Editorial

Citation

Sultan, A. and Hupli, A. (2020), "Editorial", Drugs and Alcohol Today, Vol. 20 No. 1, pp. 1-5. https://doi.org/10.1108/DAT-03-2020-075

Beyond prescription drugs: international perspectives on extra-medical use

Introduction: going beyond the concept of “prescription drugs”

Drug use reports are increasingly drawing attention to the risks attendant to the extra-medical use of prescription drugs among a variety of subpopulations. The field, which for years has been focussed on illicit drugs, has been taken unawares by the sudden rise in overdose mortality and blood-borne virus incidents associated with prescription drug use (Degenhardt et al., 2019; Farrell et al., 2019). Political agencies raising attention to aspects of this phenomenon have tried to tailor the problem to their mandate. The ministerial segment from the 62nd session of the Commission on Narcotic Drugs has therefore focussed on opioid prescription drugs such as fentanyl and tramadol with extensive discussions over the need for concerted international action (UNODC, 2019a).

A big impulse for these debates comes from the North American experience, where multiple, overlapping waves of licit prescription (oxycodone, fentanyl) and illicit (heroin) opioids have converged into a public health concern (Ciccarone, 2017; Pardo et al., 2019), resulting in tens of thousands of deaths annually. Yet, in spite of warnings that such patterns may also unfold in Europe (Humphreys et al., 2018), where analogous demographic drivers have pushed up medical opioid use, the spill over into large-scale problematic use has not yet occurred. According to the most recent European drug market analysis (EMCDDA and Europol, 2019), cannabis (€11.6 bn) and cocaine (€9.1bn) are still more significant in commercial terms than the opioid market (€7.4bn) in spite of the supply push from diversion and illicit production of methadone, fentanyl-derivatives, buprenorphine and tramadol. Moreover, even though countries such the UK have witnessed steady rises in overdose deaths, this is attributable to the decline in drug service provision rather than a new “opioid crisis” driven by prescription diversion. This demonstrates that supply-driven availability of illicit opioids is not a sufficient condition for the unfolding of public health crises. The social and cultural dynamics that drive the demand side vary across and within countries and regions and obviate the use of potentially misleading labels such as “global opioid crisis”. In this respect, UNODC recognises the underlying knowledge gap by calling for:

[…] more research […] to improve understanding of the dynamics of non-medical use of prescription drugs [and] to address their misuse effectively while guaranteeing the availability and accessibility of essential medicines in its World Drug Report (UNODC, 2019b, p. 25).

The fresh interest in academic and policy discourses point to the increased use of pharmaceutical drugs for recreational purposes, often in combination with illicit drugs, and thereby re-opens old questions and raises new ones. Suddenly the question of what constitutes a drug and how it is differentiated from a medicine is no longer a matter of semantics but an existential question for the control apparatus build on combating the “world drug problem” (UNGASS, 2016). In times of transition, it is useful to recall that drugs “can […] be considered not so much a category in themselves but as one aspect of a potentially wide range of social activities” (Sherrat, 2007, p. 7). It is human behaviour that falls within these actionable categories of licit and illicit, with serious consequences for individuals concerned. Contrary to Sherrat, the control system with its basis in internationally binding legislation is an attempt to harden the notion of “drugs” into binary set of opposing categories. These need to be filled with reference drugs, but they have no essential value themselves and are therefore interchangeable. What lends particular verve to both the discussions at the CND and the wider search of purpose for the international drug control bureaucracies is the transformation of cannabis from a Schedule 1 drug with no therapeutic value to a widely prescribed medicine. Therefore, while medicines with allegedly low addiction potential such as oxycontin are becoming a public menace, cannabis, for decades the mainstay of drug control and the most widely “abused” illicit drug is increasingly metamorphosed into a medical drug. This has become even more evident with the recent critical review of cannabis by the WHO (2018) and a resolution by the European Parliament (2018) calling for increased research and improving equal access to cannabis-based medicines in the EU.

Hypothetically, it is possible for the drug control system to switch the focus from its totemic and foundational drugs – opium, coca leaf and cannabis – and replace these with a range of pharmaceutical substitutes. Treaties may need amending, but at operational level, in terms of reporting, intercepting, preventing and “treating”, little will change. Unlikely to occur in the near future, given the deep reach of the pharmaceutical industry, we are left with the growing “problematisation” of prescription drug use in addiction research (Dertadian, 2018). At this point, these discussions are more nuanced precisely because prescription drug use is not yet under the patronage of law enforcement and criminalisation discourse. This allows for more exploration of why and how “aspects of human experience [become] targets for pharmaceutical intervention” (Coveney et al., 2011, p. 387). Scholarly interest can look at wider social processes, tracking the “transformation of human conditions, capabilities and capacities into opportunities for pharmaceutical intervention” (Williams et al., 2011, p. 711) by using the analytical framework of “pharmaceuticalisation”. The concept is closely linked to medicalisation (Conrad, 2007), with the latter denominating a medical paradigm in approaching “social” issues. However, pharmaceuticalisation does not necessarily mean medicalisation (Williams et al., 2011), rather it “is more specific in its remit, denoting as it does the transformation of aspects of human experience into targets for pharmaceutical intervention” (Coveney et al., 2011: 387). It is particularly pertinent when reconfiguring physical and mental “conditions” as amenable to pharmaceutical solutions for, i.e. anxiety, cognitive functioning or sexual performance.

As prescription drugs come into the purview of the drug control apparatus, new factors come into play that impact directly on consumers. Supply of prescription drugs through permissive doctors and pharmacies into illegal drug markets (Hulme et al., 2019), will be met by tougher law enforcement, pushing up prices in turn, to incentivize the production and trade in counterfeits. Then it raises new questions over the criminalization of “possession” and the powers extended to law enforcement, and the wider role of the repressive agencies of the state in the pursuit of public health objectives. To head off these dystopian scenarios, we argue for a more contingent approach on tackling all aspects of drug use and urge researchers to embrace the new data coming in on the extra-medical use of prescription drugs for re-overdue review of basic assumptions that underpin the drugs field.

Contributions to this special issue

Bringing together a collection of studies, we hope to further an understanding of the extra-medical use of prescription drugs in a variety of different settings and locations. Our aim is to situate prescription drugs within a wider frame, where it connects with (currently) illegal drugs and as a component in the careers of drug consumers and traders. Several authors therefore highlight how prescription drugs can complement, support and enhance other types of drug use. This relates to their legal status and availability, as well as the complex decision-making that is involved in selecting from a wide range of prescription drugs – pain relievers, tranquilizers, stimulants and sedatives. Users have to make considered choices that balance complex arrays of factors including drug effect, potential harm to health and liberty, and how drug use and risk can be integrated into lifestyles.

Recent drug policy debates have emphasised the need to complement the focus from only illicit drugs onto prescription pharmaceuticals and other licit drugs in order to generate more inclusive debates about drug using behaviours in relation to addiction and health (RAND Europe and EY, 2017). This special issue offers a debate that combines user motives, individual perspectives and supply chains in different national and cross-national contexts. All papers in this issue show a strong link between the use of illicit drugs and prescription drugs, mainly suggesting the latter to be complementary additions.

Providing for regional and cross-national dynamics of supply chains, Petruželka (2020) offers a case analysis of complex relations between illegal markets of methamphetamine and regulations of medications containing pseudoephedrine, by showing how neighbouring countries are affected similarly by the regional conflicts in law enforcements and criminal trafficking. The paper follows the regulation changes chronologically and draws a picture of intensifying controls in the Czech Republic and in neighbouring Poland, Austria, Germany and Slovakia, as the illegal methamphetamine market grew involving organised crime groups and large-scale labs. The article puts the importance of small-scale groups and user demands at the heart of bigger policy changes, underlying also the undesired negative effects of different regulatory regimes on the local contexts.

Moving from policy discussions and focusing on dynamics of local contexts, extra-medical use is especially evident among injection drug users who use prescribed drugs, often acquired from the doctors, for both medical reasons (e.g. epilepsy) and for enhanced well-being by combining them with other drugs (e.g. crack cocaine). This is shown in the article by Sultan and Werse (2020) where both statistical and qualitative data illustrate the use of prescription drugs within both demographic and individual changes. In this research on a marginalised open drug scene in an urban environment of Frankfurt city, the authors thematically analyse daily routines and conclude that drug use constitutes a complex dynamic that is not reducible to a single motive or a drug.

Madukwe and Klein (2020) in turn show how extra-medical use can be part of a coping strategy in a context of entrenched, structural poverty. In Nigeria, people working in the informal economy use tramadol to be able to work longer hours. Some of the informants, recruited from among younger populations, also report recreational benefits, including enhanced sexual performance. Drawing an overview analysis of the Nigerian historical and socio-cultural contexts of drug use, Madukwe and Klein urge for development and public health led interventions, instead of repressive measures.

Researchers are also revisiting the online supply channels and the way they are used to make sense of individual user experiences and personal motives for using prescription drugs or experimenting in search of desired enhancement effects. In this respect, Demant et al. (2020) have looked at the ways online markets provide a neutral site for selling and buying both pharmaceuticals and illicit non-prescription drugs. Their findings prompt further research questions about the role of online markets in changing the existing perceptions about what unites and distinguishes between the two “types” of drugs, as well as, professional and amateur drug sellers operating through the same online platforms.

Related to online markets are also online discussion forums, where once more a neutral space allows users of all backgrounds to share their knowledge with others anonymously. Robitaille (2020) offers an analysis on the uses of such online fora where both professional and amateur knowledge is offered in an equal “socio-cultural online space”. Robitaille argues for the importance of web-based ethnographic approach in eliciting useful knowledge around psychostimulant use for policy and implementation.

This is particularly urgent for the use of stimulants for cognitive enhancement. Of particular interest are the under-researched use patterns in Finland, as reviewed by Hupli (2020) in this issue. Research in this area could do well to draw on the experience of The Netherlands, where data have been collected since the early 2000s (Hupli, 2020). Overall, the review by Hupli shows differences in governmental action between the two EU countries in relation to human enhancement drugs and calls for more detailed data collection that would go beyond prevalence of use, whether for licit or illicit purposes.

In the final paper of this issue, Castañeda (2020) goes beyond recent changes in prevalence and zooms into the perspectives of users in the UK – in this case individuals that have experienced depression and who have sought relief from both widely used licit drugs (selective serotonin reuptake inhibitor, i.e. SSRÍs) and the most widely used illicit drug, namely, cannabis. Despite the limited sample size, Castañedás analysis of user experiences shows the importance of doctor–patient relationships in drug-assisted therapy and the value of non-drug treatment options for treating low mood. With recent amendments in the UK medical cannabis laws, and EU-wide calls for equal patient access and research into the medicinal potential of cannabinoids (European Parliament, 2018), this exploratory study highlights user perspectives in this emerging field and the importance of personalised treatment options for people with depression.

The research arena is vast and so are the possibilities to expand this field in response to consumer culture, as well as historical and economic developments. Herein the answers are not linear when there is an emerging body of research that offers a historically and contextually placed knowledge about the rise and integration of prescription drugs into lifestyles and budding use subcultures. Researchers have until now investigated historical, economic and political implications of the integration of prescription drugs into the lives of recreational and habitual drug users. Meanwhile, international academic and policy debates have been evolving in two discrete directions: those seeking evidence-based intervention and those questioning the way evidence is produced. In this juxtaposition, the knowledge that is produced to expand our understandings of prescription drugs within established social drug research is ever more elusive. In pooling the experiences of the different contributors, we hope to contribute to emerging policy and research agendas in the second decade of the twenty-first century, away from the binary divide of medicinal and recreational drugs, towards a better understanding of the roles of motivation and context.