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Edward
July 20th, 2003, 12:38 PM
http://www.newyorkmetro.com/nymetro/news/features/n_8763/
From the June 09, 2003 issue of New York Magazine.

Pill Culture Pops
With the stigma attached to mood-improving (not to mention sex-life-improving) drugs all but gone, New Yorkers are becoming their own Dr. Feelgoods, self-medicating as never before. Inside the new (totally respectable) drug scene.

By Ariel Levy

Sound the alarm. there’s a new drug epidemic in town. And most of the city wants in on it. “In certain circles of New York, it’s just regular table conversation,” says a 37-year-old publisher. “I was at lunch with clients the other day—it was a totally professional situation—and I mentioned that I have to give a speech at my parents’ fortieth wedding anniversary. I said, ‘I’ve got to get some Klonopin; I’m going to be so uptight.’ Somebody else said, ‘Oh, I always take a Klonopin before a big presentation.’ One thing led to the next, and soon everyone at the table was talking about how they’re on Xanax or Klonopin or Vicodin. No one wants to go through the hassle of seeing a psychiatrist because they don’t necessarily feel there’s anything wrong with them. It’s just the way life is in New York: Everyone’s stressed about something.”

We have entered the golden age of self-medication. Drugs have become like hair products or cosmetics: This is brain styling, not mind altering. The early buzz was that Prozac makes you a different person—changes you fundamentally, if subtly. But, habitual drug users that we are, we know that’s not true. You’re you on meds, only less freaky and more well-rested.

We have been listening to Prozac now for over ten years. In that time, SSRIs (selective serotonin reuptake inhibitors, in case you’re not on one) have become as socially acceptable as Sudafed. Not that long ago, the only people who used prescription drugs for their mental health were the deeply and obviously messy. At that time (the crack epidemic still raged), you wouldn’t have talked to your colleagues about what you took for insomnia, you bummed cigarettes off your friends instead of Ativan, and it might not even have occurred to you to take a pill for your garden-variety depression or anxiety. Now the question is not “Should I take something?” It’s “Am I taking enough?” Or “Am I taking the right one[s]?” And any lingering doubts we had about drugging our way to better mental health seem to have been washed away in the past two dark years.

‘The other night, the one person I know who doesn’t take medication said, ‘Is everyone in New York mildly sedated?’ I was like, ‘Wake up and smell the Valium,’ ” says a 26-year-old fashion publicist. “When I was in high school, it was pot; in college, it was coke; and now it’s Klonopin. Last week, my friend asked me, ‘Will you be mad if I don’t show for this benefit?’ And I said, ‘It’s fine, but why not?’ She was waiting by her phone for her psychopharmacologist to call. And I can totally relate. The psychopharmacologist is the new drug dealer—like a Park Avenue drug dealer.”

The line between medication and recreation has become blurred. What is really the difference between fixing ourselves and pleasing ourselves? “For a long time, I just took Ritalin when I thought I needed to concentrate,” says a 34-year-old writer. “But then I realized if it makes me feel normal, I should feel normal all the time. So now I take it when I get up every day—I have a friend who takes it every three hours.” (He also mentions that his dog is on an anti-anxiety medication called Clomicalm.)

When you relinquish the idea that your moods and weirdnesses are a constant, not to be messed with, any mental unpleasantness becomes fair game for treatment with a touch of this, a milligram of that. And once you start tinkering with things between your ears, more and more areas that could use fix-ups—tweaking—become apparent. Even if our doctors were worried about prescribing us Zoloft for depression and Ativan for anxiety and Ambien for insomnia, our friends aren’t.

“Somebody gave me a mother lode of Xanax,” says a 35-year-old man in the design industry. “I often give them out to friends who are getting on planes, or—for people who I know appreciate them—they make a lovely parting gift after a dinner party, packaged in a brightly colored plastic stacking box. I prefer ruby or orange.”

Jan, 25, recently sampled a friend’s Adderall, the drug now frequently prescribed for attention-deficit disorder in place of the less modish Ritalin. “I was helping out my friend, and she was like, ‘You’ve got to try this little blue pill.’ I could conquer the world if I took those pills! I was thinking of getting diagnosed with ADD just so I could get them, but I don’t want to be one of those people. We were having an auction and I was so overwhelmed; I thought, ‘There’s no way I can do all this.’ But after an hour, that little pill kicked in and suddenly I had everything organized and I had made all kinds of lists and put everything in order! My friend said when she tried coke it was like a really, really bad version of her pills. She was like, ‘Why would I ever do coke?’ ”

For many New Yorkers, the promise of the sixties slogan “Better living through chemistry” has been realized. Unless you are recklessly gobbling up piles of pills like Vanessa from Six Feet Under, psychopharmaceuticals feel like a less risky, more precise, more civilized way of getting the job done than those messy, old-school street drugs. Potentially, these drugs could actually get us off those drugs—could make those drugs uncool. “My dealer sells Xanax and Valium along with coke and ketamine and ecstasy,” says a 30-year-old journalist, “and often the prescription drugs are in higher demand than the illegal ones. Sometimes the dealers will do trades: their drugs for your prescriptions.”

As with illegal drugs, there’s a hierarchy of cool within the world of prescription pills. “Mood-stabilizing drugs—the breakfast of champions—that’s what’s still stigmatized,” says the fashion publicist. “Something like bipolar or, God forbid, schizophrenia, those are very taboo because they’re real. It’s still cool to be sane. You’re just supposed to be sane and medicated. You don’t talk about hard-core depression or being bipolar or anything that’s in essence a disorder. You talk about what’s chic and of the moment. You’re not trading those pills at a cocktail party. You trade leisure drugs—Ambien and Valium—anything you’re going to do in tandem with drinking. Ask someone when they take their meds. If the answer is ‘In the morning,’ then they’ve got some shit going on. If it’s ‘In the evening,’ they’re just playing with pills. A morning thing is you’re seeing someone and you’re working through some real issues. An evening thing is you have three martinis, two olives, and a little yellow pill.”

There are a lot of choices in the chemical armamentarium. There’s Klonopin (or clonazepam, the generic), a drug designed to prevent seizures that has the pleasant, fortuitous side effect of calming the truly anxious or putting the relatively relaxed straight to sleep. There’s Ambien, a sleeping pill remarkable for its lightning speed: unlike benzodiazepines (drugs like Ativan, Valium, and the ever-popular Xanax), Ambien can knock you unconscious in twenty minutes flat, so psychopharmacologists often tell patients not to take the pill until they are actually in bed. Recreational users like to force themselves to stay awake on Ambien, because it can produce a cracked-out, almost hallucinatory state of awareness, if that’s your bag.

Of course, there’s good old Prozac, which has a new fan base among ecstasy aficionados since Johns Hopkins researchers George Ricaurte and Una McCann conducted a study on animals that showed that ingesting Prozac within six hours of taking MDMA (ecstasy) prevents “most or all of the serotonin system reduction” associated with the drug, which is to say you don’t crash.

Wellbutrin helps people stop smoking, and unlike other antidepressants, it rarely has sexual side effects, but it doesn’t seem to work as well as, say, Zoloft on depression. “When I first went in for depression, they gave me Zoloft and stuff like that, and there was basically a guarantee that I would have trouble having sex and getting aroused,” says Robert, a 59-year-old management consultant who started mucking around with his mental state before the advent of Viagra. “I specifically remember thinking: I’m depressed. The one thing I still enjoy is sex, and you’re taking that away from me? It’s like a Woody Allen twist, like, ‘Sure, we’re gonna cure you, but now you can’t read.’ As I remember, Zoloft was very good as an antidepressant, but it had a very deleterious effect on my erection, so that’s when I said, ‘Give me a break.’ I opted for the middle ground, which was balancing a little Prozac and a little Wellbutrin so I could have a little sex.”

With solutions come side effects, and compromises—and cocktails—need to be made. “I take an antidepressant called Celexa,” says Sabina, a 25-year-old graduate student, “and I take Ambien. And then I stay up an extra half-hour just so I can feel kind of looped—I call it my little Ambien party, a party for one. Also, I sometimes get Ritalin from a friend, because I’m in school now and it’s harder to get a prescription for that.”

Even though Sabina is obtaining her pills through creative trade routes, the fact that somebody went to a doctor makes her feel that she has nothing to worry about. “In a way, you feel like it’s prescription—it should be okay,” she says. “In my life, most of the time, I try to be natural and good to my body, but when it comes to prescriptions . . . I’m not too worried about it. I have fun with it. And there’s a certain sort of cool about it.

“I don’t think I need any of it,” she continues. “Like with Celexa: I just wanted to see how I felt so when I go off it, it would give me a comparison, a reference point. And there’s no stigma because it’s New York, and we all have that image of the New York neurotic. I moved here from Boston two years ago, and I felt way more aware of being anxious once I got here. Then again, I moved here five days before September 11.”

New York has been the epicenter of our national fearing and grieving period, the house where we’ve held the shivah, and our medicating has gone up correspondingly. According to the Office of National Drug Control Policy’s Website, whitehousedrugpolicy.gov, between September and October 2001, new prescriptions for benzodiazepines (usually prescribed for anxiety) increased a whopping 23 percent in New York City, compared with an 11 percent increase nationally. Likewise, we took 26 percent more sleeping pills here, while the rest of the country spiked only a more modest 11 percent. Though we took more than twice as many of both of those drug groups as regular Americans, the place you could really see New Yorkers lapping the rest of the country was in our consumption of antidepressants: We went up 18 percent, and they went up 3. As one young woman puts it, “Even your mother was medicated on September 12.”

Lorraine, a 58-year-old mother of two who lives on Central Park West, says that September 11 pushed her from being an occasional Ativan borrower to becoming a full-fledged pill fan: “I love Paxil. I love it. I started after September 11, and it wasn’t specifically about that, but I realized that I was obsessing about everything. I’d been in traditional therapy for ten years, and my therapist didn’t really believe in medication. But then a friend started seeing this fabulous psychopharmacologist and I said, Why not? So I went to see him, and he told me, ‘You know, with all that’s gone on in your family, why shouldn’t you have some relief? Why shouldn’t you get to feel better?’ He was like Dr. Feelgood. He said I could take Paxil for the rest of my life and Ambien every night. He felt I had low serotonin.”

Did he give her a test?

“No.” She laughs. “I was wondering how he knew that. But I love Paxil. I love it. What it’s done is it makes me feel more like the glass is half full. People say, ‘I’m anxious,’ and I think, How quaint. I was supposed to go down to a lower dose, but I was thinking on the way over there, You know what? I really don’t want to. I’ve been through enough.”

The last time she was at general Store, a Portlandy restaurant on Avenue B where they play soothing acoustic guitar and serve omelettes in personal-size cast-iron skillets, Molly Small dumped an enormous container of pills—blue ones, green ones, ovals and squares—all over the antique pine table so her friends could pick out a few things to take on their flight to L.A. “Friends who ask for Xanax or Klonopin generally need it,” she says. “I don’t think there’s anything wrong with having something on flights. If you have a plane phobia, there’s no reason to sit there and freak out the whole time when you could take a Klonopin and pass out and not deal with it. Because what are you going to do about it? All this face-your-fear shit: That’s so very eighties, and I don’t really believe in it.”

Today, she is dressed in a peach-and-black-striped slip dress and massive silver hoop earrings. Everything about Small is big: big voice, big eyes, big breasts, big hair. Seven years ago, she had a big nervous breakdown. “Like you think that people have ‘nervous breakdowns’ and you know what that means? But I did,” she says. Now she takes various drugs at various times of the day: Prozac in the morning, Klonopin in the evening, Neurontin at suppertime.

She is tired, she says, of defending herself against concerned relatives and friends who are worried about her pill-popping. “People are like, Who knows what you could be doing right now if you weren’t medicated? It’s just crap. What I could be doing is crying in my room. Look, I take a minimum of fourteen pills a day. It’s not attractive. It’s not something pleasing. It’s something you have to explain to people when you start dating. I’d prefer they make one little pill that I could swallow casually, because I really do think it’s the volume of these pills—the way they’re all different sizes and shapes—that makes people think it’s like I’m in Candyland and I’m playing. But I’m not. I’m trying to keep myself sane.”

Despite the prevalence of medication in this city, the assumption persists (among the uninitiated) that taking meds will make you a grief-free zombie— that you’ll lose your edge and end up more of a suburbanite than a New Yorker. “That’s crap,” says Small. “It’s not like I walk around happy as a bee. I’m still just as conflicted and crazy as I ever was. I’m still pissy and cynical. But now I can live my life and I’m content.”

Actually, Small recently gave up Prozac for a while, just to see if she could: “You have doubting periods; you have periods where you think, Oh, I’ve just moved from being addicted to one kind of drug to another. Or: There’s nothing really wrong with me—I’m just creating all of this.” She laughs. “I went off Prozac in December. By the end of February, I was a complete and total nightmare.”

For all the well-meaning, drug-eschewing people in her life who offer advice, Small has a little tip of her own: “When I see people who so obviously need to be on medicine, I’m like, What are you waiting for? There’s an answer. I have this friend who’s been this anxious, depressed wreck for the last year or so. And it’s like: You are depressed all the time. You need, need, need, need. I really don’t have the patience to sit here and listen to you talk about how miserable you are when you won’t do anything about it. I almost find it like if you didn’t go to the dentist and then you started freaking out that you have cavities. Take care of it. Suck it up.”

Well, that was the conventional wisdom until recently. Ron Winchel, a Manhattan-based psychopharmacologist, says that the psychiatric community is only now coming to realize the potentially disastrous effect of treating bipolar people with SSRIs—and that bipolarity isn’t the easiest thing to recognize. “SSRIs are almost benign, except to the large number of people who at first look to doctors as if they have a unipolar depression, but who in reality have a variant form of one of the bipolar disorders,” he says. “For them, exposure to any antidepressant can actually make them worse, because if you give someone who is potentially bipolar an antidepressant, you can engender more of the ‘high’ side of their disorder. That leads to more depression, because you have accelerated the cycle.”

Winchel calls this “an enormous problem,” because bipolarity can masquerade as regular vanilla depression. “They may never even show mania till after they’ve been exposed to these medications. So what percentage of people who we are blithely handing out SSRIs to, thinking, Oh, there’s no side effect, are actually bipolar?”

But Winchel is also quick to point out another, less frightening, equally surprising medical possibility: “Everyone is always asking me, ‘Is this going to hurt my brain after I’m on it for a long time?’ But no one ever says to me, ‘Is it going to be good for my brain?’ There’s a couple examples—like lithium—where a drug has actually been shown to encourage the growth of healthy brain cells in regions of the brain where there is diminished activity in people with mood syndromes. And we do believe that it is bad for the brain to experience spurts of anxiety, because they are associated with secretions of chemicals that are actually toxic for the brain. So the possibility that some of these drugs that we’re using in psychiatry have neuroprotective effects is real.”

The creative usage and trading of psychopharmaceuticals—the cocktail party as pill bazaar—is what worries the doctors who prescribe the drugs. “There’s a tremendous amount wrong with it,” says Darwin Buschman, a clinical psychopharmacologist affiliated with Mount Sinai, Lenox Hill, Saint Luke’s, and Gracie Square. “Psychostimulants, which include Ritalin and Adderall, and benzodiazepines, which include Xanax and Ativan, are both highly addictive. When one is addicted to benzodiazepines, withdrawal can be life-threatening—particularly with Xanax. Heroin withdrawal is very uncomfortable but not life-threatening; same for coke. But with benzodiazepines, you can die. Period. So I am very careful as to how I prescribe those medications.”

Buschman says that “if you take a benzodiazepine every day for a month, you are addicted,” but he also says that he has patients who take these drugs several times a day and have been doing so for years: “They’re addicted, but it’s what they need. I make sure they don’t run out so they won’t have life-threatening seizures from withdrawal. See, it’s complicated, because while you can die from withdrawal, you cannot overdose on these medications. You can take 5,000 Valium, and you will sleep for a very long time, but you will not die.”

For many doctors, the frustration of working with psychopharmaceuticals is the somewhat arbitrary regulation of the different genres: Some of the least dangerous drugs are the most highly monitored, especially here. New York is the only state in which benzodiazepines are considered a controlled substance, which means they require a triplicate prescription. “Meanwhile, Vicodin isn’t a controlled substance, and it’s infinitely more dangerous than Ativan,” says Buschman.

“What drives me crazy is the people who say ‘Why don’t you try Saint-John’s-wort?’ ” says a high-profile 39-year-old who just started taking her SSRI again after an ill-fated psychopharmaceutical hiatus. “I’m like, what the f*ck
is that? Because it doesn’t have a stigma and it may not work? Because it’s not regulated? Because I can buy it at some disgusting health-food store? It just amazes me. I was telling this friend: For the past few weeks, I’ve had traditional, horrible depression. I’ve got to go back on meds. And she was like, ‘I don’t know, man.’ I said, ‘Well, I’ve been smoking a lot of pot.’ And she was like, ‘You’ve got a high-pressure job! That’s okay.’ So I said, ‘I smoked a cigarette the other night,’ which for me is a really big deal. ‘Don’t worry about it,’ she said. Then I said, ‘I think I should go back on meds.’ ‘Oh, man,’ she said. ‘You better watch that shit.’ Why?! It’s not like coke or alcohol or drugs, where you wake up the next morning and the problem is ten times worse.”

Ubiquitous lawyer (and Bonfire of the Vanities inspiration) Ed Hayes says, “I just wish the medication had been available to my father and his father. If they had this, they wouldn’t have been drunks. I have very primitive values as to what constitutes masculinity, and I used to think taking medication would mean I wasn’t man enough to handle my problems.” He got over it. “Now I take a simple medication, and the side effects are nothing.”

Before Viagra, the only options open to doctors trying to keep their patients both erect and depression-free were to minimize their dosage, prescribe intermittent “medication holidays,” or supplement an insufficient dose of a given SSRI with Wellbutrin. Even now, when you can buy Viagra over the Internet, some men still opt to work within the new sexual terrain they find their medication has redrawn for them. In certain cases, SSRIs can have the effect of delaying orgasm rather than causing impotence—not necessarily an unwelcome event for all men (or their partners).

“When you first notice the sexual side effects, you’re probably so depressed you just want to get better and you probably don’t feel much like having sex anyway,” says a filmmaker in his early thirties. “But then you start to feel better, and of course you notice. It’s a weird thing . . . I have friends who say they’re into it because it makes them last longer. For me, it’s not a great thing, but for some reason I was like, Yeah, I can live with the fact that my sex life is totally screwed up. But the second I noticed I was getting fat, I was like, Forget this.”

Like other prescription drugs circulating through the city, Viagra also has a second life. “Viagra has worked its way into the gays, at least, for recreation,” reports the designer who favors perky stacking boxes stuffed with Xanax for his party favors. “The idea is you’re doing a lot of crystal and a lot of gay party drugs, and it makes it hard to get it up. So the combo plate is you do that and Viagra and it keeps you hard and, um, ups the ante so you don’t have to worry about getting a softy from doing too much K.”

It reminds him, he says wistfully, of his very first prescription party drugs: “My first experience with pills was with downs, to come off disco drugs. It could have been a Valium, and sometimes you’d score with Rohypnol before it became the date-rape drug. That was the best. After you’re through partying, after however long you’ve been up, you want the thing that’ll bring you down the fastest and the hardest, and that’s how the hierarchy was set up.”

Using prescription drugs to work a little harder, sleep a little better, relax a little faster, has become a given in the city’s mainstream. “A friend of mine coined the term cosmetic psychopharmacology,” says Winchel.

“Is this good, or is this bad? is a quasi-philosophical question, an ethical question, more than a medical question. We do enter into this in psychiatry because of the emerging issue of whether or not there are some people we cannot diagnose with a symptom but who seem to benefit from an antidepressant nonetheless.”

A friend of mine who is currently taking Zoloft seems to be getting more agitation from this question than relief from her pills. “If you’re taking something to make your life suck less, then why don’t you just make your life suck less? This is 2003 in an advanced society of which you are one of the most fortunate members! Think if you were a little child in Cambodia who never got education, and compare that to your incredible f*ck
ing life! And you’re depressed? How can you be sure it’s not just that you’re a spoiled brat? They say chemicals are not something that you would respond to if you were not depressed, but part of me thinks that’s bullshit.”

It’s true that there are similarities between the way we test meds and the way we used to test witches. If a woman swims, she’s a witch, so you have to kill her; and if she drowns, she’s innocent. But either way, she’s dead. If a person is depressed and a medication affects her mood, then she needs it; if she’s depressed and it doesn’t, she needs a different one. Either way, she’s got to be medicated. “The way that people take it in New York,” says my friend, “I mean, everybody is on something, and that’s stupid! It’s impossible that all highly functioning people are depressed and that they all live in Manhattan.”

I ask what her psychiatrist says about all this.

“She says I’m probably on the wrong drug.”

Jasonik
July 22nd, 2003, 02:44 PM
What a great industry advertisement.

Edward
November 16th, 2005, 09:16 AM
http://www.nytimes.com/2005/11/16/health/16patient.html

November 16, 2005
Being a Patient

Young, Assured and Playing Pharmacist to Friends

By AMY HARMON
Nathan Tylutki arrived late in New York, tired but eager to go out dancing. When his friend Katherine K. offered him the Ritalin she had inherited from someone who had stopped taking his prescription, he popped two pills and stayed out all night.
For the two college friends, now 25 and out in the working world, there was nothing remarkable about the transaction. A few weeks later, Katherine gave the tranquilizer Ativan to another friend who complained of feeling short of breath and panicky.
"Clear-cut anxiety disorder (http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/anxiety/index.html?inline=nyt-classifier)," Katherine decreed.
The Ativan came from a former colleague who had traded it to her for the Vicodin that Katherine's boyfriend had been prescribed by a dentist. The boyfriend did not mind, but he preferred that she not give away the Ambien she got from a doctor by exaggerating her sleeping problems. It helps him relax after a stressful day.
"I acquire quite a few medications and then dispense them to my friends as needed. I usually know what I'm talking about," said Katherine, who lives in Manhattan and who, like many other people interviewed for this article, did not want her last name used because of concerns that her behavior could get her in trouble with her employer, law enforcement authorities or at least her parents.
For a sizable group of people in their 20's and 30's, deciding on their own what drugs to take - in particular, stimulants, antidepressants and other psychiatric medications - is becoming the norm. Confident of their abilities and often skeptical of psychiatrists' expertise, they choose to rely on their own research and each other's experience in treating problems like depression (http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/depression/index.html?inline=nyt-classifier), fatigue, anxiety or a lack of concentration. A medical degree, in their view, is useful, but not essential, and certainly not sufficient.
They trade unused prescription drugs, get medications without prescriptions from the Internet and, in some cases, lie to doctors to obtain medications that in their judgment they need.
A spokeswoman for the Drug Enforcement Administration says it is illegal to give prescription medication to another person, although it is questionable whether the offense would be prosecuted.
The behavior, drug abuse prevention experts say, is notably different from the use of drugs like marijuana or cocaine, or even the abuse of prescription painkillers (http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/pain/index.html?inline=nyt-classifier), which is also on the rise. The goal for many young adults is not to get high but to feel better - less depressed, less stressed out, more focused, better rested. It is just that the easiest route to that end often seems to be medication for which they do not have a prescription.
Some seek to regulate every minor mood fluctuation, some want to enhance their performance at school or work, some simply want to find the best drug to treat a genuine mental illness (http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/mentalhealthanddisorders/index.html?inline=nyt-classifier). And patients say that many general practitioners, pressed for time and unfamiliar with the ever-growing inventory of psychiatric drugs, are happy to take their suggestions, so it pays to be informed.
Health officials say they worry that as prescription pills get passed around in small batches, information about risks and dosage are not included. Even careful self-medicators, they say, may not realize the harmful interaction that drugs can have when used together or may react unpredictably to a drug; Mr. Tylutki and Katherine each had a bad experience with a medication taken without a prescription.
But doctors and experts in drug abuse also say they are flummoxed about how to address the increasing casual misuse of prescription medications by young people for purposes other than getting high.
Carol Boyd, the former head of the Addiction Research Center at the University of Michigan, said medical professionals needed to find ways to evaluate these risks.
"Kids get messages about street drugs," Ms. Boyd said. "They know smoking (http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/smoking/index.html?inline=nyt-classifier) crack is a bad deal. This country needs to have a serious conversation about both the marketing of prescription drugs and where we draw the boundaries between illegal use and misuse."
To some extent, the embrace by young adults of better living through chemistry is driven by familiarity. Unlike previous generations, they have for many years been taking drugs prescribed by doctors for depression, anxiety or attention deficit disorder.
Direct-to-consumer drug advertising, approved by the Food and Drug Administration in 1997, has for most of their adult lives sent the message that pills offer a cure for any ill. Which ones to take, many advertisements suggest, is largely a matter of personal choice.
"If a person is having a problem in life, someone who is 42 might not know where to go - 'Do I need acupuncture, do I need a new haircut, do I need to read Suze Orman?' " said Casey Greenfield, 32, a writer in Los Angeles, referring to the personal-finance guru. "Someone my age will be like, 'Do I need to switch from Paxil to Prozac?' "
For Ms. Greenfield, who could recite the pros and cons of every selective serotonin reuptake inhibitor on the market by the time she graduated from college, years of watching doctors try to find the right drug cocktails for her and for assorted friends has not bolstered faith in their expertise.
"I would never just do what the doctor told me because the person is a doctor," said Ms. Greenfield, who dictates to her doctors what to prescribe for her headaches and sleep problems, and sometimes gives her pills to friends. "I'm sure lots of patients don't know what they're talking about. But lots of doctors don't know what they're talking about either."
Prescriptions to treat attention deficit disorder in adults age 20 to 30 nearly tripled from 2000 to 2004, according to Medco, a prescription management company. Medications for sleeping disorders (http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/sleep/index.html?inline=nyt-classifier) in the same age group showed a similar increase.
Antidepressants are now prescribed to as many as half of the college students seen at student health centers, according to a recent report in The New England Journal of Medicine, and increasing numbers of students fake the symptoms of depression or attention disorder to get prescriptions that they believe will give them an edge. Another study, published recently in The Journal of American College Health, found that 14 percent of students at a Midwestern liberal arts college reported borrowing or buying prescription stimulants from each other, and that 44 percent knew of someone who had.
"There's this increasingly widespread attitude that 'we are our own best pharmacists,' " said Bessie Oster, the director of Facts on Tap, a drug abuse prevention program for college students that has begun to focus on prescription drugs. "You'll take something, and if it's not quite right, you'll take a little more or a little less, and there's no notion that you need a doctor to do that."
Now, Going Online for Pills
The new crop of amateur pharmacists varies from those who have gotten prescriptions - after doing their own research and finding a doctor who agreed with them - to those who obtain pills through friends or through some online pharmacies that illegally dispense drugs without prescriptions.
"The mother's little helpers of the 1960's and 1970's are all available now on the Internet," said Catherine Wood, a clinical social worker in Evanston, Ill., who treated one young client who became addicted to Xanax after buying it online. "You don't have to go and steal a prescription pad anymore."
In dozens of interviews, via e-mail and in person, young people spoke of a sense of empowerment that comes from knowing what to prescribe for themselves, or at least where to turn to figure it out. They are as careful with themselves, they say, as any doctor would be with a patient.
"It's not like we're passing out Oxycontin, crushing it up and snorting it," said Katherine, who showed a reporter a stockpile that included stimulants, tranquilizers and sleeping pills. "I don't think it's unethical when I have the medication that someone clearly needs to make them feel better to give them a pill or two."
Besides, they say, they have grown up watching their psychiatrists mix and match drugs in a manner that sometimes seems arbitrary, and they feel an obligation to supervise. "I tried Zoloft because my doctor said, 'I've had a lot of success with Zoloft,' no other reason," said Laurie, 26, who says researching medications to treat her depressive disorder has become something of a compulsion. "It's insane. I feel like you have to be informed because you're controlling your brain."
When a new psychiatrist suggested Seraquil, Laurie, who works in film production and who did not want her last name used, refused it because it can lead to weight gain. When the doctor suggested Wellbutrin XL, she replied with a line from the commercial she had seen dozens of times on television: "It has a low risk of sexual side effects. I like that."
But before agreeing to take the drug, Laurie consulted several Internet sites and the latest edition of the Physicians' Desk Reference guide to prescription drugs at the Barnes & Noble bookstore in Union Square.
On a page of her notebook, she copied down the generic and brand names of seven alternatives. Effexor, she noted, helps with anxiety - a plus. But Wellbutrin suppresses appetite - even better.
At the weekly meetings of an "under-30" mood-disorder support group in New York that Laurie attends, the discussion inevitably turns to medication. Group members trade notes on side effects that, they complain, doctors often fail to inform them about. Some say they are increasingly suspicious of how pharmaceutical companies influence the drugs they are prescribed.
"Lamictal is the new rage," said one man who attended the group, "but in part that's because there's a big money interest in it. You have to do research on your own because the research provided to you is not based on an objective source of what may be best."
Recent reports that widely prescribed antidepressants could be responsible for suicidal thoughts or behavior in some adolescents have underscored for Laurie and other young adults how little is known about the risks of some drugs, and why different people respond to them differently.
Moreover, drugs widely billed as nonaddictive, like Paxil or Effexor, can cause withdrawal symptoms, which some patients say they only learned of from their friends or fellow sufferers.
"This view of psychology as a series of problems that can be solved with pills is relatively brand new," said Andrea Tone, a professor of the social history of medicine at McGill University. "It's more elastic, and more subjective, so it lends itself more to taking matters into our own hands."
To that end, it helps to have come of age with the Internet, which offers new possibilities for communication and commerce to those who want to supplement their knowledge or circumvent doctors.
Fluent in Psychopharmacology
People of all ages gather on public Internet forums to trade notes on "head meds," but participants say the conversations are dominated by a younger crowd for whom anonymous exchanges of highly personal information are second nature.
On patient-generated sites like CrazyBoards, fluency in the language of psychopharmacology is taken for granted. Dozens of drugs are referred to in passing by both brand name and generic, and no one is reticent about suggesting medications and dosage levels.
"Do you guys think that bumping up the dosage was a good idea, or should I have asked for a different drug?" someone who called herself Maggie asked earlier this month, saying she had told her doctor she wanted to double her daily intake of the antidepressant fluoxetine to 40 milligrams.
In another recent posting, a participant wrote that his supply of the beta blocker Inderal, acquired in Costa Rica, was running out. He uses the drug for panic attacks, he said, but he has not told his doctor about it. "What do I do/say to get her to prescribe me some?" he asked.
"CraZgirl," who said she was not currently taking any medications, received a resounding "yes" to her posting that asked, "If you wouldn't go on meds for yourself, is it reasonable to do it to keep your marriage intact?"
Still, for some young adults, consulting their peers leads to taking less medicine, not more. When Eric Wisch, 20, reported to an anonymous online group that he was having problems remembering things, several members suggested that he stop taking Risperdal, one of four medications in a cocktail that had been mixed different ways by different doctors.
"I decided to cut back," said Mr. Wisch, a sophomore at the University of Rochester who runs www.thebipolarblog.com (http://www.thebipolarblog.com/), where he posts his thoughts on medications and other subjects. "And I'm doing better." Despite frequent admonitions on all the sites to "check with your Pdoc," an abbreviation for psychiatrist, there are also plenty of tips on how to get medications without a prescription.
"I know I shouldn't order drugs online," one participant wrote in a Sept. 26 posting on the Psycho-babble discussion group. "But I've been suffering with insomnia (http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/insomnia/index.html?inline=nyt-classifier) and my Pdoc isn't keen on sleep aids."
What should he do, the poster wanted to know, after an order he placed with an online pharmacy that promised to provide sleeping pills without a prescription failed to deliver?
Another regular participant, known as "med-empowered," replied that the poster was out of luck, and went on to suggest a private e-mail exchange: "I think I know some sites where you could post your experience and also get info about more reliable sites."
For a hefty markup, dozens of Web sites fill orders for drugs, no prescription required, though to do so is not legal. Instead, customers are asked to fill out a form describing themselves and their symptoms, often with all the right boxes helpfully pre-checked.
Erin, 26, a slender hair stylist, remembers laughing to herself as she listed her weight as 250 pounds to order Adipex, a diet (http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/diet/index.html?inline=nyt-classifier) pill, for $113. One recent night, she took an Adipex to stay up cleaning her house, followed by a Xanax when she needed to sleep.
Like many other self-medicators, Erin, who has been on and off antidepressants and sleeping pills since she was in high school, has considered weaning herself from the pills. She wishes she had opted for chamomile tea instead of the Xanax when she wanted to sleep.
"I feel like I have been so programmed to think, 'If I feel like this then I should take this pill,' " she said. "I hate that."
But the problem with the tea, she said, is the same one she faces when she is coloring hair: "It's not predictable. I know how these drugs are going to affect me. I don't know if the chamomile tea will work."
Online pharmacies are not the only way for determined self-prescribers to get their pills. Suffering from mood swings a decade after his illness was diagnosed as bipolar disorder (http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/bipolardisorder/index.html?inline=nyt-classifier), Rich R., 31, heard in an online discussion group about an antidepressant not available in the United States. A contractor in the Midwest, Rich scanned an old prescription into his computer, rearranged the information and faxed it to pharmacies in Canada to get the drug.
"My initial experience with physicians who are supposed to be experts in the field was disappointing," Rich said. "So I concluded I can do things better than they can."
Even for psychiatrists, patients say, the practice of prescribing psychotropic drugs is often hit and miss. New drugs for depression, anxiety and other problems proliferate. Stimulants like Adderall are frequently prescribed "as needed." Research has found that antidepressants affect different patients differently, so many try several drugs before finding one that helps. And in many cases, getting doctors to prescribe antidepressants, sleeping pills or other psychiatric medications is far from difficult, patients say.
The result is a surplus of half-empty pill bottles that provides a storehouse for those who wish to play pharmacist for their friends.
The rules of the CrazyBoards Web site prohibit participants from openly offering or soliciting pharmaceuticals (http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/drugspharmaceuticals/index.html?inline=nyt-classifier). But it is standard practice for people who visit the site to complain, tongue-in-cheek, that they simply "don't know what to do" with their leftovers.
The rest takes place by private e-mail. Sometimes, the person requesting the drugs already has a prescription, but because the medications are so expensive, receiving them free from other people has its merits.
A Post-Hurricane Care Package
Dan Todd, marooned in Covington, La., after Hurricane Katrina, said he would be forever grateful to a woman in New Hampshire who organized a donation drive for him among the site's regular participants.
Within two days of posting a message saying that he had run out of his medications, he received several care packages of assorted mood stabilizers and anti-anxiety drugs, including Wellbutrin, Klonopin, Trileptal, Cymbalta and Neurontin.
"I had to drive down to meet the FedEx driver because his truck couldn't get past the trees on part of the main highway," said Mr. Todd, 58. "I had tears in my eyes when I got those packages."
It doesn't always work out so well. When Katherine took a Xanax to ease her anxiety before a gynecologist appointment, she found that she could not keep her eyes open. She had traded a friend for the blue oval pill and she had no idea what the dosage was.
An Adderall given to her by another friend, she said, "did weird things to me." And Mr. Tylutki, who took the Ritalin she offered one weekend last fall, began a downward spiral soon after.
"I completely regretted and felt really guilty about it," Katherine said.
Taking Katherine's pills with him when he returned to Minneapolis, Mr. Tylutki took several a day while pursuing a nursing degree and working full time. Like many other students, he found Ritalin a useful study aid. One night, he read a book, lay down to sleep, wrote the paper in his head, got up, wrote it down, and received an A-minus.
But he also began using cocaine and drinking too much alcohol. A few months ago, Mr. Tylutki took a break from school. He flushed the Ritalin down the toilet and stopped taking all drugs, including the Prozac that he had asked a doctor for when he began feeling down.
"I kind of made it seem like I needed it," Mr. Tylutki said, referring to what he told the doctor. "Now I think I was just lacking sleep."

Ninjahedge
November 21st, 2005, 02:08 PM
Brave New World.