Professor Moffat told the audience that they would have to decide for themselves whether drugs were needed for pleasure. He said: "There are some that would enhance our lives with no danger to us and there are others which will undoubtedly harm us if we took them. It is up to us as health care professionals to recognise the differences and to give the proper advice to our patients."
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Tony Moffat: give proper advice |
Safety was an issue with these types of drugs. Some enhanced lifestyles without the individual becoming dependent on them. But some brought addiction and death.
Some people wanted to lose weight. Tonics and nutraceuticals might be taken to enhance the diet, or slimming aids, such as methylcellulose products and orlistat. Body-builders wanted exactly the opposite. They used food supplements high in protein, carbohydrates, minerals and other additives and might even resort to the use of anabolic steroids. Other examples of drugs used to alter lifestyles were minoxidil for male pattern baldness, Zyban for smoking cessation, fertility treatments, contraceptives, norethisterone for changing the time of menstruation, and sildenafil for erectile dysfunction.
Sildenafil could be considered an aphrodisiac, said Professor Moffat, and that class of lifestyle drugs had been used for thousands of years. Their effects were to invite intercourse, induce potency, seduce into unchastity, increase pleasure, invite sexual desire or obliterate all sense of shame. Spanish fly was probably one of the most well known. Plants such as mandrake, belladonna, opium, the grapevine and cannabis, had always been popular as aphrodisiacs. Animal substances other than Spanish fly included oysters, deer antlers, rhinoceros horn and abalone. The modern day counterpart was Ecstasy.
Whereas women at dances and in bars sometimes voluntarily took Ecstasy, there had been a proliferation of the reporting of "date rape" using drugs. Flunitrazepam (Rohypnol) was believed to be one of those medicines used by potential rapists due to its fairly quick onset of action and pharmacology. Professor Moffat told the audience that the UK government had moved to increase the control on the medicine. But before it could do this, the manufacturer (Merck) had reformulated it into a differently shaped and coloured tablet which, if put into a drink, produced a blue colour and a powder on the surface of the drink. Thus the problem had been solved by reformulation by pharmaceutical scientists rather than by legislation. More recently GBH (gammahydroxybutyrate, a general anaesthetic) had been reported to be abused in a similar fashion, and even ketamine had had a resurgence of abuse.
Turning to alcohol, Professor Moffat said that in recent years there had been a number of publications describing the medicinal properties of various forms of alcoholic drinks. The most health gain seemed to come from red wine, especially those from grape varieties such as Cabernet Sauvignon and Pinot Noir. Claret was said to be high in flavonoids, Burgundy high in antioxidants and Chilean red wine particularly high in phenolics. Red wine was thought to reduce heart attacks, the onset of Alzheimer's disease and cancer because of their flavonoids and polyphenols. "The dosage is two to three glasses a day - something achievable by most people," Professor Moffat joked.
But it was not just these substances in red wine that were therapeutic. Alcohol itself could protect against heart disease. A paper in the British Medical Journal earlier this year had said that the changes in concentrations of high density lipoprotein cholesterol, fibrinogen, and triglycerides associated with an intake of 30g of alcohol a day should reduce risk of coronary disease by 24.7 per cent. That was the equivalent of two pints of beer or three glasses of wine (red or white).
However, the down side to alcohol was that it could be abused and there were resultant large costs to society. It had been estimated that alcohol abuse cost the UK £3.3bn every year. In addition, there was £200m spent by the National Health Service on treating drink related diseases and £189m costs in road traffic accidents. Criminal activity linked with excessive drinking cost another £68m each year.
On smoking, which could be considered a drug for pleasure, Professor Moffat said that latest Government figures had shown that smoking was the single greatest cause of preventable illness and early death in the UK. There was a huge number of people who wished to give up smoking and pharmacists had an important role in smoking cessation plans. Guidelines for health professionals included asking about smoking at every opportunity, advising all smokers to stop, assisting smokers to stop, eg, by using nicotine replacement therapy, and arranging follow-up.
"The use of NRT can double a person's chances of giving up successfully and has proved its worth time and time again," Professor Moffat said.
Another weapon in the fight to give up smoking was Zyban, which had been claimed to be twice as effective as NRT. These were examples of preparations that had been specifically developed to stop the addiction caused by the pleasure-producing drug (in this case nicotine).
Pharmacists had a number of opportunities to assist in treating drug misuse. Examples of services were needle and syringe exchange schemes, the provision of citric acid (still not a universal service), instalment dispensing services, the supervised consumption of methadone in the pharmacy and the provision of information. But prevention was nearly always better than cure and the treatment of a real or potential abuse of drugs sometimes required the use of other drugs. Examples were disulfiram for the treatment of alcohol abuse, gymnema extract which made chocolate taste like cardboard, a vaccine that removed the effects of cocaine, and the possibility of knocking out the gene that allowed morphine to have its euphoric effect. "We have still some way to go to producing drugs that remove the pleasure of other, abused drugs but there are many potential avenues," said Professor Moffat.