For the first time US drug deaths outnumber traffic fatalities - and officials are waking up
These are bleak times for America's "pillbillies", the legions of addicts from Southern states who take the "Oxy Express" down to Florida and stoke up on painkillers and antidepressants, or else score from a dealer who has made the trip for them.
Florida is starting to shut hundreds of its 1000-plus "pill mills", pain-management clinics where lax laws and lax doctors have catered to an epidemic the United States belatedly recognises as an "alarming public health crisis" needing urgent redress.
Last week, the Los Angeles Times revealed drug deaths have exceeded traffic fatalities for the first time. Illegal narcotics claimed some, but this grim toll is being spearheaded by addictive, potent pharmaceuticals advertised on TV.
"Unintentional drug overdose is a growing epidemic in the US and is now the leading cause of injury death in 17 states," said Dr Thomas Frieden, the director of the US Centres for Disease Control and Prevention (CDC), in April, as the White House Office of National Drug Control Policy rolled out a strategy to deal with "pharmageddon".
After decades of worrying about the illegal traffic in drugs like heroin, cocaine, methamphetamine and marijuana, officials were finally forced to confront an epidemic that had unfolded under their noses over the past decade.
Pharmageddon is rampant, scything through a society where "meds" are ubiquitous, American as apple pie and marketed relentlessly by the pharmaceutical industry.
Victims include teenagers who party on deadly drug cocktails [one-in-five US high school students have abused prescription drugs according to a CDC study], adults with chronic medical conditions who become addicted, and elderly people who accidentally exceed their dosage.
Males aged 35 to 54 are most at risk, along with Native Americans, Alaska Natives and non-Hispanic whites.
And children are not immune. A paper published in the Journal of Pediatrics this month looked at 544,133 infants, up to 5 years old, admitted to hospital emergency departments between 2001 and 2008 for swallowing pharmaceuticals. The study showed 95 per cent had taken the drugs - prescribed for adult obesity, diabetes and hypertension - themselves.
Accidental poisonings of children jumped 22 per cent between 2001 and 2008, despite efforts to make pill canisters infant-proof. Researchers suspect drugs are left lying around homes instead of being secured in locked cabinets.
The use of painkillers like OxyContin and Vicodin, or anti-anxiety drugs like Xanax, has soared. The Times analysed preliminary data and was unable to attribute deaths to specific drugs. But in 2007, comprehensive data showed "deaths from prescription opiates, which are the narcotic painkillers, outnumbered deaths from heroin and cocaine combined", said Dr Chris Jones, a health scientist with the CDC's Injury Centre.
The CDC said it lacked more recent data, but in June the Guardian said "almost 30,000" overdosed last year with "at least half" of the deaths attributable to "legally controlled substances that were misused, abused, prescribed incorrectly, or simply just in the wrong person's hands".
Data suggests a deep-seated problem. Americans consume 99 per cent of global hydrocodone [a semi-synthetic opioid] and 80 per cent of the world's opioid pain drugs, with the measure of prescription opioid per person soaring between 1997 and 2007 from 74mg to 369mg - a 402 per cent increase.
"In my circles it's been known about for a while," said Dr Standiford Helm, of the Pacific Coast Pain Management Centre at Laguna Beach, California. "It's not a surprise at all. We've been watching different drugs used as gateway drugs for addiction. It's been growing over decades."
Nor is pharmageddon confined to the US. A similar story emerges from Britain, which the Independent says is "in the grip of a prescription drug-taking epidemic, with unprecedented numbers of medicines being handed out by GPs". Prescription drug use increased 27 per cent in five years, fed by big-ticket pharmaceutical marketing budgets and a growing public perception there was "a pill for every ill".
The paper said British doctors wrote an average 81 prescriptions each day, compared with 64 in 2007. Antidepressant scripts almost rivalled ones for antibiotics.
As the Pharmaceutical Research and Manufacturers of America lobby, "Big Pharma", takes the pill-for-every-ill mindset global, this year's UN World Drug Report warns "non-medical use of prescription drugs is reportedly a growing health problem in a number of developed and developing countries".
While pill-popping is not new, with showbusiness helping set the overdose pace, from Elvis Presley and Judy Garland, to Michael Jackson or Anna Nicole Smith, prescription abuse has reached deep into the US heartland.
Kentucky is a case in point. This year Jack Conway, the state's Attorney General, suggested Kentucky may have suffered more than anywhere else in the US.
Like other economically depressed Southern states, Kentucky's pillbillies are a lucrative market. There is an ugly echo of methamphetamine addiction, which has ravaged many poor communities, in Kentucky's plight.
Given austerity politics and deepening poverty in the US, Britain and other developed societies, "pharmageddon" may be difficult to eradicate.
The epidemic probably dates back to the late 1990s, when US data suggested patient pain was not being adequately treated. Physicians prescribed more painkillers and Big Pharma stepped up to the crease, rolling out ads extolling new wonder drugs, as more pain fed more gain. A successful pharmaceutical brand is a ticket to corporate heaven.
"The number of prescriptions for painkillers has increased significantly over the last decade," said the CDC's Jones. "We also saw the introduction of controlled-release, long-acting brands like OxyContin that were heavily marketed.
And continued sales of those types of drugs have increased. A CDC analysis last year found that, between 1997 and 2007, opiates sold to United States pharmacies and doctors increased by 600 per cent. Along with the legitimate treatment of pain, there was also an increase of people who were misusing or abusing these drugs. And people who were becoming addicted."
It is a grim irony, in a society where authorities warned citizens to "just say no" to illegal drugs, that studies show people regarded legal pills as low-risk, because they were prescribed by doctors and dispensed by pharmacists.
"People feel they may be safer and initiate drug use," said Jones, "compared to using, say, cocaine or heroin."
As prescription drug prices soared and the US made it harder to buy via the internet, dealers raced to the pill mills. By last year Florida, once cocaine central, was the epicentre of this roaring trade, with record overdoses from prescribed drugs in 2009 and 2010. Broward County in the south had become a source of oxycodone, a powerful narcotic painkiller similar to morphine, and boasted more pain-management clinics than it did McDonald's.
Without a monitoring system, or tough laws, this traffic exploded as dealers cruised cash-only clinics, a bonanza for doctors as pills flooded north into pillbilly country.
As pills trickle down from patients to friends or the street, pharmacies are robbed, addiction soars and users overdose, officials are scrambling for solutions. Besides analysing national overdose and abuse patterns, and ensuring doctors and pharmacists adhere to strict clinical procedures when dispensing drugs, the CDC wants to extend monitoring programmes - used in 35 states - across the US within 18 months, allowing doctors to cross-check a patient's computerised medication history in every state.
Florida is closing down oxycodone clinics after Governor Rick Scott, a Tea Party Republican, dropped his opposition to setting up a state prescription drug database, closing a loophole that had fed the "pill mill pipeline" to Kentucky.
By September more than 400 clinics had closed, almost 80 doctors had had their licences shelved for over-prescribing drugs, and dealers were being prosecuted. Doctors were barred from dispensing addictive drugs from clinics or their office.
The effect was dramatic. In the first half of this year, purchases of oxycodone by doctors fell 97 per cent on the 32.2 million doses bought in the first half of last year. Police in Palm Beach said the drug's Florida street price had doubled.
The elephant in the room is Big Pharma, which critics charge has undue influence in Congress. In 2006, the Boston Globe said the lobby spent about US$2 billion ($2.5 billion) annually to sway politicians and 10 times more to reach doctors.
A 2006 documentary, Big Bucks, Big Pharma: Marketing Disease and Pushing Drugs, was withering in its claim that the industry's insidious marketing was a big part of the problem, charting the steep growth in budgets for TV advertisements - where people live healthy, vibrant lives thanks to new drugs but side effects are glossed over - free medication samples to doctors and soaring company profits.
The happy people are still cavorting on primetime. But back in the heartland, as the Oxy Express runs dry, addicts are flooding treatment clinics. For many it is a hard landing.
* 37,485 People died in the United States from overdoses in 2009.
* 36,284 Americans died in vehicle accidents in the same year. Road deaths have steadily fallen since the 1970s, but drug deaths "claim a life every 14 minutes".