The Dangers of Using and Abusing Viagra

Once upon a time, a big American pharmaceutical company named Pfizer accidentally discovered a new treatment for erectile dysfunction -- Viagra, the little blue pill. Originally developed as a treatment for heart disease, its penile erection enhancing effects were noted in clinical trials and Pfizer quickly saw the drug's potential marketability as the first pill for men with trouble getting it up or keeping it up. Patented in 1996 and approved by the U.S. Food and Drug Administration for prescription-only sale in 1998, Viagra became a smashing financial success, exceeding annual sales of $1 billion every year since its introduction.

The shrewd folks at Pfizer surely knew they had a pistol of a drug on their hands -- after all, men are obsessed with their own erections. And in the beginning, Pfizer pretended to be all serious about erectile dysfunction, even managing to convince the unsuccessful Republican presidential nominee of 1996, Robert Dole, to endorse Viagra in those now-famous television commercials. You have to congratulate Pfizer for recognizing the inherent snicker factor of its product, so casting humorless elder statesman Dole, a man with the charisma of a lemon, as a spokesperson makes perfect sense. Pfizer cunningly gave us permission to mock the failed presidential hopeful about his sex life while we simultaneously and silently thanked Jesus for the discovery of the little blue pill.

Now that everyone on the planet, excluding Chinese peasants with no access to TV, knows about Viagra, Pfizer has brazenly shifted its marketing strategy. And their advertising isn't even remotely directed at men with erectile dysfunction anymore -- it's full of vibrant sports heroes (NASCAR drivers declaring, "Gentlemen, start your engines!"), attractive professional types strutting through offices (colleagues ponder what's different about Joe and Bob these days) and most recently, ads featuring guys with the blue V from Viagra's brand logo rising behind their heads like a pair of Devil horns. The slogan? "Get back to mischief?" Pfizer is now selling sexual performance, which clearly goes beyond the FDA-approved indication of the drug. The not-so-very subtle new message is obvious: every guy can have a mischievous, raging, new and improved penis.

Since 1998, 23 million men worldwide have filled Viagra prescriptions, making it one of the most successful drugs of all time. Not surprisingly, other pharmaceutical companies scrambled to create their own versions of the drug. This past year, GlaxoSmithKline unveiled Levitra, which is similar in profile to Viagra, but Eli Lilly introduced Cialis, a product the manufacturer claims will start working twice as fast as Viagra and continues for up to 24-36 hours, compared to Viagra and Levitra's promised 4-6 hour window. With Cialis, the implication is that you can swallow one Friday night and you're good to go for the whole weekend. You just know Pfizer and GlaxoSmithKline researchers are busier than Santa's elves right now, toiling away night and day to create bigger, better boner drugs. Viagra is facing some ... stiff competition.

For men, the inability to get or sustain an erection usually leads to all kinds of performance anxiety and self-esteem issues. There are multiple causes for erectile dysfunction -- from physical conditions such as heart disease, prostate cancer and diabetes to psychological factors like stress, anxiety and depression. Even drugs widely prescribed to treat anxiety and depression -- Paxil, Prozac, Zoloft, Luvox, Celexa -- have sexual side effects that can make it difficult to achieve an erection or have an orgasm. Until Viagra and its pharmacological brethren came along, the typical treatments for impotence were penile implants, penile injections, vacuum pumping and insertion of a suppository into your urethra. No wonder we're now willing to pay roughly $10 out-of-pocket per pill when insurance companies refuse to cover these drugs. Apparently, we're also willing to endure the side effects -- headache, stomach upset, flushing (a warmth and redness of the face, neck and upper chest), nasal congestion and changes in vision. And death. There are hundreds of Viagra-related deaths on record and they aren't just a bunch of elderly guys with heart conditions.

Drug task force agents report that they routinely discover Viagra in the possession of college guys who don't have erection problems -- or a prescription.
Drug task force agents report that they routinely discover Viagra in the possession of college guys who don't have erection problems -- or a prescription.

In 2000, researchers at Cedars-Sinai Medical Center in Los Angeles did an analysis of 1,473 major adverse medical events involving the use of Viagra. There were 522 deaths, most involving cardiovascular causes developing within 4-5 hours of taking a 50 mg dose of Viagra. The majority of deaths occurred in patients who were less than 65 years of age and had no reported cardiac risk factors. Other deaths were associated with the use of nitrates (drugs prescribed for chest pain, angina and heart problems) and amyl nitrate, the common ingredient found in "poppers," a liquid whose vapors typically cause an intense head rush and drop in blood pressure when inhaled. Cedars-Sinai researchers concluded that there "appears to be a high number of deaths and serious cardiovascular events associated with the use of Viagra."

As the deaths go unpublicized and the side effects are downplayed, health and law enforcement officials all over the country report that young men who do not have erectile dysfunction are using Viagra as a party drug. In Athens, Georgia, home to the University of Georgia, drug task force agents report that they routinely discover Viagra in the possession of college guys who don't have erection problems or a prescription. They steal it from parents, order it online or buy it from friends. A 2002 San Francisco, California Department of Health study of patients at San Francisco STD clinics found that gay and bisexual men were four times more likely than their heterosexual counterparts to use Viagra. The study also revealed that gay men sometimes combined Viagra use with crystal methamphetamine and other illegal drugs such as Ecstasy, cocaine and ketamine.

What's going on here? Viagra abuse? Yes, and the only real surprise is that more people didn't see it coming. Look, Pfizer guilefully marketed its little blue erection pill, successfully making Viagra a household name within a year of the drug's FDA approval. They provided generous samples to doctors' offices and in many cases, physicians simply doled out freebies to men who asked for it, impotent or not. Men all over America, gay and straight, are getting prescriptions from doctors too embarrassed to ask a lot of specific questions. Your doctor won't prescribe it? No problem. Order it from an Internet pharmacy without the benefit of a good-faith medical examination at all. You can also bet the 23 million Viagra users worldwide shared the wealth with quite a few of their buddies, too.

Last August, Dr. Jeffrey Klausner, director of STD prevention and control for the San Francisco Department of Public Health, petitioned the FDA to list Pfizer's Viagra and similar drugs as Schedule III controlled substances, making them easier to track and harder to prescribe. Klausner, one of the most cogent voices in STD and HIV prevention today, points to several studies documenting an association between recreational use of Viagra and higher rates of risky sexual behavior. In one study, co-written by Klausner, 31% of a group of men who have sex with men reported taking Viagra without medical supervision and use of the drug was associated with higher rates of STDs, including HIV. And Klausner refers to another study -- presented last July at the XV International AIDS Conference -- which found that recreational Viagra users were twice as likely as nonusers to be HIV positive.

Naturally, studies like these are wide open for interpretation and Klausner hasn't many allies. The Executive Director of New York's Gay Men's Health Crisis, Ana Oliveira, robotically repeats a familiar observation, "It's unprotected sex that increases the risk of HIV." And sounding like a woman who doesn't quite grasp the male erection, she adds dismissively, "It's a behavioral issue, not a Viagra issue." Dr. Jason Schneider, a board member of the Gay and Lesbian Medical Association and clinical instructor at Emory University in Atlanta, says Klausner is "a bit extreme," but concedes that "health providers have a responsibility to inquire about a patient's sexual behavior before and after prescribing the medication" and "drug manufacturers could put some money into educating the general public about the use of Viagra in combination with drugs that clearly do lead to risky sexual behavior."

Not surprisingly, Pfizer opposes reclassification of Viagra and balks at making label changes or increasing patient education efforts. Pfizer has, in fact, recently adopted aggressive new advertising strategies to court new consumers and win back customers who migrated to Levitra or Cialis. Meanwhile, boys will be boys. Darlene Weide, Executive Director of San Francisco's Stop AIDS Project, reports that agency surveys indicate a third of gay men interviewed there had used Viagra. "It is well-known in the gay community that Viagra is used as a recreational drug." Erectile dysfunction drugs are increasingly popular and common at sex clubs, bathhouses and even gay campgrounds, where they are shared as casually as a Tic Tac between strangers.

The FDA and Pfizer aren't going to address the sex lives of gay men. It's up to sexually active gay men, positive or negative, to use the head on their shoulders instead of the one between their legs. What do we know for sure? Men who take HIV medications are more likely to experience impotence. If that's happening to you, talk candidly with your doctor about it. Certain protease inhibitors can significantly increase blood levels of Viagra and that can lead to visual problems, headache, fainting or a condition called priapism, where a prolonged, painful erection can last hours or days.

Giving Viagra, Levitra and Cialis away to strangers or acquaintances when you are unfamiliar with their medical history or current prescriptions is irresponsible -- someone could end up unwittingly mixing these drugs with nitroglycerin or nitrate-based heart medications and the results could be fatal. Taking erectile dysfunction drugs with recreational party drugs is just a bad idea, and never inhale nitrate substances, known commonly as "poppers," if you're on Viagra, Levitra or Cialis because it lowers the blood pressure to dangerous levels and can lead to death.

David Salyer is an HIV-positive journalist, educator and activist living in Atlanta, Georgia. He leads safer-sex presentations for men and has facilitated workshops for people infected or affected by HIV since 1994. Reach him by e-mail at