Steep rise in abuse of legal drugs

Log onto e-mail anytime, and you can find one explanation for the recent dramatic and deadly spike in the abuse of prescription drugs.

"Get ANY D-R-U-G-S You NEED!!" declares a piece of spam that was sent on a recent morning. "OUR U.S. Doctors will Write YOU a Prescription You will get it NEXT-DAY via Fed-Ex!!"

It is simple and anonymous, and has helped lead to what experts are calling a national epidemic of abuse of everything from painkillers to sedatives to stimulants. Between 1995 and 2002, there was a 163 percent increase in the number of emergency-room visits tied to the abuse of prescription drugs, according to the Substance Abuse and Mental Health Services Agency.

SAMSHA estimates 9 million people now abuse prescription drugs, meaning they use them for nonmedical, and often recreational, purposes. Three million abusers are kids between the ages of 12 and 17 years old. And the abuse can be deadly: Prescription drugs now play a factor in a quarter of all overdose deaths reported in the US.

US drug officials say this represents a dramatic surge - one that took them by surprise. It has presented a whole new set of challenges, such as a lack of law-enforcement resources to track down shadowy Internet sites and unethical doctors and pharmacists. Another key issue: finding a way to balance any law-enforcement measures with the needs of legitimate online pharmacies that have helped the elderly and others save money and time.

Federal officials have decided one way to combat the problem is with education. SAMHSA and the Food and Drug Administration have launched a national campaign to warn people that the misuse of prescription drugs is dangerous, as well as illegal.

"There's an assumption that these are legal, so they're OK - that they can use them and walk away without any consequences," says H. Westley Clark, director of SAMHSA's Center for Substance Abuse Treatment (CSAT). "They don't seem to realize that this misuse can lead to serious problems with addiction."

A complex array of factors has led to the spike in abuse of prescription drugs. There's the overall increase in the legitimate use of prescription drugs as a society. For instance, since 1995, the number of Ritalin prescriptions written by doctors has quadrupled. During that same time, the stimulant became a favorite recreational drug among teens.

The number of OxyContin prescriptions written between 1996 and 2000 increased 20-fold. One theory contends that the increase in HIV and hepatitis C has prompted some illegal substance abusers to switch to prescription drugs like OxyContin, which can have an effect similar to heroin.

The rise of the Internet has been another factor. Since 1999, online pharmacies - legitimate and otherwise - have mushroomed, giving kids and addicts alike what appears to be easy access to the drug of their choice.

"Certainly the Internet has facilitated the average person obtaining controlled substances when they would not have done so," says Elizabeth Willis, chief of drug operations in the Drug Enforcement Administration's Office of Diversion Control. "Most people wouldn't go into their doctor and falsify medical complaints to their doctors, but over the Internet, they don't realize it's illegal, and they can do it anonymously."

Government investigators can only estimate how many online pharmacies exist, in part because the illegitimate ones appear and disappear quickly. The first ones started appearing in abundance in 1999. An investigation done by the General Accounting Office in 2000 found 190 Internet pharmacies operating at the time. Of those, 79 provided drugs without a proper prescription.

It's estimated there are now hundreds of such cyber-pharmacies operating from the US and overseas. Like almost every kind of commerce on the Internet, they've proven to be very difficult to regulate and, for those operating illegally, to prosecute.

In part, that's because no one agency has direct control. The FDA, which regulates medicines, has sent out letters warning some sites they may be acting illegally. But it doesn't have criminal enforcement capabilities.

The Federal Trade Commission, which regulates fraudulent claims, can investigate what are known as "cyber-script mills" and file civil suits, but again, its hands are tied when it comes to criminal complaints.

Even the Drug Enforcement Administration (DEA) is operating with limited resources and capabilities. Of the 4,000 drug agents operating in the field, less than 10 percent are dedicated to tracking the misuse of prescription drugs, which in the agency is called drug diversion. Most of their efforts are dedicated to tracking down what are called the bricks and mortar - the doctors and pharmacists who appear to be over-prescribing or handing out controlled substances at will.

The Internet investigations are intermixed with those cases, and don't have a single unit or investigator dedicated to them. What's more complicated is that these diversion agents have no arrest authority: They have to call on other departments within the DEA.

In 2002, the inspector general of the Justice Department criticized the DEA for not dedicating enough resources to drug diversion. That concern is echoed by experts in the field.

"Very little is being done on the Internet situation," says Michael Montagne, a professor of social pharmacy at the Massachusetts College of Pharmacy and Health Science. "The DEA tries to monitor it, but they're just capturing a fraction of what's coming in over the board."

The DEA currently has several cases pending against cyber-pharmacies, but can't talk about them. It's also been involved in several successful prosecutions, including one known as the Pill Box Pharmacy case. That was a pharmacy in San Antonio that opened a website and began prescribing controlled substances after a two- to three-minute telephone interview with a doctor.

In the 18 months it operated, it sold 9.3 million doses of the generic versions of Valium and the pain reliever Vicidin.