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However, recent reports indicate that sildenafil and similar ED drugs, such as vardenafil (Levitra, Bayer/GlaxoSmith Kline) and tadalafil (Cialis, Lilly), are becoming increasingly popular among healthier, younger men to enhance sexual performance. According to Pfizer, the number of men under age 45 using sildenafil tripled in the 4 years since the drug was introduced in 1998. Pharmacy benefit management firm Express Scripts says that the fastest-growing segment seeking coverage for sildenafil is men between 18 and 55 years of age.
Some authorities contend that it is improper and potentially dangerous to prescribe a drug without a compelling medical need. Others suggest that patients inclined to take drugs to enhance sexual performance will get their hands on them one way or another—buying or stealing them from somebody with a legitimate prescription, or acquiring them from dubious sources over the Internet. Reports suggest that at least half of Viagra sold over the Internet is fake. Wouldn't it be better for men to take ED drugs under medical supervision than to leave them to their own devices?
DOC News asked attendees at the recent American Academy of Family Physicians (AAFP) Scientific Assembly:
Is it proper to prescribe drugs such as sildenafil for mainly recreational reasons, without a clear medical need?
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I actually have a lot of patients on Viagra, and they have to prove to me that they have an erectile dysfunction. It's not enough to give me the impression that you want to do better. I have to get a good feeling that it's truly a problem, and also make sure that all medical causes have been attended to, of course, before I'll prescribe Viagra.
So if a patient has high cholesterol, diabetes, or hypertension that is not being addressed, he is not getting Viagra. I'll also talk to patients about not smoking and getting enough daily exercise. The bottom line is that you're not getting Viagra for recreational use. Like most medications, Viagra is not without its side effects. I want to be able to justify those side effects.
The patients I wonder about are those who may be getting the drug from an older relative with the [ED] problem. Can you stop a 28-year-old from getting Viagra from an older relative or friend? No, you can't.
Kenny Morohunfola, MD, PhD
Internal Medicine
Kansas City, Mo.
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I don't think it's good to prescribe recreationally because many of these patients don't know the side effects. They can be bad. You don't know if the patient has a precondition or is on drugs that may be contraindicated. So I don't think it would be a good idea.
They may be taking an SSRI [selective serotonin reuptake inhibitor] and have a problem with libido, so they take Viagra to compensate. They don't know that if they switch the SSRI to something else, they won't have a problem with libido.
Georgina Kalaitzidis,
MD Women's Health Fellow
Peoria, Ill.
I think it's fine to prescribe if someone has a [sexual] problem. Some of these are people with medical conditions, such as diabetes, but some appear to be healthy young adults who are still having problems. If somebody says they're having a problem, I'll prescribe.
Yanina Rubinshteyn, MD
Family Medicine
Forest Hills, N.Y.
I personally do not prescribe Viagra for recreational purposes. It gives me an opportunity to talk to a younger man about sexual dysfunction, their anxiety about relationships—other issues that are usually more prominent.
I had one partner who would give [patients] a couple of samples, let them use an eighth of a tablet to give them a psychological effect, but I don't believe in that. I don't think it's ethical to prescribe any medication that's not indicated.
Any new drug that relates to sexual dysfunction is going to be misprescribed. Most young men think it's going to let them have sex three or four times a night. Many young men think that it will allow them to overcome premature ejaculation.
David Peter, MD
Family Medicine
Portland, Ore.
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I don't think it's ethical to prescribe under those circumstances. I've heard a lot about it, but it really hasn't come up in my practice.
Actually, it did come up once. Another physician asked me for it. I couldn't understand why he wanted it until he told me why. Basically, he wanted a second orgasm shortly after the first.
Albert Verrelli III, MD
Family Medicine
Clinton, N.C.
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In my opinion it's not proper. If I have a patient with sexual dysfunction, I try to find the cause. Usually we need both partners to find out what's going on. We will first try to help them with nonmedical treatments.
I won't prescribe Viagra unless there's a medical indication.
Naghan Abu Shaqra, MD
Women's Health Fellow
Peoria, Ill.
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Young men are asking for it more and more. I basically use products [for the indication] they're approved for, so recreational use of Viagra, Cialis, or any of the other products for erectile dysfunction is not what I advise.
If a young man comes to me for this, I'll sometimes even scare them. We can use some of the information we have to find something more suitable for them. If I highlight the side effects, the dangers associated with the use of these products, maybe that will scare them. Because if they don't get it from me, they're going to get it from somewhere else, maybe over the Web. So I believe that by highlighting the side effects maybe they'll change their mind.
Domingos Sebastiao, MD
Family Medicine
Lisbon, Portugal
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I don't think it's prescribed in doctors' offices as often as it is bought over the Internet, brought in from other countries where safety is an issue. It's inappropriate to use these medications for recreational purposes. Young healthy males don't need that enhancement. It's usually being used while they're impaired by other ways, from alcohol or drugs. They still want to have sexual performance, so it doesn't seem to be an appropriate use of that medication.
John Tomedi, MD
Family Medicine
Kulpmont, Pa.
TALK BACK: DRUG IMPORTS
Increasing numbers of Americans are doing an end run around the U.S. drug industry by buying their prescription medications from sources in Canada or Mexico.
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Drugs imported from Canada or Mexico cost 30% to 50% less than the same drugs sold in the U.S., leading many Americans to search the web for mail order sites and go on cross-border drug-buying bus trips.
At least 20 states have sought permission from the Food and Drug Administration (FDA) to circumvent the U.S. market and import drugs from foreign pharmacies.
FDA has taken the official position that safety and purity of imported drugs cannot be assured, opening the door for counterfeits and dangerous drugs. Drug importation is also opposed by the Pharmaceutical Research and Manufacturers of America (PhRMA) and pharmacy trade groups.
Opponents of drug importation say the products could be ineffective or toxic and aren't subject to the strict regulatory review as in the U.S. Proponents contend that drugs are imported from legitimate, licensed pharmacies located in other countries and can be purchased with confidence.
What do you think? Is importation of prescription medication right for your patients?
Send your comments to docnews{at}diabetes.org.
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