Hawkers in popular bars sell anti-impotence drugs, whispering that they have “blues” available for 5 bucks a pop, less than the pharmacy price.
Friends pass their pills along to others, often drug users who use them to counter the effects of drugs such as methamphetamines or Ecstasy, which can leave them unable to get an erection.
Web sites sell the drugs - or counterfeits - to nearly anyone who requests them.
And many healthy young men with normal sexual functioning are asking their general physicians for Viagra, Levitra or Cialis to help them conquer anxiety or offset the effects of smoking and partying.
At the same time, the makers of the erectile-dysfunction drugs are running racier-than-ever campaigns targeting younger men and straying from the depictions of the drugs as medicine. “Get back to mischief,” woos the latest Viagra slogan, with devil’s horns seeming to emerge from behind a middle-age man’s ears.
These are all part of the new and rapidly changing face of erectile-dysfunction drugs. Since the first impotence drug, Viagra, debuted in 1998 to address a physical problem for some men, it and newer sister drugs Levitra and Cialis have been used increasingly by healthy younger men for perceived performance-enhancement purposes or as psychological life-preservers to alleviate performance anxiety.
“When Viagra first came out, the whole emphasis was on older men, with Bob Dole doing the marketing and the age group being around 70,” says Dr. Abraham Morgentaler, a urologist and associate professor at Harvard University. “Now we’re seeing the bar lowered, not just for men wanting it but for physicians giving it out to those who are younger and less severely affected.”
One concern is that the drugs may be psychologically addictive, says Morgentaler, author of “The Viagra Myth,” a book about the common misperceptions surrounding the drug. Healthy men may begin to feel inadequate without the pill, he says.
“For younger men to feel the need to take a pill to be deemed adequate is a lost opportunity to find out that who they are is enough and that they can be loved for who they are.”
Many seem to have gotten the wrong idea about what the drugs can do. One cardiologist tells of a healthy man in his 20s with no apparent functional problems who asked for a prescription to help him celebrate his anniversary in Las Vegas. And a sex therapist says that men as young as 16 have sought her help, thinking they need Viagra to have sex or that it might compensate for having a smaller penis.
In fact, the pills enable some men who have hypertension, diabetes or prostate problems to get an erection by increasing blood flow to the penis, provided the brain kicks in with some sexual stimulation. They don’t make people better lovers, instantly mend broken relationships or enlarge penises.
Still, many doctors and drug companies say they don’t believe the drugs are being overused and, in any case, see little danger in them. About 75 percent of the erectile drugs are now prescribed by general practitioners rather than urologists or cardiologists.
Dr. Louis Kuritzky, a clinical assistant professor at the University of Florida’s department of community health and family medicine, says he generally gives a prescription when asked. “There’s no way to prove they have it any more than a woman having menstrual cramps or headaches. We trust them unless there’s reason to believe otherwise.”
Even if the cause is psychologically rooted, Kuritzky says, many people can’t afford the money or the time that therapy would require. The pills, he adds, can offer a temporary quick fix to restore confidence, which may be all that’s needed.
“When you have garbage that is rotting, the best thing to do is to take it out,” he says. “But if you can’t, sometimes it’s best to spray perfume on it. Sex therapy is a luxury for only the economically elite.”
Pfizer, which sold $1.9 billion worth of Viagra last year and says 23 million men worldwide have tried it, maintains that it is not promoting the drug for enhancement purposes. Spokesman Daniel Watts says the company believes that if a man is troubled enough by erection problems, then he should consult a doctor about a possible underlying condition.
Carole Copeland, a spokeswoman for Eli Lilly, which makes Cialis, says the company “strongly discourages” use by those seeking enhancement only. “It’s just not safe. People who don’t have a condition that necessitates it shouldn’t use any drugs,” noting that erectile dysfunction drugs can be deadly if taken with nitrates.
Dr. Sanjay Kaul, a cardiologist at Cedars-Sinai hospital in Los Angeles, questions whether some of the purported need for the drugs has been drummed up by the drugmakers’ advertising and reports that 30 million men in the United States may suffer from erectile dysfunction. “It seems the disease was created overnight with Viagra.”
There’s little doubt that the age of erectile drug users is getting lower. Express Scripts, which, with 50 million members, is one of the nation’s largest managers of employee prescription-drug benefit plans, said the fastest-growing segment of users who applied for reimbursement of Viagra prescriptions was men ages 18 to 55 during 1998 to 2002.
The number of men younger than 45 using the drug tripled during that time, although it is still small compared with the majority of users, who are older than 50. Pfizer says the average age of men taking the drug is now about 53, lower than it was previously, although exact comparisons aren’t available. As of earlier this year, about 8 percent of prescription Viagra users were age 34 to 40, about 26 percent were in their 40s, 36 percent in their 50s and 22 percent in their 60s, Pfizer’s data shows.
Some healthy men who have used the medications say the drugs enable longer-lasting and firmer erections and reduce what is known in urological parlance as “refractory time,” the amount of time between erections.
Dr. Ira Sharlip, a urologist and clinical professor at the University of California, San Francisco, who serves as spokesman for the American Urological Association, maintains that the drugs “can’t make a superman out of a normal man.” Although middle-age men who have seen firmness decline may note an improvement with the drugs, he says, an already firm erection won’t become any firmer.
But Kuritzky, the Florida physician, says that since the brain is such a critical element in sexual functioning, the so-called “placebo effect” can play a big role for some men.
If a man with a healthy cardiovascular system thinks his erections are or will be better with the drug, that’s often what counts the most (at least in the man’s own assessment). The same might be true if a guy with normal sexual functioning believes that an amulet in his hand will make him into the Hercules of sexuality, Kuritzky says.
The U.S. Food and Drug Administration and physicians say the drugs are safe for most men if used as directed, with the exception of those taking nitrates or those with poor cardiovascular health.
They acknowledge that some men experience headaches or flushing and in rare cases extended and painful erections that won’t subside, a condition called priapism.
Cedars-Sinai cardiologist Kaul isn’t convinced that the drugs are safe and says he probably wouldn’t take the drugs himself if he were to need them.
In 2000, he and colleagues at Cedars-Sinai analyzed 1,473 major adverse reports associated with Viagra use filed with the FDA. Of those, 522 people died, most due to heart attacks. Most had taken the standard 50 milligram dose of Viagra within the previous few hours and most were younger than 65 with no known cardiac risk factors.
Some of the deaths occurred in patients who had taken the drug with nitrates, but 88 percent of the deaths had occurred in those who had not.
Kaul notes that one cannot be sure that the medication caused the attacks, just that there was an association with taking the drug. It also could be that some of the victims had previously been sedentary and the drug enabled them to engage in sexual activity, which in itself caused the heart attack.
Mark A.R. Kleiman, a public-policy professor at the University of California, Los Angeles, and director of its drug-analysis program, goes so far as to contend that the drugs meet the criteria for distribution as “controlled substances” in the United States, handled in the way drugs such Oxycontin are.
“Using a prescription drug for a purpose not prescribed is in essence drug abuse,” Kleiman says. “Clearly there is a lot of demand for the drug among people who don’t have the condition,” he says. “It’s not that men have it (erectile dysfunction) or don’t have it, it’s that men vary in sexual performance,” he says. “A lot of people want to be higher on the curve. Being a 50-year-old who no longer performs like a 20-year-old is not a disease.”
American Urological Association
Revision date: July 5, 2011
Last revised: by Janet A. Staessen, MD, PhD