Chapter 62. Prescription, over-the-counter, and black-market drugs

Americans tend to distinguish drugs by the channels through which they are distributed as well as by their chemistry and their pharmacological effects. Three major channels are recognized:

(1) The legal over-the-counter market. This is by far the biggest channel of drug distribution, delivering caffeine, nicotine, and alcohol plus vast quantities of psychoactive drugs sold over the counter in drugstores, supermarkets, and service stations.

(2) The prescription market. This market delivers barbiturates and other sedatives and hypnotics, minor tranquilizers (antianxiety drugs), amphetamines and other stimulants, and antidepression drugs–– plus some narcotics. In 1964, 149 million prescriptions (including refills) for psychotherapeutic drugs were filled in American drugstores. During the next six years, such prescriptions increased by about 7 percent a year, to a total of 214 million in 1970. The great bulk of the increase, however, was accounted for by antianxiety drugs, as shown in Figure 13 below. In 1970, minor tranquilizers accounted for 38.8 percent of all psychotherapeutic drug prescriptions and refills, hypnotics ("sleeping pills") 17.5 percent, stimulants 13.2 percent, sedatives 11.1 percent, and antidepressants 9.2 percent. The remaining 10.2 percent were for antipsychotic drugs (major tranquilizers), not covered in this Report.

(3) The black market. This route of distribution handles marijuana chiefly, plus relatively small amounts of LSD and LSD-like drugs, amphetamines and other stimulants, barbiturates and other depressants, heroin and other opiates, and bootleg alcohol.

How many people secure their stimulants, depressants, and tranquilizers by prescription? Over the counter? From the black market? Fresh light is thrown on these questions by the data assembled in another portion of the NIMH "Psychotropic Drug Study"–– that under the direction of Drs. Manheimer, Mellinger, and Balter.

"In 1967-68 several polling studies of the Gallup type–– including two that we were involved in–– indicated that during the previous year 25 percent of adult Americans had used some psychotropic drug, either a prescription or over-the-counter preparation," Dr. Balter of the NIMH reports. "We now have good reason to believe that this figure of 25 percent is low. Through fortunate circumstances we have been able to do some validity studies on the polling type of approach and find it to be quite a bit in error in the direction of underreporting. If one adjusts for probable error of underreporting, the figures for 1967 would range between 33 and,35 percent, which translates into 35-40 million people." The most popular psychoactive drugs, the same surveys show, are the antianxiety drugs (minor tranquilizers). Next came the sedatives and hypnotics, and then the stimulants and antidepression drugs. (Some people of course, take drugs of more than one type.)

FIGURE 13. Psychotherapeutic Drugs: Prescriptions Filled in U.S. Drug Stores (1964-1970)

Some 75 to 80 percent of the psychoactive drugs prescribed by physicians in private practice, Dr. Balter notes, "were prescribed for the purposes of sedation, tranquility and sleep. Americans, in the main, at least those [who] visit physicians, come with problems that require calming down; it's peace that is desired, it's tranquility or sleep that is being sought. Only 20 to 25 percent of the prescriptions involved called for drugs that produce an increase in energy or elevation of mood. From these data it appears that the major American malady is tension or agitation rather than depression." As will be shown below, however, stimulants from nonprescription sources substantially alter these proportions.

Thus the excess of sedatives and tranquilizers over stimulants tells more about the complaints people bring to physicians and the prescription policies of physicians than about the use of drugs.

The above figures refer only to people who took drugs during the year 1967. When respondents were asked if they had ever used such drugs, "the obtained figure was close to 50 percent; assuming a similar error of underreporting the true figure is probably more like 60 to 70 percent, which implies that some 80 to 90 million people out of an estimated adult population of 122 million had used psychoactive drugs at some point in their lives. These figures indicate that the use of some psychoactive drug is the rule rather than the exception."

During the nineteenth century, it will be recalled, two-thirds or more of all opiate users were women. In 1967, more than two-thirds of all users of psychoactive prescription drugs were women. Indeed, women in that year accounted for:

53 percent of the adult population
59 percent of all visits to doctors
60 percent of all drugs prescribed
63 percent of all barbiturates prescribed
66 percent of all nonbarbiturate sedatives and hypnotics prescribed
68 percent of all antianxiety drugs (minor tranquilizers) prescribed
68 percent of all psychoactive drugs prescribed
71 percent of all antidepressants prescribed
80 percent of all amphetamines prescribed

"As you move toward drugs used to treat the more frankly psychological or functional disorders," Dr. Balter notes, "you get an increasingly higher proportion of the drug prescriptions going to females." If  nonprescription stimulants, depressants, and tranquilizers are added in, however, the male-female ratios change, as we shall show below.

There are also clear-cut differences in psychoactive drug prescriptions between the young and the middle-aged. "Amphetamines are typically used by the younger age groups," Dr. Balter points out, "with the peak between 20 and 49.

Some 65% of all the amphetamine prescriptions go to people in this age range. However, there are marked male and female differences. Interestingly enough, prescribing of amphetamines for females reaches a relatively high level at age 20, stays relatively constant until age 49, and then drops off rather sharply. Prescribing of amphetamines for males shows a progressive increase until about age 40, stays constant between 40 and 49, and then drops off rapidly. With respect to male-female age differences on the amphetamines there's a real question whether we're dealing with esthetics, obesity, incidence of other medical problems, or a differential disposition to come to the physician with certain problems at various ages. The tranquilizers are mid-life drugs, that are frequently prescribed for ages 30 to 59. They have a relatively flat distribution, with a major peak in use between 40 and 60. Sedatives are popular in late middle age and show a steady increase into the 60's. Sleeping pills, which have a similar pattern, are infrequently prescribed to people under 30. At age 40, we begin to see a sharp increase in their use.

In a [1967] polling study in California, which covered the entire state, we found that men had a particularly clear-cut pattern of drug use: stimulants in the 30's; tranquilizers in the 40's and 50's; sedatives and hypnotics in the 60's. If these data reflect stresses in life and the distribution of problems and needs in the population at large, ours is a highly patterned, if not morbidly predictable existence.

For the use of psychoactive prescription drugs among men and women aged sixty-five or older, we must turn to a study made by the United States Department of Health, Education, and Welfare's Task Force on Prescription Drugs. That study indicates that during the year 1966, the average American aged sixty-five or older secured 3.6 prescriptions for psychoactive drugs during the year–– a higher rate than the rate for adults under sixty-five. And a substantial proportion of the psychoactive drugs they use are the very same drugs that young people purchase on the black market–– narcotics, barbiturates, and amphetamines. The study makes it clear that Americans aged sixty-five and older rarely have to patronize the black market for drugs; they can and do secure substantial supplies of psychoactive drugs on prescription at pharmacies.

Much more detailed information concerning the people who use various types of psychoactive drugs, and where they get them, was obtained as part of the NIMH project by interviewing 1,026 Californians aged twenty one and over–– a carefully selected cross-section of the state's noninstitutionalized residents. This survey was concerned with stimulants, sedatives, and tranquilizers taken on prescription, purchased over the counter, or secured from friends or in other ways–– for example, on the black market.

A respondent will answer in one way if asked to name the stimulants, sedatives, or tranquilizers he has ever used. He may answer quite differently if asked to name the drugs be has used  within the past twelve months–– and give yet another answer if asked which drugs he uses frequently. Californians were asked all three questions. The percentages are given below.

As in the national studies, women mentioned almost twice as many drugs as men in the California study. "The greater use of drugs by women contrasts sharply with the available evidence regarding drinking," the survey group noted. just as in the nineteenth century, when women took opiates at home while their husbands drank liquor in saloons, so in California in 1967, women took prescribed stimulants, sedatives, and especially tranquilizers at home.

Marital status, it turned out, had a marked effect on drug use: "Eighteen percent of those who are divorced or separated say they have used tranquilizers frequently, as compared with 10 percent of married persons and only 3 percent of those who are single. These findings are consistent with studies showing that divorced members of our society have a disproportionate share of physical and mental health problems. Although they seldom use tranquilizers, single persons are close to the overall average in their use of stimulants and sedatives. Persons who are widowed tend to use sedatives somewhat more often than others–– a reflection, perhaps, of their older age."

Yet another feature of the NIMH-funded "Psychotropic Drug Study" was a survey conducted late in 1967 and early in 1968 of a cross-section of San Francisco residents aged eighteen or over–– 1,104 of them. One finding concerned the very widespread use of over-the-counter psychoactive drugs. About 12 percent of all drugs mentioned by respondents, for example, were over-the-counter stimulants such as  NoDoz (caffeine), 11 percent were over-the-counter sleeping pills such as  Sominex or  SleepEze, and 5 percent were over-the-counter tranquilizers such as  Compoz. Of all the mentions of psychoactive drugs by respondents in the sample, 28 percent were over-the-counter proprietary remedies.

A substantial proportion of respondents used  both prescription and over-the-counter drugs. The preponderance of women using psychoactive drugs was more evident for prescription drugs than for over-the-counter drugs.

By far the most remarkable finding of the San Francisco study, however, concerned the existence of a substantial "gray market" as well as a black market in psychoactive drugs.

Most people think of a prescription drug as one that is prescribed for an individual patient by a physician and is taken solely by that patient. But in the San Francisco study 27 per cent of the prescription psychoactive drugs most recently used were obtained through informal ("gray-market") channels. In 17 percent of the cases the informal channel was a friend. The user's spouse was mentioned much less frequently (3 percent), and in most of these cases it was the wife, not the husband, who was the informal supplier. The remaining informal sources were divided about equally between relatives and other miscellaneous persons.

The non-medical source mentioned most often [Dr. Mellinger reports] is someone described by the respondent as "a friend." In most cases, this designation can probably be taken at face value. Respondents often described the friend as a roommate, a boy friend or girl friend, and so on. In other cases, the relationship of the friend to the respondent was not quite so clear. We were curious, naturally, about the possibility that the friend might be "the friendly neighborhood pusher." However, other parts of the interview were really more important for our purposes, so we resisted the temptation to ask respondents to be more explicit. In short, I cannot tell you how many of these drugs were obtained through truly legal channels. Suffice it to say that a good many of the prescription drugs are being obtained through channels that we can at least describe as "informal."

Who are the people who secure their psychoactive drugs through these "informal" or "gray-market" channels? Though women use more psychoactive drugs than men do, men are much more inclined to rely on informal channels for obtaining their prescription drugs. Thus 41 percent of the prescription psychoactive ' drugs used by men were obtained through such channels, as compared with 20 percent of the prescription psychoactive drugs used by women.

Young people, the San Francisco survey also indicates, are much more likely to secure their psychoactive prescription drugs through "informal" channels, without a prescription. Here are the figures: under thirty, 51 percent; thirty to forty-four years old, 24 percent; forty-five and older, 10 percent.

If both age and sex are considered together, the figures are even more startling. For example, 69 percent of all psychoactive prescription drugs secured by males under thirty were secured without a prescription!

These figures clearly suggest the progressive breakdown of the distinction society has tried to draw between psychoactive drugs secured on prescription (good) and psychoactive drugs secured in other ways (had). The generation under thirty (at least those polled in San Francisco) simply refuses to abide by this distinction; a majority of them secure their psychoactive prescription drugs without bothering about a prescription.

The Parry-Cisin studies indicate a much lower use of prescription drugs without a prescription in their  national sample. In many respects, however, San Francisco drug use in one year tends to foreshadow patterns that become visible elsewhere a few years later.

What will the picture be a decade or two hence? Will the generation now under thirty, as it matures, change its ways? Or is the securing of psychoactive drugs on prescription a fading custom, likely to decline further as prescription-users die off and nonprescription cohorts take their place? Indeed, are we only one generation away from defining the amphetamines, the barbiturates, the tranquilizers (and perhaps also marijuana) as nondrugs, like caffeine, nicotine, and alcohol?

A closely related question also arises: Will the present generation of young people, who use most of the stimulants, continue to use stimulants as they age–– or will they shift first to tranquilizers and then to sedatives like their elders today? Only time will tell–– and only time will tell whether a new generation of physicians, who have themselves been using stimulant drugs, will be more willing to prescribe these drugs to their patients than today's physicians are. (No study has been found of the relative proportion of sedatives, tranquilizers, and stimulants prescribed by young, middle-aged, and elderly physicians.) In any event, the relative unwillingness of today's physicians to prescribe stimulants may be one of the reasons why young people, especially young males, are securing these drugs primarily over the counter, or from the "gray market," or from the black market.

Another reason why so high a proportion of prescription drugs are secured without a prescription may be simple consumer economics. Many prescription drugs–– especially the barbiturates and the amphetaminesare quite inexpensive at wholesale. Here are some typical 1970 wholesale prices, as presented by Dr. Richard Burack in his  New Handbook of Prescription Drugs:

Those wholesale prices, it should be noted, already include a considerable markup above the manufacturers' prices. When a patient secures such drugs on prescription, however, several factors combine to increase the cost.

In the first place, many physicians prescribe a heavily promoted drug by brand name rather than by generic name. The price ranges above are for generic-name drugs. If a physician specifies the Dexedrine brand of dextroamphetamine sulfate in a prescription, its cost reflects a wholesale price of $22.60 per thousand tablets. Sodium pentobarbital under the brand name Nembutal carries a wholesale price of $16.20 per thousand capsules; the Pulvule brand of the same drug commands a wholesale price of $22.50 per thousand capsules. The wholesale price for a thousand capsules of the Seconal brand of sodium secobarbital is $18.30.

Next, most pharmacies have a minimum charge for a prescription often two or three dollars, sometimes more. On drugs such as the U.S.P. amphetamines and barbiturates, this minimum may multiply the wholesale cost per thousand many times over. A $3.00 charge for 50 dextroamphetamine tablets on prescription is not unusual; the wholesale price of those 50 tablets, in lots of 1,000, is somewhere between 31/2 and 17 cents.

Also, the purchaser who buys on prescription must often pay the physician a fee. Sometimes the prescription is refillable; sometimes it is not. Even if it is refillable, the total cost of the prescription plus the physician's fee is likely to be as high as, or higher than, the price of the same drug on the black market. And there is no long wait in the physician's reception room followed by a trip to the drugstore when you buy on the black market.

Another reason why some young people secure psychoactive prescription drugs without first securing a prescription is that they just don't like doctors. They may either know from experience or suspect on general principles that if  they were to ask for the psychoactive drugs their parents are taking, they would be turned down–– perhaps gently, perhaps brusquely, perhaps angrily.

These lines of thought suggest that American medicine may be facing a crisis, or rather, failing to face it. Many members of the generation now entering maturity in San Francisco have formed the habit of securing their psychoactive drugs–– a substantial proportion of all drugs–– without bothering to obtain a prescription. If the habit continues as these young people mature, and if it spreads across the country, the psychoactive prescription drugs will inevitably become "nondrugs," rather than continuing to be considered medicines for which one turns to a physician.

The fact that American physicians are currently writing some 260,000,000 psychoactive-drug prescriptions a year raises the question: are they overprescribing these drugs? Perhaps they are. But the figures cited above, and the existence of booming black and gray markets in psychoactive prescription drugs, suggests that they may simultaneously be  underprescribing certain drugs to certain patients–– particularly the stimulants, and particularly for the needs of the young. The result is not to curtail the use of psychoactive drugs by young people. Rather, the clear effect is to increase the use of such drugs by young people  without medical supervision.

It is possible to argue that the use of prescription drugs, even under medical supervision, constitutes a national peril and should be discouraged. * It is equally possible to argue that tens of millions of patients would not continue to take these drugs, and pay vast sums for them, if they did not serve a useful purpose; and that physicians would not continue to prescribe them, despite the many hazards, if they did not perceive substantial benefits to their patients. The issue need not here be decided. The important point from the perspective of this Report is that the use of "good drugs"–– prescribed sedatives, hypnotics, and antianxiety drugs (minor tranquilizers), and prescribed stimulants and antidepression drugs–– constitutes an essential feature of the American drug scene, along with the "nondrugs" (caffeine, nicotine, alcohol) and the "bad drugs" (marijuana, LSD, the black-market barbiturates, the black-market amphetamines, and the black-market narcotics). The goal of a sound national policy must be to maximize the benefits and minimize the hazards of all psychoactive drugs rather than to single out for condemnation a handful of drugs that happen at the moment to be illicit and to be attracting the wavering spotlight of public hostility.

* Even where the prescribed drugs are clearly doing harm, however, the question must be asked whether, without the drugs, even more devastating consequences might not follow–– alcoholism, disruption of family relationships, child abuse, loss of job, mental hospitalization, suicide, etc.

This, in brief, is how the drug scene of the 1970s looks through a panoramic lens. In the chapters that follow, we shall focus more closely on a small segment of the panorama–– the  youth drug scene.

Footnotes
Chapter 62