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When Anne's grandmother was hospitalized two years ago with chest pains, she couldn't remember what medications she was on. So doctors sent Anne to the woman's home in eastern Washington State to look in her cabinets. What they found shocked both the family and the doctors. In the basement, the woman had several copies of the Physician's Desk Reference, scales for weighing pills, and a cupboard chock-full of both prescription and over-the-counter medications. All in all, doctors told the family later, she had 11 types of prescription medications, including at least 400 Valium pills. Her medications, doctors said, would probably fetch about $15,000 on the street. "When I went down there," says Anne, "I thought, 'Oh my God, it looks like a pharmacy in here.' "

To get pills, Anne's grandmother would go from doctor to doctor complaining of anxiety, asking each for a prescription so that, unbeknownst to the doctors, she racked up a huge stockpile of drugs. The practice is known as "doctor shopping," and it's one of the most common ways that prescription pills are obtained illegally. Figuring out how to stop the practice, along with other strategies people use to obtain prescription drugs illegally, is a major challenge facing law enforcement, the medical profession, and government agencies.

Though use of illicit drugs has held relatively stable, prescription-drug abuse has risen dramatically in the past few years. Indeed, only the illegal use of marijuana is more prevalent today. Although abuse is rising among all age groups, officials are especially concerned about abuse among teenagers: One in 10 high school seniors has tried the painkiller Vicodin without a prescription, and 1 in 20 has taken the potent pill OxyContin.

Local, state, and some federal agencies have been combating this problem for decades. But the issue started getting widespread attention just last year, when the Bush administration released its first-ever plan targeting prescription-drug abuse. The White House set up new federal programs--including increased physician education and support for state prescription monitoring efforts that can catch people with multiple prescriptions for the same drug. In addition, two members of Congress introduced the Prescription Drug Abuse Elimination Act, some provisions of which passed as part of another bill. And outside the government, the Partnership for a Drug-Free America recently completed a study of adolescent attitudes on prescription drugs and will most likely release an ad campaign later this year warning of the dangers of popping pills. As these efforts gear up, experts at all levels are realizing that fighting the war on prescription drugs may be unlike anything they've done before.

"Kiddie dope." "We are faced here with a different kind of threat," says John Walters, the U.S. drug czar. "With most illegal drugs, such as cocaine, production and distribution are illegal activities. In this case, this is a diversion from a legitimate source."

In contrast to other types of illicit drugs, fighting this threat takes more finesse than force. Education is one of the main components--people are still unaware that prescription drugs can be just as dangerous as illegal drugs. There's an idea that because doctors recommend prescription drugs for some uses, they must be safe. The perception even extends to law enforcement, says John Burke, vice president of the National Association of Drug Diversion Investigators. Federal agents and others refer to prescription pills as "kiddie dope" and don't regard rounding up those who sell it illegally as a top priority, he says.

This drug war also has different players: medical professionals, patients, and pharmaceutical companies, all of whom have legitimate uses for the drug--and lobbyists in Washington to make sure their interests have a voice. The word balance is often used to describe the complex task of keeping these groups happy while preventing the drugs from falling into the hands of illicit users and criminals. The most delicate relationship right now is between law enforcement and doctors, who want to be able to prescribe medication as they see fit without evoking suspicion of drug trafficking--a fact not lost on the Drug Enforcement Administration. Says William Walker, head of the agency's Office of Diversion Control: "The DEA in no way attempts to hinder any medical practitioners who are legitimately prescribing and administering controlled substances to their patients."




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Anxiety and pain. Haley Bruns knows firsthand how dangerous prescription drugs can be. She became addicted to the anxiety medications Xanax and Ativan but has been sober for about five years now. When she had knee surgery last month, however, and was prescribed the painkillers Percocet and OxyContin, she was wary. Even though she's never been addicted to those drugs, she says: "I didn't want to tempt myself." She solved the problem by getting only a few pills at a time from the pharmacist, even though it meant going into the store every day. "The first time I did it, the pharmacist was like 'you're nuts,' " she says. "I think it's a great way of doing it."

Painkillers like Vicodin, Percocet, and OxyContin, derived from opiates, technically known as narcotic analgesics, are the biggest concern among policymakers and experts because they can be very addictive. Even patients who use them properly for pain can become addicted, though it happens rarely. Abuse of these drugs is increasing "quite dramatically," says Nora Volkow, director of the National Institute on Drug Abuse. More than 31 million Americans say that they have illicitly used narcotic analgesics, and emergency room visits related to this type of drug have more than doubled in the past decade, to 108,000 in 2002. People take the drugs because they produce a sense of euphoria, similar to the high from heroin. When taken improperly, these drugs can be fatal.

But the heavy focus on abuse of painkillers, along with several high-profile court cases involving doctors, has had a chilling effect on pain medicine, doctors contend. Millions of patients, they say, are suffering because doctors are either underprescribing to avoid suspicion or are leaving the field altogether. One woman in New York started a patient advocacy organization, the Pain Relief Network, because of her husband's chronic joint pain. "These people deteriorate because it hurts to move," says Siobhan Reynolds. "I can't even begin to explain the severity of the repercussions on their lives."

Rift

The Office of Diversion Control says it's not in the business of prosecuting doctors who operate legitimate medical practices. The problem is that there isn't an agreed-upon definition of what prescription practices are legitimate. Diversion Control tried to address this problem several years ago when a couple of its agents teamed up with four pain specialists and spent two years writing a "Frequently Asked Questions" document that addressed issues like how narcotic analgesics should be used to manage pain and what federal regulations were involved with prescription painkillers. The 32-page document was released in August 2004 and lauded in the Journal of the American Medical Association. Shortly after, the DEA pulled the FAQ off its website with no explanation, according to David Joranson, the director of the Pain and Policy Studies Group at the University of Wisconsin and a member of the drafting committee. "It was just amazing to have that collaboration unilaterally ended," he says, "without explanation."

If that rift is not mended, it could impede the war on prescription drugs, which depends on cooperation between the medical community and law enforcement. Ensuring such cooperation will require strategies new to drug enforcement. But at least one person is optimistic. "Unlike street drugs, people don't want to do the wrong thing here," says Walters. "The vast majority of the people we're dealing with are committed to people's health and welfare."

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