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24/02/2008 00:00:00

UK: 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

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

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

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 kill
himself 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?

Author: The Sunday Times via UKCIA

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