How OxyContin's Pain Relief Built 'A World Of Hurt.'

May 29, 2013

Guest: Barry Meier - John Powers

TERRY GROSS, HOST: This is FRESH AIR. I'm Terry Gross. Prescription painkillers have become the most widely used drugs in America. My guest Barry Meier has been investigating painkillers for more than 10 years. He's a reporter for the New York Times who covers the intersection of business, medicine and public health. His new e-book, "A World of Hurt," was published today.

It's about high-dose opioid painkillers and the consequences that come with long-term use. It focuses especially on OxyContin, how it came to be prescribed for chronic pain, and what the consequences have been. It also examines how Oxy became a street drug. Meier's previous book, published in 2003, is called "Painkiller."

Barry Meier, welcome to FRESH AIR. Let's start with an overview. What is Oxy, and how does it compare to, say, morphine or Percocet or Vicodin?

BARRY MEIER: Sure. OxyContin is basically a time-release form of a narcotic called oxycodone. It's in the same class of drugs as morphine, codeine. They're basically all natural or synthetic variations of the - from the poppy seed. What made OxyContin so unique is that it was a pure version of the drug. It wasn't mixed with aspirin or acetaminophen the way it's found in other narcotic painkillers like Percocet.

And it was in a time-release form, so the drug was supposed to - you take it, and you are supposed to get pain relief for about 12 hours or so.

GROSS: But people who wanted to use it to get high found a way around that.

MEIER: Correct. All you needed to do was to crush it, chew it, grind it down, and basically the entire narcotic pain load that was contained within the drug was released immediately, which is why it was such a powerful high and such an addictive drug when it was abused that way.

GROSS: You've been writing about how medical and social attitudes toward opiate painkillers keep shifting. You write a lot about the war on pain, which started, what, in the '80s, where attitudes shifted to be more open to the long-term use of opioids in the treatment of pain. This actually started with cancer and with people who were, you know, terminally ill and sought pain relief. Let's start there.

MEIER: Sure, that's correct. I mean basically in the 1980s or '70s, drugs like morphine were not widely used in this country because of fears of addiction related to them. And as a result of that, a lot of people at their end of their lives, be it cancer sufferers or people who were dying, were denied these drugs.

And there was a lot of suffering as a result of that. In the '80s there was a realization that these drugs could be used successfully on cancer patients and terminally ill patients. And then in the mid-1990s there was really a revolution that took place. There was a study done here in New York by a pain expert who found that if I gave these same drugs to people with non-cancer pain, common pain like back pain, arthritis, facial pain, that it appeared that they also weren't getting addicted.

And that opened the door to the widespread medical use of drugs that had previously been reserved for cancer patients into the general patient population.

GROSS: Did the manufacturer of OxyContin do anything to promote the long-term use of the drug for pain patients who didn't have cancer, people with back pain and nerve damage?

MEIER: Oh, absolutely. The company that makes OxyContin, Purdue Pharma, launched what was an innovative and huge campaign to introduce drugs that had previously used for cancer treatment into general pain. That involved training hundreds of doctors to go out and speak to their medical colleagues about the benefits of these drugs.

And most importantly, the FDA allowed them to make an unusual claim, and that is that because OxyContin was a time-release drug, it would be less prone to causing addiction and less attractive to people who abuse drugs. So this became part of what was a steady drumbeat that was sounded not only by the company but by many leading pain experts, that in fact with this drug we had what was really a unique new weapon to deal with an age-old problem.

GROSS: When OxyContin started entering the realm of medical use for long-term chronic pain, like back problems and nerve pain, was it controversial within the medical field?

MEIER: There was some controversy. You know, prior to that there had been other approaches to treating pain, sometimes successfully, sometimes unsuccessfully. It basically involved, you know, physical therapy, behavioral therapy. Pain is a very, very complex condition, particularly chronic pain. And what happened was that with the introduction of what seemed to be kind of a wonder drug, insurers shifted to basically paying only for drugs, much as they did when antidepressants replaced psychotherapy.

So whatever controversy there was at the point of introduction, it was kind of quickly swept aside by economic forces, and these drugs, OxyContin in particular, were very quickly and widely accepted by many, many doctors.

GROSS: You write about how pharmaceutical companies who manufacture painkillers have actually funded medical and patient pain groups. Would you describe the funding and the relationship of the pharmaceutical companies to these groups?

MEIER: Sure, these types of arrangements are found throughout medicine, where you have drug companies funding patient or advocacy groups that represent a particular disease or particular interest that they have. This in the area of use of opioids became very, very well-funded with the launch of OxyContin and continued for about a decade or so.

The dilemma here is that companies have legitimate commercial interests, and that is to make sure these drugs are available for patients, and that became the drumbeat to which the patient groups marched as well, and so it became very focused on changing state laws or deterring any effort that might limit the availability of these drugs to patients, rather on the issue of whether these drugs were actually beneficial to the patients who were taking them.

GROSS: What were some of the early problems that pain specialists started reporting?

MEIER: Well, the person that sort of first sounded the alarm about this was a doctor in Boston, her name is Jane Ballantyne, and she was the head of pain treatment at Massachusetts General. And in 2003, I mean she accepted that these drugs were beneficial. She was a soldier in this war on pain, and as she kind of walked around Massachusetts General, she started seeing things that caught her attention.

For example, chronic pain patients who were given these drugs started improving. They would improve for a while, and suddenly their improvement would stop. Their pain would return, they would lose function, or the improvement in function they had achieved would be lost, and she began to wonder why this was going on.

And that led her to start studying animal tests involved in these drugs and basically began to lead her to question whether these drugs were really beneficial for many patients in the long term.

GROSS: And what some doctors started finding, you write, is that patients would become tolerant of the drug. They would develop a tolerance and require increased doses. Does that frequently happen?

MEIER: It's a very common thing, and it's sort of part and parcel of using these drugs. Essentially, unlike many other types of medications, where you can sort of be prescribed a dosage and stay on that dosage for a long time, your body adapts to these drugs. And when your body adapts to these drugs, which is the situation called tolerance, essentially you require more of the drug to get the same killing effect.

And so what happens then is a steady escalation in dosage, and it can keep going and going and going and going and going, to the point where after a year or two of treatment, you are on extremely high levels of these drugs, and the higher level you take these drugs at, the more potential side effects that can occur.

So you had people who became addicted to it through its medical use, and increasingly we're seeing evidence that patients become dependent upon it. We're seeing consequences where people's hormonal balance is basically being affected and their production of sexual hormones is being decreased, which is leading to lethargy.

We're seeing a variety of ill effects that are being produced by the long-term medical use of these drugs as opposed to their abuse.

GROSS: And one of the side effects you write about is basically disengaging from life.

MEIER: Correct. I mean I had a doctor who I greatly respect mention to me that, you know, we thought the big problem with these drugs was addiction. What we didn't realize is that people who take them would opt out of life. And, you know, you see it across the spectrum. One of the more startling things is in the area of workplace injuries. I mean things like back strains are very common problems.

But what folks have discovered is that the more patients that - you know, workers who are treated with these drugs for back strain, the longer and longer and longer they stay away from work. In fact, we've kind of created kind of a legion of chronically unemployed people who are dependent on these drugs.

GROSS: It makes me wonder, though, maybe the people who became dependent on drugs were the people who didn't respond to other forms of therapy like physical therapy, or maybe they were in more severe pain than the other people who were able to return to work, and consequently stayed on drugs longer.

MEIER: That's possible, but we don't know that because the way our medical system is set up right now is that we really don't finance the treatment of these chronic pain conditions through alternative means. If you look at data from other countries where there is more aggressive use of alternative pain treatments, what you'll see is that in many cases people recover far more quickly from chronic pain conditions when they're given alternative forms of treatments than when they're given opioids.

GROSS: So I don't want to unnecessarily scare people about using painkillers when they come out of surgery or when they've been in a terrible accident. So would you just address that? I mean...

MEIER: Absolutely.

GROSS: I think it's good to have cautionary advice, but there's times when you really need a painkiller.

MEIER: There is no question that these drugs are extremely beneficial. They're valuable, vital drugs. And there should be no hesitation in their use after conditions like surgery or accidents or cancer treatment or end-of-life use. One does not want to turn the clock back to the limitations of these drugs in certain medical treatments.

The question becomes how effective are these drugs in the long-term treatment of chronic pain, and the dilemma that we're facing now, after an experiment that began 15 years ago, is we really don't know that answer. And what we're seeing the longer these drugs are being used are consequences from their long-term use that weren't envisioned when this experiment began.

(BREAK)

GROSS: If you're just joining us, we're talking about pain medicine, particularly various forms of oxycodone. My guest is Barry Meier. He's a New York Times reporter who covers the intersection of business, medicine and public health. He's the author of a new New York Times e-book, which is called "A World of Hurt: Fixing Pain Medicine's Biggest Mistake." It's his second book about painkillers.

So OxyContin also has an underground history. How did it start catching on as a high?

MEIER: Well, it started catching on pretty soon after it appeared on the street. This is going back about a decade ago or so. And people that abuse drugs are very clever in finding ways of abusing whatever new drug comes onto the market, and it was quickly discovered that OxyContin could be crushed and snorted or chewed.

And it sort of became the hottest drug on the street...

GROSS: And as you explained before, the advantage of crushing it is that it was a time-release capsule, and if you crushed it, all of the opiate would be released at once. So you'd get...

MEIER: Correct.

GROSS: ...a bigger hit at one time.

MEIER: Absolutely. I mean you got a huge hit at one time. And you know, to people who had never tried it before, it was extraordinarily dangerous as well, because that big hit could actually kill you from an overdose. So people in areas like Appalachia and Maine, where there was a large-scale use of painkillers for work-related problems, et cetera, started catching on to that there was this really great new drug on the street if this is the way I'd like to get high.

And it kind of ran like wildfire. It really started catching on in 1999, and by 2001 it was all over much of the Eastern United States and then spread across the country.

GROSS: So one of the first places it caught on was in Appalachia because of work-related pain problems? Is that what you're saying?

MEIER: There was - you know, if you look at sort of the atlas, if you will, of how drugs are prescribed around the country, what types of drugs are prescribed in different parts of the country, there usually is a pretty straight correlation between the use of narcotic painkillers in areas where you have physical labor, jobs like mining, farming, logging, where people get a lot of back problems and muscle injuries and things of that nature.

And it also - in many of these areas you have doctors who are generalists, you know, they're not specialists. So most folks are going to a general practitioner, a family doctor, and when they were told that OxyContin was a less abusable drug than drugs that had preceded it, they said great, this sounds like a good thing for my patients. So they, you know, they started prescribing it very heavily.

GROSS: When Oxy started to catch on on the street, what kind of pill mills grew up around that new craving for it?

MEIER: Basically an industry. You basically had these pain clinics open up, doctors that supposedly specialize in treating pain. These in fact were doctors who had no experience in treating pain and were probably the wrong person to go to see if you actually had pain.

But they were essentially clinics where you could walk in and the doctor would say to you, How do you feel? Well, I'm in pain and I think OxyContin would work for me. And the doctor would write you a prescription, you would pay cash for the appointment, and the cycle would start.

And these literally proliferated throughout the United States. I mean, they started in places where Oxy abuse first started. But more recently you would go to states like Florida and there would be literally hundreds of these pain clinics that would draw drug abusers from around the country.

GROSS: Why Florida?

MEIER: Florida's kind of interesting because Florida's one of the states where Oxycontin abuse did start early. But there's also a unique - or there was until very recently a unique aspect to Florida law, which allowed doctors to not only prescribe a drug but dispense a drug as well. So if you went to your doctor and your doctor said to you, you needed X drug, and you said fine, normally you would take it to a drugstore. In this case the doctor would say to you, you need X drug and as a matter of fact I can sell it to you, or you can go to the office next door to my office and buy it there. So it became very financially rewarding for these doctors to set up clinics in Florida and attract people from all over the Eastern Seaboard.

GROSS: The street use of Oxy has led to overdoses. Can you give us a sense of what the scope is?

MEIER: It's enormous. I mean the current statistic is that about 16,000 people a year die of overdoses involving prescription narcotics.

GROSS: But this is the street use of it.

MEIER: Right. The presumption is that the vast majority of overdoses involve the abuse of the drug. There may be a small fraction of those that involve people who become medically addicted to the drugs who then go on to abuse them. You know, it's a huge problem. I mean the number of people dying from these drugs is second only to the number of people that die in car accidents.

And what's been startling to me over time is seeing this number grow. I mean, you asked me before about what was most sort of - what I've seen over the years. And what I've seen is the number of people dying of overdoses quadrupling between 2003 and today, and that's a staggering increase.

GROSS: What approach has the Drug Enforcement Agency and other law enforcement groups taken to trying to crack down on the street use of Oxy?

MEIER: The DEA has arrested hundreds of doctors who worked in pain clinics. It's prosecuted many of these doctors. I mean some of these doctors are criminals. The folks that run these clinics do it for money. But many of the doctors that work there are well-meaning; they're, you know, often retired doctors; they're doctors looking for added income.

You know, the problem is, is that many of the doctors that work in these clinics don't understand how to treat pain, they don't understand how to recognize symptoms of abuse, and they unfortunately become facilitators of this entire system.

(BREAK)

GROSS: This is FRESH AIR. I'm Terry Gross back with Barry Meier, author of a new e-book about opioid painkillers called "A World of Hurt." Meier is a New York Times reporter who covers the intersection of business, medicine and public health. He's also the author of the 2003 book "Painkiller." Earlier, he was telling us how OxyContin became a street drug. One reason was that the original time-released version - approved by the FDA in 1995 - could easily be crushed and that would release the entire narcotic payload at once so the user could get a big hit and get high.

OxyContin changed its formula to prevent smashing from releasing the full dose at one time. So what's the state of OxyContin now in terms of its, you know, capacity to be a good, quick high like the previous version?

MEIER: OxyContin right now is probably not a good high. When you try to smash it now, it turns it kind of into this gummy goo. So it can't be easily injected or abused in the way that it was abused prior to the reformulation. Even going back a number of years ago, doctors, because of the uproar over OxyContin abuse, started shying away from it. They'd moved on, then, to drugs like methadone. And methadone, while it's most popularly known as an addiction treatment, is also a widely used painkiller. So people abusing the drug, let's say OxyContin, would then go on to methadone. Or doctors would start prescribing sort of the generic oxycodone tablets and people abusing drugs would go on to that. So you kind of had this game of leapfrog between doctors and people seeking out drugs to abuse.

GROSS: Painkillers are not just recommended by pain specialists, other doctors can recommend them too. It's very easy to get addicted to drugs. When you overuse them it's difficult to wean yourself from those drugs. Do you think the doctors who prescribe pain medicines are necessarily trained in how to wean patients off of those medicines?

MEIER: Well, I think that's absolutely true, but it's - to expand beyond that just a little bit, that doctors who prescribe these drugs are not really that well-trained, and in many cases, not trained at all in pain treatment. So basically you have patients who are coming into these offices with extremely complex conditions. And, you know, chronic pain can be part physical, it can evolve or begin as a psychological or emotional problem, and they're very complex patients to treat, and most general practitioners, family doctors, don't have the time, training, skill or interest in treating these patients, which is often the reason why they prescribe them a drug.

You know, one of the big dilemmas that's spun out over this past decade has been the lack of people who can specialize in pain treatment, who know this area. And I think that's an area that is extremely important for both the medical industry and the medical profession and society to come to grips with - that is making sure that there is a cadre of well-trained, knowledgeable doctors that can properly treat these patients.

GROSS: You've been writing about pain medication for over 10 years. You wrote a book about the subject back in 2003, so you seen this whole story evolve. You've been reporting on it as it's evolved. What are some of the biggest surprises you've witnessed?

MEIER: I would say the biggest surprise that I've witnessed is, you know, back in 2003, when "Painkiller" came out, the prevailing medical thought and my thought was that there was a line of demarcation - a bright line - between the benefits of these drugs for patients and their abuse on the street. So one of the big realizations for me is that that bright line is certainly not very bright and in fact may be a mirage.

GROSS: What changed your mind?

MEIER: Basically, the scientific evidence that's been coming out, the experience of patients. Because back when I wrote the book, the use of these drugs for chronic pain was a fairly new phenomenon. There wasn't really a lot of data that had been gathered about their effectiveness. And now that this experiment's been going on for more than a decade, there is increasing evidence that for, while these drugs are very beneficial for some patients, they are, in fact, not beneficial at all for many patients.

GROSS: You mean they won't even help the pain at all?

MEIER: Well, they will help the pain for a period of time until you get to that point of tolerance and then you'll need more, and unfortunately for some patients, their ability to function will start to decline as the amount of medication they take increases. So that's the dilemma.

GROSS: You know, you have forces from both ends of the spectrum. I mean, there has for a long time been resistance to the use of morphine from people who are just like anti-drug for moral reasons and are afraid like any use of morphine is going to be addictive - even if like you're dying of cancer, you have like two weeks to live, you know, there was this fear, oh no, you can't let the patient get addicted. What's the problem? They're dying. They're not even going to be around in two weeks, so why is addiction a problem? And then on the other end, you know, you write about how there's people who are saying well, let's not worry about addiction because it's going to solve the pain problem. And I guess, what's the controversy in the field now?

MEIER: Well, I mean the issue that you brought up is a very important one and sort of central to this. John Hockenberry put it very well when he said, when he wrote an essay one time, when you try to balance the damage caused by pain against the damage caused by drug abuse, nobody wins. And that's absolutely right. How do you balance these two things against each other? How do you give pain patients relief and avoid these drugs kind of spilling over into the street and causing abuse? And I think that whole issue is perhaps being in the process of being reframed from the standpoint of, you know, if we really just focus on what is the best way of treating pain, then we kind of address the second issue, because maybe we need to put more patients into other ways of treating pain than simply doling out drugs and dealing with, you know, alternative pain treatments and things of that nature.

GROSS: Barry Meier, thank you so much for talking with us.

MEIER: Thank you, Terry. It was a real pleasure.

GROSS: Barry Meier's new e-book, "A World of Hurt," was published today.

Coming up, John Powers tells us about the Cannes Film Festival, the film that won the top prize, the films he liked best and the one that got the most boos. This is FRESH AIR.

(SOUNDBITE OF MUSIC)

TERRY GROSS, HOST: The Cannes Film Festival, held annually on the French Riviera, is the world's most important film festival. This year's festival wrapped up on Sunday. Our critic-at-large, John Powers, attends it most years and when he does, we like to talk with him about the best and worst films he saw there.

John, welcome back to FRESH AIR. Welcome back from France.

JOHN POWERS, BYLINE: Hello.

GROSS: So let's start with the film that won the grand prize at Cannes.

POWERS: Well, the Palme d'Or winner is a French film called in French, "La Vie d'Adele," but in English it's called "Blue Is the Warmest Color." And it was the film of the festival, by which I mean, it was the film that people loved the most, some hated the most and everyone talked about the most.

The quick version of it is that it's a film about basically centered on two young women who fall in love. And it is a - so it's a lesbian love story but of a very special kind, partly because the film is three hours long, partly because the centerpiece of the film at some level is the longest, most explicit sex scene I've ever seen in a film that wasn't a film designed for a porn theater, and partly because the film is very emotional, very natural in its acting. So it's an incredibly expressive movie that is also kind of exasperating, especially for English-speaking people, I think.

GROSS: Well, part of it too is that the filmmaker is French-Tunisian and I think this film is going to be very - or is already very controversial in part of the Muslim world and I think it's - correct me if I'm wrong - I think it's already been condemned by Islamic extremists.

POWERS: Oh yes, you know, the interesting thing is - the film director's name is Abdellatif Kechiche, who is perhaps the most acclaimed film director in France. He's already made two films, one called "L'esquive," the other called "The Secret of the Grain," that completely swept the Cesar Awards, which are the French equivalent of the Oscars, and were huge hits. And with this, by winning Cannes, he now is probably the most acclaimed French director - and curiously in some ways, the most French French director. That if you actually looked at the fantasies of Frenchness, of the things they like films to be about - crazy love, big emotions, natural acting, freedom of the body with nudity and all the rest - he gives them all. So he's like Tunisian-born, being condemned by Muslims, yet is somehow quintessentially French in a way, that's very interesting.

So you have that going on with the controversy surrounding it, plus the fact that the acting is really, really great in the film because he's one of the best directors of actors in the world. And I kept saying to people in the days after I saw the film that all the acting in the films afterwards didn't look as good as it should because he's so good at getting people behaving the way people behave that when you see the films afterwards everybody seems kind of actory, like they're working too hard.

GROSS: So do you think this very, very long sex scene in the movie is meant to be arousing for people in the audience?

POWERS: I don't think it is. Interestingly, a lot of people complained that it wasn't arousing enough, which I think is that they felt that it was clinical. And I don't think it's actually clinical, but that somehow you're detached from it so it's not trying to turn you on, which I think is actually a virtue of the way that the filmmaker did it. Because, in fact, one thing is undeniable is that the actresses are - seem excited. The characters are having good sex for them. But at the same time, it's not really intended to or achieving titillation for the audience. It goes on too long and maybe it ogles the women's bodies a little bit, but having said that, it's not some sort of cheap HBO, Showtime, ghastly sex scene of the kind that makes me want to turn off the TV. It's a completely different thing.

GROSS: So John, I am very selfishly now going to ask you about the film that played at Cannes that's the film that I most want to see, that I'm most curious about, and it's the new Coen Brothers movie, "Inside Llewyn Davis," which is set in 1961 in the Greenwich Village folk scene. What did you think?

POWERS: Oh, it was my favorite film at Cannes.

GROSS: Oh, good.

POWERS: I, you know, I have not been a great Coen champion or detractor, I'm kind of up and down on them. I think this may be their best film. And what it is it's - in a way it's a very simple story. An actor named Oscar Isaac plays Llewyn Davis, who is a sort of a folk singer in the early '60s based kind of loosely on the singer Dave Van Ronk. And what he is is he's a guy who sings traditional folk songs and has a beautiful voice and somehow he's just not making it, you know, that he's struggling in his career and then you watch him more or less go through a day or two or three as he struggles, and he travels around more or less trying to make his career go. And he has a kind of odyssey, accompanied in a huge part by a cat that he somehow finds himself stuck with.

So you have a kind of selfish, grumpy, artistic folk singer caught with a cat, traveling around trying to get his life together. And at that level basically, that's the plot. In some way it's kind of a shaggy dog story, but in fact, what it's all about is about this guy who was at this moment of history, who has talent, and his perceptions are the perceptions of a person who is living in the Bob Dylan era. He actually will remind you in some of the things he says of something that Bob Dylan might have said. But he hasn't yet adjusted his music to the world that Bob Dylan will create. He's not Bob Dylan. He's a really good folk singer on the verge of a breakthrough of consciousness who isn't making the breakthrough himself.

The film is also - may I add, just because maybe this makes it sound serious - it's really, really funny; that it's funny in a way that the Coen Brothers often aren't funny, which is it's not snide funny. It's kind of warm, sly funny. There are no big caricatured characters. There's no nasty violence played for laughs. It's the most muted, quiet, sweet film they've ever made, I think in part because they actually love the folk songs. And there's a lot of folk singing in the film.

GROSS: Are they original songs or old folk songs?

POWERS: They're all - there's one new song, a hilarious kind of gimmick song that people sing in the thing. But all the rest are all old folk songs played absolutely straight. And part of the interest of the film and the achievement of it is this actor Oscar Isaac, who people know if they - if they see the film they'll know him from other things - is that he actually sings live these songs very beautifully while playing the guitar. And, you know, the music producer, T-Bone Burnett, in talking about it, said he thought this might be unprecedented in movie history, that somebody came in, learned 30 minutes of music and then performed it live. So he's giving a really, really great performance.

GROSS: Tell us about another film that was a favorite of yours at Cannes.

POWERS: Oh, I think the film that didn't win anything that I really loved was a film called "La Grande Bellezza," "The Great Beauty." It's by a guy named Paolo Sorrentino, who has been struggling for years to make the great film that you always think he's going to make.

This one is essentially his version of "La Dolce Vita" meets Fellini's "Roma." It's set in Rome and it's about a guy who is a writer, whose kind of - if you remember "La Dolce Vita," Marcelo Mastroianni played a kind of observer of the rich person scene, and this guy is the older version of that. And he essentially just looks at the rich people in Rome behaving decadently and stupidly.

You see all the phony art. You see all the crazy dancing. You see all the meaningless sex. But as the movie progresses, you get this vision of the world in which there's all this craziness and selfishness. Yet if you look properly, there are all these little glimpses of beauty underneath.

Part of that beauty is simply Rome, so that this is the most beautifully shot film about Rome I've ever seen. I mean I think almost everybody I know thought: I've got to go to Rome...

(LAUGHTER)

POWERS: ...when they watch this movie, 'cause somehow the filmmaker, Sorrentino, got them to just let him like empty out entire streets so that the hero can walk at night. And it's just ravishingly beautiful. But what the film is about is about finding the beauty in the ridiculous and the absurd. And it's really very moving. It starts off so aggressive 'cause it's loud music and Italian people going crazy. And it ends quiet and soft and beautiful.

I mean it was my favorite thing. I don't know why it didn't win anything, but you know, things you like don't always win - that's the story of the world.

GROSS: Usually at Cannes there's at least one film that gets a lot of boos. People are very - are not reluctant to let their emotions be known. So what got the most boos this year at Cannes?

POWERS: This year's boo winner was a film called "Only God Forgives" by Nicolas Winding Refn. He's a Danish director who makes tough-guy, stylized, more or less action movies for art-house audiences. His last film was a film called "Drive," with Ryan Gosling. In this one he's made a film set in Thailand where Ryan Gosling plays a mama's boy who runs a kick-fighting academy and gets involved in a plot with murder and all the rest. This was the film that I guess what I'd call the fanboys of Cannes - and there are a lot of them, the ones who just really love cool action movies - were dying to see. It was the film that people came the earliest to see. It was the hardest ticket to get in. And the movie started and they were so revved up, you could actually feel the palpable excitement of the nerdy guys in the room.

And then gradually you could feel the air sink out, as somehow it wasn't the movie they wanted it to be. And you know, they felt it was a disaster in part because the guy they think of as the hero - the Ryan Gosling figure - turns out to not be the fantasy figure they want in a movie. He can't fight. He's a mama's boy, with an overbearing mother played by Kristin Scott Thomas. But he is a mama's boy who can't deal with his mom. In order to escape her, somebody else has to kill her for him. So this is like almost the nightmare of a fantasy for someone who goes in loving the tough-guy fantasy of tough-guy drivers and tough-guy outlaws.

The hero here is a guy who can't do any of this stuff and needs a real man to do it for him; which is like the most paranoid nightmare, I think, of the kind of fanboy who loves Refn's work.

GROSS: You're making it sound interesting.

POWERS: Well, it's only 90 minutes. I mean I thought it was kind of interesting because I felt as though he, Refn, was unconsciously making a movie about his fan base, which is something you don't see very often. The audience that loves him tried to say they liked it but they thought it was a - they didn't like it really. And the rest of the world never liked this guy's films anyway, so they gleefully booed.

And it must be said that at Cannes, people don't just boo, they like booing. You know, it's a great release, partly 'cause, you know, in this case people stood outside at 7:30 in the morning to see the film. So when it wasn't good, they were ready to boo. And boy, did they.

(BREAK)

GROSS: So Best Actor and Best Actress, Best Actor went to Bruce Dern, who is in Alexander Payne's new film, and Best Actress went to the woman who was the lead in...

POWERS: Berenice Bejo.

GROSS: Yes, I don't know how to pronounce it. She was the lead in the French film "The Artist," which won all the awards at the Oscars, what, two or three years ago. So thoughts about their wins?

POWERS: Well, I think, you know, Bruce Dern is very, very good in the Alexander Payne movie. He plays an old guy who has gotten one of those Publishers Clearing House things and thinks he's won a million dollars and is going off to claim it in Lincoln, Nebraska, accompanied by his son, played by Will Forte from "Saturday Night Live." And he more or less plays a kind of crabbed, difficult guy who's a cussed figure.

In fact, I don't think he was the best actor in the festival. I think Michael Douglas did a better job in "Behind the Candelabra," which just showed on HBO. But Bruce Dern is really, really good. It was actually a good festival for him because when they showed "The Great Gatsby" on opening night, you got to see that Joel Edgerton's performance as Tom Buchanan wasn't as good as Bruce Dern's in the earlier film version.

So, Bruce Dern not only won Best Actor, he got to be the best Tom Buchanan in "Great Gatsby" at Cannes.

(LAUGHTER)

POWERS: So the Best Actress went to Berenice Bejo who everyone remembers from "The Artist." She was in the new film by the guy who made "A Separation." And it's a kind of, once again a domestic family mystery. She's very, very good in the film, but she's not as good as Adele Exarchopulos and Lea Seydoux, who are the two stars of the film that won, "Blue is the Warmest Color." Their performances were off-the-charts great, whereas she's merely really good.

GROSS: Well, Cannes isn't just about movies. It's about parties.

(LAUGHTER)

GROSS: What's the best party you went to?

POWERS: Oh, my favorite party was a party for the AIDS research organization amfAR. And every year they hold a sumptuous party somewhere. This year was at the Hotel Cap d'Antibes. And you turn up where hundreds of people are dressed in black tie, including me - I was very James Bond, I must tell everyone.

(LAUGHTER)

POWERS: And I...

GROSS: No, you weren't.

(LAUGHTER)

POWERS: Oh, OK...

(LAUGHTER)

POWERS: OK, I was a short James Bond. Can we go that far?

(LAUGHTER)

POWERS: And you turn up and two things happen. There's entertainment and there's an auction of various things. The entertainment on the night was you got to hear Shirley Bassey sing "Goldfinger." So she came out and belted out "Goldfinger" and did it better than she did at the Oscars.

GROSS: That's why you felt James Bondish.

POWERS: I think that is why I feel - I think that probably is the connection. You know, and she was really, really good, and it was fun to hear her. You know, you also got to see one of the rare appearances by Duran Duran, singing "Hungry Like the Wolf."

And really it's - you know, in terms of "The Great Gatsby" with those crazy parties, I mean at some level you haven't lived until you've been in this huge building filled with black-tie rich people leaping from their dinner table to boogie to "Hungry Like the Wolf."

It's out of this world. But the amazing thing is not that. It's the actual auction, where they auction off for a million and a half euros, in this case, the right to attend all the Oscar parties, including the behind-the-scenes Oscar parties on Oscar night. That went for a million and a half euros.

My favorite, and the best, of course, was the bidding for the right to sit next to Leonardo DiCaprio as you got blasted into outer space on Virgin Galactic Airlines. That went for a million and a half euros, which is basically $2 million.

So you have that going on. You have rich people swirling. I got to step on the back of Paris Hilton's dress, even though I didn't want to - I got bumped into it. And you know, you got to see also lots of beautiful people. There were lots of famous stars there. Leonardo DiCaprio was there. Nicole Kidman was there. I hadn't seen Goldie Hawn in a long time; there was Goldie Hawn.

You know, as I say, Shirley Bassey who, I think, looked younger than some of the members of Duran Duran...

(LAUGHTER)

POWERS: And she must be, you know, 100, whereas the Duran Duran guys looked a bit like they'd lived the rock star life. So at 50 they were in worse shape than Shirley was.

GROSS: Is Leonardo DiCaprio planning on going into outer space?

POWERS: Yes, he is. I think, you know, he - I think it's not deep outer space. I mean I think it's one of these things where you get out of the stratosphere and then just come back down. So it's more like a shuttle flight. But yes, he is. No, I mean I think he'd already bought his ticket. And the question was: Who would get the ticket next to him? So I mean he is a great supporter of amfAR and so he was a good sport the entire night.

You know, all the stars are actually very, very happy to be there and it's an exciting thing. I mean it's real spectacular "La Dolce Vita" stuff.

GROSS: Some of the films that you've mentioned will probably get a lot of attention when they open in America. Would you just tell us, I mean briefly, about a film you think we should see that won't have all that ballyhoo when it opens?

POWERS: There's a lovely little film called "The Lunchbox." It's an Indian film which is set in Mumbai. And it basically involves the way they use lunchboxes in Mumbai, which is that people send them to the office from their home. This one has to do when a lunchbox gets sent to the wrong person. The guy who gets it sends it back to the person with a note and gradually they develop a relationship between a lonely business guy and a lonely wife.

It sounds simple but it's nicely turned, beautifully acted and very moving and has a really, really great performance by Irrfan Khan, the great Indian actor who people will remember as the older guy in the "Life of Pi." It's a very, very good film, very touching. I think people are really going to like it.

GROSS: Well, John, thank you for telling us about Cannes. It's always great to talk with you.

POWERS: Oh thank you, Terry.

GROSS: John Powers is FRESH AIR's critic-at-large and is the film and TV critic for Vogue and vogue.com.

Transcripts are created on a rush deadline, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of Fresh Air interviews and reviews are the audio recordings of each segment.