On a subsection of the social media website Reddit, users swap “pill porn” pictures of prescription drugs they have acquired. Some show hundreds of pills in bags or held in cupped hands. In one video, a user eats an ice cream sundae sprinkled with broken Xanax pills. Every now and then, someone posts a picture of some pills described as “work meds”, used to “fast forward” the hours in a tedious job. But the drugs being discussed are not simply recreational. One user asks the forum for advice on medicating “severe social anxiety and general anxiety”. Within minutes, others offer their recommendations: “I’d say Klonopin”; “if we’re talking strictly social anxiety I’d go with pregabalin”; “Ativan is pretty good”; “Try phenibut, dude… you can buy it online safely.” Unable or unwilling to access mental health services, large numbers of people – particularly the young – are self-diagnosing and self-medicating mental health problems with drugs they buy online.
In a survey of 147 regular UK users of benzodiazepines on the same forum, the most common reason for taking these drugs was the self-medication of mental health problems. More than 80 per cent of respondents had sought help for mental health problems, but 77 per cent said they found mental health services to be inadequate. Many cited a lack of access to services or long waiting times for treatment as their reasons for turning to self-medication. Many say they bought drugs such as diazepam (sometimes branded as Valium) and alprazolam (sometimes branded as Xanax), from the dark web.
In a heavily guarded warehouse near Potters Bar, the true scale of the UK’s problem with unlicensed medications becomes clear. Huge crates, each capable of holding two tonnes of material, stand on racks of shelves forty feet high. Inside the crates are evidence bags containing thousands upon thousands of pills – tramadol, diazepam, zopiclone, pills for erectile dysfunction, sleeping pills, painkillers, antidepressants – that the Medicines and Healthcare products Regulatory Agency (MHRA) has confiscated. So far this year, the MHRA has destroyed more than 40,000 tonnes of drugs.
Many of the unlicensed medications the MHRA confiscates are unlicensed generic drugs sent from China and India. Many online sellers will order a few hundred tablets at a time in the hope that some packages will get though Border Force checks; some will simply order 200,000 tablets, enough to fill several pallets, and hope for the best. It is rare that the MHRA sees fake drugs being manufactured in the UK, although one employee describes a raid in which they found cement mixers used to make steroids. The cheaper, easier and safer route is to order large amounts of unlicensed drugs from a country with less regulatory oversight. In one room in a pharmacy in Manchester, another MHRA official remembers, they found more zopiclone (a powerful sleeping pill) than was held by all of the hospitals in Greater Manchester.
Analysis by the MHRA shows that for some drugs related to mental health, people are spending on average £90 at a time. Customers come from a broader range of backgrounds, demographic groups and social classes than those who typically buy drugs for recreational use. This appears to confirm the anecdotal evidence that self-medication could be the reason behind many sales. And for those that do self-medicate, more stress can await: the credit cards used for these transactions are often cloned shortly after they’re used.
While many use the dark web to buy strong prescription drugs, they can also be bought in a few clicks through a search engine or social media. “We have some success [closing down] websites”, explains the MHRA’s senior policy advisor, Lynda Scammell. “If they’re hosted in the UK then we work with the service provider to get them removed. In Europe, we can get them shut down. But many of them will host the website in countries where there is not robust control. We write to them, and the response we get will be… mixed.”
Even when a website is shut down, the underlying technology is so easily replicated that it can up again within hours. “The Americans call it ‘Whack-a-Mole’,”says Scammell.
Along with openly drug-specific forums on Reddit, other social media sites including Facebook and Instagram are widely used to advertise drugs for sale. Unlicensed drugs can also be bought without prescription through eBay. Spotlight found numerous completed eBay auctions in which powerful prescription drugs including the antidepressant fluoxetine (sold as Prozac), the epilepsy and anxiety medication pregabalin and the tranquiliser diazepam had been sold through the online marketplace in the past month. A search for one prescription drug, pregabalin, led eBay’s search facility to suggest searches for other potentially dangerous and addictive medications, including gabapentin, codeine, amitriptyline and tramadol. The website does not display any warnings when users search for these items. Spotlight invited eBay to comment on these findings and did not receive a reply.
For organised crime, the move into prescription drugs brings the promise of new customers and relatively low-risk. The production and sale of class B and C drugs such as cannabis can carry a maximum sentence of 14 years, while medicines crimes typically carry civil penalties and where criminal cases are pursued, sentences are usually less than two years.
In some cases, however, it is not even necessary to break the law to self-medicate without medical oversight. In the UK, people with mental health problems including depression, addiction, anxiety and eating disorders have been able to secure large quantities of drugs without the knowledge of their GP, by using online prescribing services. These services exploit the fact that doctors across the EU are given mutual recognition of qualifications, meaning a doctor in Bulgaria or Romania can issue an online prescription that is valid in the UK. This means that pharmacies in the UK can legally sell drugs once an “online consultation” with a doctor based overseas has been completed.
There are, Lynda Scammell points out, many “perfectly valid” prescribing services being run by high-street chemists, using consultations with doctors in the UK who are regulated by the Care Quality Commission. But other pharmacy websites visited by Spotlight patently exploited the system.
One website visited through an advert on Google, “prescriptiondoctor.com”, offered a short questionnaire for a prescription of 200 tablets of codeine phosphate, a strong opioid painkiller, at 30mg. The questionnaire pre-filled important questions, such as the level of pain the patient experiences – the “usual daily pain” level was set at 7 on a scale of 1-10, and the pain experienced after taking the medication was pre-filled at 2. This website is run by Al-Muhsineen Ltd, which runs a pharmacy in Bolton.
In a “consultation” on the website of another online pharmacist reached through a Google advert, “theindependentpharmacy.co.uk”, any answer that would have been a warning sign for a GP was flagged as “an error in your consultation”. Rather than suggesting that the patient not buy 100 tablets of co-codamol, the website instructed the user to “rectify any errors that are highlighted in red” before continuing the order. Like other websites, its order form told patients which blood pressure option they should select to be passed as “normal”. The Independent Pharmacy is regulated by the CQC.
A third website advertised on Google, “doctor-4-u.co.uk”, noted that it could no longer prescribe the powerful sedative painkillers pregabalin and gabapentin, but openly recommended that “you could consider ordering amitriptyline instead”, an antidepressant that carries a risk of side effects and overdose if used improperly but which, it offers, “is not currently listed as a controlled drug.”
In some cases, these prescribing services have supplied fatal amounts of drugs to people in the UK. Jennifer Lacey was prescribed 100 tramadol 50mg tablets by a doctor registered in Prague. She used them to kill herself in June 2018; the coroner noted that the Czech doctor “had never see her… had no access to her medical records, not had communicated with her GP”. Richard Breatnach from Brighton bought 126 dihydrocodeine tablets, having been prescribed them by a doctor online whom he had never met and to whom he was easily able to lie. He died from an overdose in 2016. And in July 2017, Debbie Headspeath from Ipswich was found dead at her home after overdosing on opioid painkillers, to which she was addicted; in the months leading up to her death, Ms Headspeath had taken thousands of codeine tablets that she had bought online.
Lynda Scammell says one item in particular in the “consultations” of online pharmacies is a concern: the fact that a patient can “tick a box saying ‘don’t tell my GP’”. Under the EU’s data protection rules, patient privacy is protected from everyone – including the doctor who would be able to identify drug-seeking behaviour.
The end result of this trend is what Eytan Alexander, the managing director of UK Addiction Treatment Centres (UKAT), describes as a “staggering” rise “across the board” in patients presenting with complex problems that involve pharmaceutical drugs. Alexander says UKAT is “absolutely” seeing the knock-on effect of a lack of access to mental health services. He gives as an example the fact that large numbers of UKAT patients are using both alcohol and antidepressant, because doctors who lack the time or resources to address the underlying problems in people’s lives that have led them to an alcohol addiction are often left with no choice but to prescribe antidepressants. Alexander agrees, too, that the internet offers a dangerous combination of a community in which people “start talking to other people, diagnosing themselves”, and a fast, efficient delivery mechanism for drugs that only “amplify the problem”.
It is unlikely that access to unlicensed medications will slow down, however, not least because the UK is now committed to more technological delivery of health services. “The Secretary of State has thrown his weight behind digital healthcare provision, and that’s fine,” one MHRA official observes, “because everyone wants to save the NHS money. That’s great – as long as it’s safe.”