” Dr. Passik said that the same letter was also mischaracterized as a “mea culpa” in Meier’s book, “Pain Killer, A Wonder Drug’s Trail of Addiction and Death. Passik said he was not issuing a “mea culpa” in writing the letter.

Conclusion
Meier’s Nov. 25 article was framed around the “threat posed to patients by narcotics,” and stressed how drug companies and pain management professionals underestimated this threat. Dr. Passik argued that the problem really lies with the failure to assess patients (and the failure to match opioid therapy to the relative level of risk in the patient) rather than qualities inherent in the narcotic itself.

Does Dr. Passik’s claim about being “misportrayed” mean that Meier is “factually incorrect?” Slate claims that it was unfair to compare Meier’s article with the Orlando Sentinel because Meier made no “factual errors.” Yet, as the physicist and historian of science, Spencer R. Weart points out in his new book, The Discovery of Global Warming, “Scientists rarely label a proposed answer to a scientific question “true” or “false,” but rather consider how likely it is to be true. Normally a new body of data will shift opinion only in part, making the idea seem a bit more likely or less likely.”

In considering the balance of scientific opinion and reliable evidence, it is clear that Meier has mischaracterized the problem of accidental addiction by emphasizing unquantified and unknown risks over what we reliably know. And as such, his selective quotation from Dr. Passik’s letter was deeply misleading.

In view of Passik’s cautions about OxyContin abuse and diversion, it is important to note the following: The only reliable scientific evidence we have on OxyContin abuse shows that drug addicts are the main abusers of the drug, and that they typically consume multiple drugs at the same time. The most compelling scientific data explicating this pattern of abuse comes from the Journal of Analytical Toxicology, which in March 2003 published a paper that found that the overwhelming majority of drug abuse deaths (96.7 percent) involving Oxycodone (the active ingredient in OxyContin) were related to the ingestion of multiple drugs. The study, though funded by the manufacturer of OxyContin, Purdue Pharma, was conducted by outside consultants, was subjected to peer review, and was accompanied by a commentary from a former president of the National Association of Medical Examiners praising its methodology.

In addition, a 2003 position paper of the .College on Problems of Drug Dependence task force on prescription opioid non-medical use and abuse,. which includes DEA representation as well as medical experts from Johns Hopkins, Memorial Sloan Kettering Cancer Center etc, noted the following:

The overall consensus in the pain management community is that the majority of chronic pain patients on long-term opioid therapy are not abusing these drugs.

The task force also found that the press was promoting a misleading view of opioid abuse and diversion

by placing .”an overriding emphasis on the drug, and a de-emphasis on the opioid addict. The reasons for an addict’s abuse of opioids are markedly different than the legitimate reasons for patients to use opioids.”

Whether you think Meier was slightly or “massively” misleading will probably depend on how much pain you are in. But for Slate to say that comparison of Meier’s work with the Orlando Sentinel is “naccurate” doesn’t make sense. Similarly, to say that Szalavitz unfairly compared Meier’s article with the Orlando Sentinel because Meier’s “contained no factual errors” mischaracterizes Meier.s article. Meier’s reporting is sufficiently misleading on the issue of opioid abuse and diversion to warrant mention in a similar context.

Correction Number 4

What Szalavitz wrote:
(Barry Meier’s article, for example, described what he called a South Carolina .pill mill. that sold prescriptions to addicts; the doctors in that clinic, however, claimed they were just treating patients. pain. One pleaded guilty to avoid decades in prison after being lambasted in the press; another committed suicide rather than testify against his colleagues.)

Slate’s correction:
The column incorrectly states that Meier’s Nov. 25, 2003, article referred to a South Carolina pain-management clinic. The Times article in which Meier mentioned the South Carolina clinic was published on Dec. 10, 2001. Also, Meier did not call the pain-management clinic a “pill mill,” as the quotation marks in the Slate article implied.

Analysis
Earlier drafts of the article for Slate noted that the South Carolina episode was covered in a different story for the Times; once again, Szalavitz’s failure to scrutinize Slate’s final edited version allowed the error into print.

Slate is also correct in noting that Szalavitz misattributed the term “pill mill.” Descriptively, the term is correct; but Meier used it in articles on January 19 and 20, 2002 to describe similar cases brought by the DEA against pain management doctors in Florida and California. He also used the term when discussing such cases generally on radio.

Conclusion
Slate’s correction is valid. Szalavitz should have read the edited copy more carefully. She should have double-checked the articles in which Meier used the term “pill mill” rather than rely on memory.

Correction Number 5

What Szalavitz wrote:
(Barry Meier’s article, for example, described what he called a South Carolina .pill mill. that sold prescriptions to addicts; the doctors in that clinic, however, claimed they were just treating patients. pain. One pleaded guilty to avoid decades in prison after being lambasted in the press; another committed suicide rather than testify against his colleagues.)

Slate’s correction:
The column incompletely describes the status of prosecutions of the doctors at the South Carolina pain clinic, discussing only two of eight cases. The column should have reported that six other doctors either pleaded guilty or were convicted at trial. (The column’s claim that one doctor committed suicide rather than testify against his colleagues is still being investigated by Slate).

Analysis
It is true that Szalavitz incompletely described the status of prosecutions of the doctors from Comprehensive Care in South Carolina. But in the interest of completeness, it would probably have helped readers to give some sense of why this case is so significant. The appeal by Eli Stutsman (of Oregon v Ashcroft fame) and the Pain Relief Network, a non profit advocacy group, on behalf of one of the convicted doctors, Deborah Bordeaux, will be a test case against the Drug Enforcement Agency’s entire campaign against alleged pill mills. As for the claim that one doctor committed suicide rather than testify against his colleagues, STATS has read a letter addressing this issue from the doctor’s brother, Allen Moore (a copy of which was sent by Moore to Slate).

Moore claims that his brother told him repeatedly before his death (and left notes on his computer to the same effect) that he believed that none of the doctors at the clinic had done anything outside the bounds of normal medical practice, and that he was under pressure from the federal prosecutors to plead guilty and testify against his colleagues or face 20 to 100 years in prison. He pled guilty, but he hung himself from a tree in his mother’s garden before he could testify against his co-workers. Szalavitz’s point is supported by a preponderance of evidence. At the same time, it is impossible to prove or disprove a person’s state of mind or intentions. In other words, Slate appears to be opening a line of correction that cannot yield a material fact.

Conclusion
Szalavitz’s account of the South Carolina prosecutions was incomplete. But if it is important to include the fate of the other doctors, it is just as important to note that the circumstances around their trial and conviction – notably the federal prosecutor’s use of civil law in a criminal trial – have led to an appeal that could overturn the DEA’s campaign against prescription abuse.

Moore ’s intentions at the time of his suicide cannot be definitively proven; however, since the circumstantial evidence lends strong support to Szalavitz’s characterization, the claim should have been handled in an uncontroversial fashion by attributing it to the doctor’s brother.

Correction Number 6

From Slate:
The column incorrectly states that .abuse accounts. involving OxyContin began to rise in 2001 only after media reports and prosecutor disclosures instructed potential users on how to work around the drug’s time-release mechanism. An earlier increase in OxyContin use was recorded by DAWN (Drug Abuse Warning Network) in 1998.

Analysis
Technically this is true; but Slate has framed the correction in a way that sounds misleading. Yes, the recently disaggregated figures from DAWN show that the number of OxyContin .mentions. (i.e., the number of times OxyContin was recorded in an emergency department visit due to drug abuse or suicide attempts) went from 0 in 1996 to 4 in 1997 to 527 in 1998. But the most dramatic increase occurred between 2000 and 2002, when the number of mentions went from 2,772 to 9,998 (2001) and then to 14,087. There is a clear correlation between the media coverage of OxyContin, which began during the February sweeps in 2001 and the sharp increase in emergency room mentions of OxyContin abuse during and after this time period. As the Washington Post television critic Tom Shales wrote in Electronic Media (March 26, 2001):

A national epidemic? No. Not even close. But TV newscasts have tried to portray it that way in stories filled with hype and half-truths. And in the course of “reporting” on abuse of the drug, they’ve all aired how-to pieces that include handy, easy-to-follow instructions on the correct abuse procedure. They tell you how to get high. Then the correspondents do follow-up reports expressing shock and dismay that the abuse is becoming more popular. Yeah, more kids are using the drug to get high because they heard about it and even saw how to use it on the evening news.

Conclusion
Szalavitz should have written “began to rise sharply” instead of “began to rise.” Slate should not have implied that the increase in 1998 invalidated the claim that media coverage in 2001 had an impact on OxyContin abuse. And, strictly speaking, Slate should have said there was an earlier increase in 1997.

Summary
When making claims about media inaccuracy, factual accuracy, clear attribution and argument from evidence are crucial. Most of the mistakes Szalavitz made were trivial and did not undermine the argument she made in her column for Slate; but as they were trivial, they were also easy to check out and get right.

Understandably, some readers will wonder whether she was wrong on the big picture, too. Similarly, she should have read her column more carefully after it had been edited by Slate. Her failure to do so, which produced two errors, is her failure alone.

In broader terms, as Barry Meier and the New York Times played such a central role in the media’s coverage of the apparent widespread abuse of OxyContin, neither should have been relegated to a digression or parenthetical aside. Even within the loose boundaries of an opinion column, claims of malfeasance need to be balanced by a proportionate amount of evidence and argument. Szalavitz condensed too many ideas about Meier and his work into too short a space – namely, that Meier’s reporting was massively misleading, biased (and biased in way different from the biases in the Orlando Sentinel coverage), that he shouldn’t have been allowed to cover OxyContin, and that he claimed, erroneously, that accidental addiction has been underestimated.

Having said that, Slate’s editors are also responsible for the material they publish. Slate is not a notice board or a blog or a vanity publishing enterprise; its articles are edited; and editing must clarify what is unclear in the story.

Given that such an extensive correction could end a freelancer’s career (the stipend Szalavitz receives from STATS is modest), Slate’s editors have a duty to treat their writers fairly and to ensure that any correction to their work is scrupulously accurate.

To summarize, on matters of fact and attribution, Slate is correct to point out that Szalavitz conflated two of Meier.s articles, misattributed the term pill mill and incompletely described the status of prosecutions at Comprehensive Care in South Carolina.

But two of Slate’s substantive charges against Szalavitz are wrong. The first – that she should not have compared Meier’s Nov 25 article with the Orlando Sentinel series – is not a factual error. The second – that she mischaracterized the nature of Meier.s article on iatrogenic addiction – is not supported by a full reading of Meier’s story.

The third substantive charge, that she should not have described Okrent’s column as dealing with bias, is correct. But Slate phrases the correction in a manner that is incomplete and misleading. Okrent did not conclude that there was no conflict of interest: he found that the appearance of a conflict of interest warranted Meier.s removal from the story.

In the case of the Comprehensive Care doctor who committed suicide, his family possesses sufficient evidence to claim that he committed suicide rather than testify against his colleagues. Given the impossibility of proving the doctor’s state of mind, the claim is easily handled by attributing it to the family.

Finally, while Slate is right to say that DAWN mentions for OxyContin rose in 1998, the rise was tiny

compared to the rise in 2001 cited by Szalavitz as being a result of increased media exposure.

 


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