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Abuse of prescription drugs fuelled by online recipes

05 June 2006, NewScientist.com news service, Hazel Muir

"IF YOU just swallow them you will not be getting the full effects." Instead, the website tells abusers of a common prescription drug to crush the time-release beads and snort them, or swallow the powder in a piece of tissue paper to get a longer-lasting "hit".

These words could kill. Yet tampering with prescription drugs to amplify their effects is a growing health hazard. A study published this month suggests that droves of people are turning to the internet to search for and swap advice on how to tamper with prescription drugs, for instance, by snorting those prescribed for hyperactivity disorders, or chewing skin patches containing potentially lethal painkillers (Drug and Alcohol Dependence, DOI: 10.1016/j.drugalcdep.2005.11.027). Toxicologists are calling on pharmaceutical companies to wise up to these tricks.

"Drug misusers are tampering with the drugs to get high, and you get high by getting the drug in faster or giving a bigger dose," says Edward Cone, the author of the study and a toxicologist at ConeChem Research in Maryland, which advises the pharmaceutical industry on drug abuse prevention. "All of these drugs are toxic or lethal at certain levels, so this is a very real health issue."

In March, the International Narcotics Control Board released a report identifying North America, especially the US, as a hotspot for prescription drug misuse. In 2003, the US National Survey of Drug Use and Health showed that the number of people misusing legal painkillers, tranquillisers, stimulants and sedatives had reached 6.3 million - more than twice the number taking cocaine.

Users get hold of the drugs by every route imaginable, including conning doctors with bogus ailments, using prescriptions intended for other people or buying them from illegal internet pharmacies. "In the US, the abuse of pharmaceutical drugs is reaching epidemic proportions," Cone says.

The appearance of websites detailing the recreational use of these drugs, which even post recipes on how to heighten the hit, is the latest twist in this trend (see "Recipe for abuse"). The traffic on some of the sites is enormous. One, which includes around 3000 personal accounts of experiences with a wide range of legal and illicit drugs, receives an average of 420,000 hits a day. "Some people post their progress on beating a new formulation almost on a daily basis. Then others respond with questions and experiences of their own - it feeds on itself," says Cone.

For instance, some sites suggest ways of tampering with skin patches designed to slowly release the opioid painkiller fentanyl. Users sometimes extract the drug from a patch to eat, inject or smoke. Yet a single patch can contain enough fentanyl to kill several people, according to toxicologist Bruce Goldberger from the University of Florida in Gainesville. "It's like Russian roulette - you just don't know how much drug you're going to get," he says.

"Users sometimes extract fentanyl from a patch to eat or inject. Yet a single patch can contain enough to kill several people"

Goldberger says the tampering problem began to escalate in the mid-1990s when OxyContin came on the market. OxyContin, made by Connecticut-based company Purdue Pharma, is a sustained-release formula of oxycodone, another powerful opioid painkiller. Recreational users quickly realised they could defeat the sustained-release formula by chewing the tablets, or crushing them to snort or inject.

Surveys by the US Drug Abuse Warning Network (DAWN) suggest the number of emergency hospital visits involving oxycodone misuse increased about 10-fold between 1996 and 2004. Estimates suggest that in 2004 there were more than 36,000 admissions involving misuse of the drug, now nicknamed "hillbilly heroin".

There are no official US national statistics on how often drug tampering leads to a fatal overdose. But tampering is implicated in roughly 200 deaths each year in Florida alone, according to Goldberger, whose lab oversees much of the state's post-mortem investigations. He adds that because the circumstances of a drug overdose are often unclear, that is probably the tip of the iceberg.

Whether the popular online schemes for drug tampering are effective is often unclear. "Many of the procedures look like they would work," says Cone. "But as far as I know, there is no one evaluating them." Users therefore have no way of assessing them - except by giving them a go.

Goldberger says he was reluctant to discuss the problem of drug tampering publicly several years ago, for fear of planting the idea in someone's head. "But today, the information is already out there," he says. "If you don't know how to tamper with a product all you have to do is a Google search."

So what should be done? Goldberger says education about the hazards of drug tampering is vital, along with systematic surveys to uncover the real extent of the problem. Cone argues that companies could also do much more to make their drugs tamper-resistant, by making tablets that are likely to be abused harder to crush and snort, for instance (see "Tamper proof"). While these measures wouldn't stamp out drug tampering completely, "we can certainly do better than we're doing now," says Cone.

"The number of emergency hospital visits involving oxycodone increased 10-fold between 1996 and 2004"

The good news is that some barriers to tampering seem to be genuinely effective. Disgruntled recreational users report online that one methylphenidate drug called Concerta, a stimulant used to treat attention deficit hyperactivity disorder (ADHD), is very difficult to crush and snort. One user's verdict reads: "No effects to very minimal with an irritated nose full of chunks."

Another example is Marinol, used to treat nausea in chemotherapy patients. Marinol capsules contain a synthetic version of the psychoactive chemical in cannabis mixed with sesame oil, which is hard to remove. That means, in other words: "Smoking it is disgusting and tastes like a bowl full o'seed".

Pharmaceutical companies are starting to take the problem seriously, says Nora Volkow of the National Institute on Drug Abuse in Bethesda, Maryland. For instance, Purdue Pharma is reformulating OxyContin to make it less easy to tamper with. Novartis, which makes Ritalin, an ADHD drug that some people take recreationally, has also developed a one-a-day Ritalin tablet that parents can give their children before they go to school, so there is less risk of the drug falling into the wrong hands in playgrounds.

"We have a role to play, but we're not the only ones," says Chris Lewis, a spokesman for Novartis, who believes that society as a whole should be doing more to educate people about the hazards of misusing prescription drugs. He stresses that the company makes sure doctors are fully aware of the drug's uses and potential risks.

Some industry experts question whether tamper-proofing is the best route. "We make medicines in the most palatable and effective form for the patients who need it - that is our responsibility," says Richard Ley, a spokesman for the Association of the British Pharmaceutical Industry. He says making drugs tamper-proof would make them more expensive for patients and health services, and delay the marketing of vital new medicines.

That view is understandable, says Volkow. But she argues that prescription drug abuse is now so out of control in the US that cooperation from pharmaceutical firms is essential. "We have an urgent problem that needs to be stopped. In our high-school surveys of kids aged 12 to 18, 10 per cent have tried opiates for non-medical reasons - it's gigantic."

From issue 2554 of New Scientist magazine, 05 June 2006, page 6
Recipe for abuse

Internet forums document a bewildering range of recipes for tampering with prescription drugs. For example, users of some online forums recommend snorting oral amphetamines and drugs to treat attention deficit hyperactivity disorder. This defeats the tablets' sustained-release mechanisms and delivers a faster, more intense hit.

Users have also twigged that they can manipulate the absorption rate of prescription amphetamines by mixing them with chemicals that alter their pH. The drugs can be addictive, and very high doses can raise blood pressure and cause dangerous heart problems.

Other commonly abused prescription drugs are tranquillisers, which recreational users frequently mix with other drugs, taking a tranquilliser to combat a cannabis-induced panic, for instance. Long-term use can lead to physical dependence and addiction.

The most commonly abused prescription drugs are opioid painkillers. Most misusers take these drugs orally, but some people snort them. Websites also detail ways to "purify" the narcotic component by dissolving the tablets. These drugs are addictive, while a large single dose can cause severe respiratory problems and death.

Tamper proof
  • Drug companies could use a variety of chemical tricks to discourage tampering:
  • Simply making tablets harder to crush can prevent users snorting or injecting them.
  • Companies could add a substance that blocks any psychoactive hit if the user snorts or injects a drug.
  • To prevent people "purifying" the narcotic component by dissolving the drug, manufacturers could design tablets that turn into a useless jelly in water.
  • They could add a waxy coating or matrix that traps the drug if someone tries to extract it through heating.
  • In some cases, just a nasty flavour or dye might be enough to discourage all but the most hardened drug abuser.