Mention the war on drugs, and most people think of Coast Guard cutters intercepting boats loaded with bails of marijuana or customs officials finding packets of cocaine hidden in luggage. But another battle is being waged - this one against the abuse of prescription drugs.
The fight gained visibility recently when Kitty Dukakis, wife of Massachusetts Gov. Michael Dukakis, disclosed that she had successfully overcome a 26-year addiction to amphetamines, once widely prescribed as diet aids. Mrs. Dukakis, whose husband is seeking the Democratic presidential nomination, told of trying to quit twice before her husband confronted her with a receipt from a doctor for more of the stimulants.
Mrs. Dukakis said she sought treatment for her addiction in 1982. Others are not as responsive to warning signs. In 1986, some 53 percent of all drug-related emergency-room visits reported to the United States Drug Enforcement Administration's warning network on abuse involved the use of legal drugs in some way.
Of the top 20 controlled substances being abused, 14 are legally manufactured drugs, says Ronald Buzzeo, deputy director of the DEA's office of diversion control. Of that 14, seven are from one family of drugs, known as benzodiazopines, used in prescription tranquilizers and sleeping pills. That's a high proportion from one family of drugs, he notes.
Abuse of pharmaceuticals has a long history.
Medical specialists point out that during and after the Civil War, opium-based pharmaceuticals were subject to abuse as soldiers who had been treated with opium became addicted. At the turn of the century, some people held ``laughing gas'' parties. Later, heroin was introduced as a supposedly nonaddictive substitute for morphine.
Today, the problem ``is a lot larger than anybody realizes,'' says Mark Hertzman of George Washington University.
The routes to abuse of prescription drugs vary. In some cases, people addicted to other drugs, such as cocaine, will use prescription drugs to offset unpleasant side effects or to counter harsh withdrawal symptoms. They buy illegally acquired prescription drugs off the street, or use a variety of ruses to get doctors to write them prescriptions.
In other cases, such as Mrs. Dukakis's, a patient becomes addicted through prescriptions for a condition.
``That's often how it gets started,'' Dr. Hertzman says. Usually the drugs are given with good intentions, but often the perceived need to prescribe a drug stems from an inadequate diagnosis of the patient's complaint, he adds. In short, it's often faster and less harrying to treat with a drug than by other means.
At its broadest, specialists say, the problem can be traced to the fact that the United States is a drug-oriented society.
``Take drug ads, for instance. Each one poses a problem that is solved by drugs. This reinforces the notion of quick solutions, that drugs are a vehicle for attaining things,'' says Lawrence Wallach, an associate professor at the School of Public Health at the University of California, Berkeley.
``Society uses far too many drugs,'' observes William Kinnard Jr., dean of the school of pharmacy at the University of Maryland. ``Patients expect the termination of a visit to a doctor to end with a prescription.''
But Hertzman points out that many doctors also share the notion that a prescription is the most tangible evidence that they've cared for their patient.
Although efforts to reduce the abuse of prescription drugs have met with some success in the past few years, some analysts are concerned that addicts may shift increasingly toward prescription drugs. The reasons vary from the purity of prescription drugs over street drugs, to the hunch that as employers increase the use of drug testing, one way for an addict to avoid the impact of a positive test result is to prove that he or she has a prescription.
Much of the effort to deal with the problem focuses on physicians, who are what Tony Tommasello, director of drug-abuse information at the University of Maryland's School of Pharmacy, calls ``the gatekeepers'' when it comes to prescription drugs.
One example is the five-year-old prescription abuse drugs synthesis program, known as PADS. The program, developed by the American Medical Association, traces prescription patterns among physicians in a given state, as well as other information, to pin down physicians and other health-care practitioners who appear to be dispensing unusually high amounts of drugs.
Such physicians usually fall into four categories, says an AMA spokesman: those who are dishonest, diverting drugs to make a profit; those who are themselves addicted and may be selling drugs on the side to help finance their habit; doctors who have been duped into prescribing drugs for addicts; and those who may be misprescribing drugs because they haven't kept up with current practices.
The outcomes of the investigations range from prosecution and revocation of licenses to efforts at educating doctors and others about the most common ruses used to obtain drugs and about the latest prescription practices.
According to the AMA, 27 states and the District of Columbia are taking part in the program. In states where data are available, the program has reduced the consumption of prescription drugs most widely abused between 30 and 70 percent. The results have also shown up in fewer emergency-room cases involving those drugs and savings in state medicaid payments that went to reimburse fraudulent drug claims.
In addition, several states have recently tightened up on reporting requirements for prescription drugs to make it easier to track down health practitioners who appear to be overprescribing drugs. One such measure is now under debate in the Massachusetts legislature.