LEGAL DRUG CRAZE IS NEW KILLER

Once it was cocaine, speed or heroin, but now the fashion is for
legal pills, washed down by spirits. Last week's news that actor
Heath Ledger, right, died from an overdose of prescription tablets
shed light on a startling new trend - misuse of over-the-counter
pills now kills more Americans than illegal drugs. Elizabeth Day in New York

Alex is a man who prides himself on sticking to routine. He likes to
start the day with a large cappuccino from Starbucks and to end it
with a handful of anti-depressants washed down with vodka. 'It's my
treat after coming home from work,' he says. 'I guess it just chills
me out a little.' In many ways Alex, 31, is a typical well-heeled
young New Yorker. He works in finance, holidays in the Hamptons and
enjoys partying at the sort of exclusive nightclubs where having your
name on the guest list is a prerequisite to entry. He also likes to
get high on prescription drugs.

Tonight he is celebrating a friend's birthday at Marquee, one of the
city's hippest nightspots. The main bar, lined with leather
banquettes, is cast in a shadowy half-light. In the upstairs lavatory
there is a small framed sign on the back of the door reminding guests
the use of illegal drugs will not be permitted.

But Alex would not consider himself a drug abuser. For him, those
small white Xanax tablets on his bathroom shelves are simply a
recreational accompaniment to the $15 Grey Goose vodka martini he has
just been served. And, what's more, they're entirely legal.

Over the past five years the United States has seen a ferocious
increase in prescription drug abuse. According to the 2006 National
Survey on Drug Use and Health, 49.8 million Americans over the age of
12 have reported non-medical use of illicit drugs in their lifetime,
20.3 per cent of the population. Among teenagers aged 12-17,
prescription drugs are second only to marijuana in popularity, and in
the past 15 years there has been a 140 per cent increase in
painkiller abuse. It is the fastest-growing type of drug abuse in the
US. Even more worryingly, prescription drugs have made it on to the
party scene as a legal, seemingly safe, way to recreate an illicit high.

Until last month this was a largely silent epidemic. But the death of
Heath Ledger, a regular at Marquee and other nightclubs, thrust it
into the spotlight. The 28-year-old actor died from 'acute
intoxication' caused by an accidental overdose of anti-anxiety
medication and prescription painkillers.

'Americans love to get pills for everything that ails them,' says Dr
Howard Markel, a professor of paediatrics and psychiatry at the
University of Michigan. 'The misuse of those drugs has become one of
the major health problems of our time.' The UK has less of a
prescription culture than the US, although many experts believe the
advent of internet pharmacies means it is only a matter of time. In
the US, where pharmaceuticals are advertised on prime-time
television, pill-popping has become normalised, a socially acceptable
means of alleviating stress, sleeplessness or anxiety.

The most commonly abused prescription medications fall into three
categories: opiate-based painkillers (OxyContin and Percocet);
central nervous system depressants prescribed for anxiety and sleep
disorders (Valium and Xanax); and stimulants, used to treat attention
deficit disorders (Ritalin and Adderall).

Within these categories, the pharmaceutical industry has provided a
full set of substitutes for just about every illegal narcotic
available. Methylphenidate, the active chemical in Ritalin, targets
the brain's pleasure-producing centres in the same way as cocaine.
Antidepressants can act as serotonin-boosting 'uppers'. A few years
ago OxyContin, an extremely powerful painkiller developed for cancer
patients, became known as 'hillbilly heroin' after an epidemic of
abuse took root in poor rural communities.

Such mishandled drugs now kill 20,000 a year, nearly twice as many as
10 years ago.

Dependence on legal drugs is not a new problem - during the American
Civil War morphine abuse was labelled 'the soldiers' disease' - but
the practice of prescribing drugs has metamorphosed from a medical
treatment of last resort to a way of life. 'The problem has been
greatly worsened by the internet, and that affects all countries -
including Britain,' says Susan Foster, of the National Centre on
Addiction and Substance Abuse at Columbia University, New York. 'As
long as you have a credit card, anyone can log on and have
potentially lethal drugs delivered to their door. You don't even need
a prescription. You have what's called an "online consultation" where
you are asked how old you are, how bad your pain is.'

The substances most commonly traded over the internet are
tranquilisers such as diazepam and stimulants like Ritalin. However,
the most dangerous are the opiates, which include codeine and morphine.

The painkiller fentanyl can act like heroin and traffickers get hold
of supplies by forging stolen prescriptions, breaking into pharmacies
and stealing stocks or buying the drugs from patients who have been
prescribed it. Another opiate painkiller, buprenorphine - prescribed
for heroin addicts trying to kick their habit - is peddled in
countries as diverse as India, Iran, Finland and France. From
2001-05, the global consumption of buprenorphine more than tripled to
1.5 billion daily doses.

Doctors are woefully ignorant of the dangers; a 2005 study by Casa
found that 43.3 per cent of them did not ask about drug abuse when
taking histories. Even if they do, the seasoned drug abuser will go
from one doctor to the next until they get the quantities they want -
a practice known as 'doctor-shopping'.

This was Jeana Hutsell's experience. A petite 35-year-old from
Canton, Ohio, with cropped peroxide blonde hair and square-framed
glasses, Hutsell became hooked on Percocet, an opiate-based
painkiller, when she was prescribed it 12 years ago after an
operation for Crohn's disease. 'I went to the doctor with abdominal
cramps and he began writing me copious prescriptions,' she says.
Within a year, her habit had escalated to 60 pills a day and she was
sewing emergency stashes into the lining of her handbag. 'I felt they
gave me personality. They made me chattier, friendlier.'

Hutsell began forging prescriptions, sometimes walking into hospital
casualty departments over the weekend and saying she had run out. 'I
felt justified and safe because my doctor was giving them to me. I
wasn't getting them on the streets - I was going to a pharmacy.'

Whereas illegal street narcotics - heroin or crack cocaine - are more
likely to be used by the poorer socio-economic classes, prescription
drugs have become the preserve of the rich. In the privatised
American healthcare industry, these pills do not come cheaply: an
antidepressant like Wellbutrin can cost from $1,000 to $2,400 a year.

Wealthy individuals also enjoy the luxury of paying private
physicians - known as 'script doctors' - to provide them with
prescriptions. And often, because the drugs are viewed as
performance-enhancers, they will be taken by those at the higher end
of the social strata: by the college students and Wall Street
traders. In the 1980s cocaine was the glamour yuppie drug. Now, the
line of white powder is being overtaken by the little white capsule.

Phoenix House is a tall, grey stone building on the Upper West Side,
a former 19th-century hotel with mosaic-tiled floors in the hall. The
genteel appearance belies its gritty purpose: Phoenix House is a
rehabilitation centre for drug and alcohol abusers, treating 6,000
people a day. In recent years, such centres have seen a substantial
increase in prescription drug admissions - some counsellors say that
they account for 90 per cent of new patients.

Professor David Deitch, the chief clinical officer, does not want to
use the word 'epidemic', but he concedes that 'the genie is out of
the bottle'. 'You see prescription drug abuse in the same circles
that you saw cocaine abuse - the high-performing executive class.
They might have a big day, so they take some something to get to
sleep. Then they'll take another pill the next morning to enhance
their performance. Then they'll go out and use all kinds of drugs at
a party, and then to recover from the party the next morning they'll
take a different pill. It's pervasive.'

Celebrities who have admitted their own struggles with prescription
medication include Elizabeth Taylor, the talkshow host Rush Limbaugh,
and Cindy McCain, the wife of the Republican presidential candidate
John McCain. More recently, there have been rumours that Britney
Spears has been self-medicating. The impact has percolated down to
impressionable adolescents. One of the most popular forms of
recreation among high-school students is the 'pharm party'. Teenagers
raid their parents' medicine cabinets, then pool their resources.
'You throw your drugs into a bowl in the middle of the room, then
people pick pills out and chase them with alcohol,' says Susan
Foster. 'We've seen these internet recipe sites where you go online
to find out how to mix drugs for a certain effect. You can trade
drugs online - in fact, at one college the students reported that
they had a prescription drug trade forum on the university website.'

Markel tells the story of one of his patients, a 16-year-old student
called Mary, who liked to down a few tablets of OxyContin with a
single shot of vodka. She called the combination 'the sorority girl's
diet cocktail' because it gave a stronger kick of inebriation with
fewer calories than alcohol alone.

'There's a cachet to this sort of drug abuse, encouraged by the Paris
Hiltons and the Lindsay Lohans going into rehab, so it becomes a
really cool druggy, party culture,' Markel says. 'Now teenagers don't
want to smoke and drink, they want to take a pill because it's so
easy to get and some of them can really make you feel good.'

But it is easy to overdose on prescription drugs, partly because your
consciousness is impaired and it can be difficult to remember how
many you've taken, and partly because mixing medication without
specialised knowledge can produce fatally toxic results. And however
legal these drugs might be, their misuse carries the same
consequences as illegal narcotics: the familiar, dispiriting tale of
the addict losing their family, friends, job, home and, sometimes,
their life. After two years of Percocet addiction, Jeana Hutsell took
stock of the wreckage her life had become: 'I was homeless, I didn't
have a car, my family didn't like me. I realised that I was the cause
of all my problems. That was the turning point.'

Others are not so lucky. Randy Colvin, an abuser of Valium, Xanax and
Percocet, died of a drug overdose on his 35th birthday. 'We tried to
save him and we lost,' says his older brother Rod. 'For 15 years we
tried to get him into treatment and each time he would be in denial,
he would be furious with us. My mother and I even tried to get a
court order so that he could be sectioned. We did everything we
possibly could. Addiction is a family disease. His death was very painful. '

For Heath Ledger's parents, the grieving process is still in the
rawest stages. Their son cemented his fame for reasons that were
nothing to do with his talent. Instead he is for ever associated with
a seedy death on the floor of a Manhattan apartment, just one more
victim of the pill-popping epidemic that has become America's secret illness.

Danger Zone Painkillers

Popular brands include Nurofen and Solpadeine, which can prove addictive.

Anti-anxiety drugs

Tranquillisers have been involved in numerous recent fatal overdoses.

Sleeping tablets

Users can become dependent in just two weeks. Ledger was taking Restoril.

Anti-depressants

Prozac withdrawal symptoms are common and can be physically painful