http://www.timesonline.co.uk/tol/life_and_style/health/article3403941.ece

Prescription drugs: legal and lethal

Forget
heroin and cocaine. The dangerous drugs claiming the lives and minds of
the stars are prescription painkillers and a new class of happy pills
that doctors are handing out by the million

What finally killed Heath Ledger wasn’t heroin or cocaine. Despite his
well-publicised problems with illegal hard drugs in the past, the
potentially lethal compounds found in the Manhattan apartment of the
28-year-old Hollywood actor after his death in January had all been legally
prescribed. Just another victim of the American private-health system, you
might think, the prescription-on-demand culture that wiped out Elvis Presley
and Marilyn Monroe. Not our problem.

Think again. Of the six sedatives, painkillers and anti-anxiety drugs Ledger
was taking, three had been prescribed here during his recent spell filming
in London. In common with a growing number of young serial drug abusers –
including his fellow film star Owen Wilson, whose attempted suicide last
year was attributed to a three-day binge on the legal painkiller OxyContin –
Ledger had moved on from street drugs. Having been caught on film two years
ago at the Chateau Marmont in LA snorting a white powder, he had discovered
a less troublesome, if no less dangerous, route to oblivion.

That most of us haven’t yet registered this shift reflects the fact that when
it comes to thinking about drugs, we’re like a broken record. We think about
the drugs governments are prone to declare “war” on. So it is that the
argument about the dangers of cannabis drags on, while the tabloids feast on
pictures of Pete Doherty and Amy Winehouse with their crack pipes, or
speculate that Britney Spears might be a victim of the new “drug scourge”
methamphetamine, better known as “crystal meth”. But beneath the media
headlines and moral panics, the ground is shifting. The problem with drugs
is moving nsidiously closer to home. All of our homes.

In one of its less sensational aspects, our escalating fondness for taking
drugs that won’t get you arrested can be measured in the 10% annual rise
over the past three years in the use of antidepressants, notably our old
friend Prozac. The NHS issued 31m scripts for Prozac in 2006, a blanket
figure that, however it breaks down

in terms of the numbers of users referred to, suggests that a lot of people
are regularly taking a powerful antidepressant. Then there are the Valium
guzzlers. The Council for Involuntary Tranquilliser Addiction (Cita), run by
Liverpool University, guesstimates that there are as many as 1.5m nervous
types in this country who have become accidentally addicted to
benzodiazepines, the family of tranquillisers to which Valium belongs.
Others take them knowingly, for fun. According to Professor Heather Ashton
of Newcastle University, author of a pamphlet on addiction to
benzodiazepines, these “are now taken illicitly in high doses by 90% of drug
abusers worldwide. They are part of the drug scene”. So well integrated are
they that abusers will crush the pills and snort or inject them, the same
way they might cocaine or heroin.

More worrying in a way, because they attract less attention, are those
habit-forming drugs that can be bought without prescription at high-street
pharmacies. Concern about these has given rise to a new coinage in the world
of drug dependency, “OTCs”, an abbreviation for painkillers bought “over the
counter”. This usually refers to the more powerful varieties of OTCs, such
as codeine, which contains synthetic opiates. At a conference of the General
Medical Association in 2004 it was suggested that there might be 50,000 OTC
addicts in Britain today. The authorities are also concerned about OTC drugs
causing suicidal tendencies: the European Medicines Agency is calling for
OTC drugs to come with a “suicide rating”.

A few words of reassurance at this point for those concerned that they might
be developing a dependency on analgesics, anti-inflammatories, hay-fever
tablets or other popular remedies. Drugs that carry a risk of addiction do
so because they alter the binding of neurotransmitters to receptors in the
brain. In short, they are, in different ways, mood-enhancers. A couple of
aspirin cannot affect your Monday-morning feeling nor induce a sense of
numbness the way synthetic opiates do.

We could, though, get hooked on other readily available painkillers. The
comedian

Mel Smith publicly confessed to having developed a dependency on Nurofen Plus
– the enhanced version that adds an opioid to ibuprofen, the active
ingredient – while treating himself for gout. Smith suffered a seven-year
addiction he referred to as his “dark secret”. “They didn’t make me feel
high. They helped me to relax.” His 50-tablet-a-day habit landed

him in hospital with two burst stomach ulcers. The pharmacists’ trade body,
the Royal Pharmaceutical Society, has become increasingly insistent that its
members check the symptoms of anybody asking for OTCs; the move was prompted
by a survey of its members in Scotland that revealed that nearly half
suspected they had sold painkillers to customers with something other than
pain relief in mind.

But would this help a user such as Mark, an IT manager from the Midlands in
his forties? His OTC drug problem began after he contracted MRSA while in
hospital with severe pneumonia. The excruciating pain he felt eventually
passed, and he was discharged; but then a chest infection set in,
reawakening memories of his MRSA agony. As he didn’t have a good
relationship with his GP, he asked a chemist for the strongest pain relief
available. He came away with co-codamols, which contain codeine. For years
Mark carried on taking these tablets – primarily for migraine symptoms –
until in 2004 he was diagnosed with high blood pressure. Signed off from
work, he soon realised it wasn’t the anxieties of his job that were causing
his blood pressure to soar: it was the stress he felt without his
painkillers. “I managed to get them down to eight a day, but I couldn’t cut
them out totally. I went on like this for about four months.” Luckily, the
doctor he eventually confided in worked part-time with the South Derbyshire
Substance Misuse team.

Clean for four years, Mark now helps to run Codeine Free, one of the websites
that have sprung up recently to offer advice and discussion forums on OTC
drug addiction. The best-known of these, Over Count, was set up in Dumfries
by David Grieve, a former policeman who spent £18,000 over a two-year period
getting hooked on a popular proprietary cough medicine with a synthetic
opiate base.

The prescription drugs causing most concern are antidepressants. Prozac, which
has been around for 20-odd years, is old news. The two newcomers currently
causing medical debate

are the branded drugs Efexor and Cymbalta. These are classed as “selective
seratonin and noradrenaline reuptake inhibitors”, or SSNRIs. The added “N”
is what makes them special. Unlike Prozac and other SSRIs, these drugs do
not simply increase levels of seratonin, the brain chemical that makes us
feel more sociable and relaxed. They also boost adrenaline, making us more
energetic and sometimes slightly manic.

Cymbalta was developed by Eli Lilly after its patent on Prozac ran out in
2001, which meant that the latter could now be manufactured as a “generic”
drug and sold more cheaply. During the clinical trials of Cymbalta in 2003,
one of the paid guinea pigs, a female student, committed suicide; but it was
approved for medical use in the US in 2004, and a year later was generating
$1 billion worth of sales. In the UK, Cymbalta has only just started to be
prescribed. In America it’s a phenomenon, one of the pharmaceutical
industry’s greatest hits. The financial analysts at Merrill Lynch, which
part-owns Eli Lilly, have estimated that the market for Cymbalta will be
worth over $3 billion in 2009, overtaking the original SSNRI drug it was
modelled on, Efexor.

Currently prescribed in the UK for conditions that range from chronic
depression to hormonally related hot flushes, Efexor is less common but more
controversial than Prozac. One of its most prominent former users is Robbie
Williams. Hooked on cocaine and alcohol for most of the 1990s, Williams was
back in rehab in February 2007 for what he described as “prescription-drug
addiction”, the chief of these being his favourite antidepressant, Efexor.
Whether Williams realised what was happening when he began taking pills
prescribed by his LA psychiatrist is not clear. But he must have had an
inkling that keeping depression at bay was not the only role Efexor played
in his ostensibly sober life. He compared the feeling of taking it to
“coming up on an E” (ecstasy tablet), and spoke glowingly to George Michael
about its energising effect on his live performances – both of which
endorsements were reported in Chris Heath’s biography of the star, Feel.

Efexor, which has been around for a decade, has become a cause for concern
since an online petition was started in America in 2001. It now contains
over 15,000 aggrieved signatories. There are complaints that doctors gave no
indication, or flatly denied, that the drug carried any significant side
effects or risk of dependency. For its part, the drug’s manufacturer, Wyeth,
acknowledges that Efexor may cause unpleasant side effects such as nausea,
insomnia and raised blood pressure in a small number of cases – its data
suggest around 10%. The online complaints about the withdrawal symptoms go
further, listing raging headaches, panic attacks, night sweats and vomiting.
One petitioner writes: “I have lived my life saying ‘no’ to drugs. Now I’m
having withdrawals from something my doctor gave me. This is a crime.”

It does at least suggest how hazy the line is that separates the gear you buy
from a dealer on the street and the stuff prescribed by the guy in a white
coat. Plenty of British doctors, however, disagree. One Harley Street GP
with several highly stressed celebrity patients says Efexor is “a formidable
agent that can change people’s lives in ways that are wonderful. To demonise
it is wrong”. Efexor dependency is manageable, and ultimately avoidable, he
says. The key lies in careful administration and monitoring to minimise the
problems. “It’s like having a brilliant chainsaw. You don’t try to have a
shave with it.”

) ) ) ) )

When predicting the future for prescription-drug abuse in this country, all
eyes are on America, where the situation has been barrelling out of control
for decades. It was reported last year that prescription drugs in the
States are responsible for more deaths than either cancer or road accidents.
Tranquillisers abused by recreational users enjoy a high profile

there thanks to Xanax. Designed to combat anxiety, but widely taken in excess
with alcohol – whose effects it mimics and intensifies – Xanax is as common
as Prozac, and far more socially troublesome. It has become synonymous, in
law-enforcement circles, with wildly uninhibited behaviour and late-night
call-outs to suburban addresses. It was one of the six prescription drugs
found, along with empty bottles of booze, in Heath Ledger’s apartment.

The real worries, though, surround painkillers. Dihydrocodeine, or DF118, as
it is referred to in the UK, is the preferred American alternative to
diamorphine, the pharmaceutical name for heroin. In the US, which outlawed
heroin in

the 1920s, dihydrocodeine is the active ingredient in the popular branded
painkiller Vicodin. Recently identified by the US Drug Enforcement
Administration as the fourth most widely abused drug in the country – after
cocaine, heroin and marijuana – Vicodin has seeped into American popular
culture. The rapper Eminem wears a Vicodin tattoo on his arm. Celebrity
abusers have ranged from Ozzy Osbourne to the ultra-conservative chat-show
host Rush Limbaugh, who began taking it for back pain and went on to spend
$300,000 on it in three years. Or at least that’s what his former
housekeeper told the National Enquirer.

An English film producer who works in LA, and does not consider himself a
druggie, was prescribed Vicodin for a back problem. “There was no warning
that it was addictive,” he says. “But I knew it was dangerous the first time
I took it. It gives you this warm feeling which is rather delicious, and I
am very careful not to take it now unless the pain is serious.” His view is
that in LA today the misuse of prescription drugs is “not about getting out
of it. They keep you going.

They encourage a hyper work ethic”. The epidemic

of prescribed antidepressants he holds in similar regard. “There’s an
incredible stigma against depression in California, where it’s regarded as
worse than bad breath.”

The actor Owen Wilson had his own prescription for a bout of severe depression
last year: OxyContin (oxycodone). Manufactured in the UK, but only sparingly
prescribed here while its effects are monitored by our Medicines and
Healthcare products Regulatory Agency (MHRA), this powerful opiate offers a
dystopian glimpse of future drug abuse. Its rocketing popularity with the
recreational crowd derives in no small part from its superior design. Like
many of the new prescribed substances, OxyContin is, by comparison with the
powders that are traded on mean streets, a smart drug. Whereas a shot of
heroin will deliver its entire opiate charge at once, with possibly fatal
results, OxyContin is released in stages over six to eight hours. For the
cancer sufferers for whom the drug was developed, this means longer and more
effective pain relief. For an abuser, it means a longer, more consistent
high, with a reduced risk of an overdose.

In the US, OxyContin is now regarded as the most dangerous substance in the
recreational arsenal, widely tipped to take over from heroin as America’s
favourite opiate. In its first year on the market, sales of OxyContin were
worth $40m. Four years later the manufacturers were shipping $1 billion
worth of a drug that had acquired the nickname “hillbilly heroin” because of
its popularity among poor rural communities in the Appalachians. Sales of
OxyContin have roughly doubled in America in this century. Since the cost of
it is often covered in the first instance by health-insurance plans, it
offers a double whammy for the potential abuser: a long, strong high that is
both highly addictive and cheap.

This new pharmaceutical order has been vigorously embraced in the US,
particularly by the young. Several studies have shown an alarming hike in
prescription-drug abuse in the under-25s. A National Household Survey in
2001 discovered a doubling of the numbers of 12- to 17-year-olds reporting
an interest in Xanax and Vicodin between 1996 and 2000.

Wherever youth pitches its tent, a new slang takes root. “Pharming” is
consuming a cocktail

of prescription drugs. “Doctor shopping” is visiting several physicians to
fulfil a medicines wish list. And if that doesn’t pan out, there are always
“pill ladies”, elderly prescription-

holders who take advantage of the difficulties experienced by the young in
obtaining heavy-duty drugs created to ease chronic back pain or the
suffering of cancer patients. And for the truly desperate, the practice of
robbery has acquired a new subdivision: “prescription theft”.

The most vivid insight into the transmission of the new drug culture has been
provided by the stars of the real-life soap The Osbournes. The head of the
family, metal guru Ozzy, was for years addicted to Vicodin, a subject he
explored on his latest album, Black Rain. His children have long since
overtaken him. His daughter Kelly entered a rehab clinic at the end of the
TV series claiming: “They found 500 pills in my room when they cleaned it.”
His son Jack started popping Vicodin aged 14. At 17 he was a multiple
prescription-drug addict. Street drugs he never bothered with. After he
cleaned up, Jack Osbourne spilt his guts on MTV, naming nine medications
that he used on a regular basis. His favourite was OxyContin.

Evidence of just how deeply entrenched

over-medication currently is in the US unfolded in the LA courtroom where Phil
Spector stood trial last year for the murder of Lana Clarkson.

In one of the pre-trial hearings, his lawyers argued that the police, who kept
their client locked in a cell for most of the day after the fatal incident,
had acted unlawfully. Their reason was that Spector, at the time, was a
prescription junkie, suffering withdrawal symptoms from seven named
medicines. Two of these were powerful benzodiazepines. One, Klonopin, is a
tranquilliser much more potent than Valium.

It is notoriously dangerous when taken with alcohol: users become quite
unhinged. Which was why Spector’s lawyers were so insistent that although
the accused spent a lot of time in bars on the night of Clarkson’s death,
and ordered a number of alcoholic cocktails, he didn’t actually drink them.
That Clarkson was, at the time, buzzing lightly on Vicodin, the painkiller
she was still taking two years after breaking both of her wrists, was
another twist in the tale. Spector and Clarkson were a very modern American
couple: plain-clothes druggies whose habits were known only to their doctors.

The situation in the UK is nowhere near as bad, but it does seem to be getting
worse. In

the same week last year that Robbie Williams went public with his
prescription-drug habit, a private GP was banned for nine months for
prescribing addictive or dangerous drugs from his website, e-med. The
General Medical Council ruled that Julian Eden had adopted a “cavalier”
approach to patients who contacted him online. In particular, the GMC was
appalled by the case of a 16-year-old boy, with a history

of self-harming and mental instability, who

tried to after Eden issued him with a prescription for the
beta-blocker propranonol. Another woman, a mother of three, obtained a
year’s supply of dihydrocodeine and Valium. A third “patient” received 51
repeat prescriptions for two so-called “hypnotic” sedatives similar to the
date-rape drug Rohypnol.

Eden’s activities came to light after he was exposed by two undercover
reporters, both of whom were prescribed drugs that usually require a full
medical consultation within minutes of logging on to e-med. Making matters
worse, the GMC said, was the fact that Eden made no attempt to contact the
GPs of his online clients.

Eden is, or was, a real doctor. As anybody with a broadband connection on
their computer knows, prescription drugs of the more popular kind are now
being sold from thousands of websites by anonymous peddlers. Every day I
receive spam e-mails offering unlimited quantities of, say, the
tranquilliser Xanax, or the highly addictive and widely abused sleeping pill
Ambien. The asking price is usually $2 a tab. This dodgy online pharmacy is
invariably just a click and a credit-card payment away.

According to a report published in 2006 by the United Nations’ International
Narcotics Control Board, the misuse of pharmaceutical drugs now outstrips
the trade in illicit substances globally.

As many as a tenth of these “medicines” the UN estimates to be counterfeits –
crude, even dangerous, chemical copies of generic drugs manufactured by
criminals in the Third World. The UN report explains this growth as a
guerrilla response to the “war on drugs” fuelled by improved electronic
communications.

Parliament is at

last waking up to

the problem. Dr Brian Iddon MP, chair of the House of Commons all-party group
on drugs misuse, is carrying out the first proper assessment of prescription
and OTC drug abuse in this country. A scientist by training, with degrees in
chemistry, Iddon understands the problem better than most MPs. He reports a
surge in intravenous Valium and Prozac abuse

by crack addicts in his Bolton constituency

who use tranquillisers and antidepressants to soften their comedown. Iddon’s
group hopes to publish its report in the spring.

Iddon, whose committee is considering the findings carefully and has already
received evidence from many users and their families, says: “Whatever
happens in the USA comes to the UK, usually about 5-10 years later. So my
guess is that we’re heading for the rates of misuse of legal substances that
the USA is seeing now. The internet supplies the drugs if doctors will not,
or if patients do not want their doctors to know what they are up to.
Anything is available on the internet, and there is little control of
internet pharmacies or wholesale suppliers.

“The DoH has produced guidance for doctors which is still being ignored. For
those who become addicted there should be more access to treatment. The NTA
[National Treatment Agency] should treat all those with problems caused by
‘misuse’ of any substance – legal or illegal, including prescription
medicines and OTCs, as well as alcohol.”

But the pharmaceutical companies have a responsibility too. The MHRA
yellow-card scheme is slow to pick up problems and, even when adverse
reactions to a new medicine start to come in to the MHRA, it has little
power

to take action against the drugs companies.

Not that a parliamentary report will do a lot

to tackle the root of the matter: our proclivity as a species to seek chemical
solutions to our chronic discontents. Harry Shapiro, who heads DrugScope, a
British charity that offers advice on addiction issues, blames the rise in
prescription and OTC drug abuse on our increasing tendency “to medicalise
feelings which can’t simply be wished away by swallowing a pill”. Then
again, depriving the desperately unhappy of what may turn out to be bad
solutions won’t work either, Iddon believes. “What on earth do we prop these
people up with, then?”

This is not a purely rhetorical question. Iddon has seen blue-sky policy
documents, so-called “foresight programmes”, drawn up by the old Department
of Trade and Industry, that call

on drugs companies to invent a “safe” recreational drug: a happy high with no
side effects and no risk of dependency. It could

signal the beginning of the end of the war on drugs. It could also take us one
step nearer to the zonked anaesthesia of Aldous Huxley’s Brave New World.
More soma, anyone? s