What do Michael Jackson, Heath Ledger, Marilyn Monroe and Elvis Presley have in common? They were all taking tranquillisers – prescription drugs for insomnia, depression, anxiety – at the time of their deaths. The results of toxicology tests undertaken after Jackson's death in June are expected to reveal the presence of drugs to alleviate pain, depression and anxiety, and will inevitably reignite the debate about the benefits and human costs of drugs that are prescribed by doctors or bought over the counter in vast quantities the world over.
All drugs can cause side effects, but two types of legal drug are habit-forming: benzodiazepines (tranquillisers) and opiate-based painkillers (such as morphine and codeine); both can have serious, even fatal, consequences for users. Yet addiction to legal drugs is a controversial and complicated issue. It typically involves an accidental or involuntary dependence to medication first taken, and given, in good faith for a genuine ailment or condition. Jackson, for instance, is believed to have become addicted to Demerol (known as Pethidine in Britain) after suffering from a serious burn during the filming of a Pepsi commercial in 1984.
But critics, including many former addicts, argue that these drugs are too readily available, and are taken for too long, with little regard for, or understanding of, the long-term physical and psychological consequences. The addictive qualities of the drugs in question are all too apparent: tranquillisers, as the name suggests, relax and calm the subject; by contrast, opiate-based painkillers induce a state of euphoria (though they can have a sedative effect in high dosages). Worse, the chemistry of both types of medication means taking them every day for just a few weeks can lead to dependence and, if stopped abruptly, nasty physical and psychological withdrawal symptoms – occasionally, fatal seizures. The rising numbers of people thought to be addicted to legal drugs in the UK is shocking: there are in this country around 400,000 heroin addicts, yet there are believed to be up to seven times as many in thrall to tranquillisers and opiates.
Benzodiazepines ("benzos") were touted as the world's first wonder drugs. Introduced in the 1960s to treat anxiety and insomnia, within a decade they became the UK's most commonly used medication, with more than 30 million prescriptions annually at their peak. Last year, more than 22 million prescriptions for these drugs, including diazepam (Valium), lorazepam and temazepam and the newer "Z" tranquillisers, such as zopiclone, were dispensed by chemists in Britain (this does not include drugs used in hospital). The figures confirm what support groups and helplines have long said: millions in Britain are still in the grip of "Mother's little helpers", which continue to be inappropriately prescribed to men and women, young and old, for everyday and normal pressures such as wedding-day nerves, bereavement, domestic violence and financial woes – and lead many to addiction.
The Government can claim some success in its war on illegal drugs: its strategy between 1998 and 2008 was primarily focused on heroin users, and it succeeded in getting record numbers of the country's estimated 400,000 addicts into contact with drug-treatment services and on to the legal substitute, methadone. In stark contrast, the policy of successive governments for prescription drugs has been simply to warn doctors about the potential of dependence on benzodiazepines to try to prevent addiction occurring. This has led to informed estimates that between 1.5 and two million people are addicted to tranquillisers in the UK; we have little idea of how many are addicted to prescription and over-the-counter (OTC) painkillers, but it is thought, conservatively, to be tens of thousands. And many of these "legal addicts" are fighting their drug battles alone. They are generally not welcome in government-funded drug services, nor do many want to seek ' help in centres frequented by street-drug users, as they do not perceive themselves as addicts and have quite different needs. Nor do most GPs understand enough about the drugs, their long-term effects or how to wean people off them. So, apart from a handful of services set up by pioneering individuals, charities and NHS organisations, the majority of these addicts have nowhere to turn.
The problem with these drugs (though they are very useful medications when used correctly) is not only their addictive nature, but also the manner in which, for decades, they have been prescribed. In 1988, the Committee on Safety of Medicines told doctors that tranquillising drugs should be prescribed only for severe anxiety or insomnia, and for a maximum of two to four weeks. A reminder of these guidelines was issued by the Government's chief medical officer, Sir Liam Donaldson, in 2004, but apart from that, there has been scant interest from a succession of governments. The figures suggest this "hands-off" strategy has failed. The Department of Health has finally agreed to review its policy, but has rejected calls to study the problem in greater depth, deflecting responsibility back on individual doctors and "abusers" – a label that angers many of those who lost years to these widely prescribed drugs, which are mistakenly viewed as benign.
Colin Downes-Grainger, 62, a former primary-school teacher, was given 17 different tranquillisers, sleeping tablets and anti-depressants from the age of 25 for work-induced stress. "To be labelled as a drug abuser feels dark, surreal and wrong," he says. "All I did was go to my GP with a problem and follow his advice. I spent the next 10 years in my bedroom, missed my children growing up in large parts, and had my life taken away needlessly. I can live with the fact that when these drugs were first introduced, no one really knew about all of the problems. But the fact that, decades later, people are still being made into addicts is indefensible."
Heather Ashton, emeritus professor of clinical psychopharmacology at the University of Newcastle upon Tyne, set up the first NHS withdrawal clinic in 1984; it was oversubscribed for 12 years, but none of her colleagues wanted to take over from her when she retired in 1996. "It just wasn't fashionable in the medical world – not enough people believed it was a problem, and although many have now come round, it still isn't widely understood. The inaction from government is incomprehensible. I have spoken to so many ministers and committees and each time you think you've made your point, then nothing happens. The right of doctors to prescribe as they see fit always takes preference – but it hasn't worked."
Ten years after coming off all the medication, Downes-Grainger still suffers from various sensory problems, joint and muscle pain, permanent insomnia and exhaustion. According to Professor Ashton, around 15 per cent of long-term benzo-diazepine users will have long-term, possibly permanent, physical problems (which can mimic symptoms of early multiple sclerosis) even after they stop. Curiously, she has repeatedly been denied funding to study these effects more rigorously by The Wellcome Foundation, the Medical Research Council and the other main supporters of medical research.
Since reporting of such incidents began, there have been 12,247 adverse reactions related to benzodiazepines (including 198 deaths) and opiate painkillers (403 deaths) reported to the Medicines and Healthcare products Regulatory Agency (MHRA). But reporting is itself problematic: research shows that only five to 10 per cent of adverse drug reactions are ever reported by health professionals, which means thousands of people may have suffered harm or died as a result of medications meant to help them – far more, it may be surmised, than have ever died from taking illegal drugs such as heroin or ecstasy. Yet the current head of the Government's Advisory Council on the Misuse of Drugs, Professor David Nutt, is on the record denying that there are any risks associated with long-term use of benzodiazepines.
The over-use of opiates as painkillers is equally alarming. Despite being the most common reason why any of us ' visits the doctor, pain is poorly understood and frequently treated with pills rather than investigated. Sir Liam has called for urgent action to address a gaping hole in medical training, which currently fails to teach students anything about chronic pain, saying: "Although we now have effective means of tackling both pain and the consequences of pain, services have not kept up with demand and too many people struggle to cope with their symptoms."
There were 15.96 million community prescriptions for opiates such as morphine and dihydrocodeine in England and Wales in 2008 – a rise of 55 per cent in five years. In the same year, 290 million packets of OTC painkillers such as paracetemaol, aspirin and Nurofen Plus were sold in Britain's chemists and supermarkets. Of these, 27.5 million packs were products containing codeine – similar to, but much milder than, morphine. As with all opiates, the most serious potential side effect is death due to respiratory depression – something linked to, but not yet confirmed in Michael Jackson's death. Withdrawal symptoms are similar to those experienced by a heroin user: stomach cramps, diarrhoea, vomiting, the sweats and hallucinations.
Brian Iddon, a chemist and Labour MP, chaired the All-Party Parliamentary Group on Drug Misuse for ten years. Under his watch (he stepped down in June), the group conducted an inquiry into OTC and prescription-medication addictions in 2008 and found too many doctors were still not following prescribing guidelines, and handing out repeat prescriptions for habit-forming drugs. The committee also criticised the MHRA for failing to reduce the pack size of OTC codeine painkillers from 32 to 18, and urged it, and the drugs firms, to do more to monitor the risks posed by these drugs.
Martin Johnson, a Barnsley GP and chairman of the Royal College of GPs' pain-management committee, first became interested in pain as a medical student after his grandfather's very sore sciatic shingles was badly treated. A quarter of all the patients in his surgery are on painkillers but he, like other GPs, has no idea how many are taking OTC medications as well, as there is no joined-up system for counting or monitoring patients who take habit-forming painkillers. "The problem is that pain has never been accepted as a true area of medicine and most doctors are still not that interested. So, for too many doctors, a prescription is a quick fix and quick consultation," says Dr Johnson. "This means that you, I, or anyone who has an acute problem can end up with a long-term untreated condition. For example, there are 650,000 whiplash injuries a year in UK and a high proportion are given a prescription and told to go away and rest, which is totally inappropriate advice and will lead to unnecessarily pain and more painkillers. Even fewer doctors can recognise a dependency or would know how to help someone withdraw safely. Medically speaking, addiction and pain are in different worlds."
Dr Beverly Collett, a consultant in pain management in Leicester, set up a monthly clinic for patients addicted to painkillers 10 years ago. She sees patients jointly with a psychiatrist – one of only a handful of such services in the UK. Together, they try to deal with the physical and psychological aspects of pain, drug dependence, withdrawal and the mental-health problems many of their patients have. "The people we see have different chronic-pain problems and have often been put on multiple medications and mixtures of drugs," she says. "The relationship with their GP has often broken down. These aren't people who set about trying to get high; these are people who are desperate to get their pain under control and the addiction creeps up on them. Back pain is common among these patients and we have one man who smashed his ankle during a suicide attempt. But at the heart of all these problems is that doctors do not understand how to treat chronic pain."
A recent survey of callers to the telephone helpline Over-Count (set up to help those addicted to OTC drugs) found the most common age range of those addicted is 18 to 36; two-thirds are women; users generally stick to one product, and 100 per cent say they have no inclination to progress to harder or illegal drugs. The vast majority ended up accidentally hooked, because the cause of their headache or backache had never been treated. Allowing people easier access to medication is something the Government is keen to promote in order to reduce the NHS medication bill – which hit £10bn in 2007 – and relieve some of the burden on GPs. But this could lead to more addiction – and expense.
Barry Haslam, 65, a former accountant from Oldham, persuaded his local NHS Trust to pay for a specialist withdrawal clinic – one of only a handful in the country – after he lost 10 years of his life to a cocktail of antidepressants and benzodiazepines. He was the first person to be awarded Disability Living Allowance because of the long-term damage caused by the medication. The Benzo Project, run by Suzanne Atreides for the charity Addiction Dependency Solutions, has started to see people dependent on painkillers as well. "People dread coming in to me," says Atreides. "They think I'm going to stop it straight away and can't imagine life without their tablets. But I work as slowly as they need me to, at their own pace – 92 weeks in one case. Many people feel embarrassed and keep it secret from their families for years, but the fear of getting caught just adds to their stress. There are so many people addicted out there; left on the drugs, as it's easier."
There is no doubt that drugs which alleviate pain, crippling anxiety and insomnia help millions of people across the world every year, but are they given out too easily when other options could be considered? The most effective pain clinics advocate the use of psychology and psychiatry alongside pharmacology, but patients can wait years for an appointment.
Michael Jackson's blood results are expected any day now. But for the millions of people living the nightmare of legal drug addiction – ashamed, unacknowledged and with nowhere to turn for help – pointing the finger of blame at Jackson's doctor or scrutinising the troubled star's addictive personality will change nothing. Instead, the millions who are believed to be caught up in legal addiction, the pharmaceutical industry, the medical profession, the Government, and all of us who are happy to take a pill for every ill, have a duty to acknowledge the truth – and do something about it. n
Mark Lawton: addicted to morphine
"It was an ordinary Sunday night in 2002: we were getting the kids ready for school the next day – the eldest was in the bath – when the door bell rang. My partner Julie answered it and then, bang, everything changed. A man ran into the house and shot me twice in my right leg, in a case of mistaken identity. The next thing I knew, I had woken up in hospital with doctors telling me they'd have to cut my leg off."
Mark Lawton, now 40, refused to accept this fate and, against medical advice, signed himself out. He spent the next few months at home in agony, taking just paracetamol while searching for a surgeon who would try to save his leg.
Finally, in August 2002, he was admitted to the nearby Hope Hospital, for the first of 15 operations.
His shin was removed and his foot was attached just below his knee with 19 pins. He was told in hospital to take as much morphine as he needed to stay on top of the pain, so he did.
"I was in agonising pain and I started eating the Sevredol tablets like toffees; I would clock-watch until it was time for the next one. I went home after 23 days with a spanner, so I could break the bone everyday to let the shin re-grow, and as many tablets as I needed. Looking back now I was already hooked – I was a junkie."
Around a year later, still in a wheelchair, still on regular morphine from his GP, he missed a dose.
"I was lying on the bed, curled up in a ball, sweating and shaking. The doctor came around, gave me an injection and I felt better. That was the first time I realised what I'd become: I was as bad as a heroin addict who needed his fix."
But over the next few years, try as he did to cut down, he couldn't do without the tablets completely. His weight dropped, his appetite got smaller, and he rarely left the house, having lost his job as a butcher.
"You know how a man should be able to eat a proper plate of meat pie and chips; well, I couldn't do it any more. All I could think about was making sure I didn't run out of medication. It was the first thing I thought about when I woke up and the last thing before I went to bed. It's wrecked my life; I hate it."
After begging his GP for help again, he was recently referred to see Suzanne Atreides, a counsellor with the charity Addiction Dependency Solutions, who runs a unique project in Oldham, where he lives. Lawton is now down to 15mg of morphine a day (from 40mg), his appetite is improving and for the first time in years, he has some hope.
"The doctors never once told me I could get hooked," he says. "It was always like, 'Take as many as you need, the nerve damage is really painful, so don't try to do without them.'
"I would just pick up the prescriptions, no questions asked, no advice. Now I've found someone to help me, I'm determined to get off them by Christmas. I have to get my life back." NL
Jane Hadi: addicted to Valium
Jane Hadi, 52, from Bristol, can't remember a life without pills. "I was going through a personal crisis, I was ill and stressed, so my mum took me to the doctor. He gave me Ativan [a form of lorazepam]; I was 12."
In 1969, Hadi wanted to be a lawyer. She loved school, liked playing outside with her friends and she remembers herself now as a happy child. The day she started taking lorazepam, all that changed."I can't really remember how I felt before. I was emotional and used to cry sometimes, and the tablet made me feel nice. My mum never questioned it – why would she? But if she knew then what we know now, she would never have let me take them."
Life went on. Hadi met her husband, Basem, a car mechanic, when she was 18. They got married and had four children. It was when she was pregnant with her eldest child, in 1977, that she first stopped taking the medication. "I remember feeling really emotional, having mood swings; I was a nightmare to live with. I thought it was the pregnancy but looking back now it was withdrawal symptoms." She stopped during each pregnancy, but after each birth, the doctor put her straight back on Valium.
"I would take them every time something went wrong with the kids; maybe one of them fell over, and I would take one to cope. This is how I'd been brought up: 'Take a pill if you're not coping.'"
Ten years ago, Hadi was admitted to a psychiatric hospital where she was diagnosed with bipolar affective disorder (manic depression), taken off the Valium and instead prescribed a major tranquilliser. The next four years at home were hell. "I couldn't cope with the kids, the housework, with cooking; I couldn't do anything. My legs hurt, my back ached, I felt terrible. So I started to drink, heavily, from 10am to 11pm, just so I could cope with life."
In 2005, as her son's wedding day approached, Hadi looked into the mirror and hated the overweight, puffy face in front of her. "I'd seen a programme on TV about people buying Valium online. I couldn't go to my GP – she's been so happy that I'd come off them and I didn't want to disappoint her – so I started buying them on the internet.
"It was easy, it only cost me £80 for 100 tablets and soon I was taking 30mg a day, more than ever before."
Three months ago, Hadi went back to her GP for help after she realised she couldn't pay the £2,000 credit-card bill for the pills. She now gets help from Battle Against Tranquillisers (www.bataid.org) and is reducing her dose by 1mg every three weeks. "I don't want to ever stop completely, I couldn't cope, but I'd like to get down to 10mg a day. It's like a love-hate relationship: I can't live without them but they rule my life. I do feel angry because I should never have been put on them, but it's all I know." NL
David Grieve: addicted to cough syrup
It was 1975; David Grieve (now 59 and living in Dumfriesshire) was working as a psychiatric nurse in Portsmouth, when he developed a bad cough, so he went to the chemist, and got some cough linctus. It contained codeine (a mild, but addictive opiate like morphine) and ephedrine (a stimulant and decongestant, also addictive). He took it for four days, then stopped. But his cough came back, so bought another bottle.
"I was taking it as directed on the bottle and I felt great; full of energy and alert. After the second bottle, my cough was gone, so I stopped. But a few weeks later I was having a bad weekend, so I bought a bottle to make the downer go away. Over the next year I did it a few times, but soon two teaspoons weren't enough, so I kept upping the dose, to get the same effect."
Over the next few years, Grieves moved to Merseyside, trained as a policeman and progressed on to a bottle a day, still trying to kid himself that he could stop at any time. By the time he moved his family to Scotland, he was close to taking 90 bottles – nine litres – every week.
"I would go 'trawling' three times a week: Monday I'd travel north to Edinburgh or Glasgow, Wednesday as far south as Stafford, and Friday I'd go east to Newcastle. Each time I'd buy 30 bottles from different pharmacies. My wife had found out by this point, but I loved the cough mixture more than my family."
By 1990, it had become a huge burden. Grieve had given up work so he could trawl, and spent £20,000 in the last two years of his addiction. His doctors were at a loss as to how to treat such a serious addiction. It wasn't until 1992, 17 years after he had begun, when he became critically ill, having damaged his liver, kidneys and gall bladder, that he pleaded with his doctor and a chemist to help him withdraw. "If I had carried on, I'd have been dead in a year, so over the next nine-and-a-half months, I cut down from 10 bottles a day to none. It was 10.25am on 13 September 1992 that I drank my last 50ml; I haven't touched a drop since."
The following year he started up the Over-Count helpline to help those addicted to OTC drugs, after a magazine article about his life attracted interest. In the first year, the line took 1,000 calls; it has taken nearly 20,000 since. The addictions have moved on – very few people are dependent on OTC cough mixtures now that the ingredients have been changed. Instead, most people use codeine-based tablets such as Nurofen Plus, which the majority – 92.9 per cent – started taking for minor, but painful, physical ailments. "The Government's move towards more self-health means this is a 21st-century problem which is not going away. More and more people come to us each year and all are struggling to get help, yet stopping these medications abruptly can be fatal.
"Joe Public has to take more responsibility, but he can only do that if the information is available in a form he understands. Most people still don't think something which is so easy to buy can be addictive, and many don't read the information leaflet after the first time; it's too small, too technical and people find it boring." NL
To contact Over-Count, call 01387 770 404 or visit myweb. tiscali.co.uk/overcount/index.htm. For Addiction Dependency Solutions, call 0161 834 9777 or visit www.adsolutions.org.uk
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