Viagra Fever

It did not arrive in a plain brown wrapper, but it was close. When the UPS delivery man knocked on Mike's door in Regina on the morning of May 22, he was carrying a brown envelope, albeit festooned with Canada Customs stickers and formal-looking information about the contents.

Viagra Fever

It did not arrive in a plain brown wrapper, but it was close. When the UPS delivery man knocked on Mike's door in Regina on the morning of May 22, he was carrying a brown envelope, albeit festooned with Canada Customs stickers and formal-looking information about the contents. Inside, there wasn't some newfangled sex toy or dirty movie. But Mike was still hoping that the package's contents would spice up his sex life, to say the least. For the past two years, Mike - a 36-year-old salesman who, not surprisingly, requests anonymity - has had trouble achieving an erection. Sex with his wife had "virtually stopped," he says. "My brain was willing, but everything else wasn't. And I've been scared. I didn't want to face the prospect of things not working."

Small wonder, then, that his hopes were riding high on the 10 diamond-shaped pills that arrived from a pharmacy in Minot, a North Dakota town four hours south of Regina. Mike had heard about Viagra, the groundbreaking oral medication for erectile dysfunction (the more precise and politically correct term for impotence) produced by Pfizer Inc. of New York City, and available in the United States since early April. Trouble is, Canadian authorities have yet to approve the drug - and are unlikely to do so until at least the fall. But Mike was not about to wait. Instead, he found the Minot pharmacy in a phone book and confirmed that it would honor a prescription written in Saskatchewan. Mike's urologist refused, but his GP wrote the prescription and sent it to North Dakota. A week later, the UPS man stood on Mike's doorstep, carrying the promise of potency.

A few days later, when his wife of two years had a day off, Mike took a pill and waited, thinking - and worrying - about whether it would work. "And all of a sudden, about 45 minutes later, there it was. Like, whoa! Hello!" It was not perfect: his penis was not completely hard, and it took him about four hours to reach orgasm. But he can live with that. "It's like a dream come true," he says.

Mike is not alone, either in praising Viagra or in getting it through the back door. A relative handful of Canadians - those who participated in Pfizer's trials at 27 urology clinics across the country - are still receiving Viagra through official channels. But across the country, thousands of the estimated three million other Canadian men who suffer from some degree of erectile dysfunction are jumping on the Viagra bandwagon, too. Not to put too fine a point on it, they want a piece of the action. Many are going to American urologists for consultations. Others, like Mike, are demanding that Canadian doctors write prescriptions to be filled in border towns. And more troubling, some are using the Internet to order the drug, sight unseen by any specialist.

Viagra fever has hit Canada, bringing with it a host of questions about its ethical, social and sexual implications. Should Canadian doctors be writing prescriptions that can only be honored in the United States, and not in the province in which they are licensed? Should the government deny medication to Canadians, no matter what the demand? And what about women? What do they think of the craze over the pill? Down the road, could using Viagra benefit women, too?

It might seem like a lot of fuss over a little blue pill that Pfizer developed as a treatment for angina, only to find during testing that it had the side-effect of facilitating erections. It works by regulating the balance of two chemicals that, in healthy men, result in a hard penis. The first is cyclic GMP, which is produced during sexual arousal and widens blood vessels into the penis. The other is an enzyme called phosphodiesterase Type 5, which breaks down cyclic GMP. Viagra, whose generic name is sildenafil citrate, works by blocking that enzyme's action, so any GMP produced by the man has more effect. Viagra does not result in spontaneous erections. But an hour or less after taking it, many formerly impotent men respond to sexual stimulus. In U.S. tests, Viagra was 75-per-cent effective.

At the equivalent of $12 to $15 a pill in the United States, Viagra is relatively expensive. It does have some unpleasant side-effects: flushing, headache and heartburn; in a few cases, it causes vision to be blurred by a bluish tinge. But that has not stopped Viagra from becoming the most widely prescribed new drug in history, now taken by more than one million men. Other treatments for impotence - such as pumps and penile injection therapy - boast higher effectiveness rates, but Viagra has them beat for convenience. "It is a tremendously big deal," says Dr. Brewer Auld, a urologist at the Queen Elizabeth II Health Sciences Centre in Halifax, who oversaw a clinical trial. "We haven't had a good oral therapy, so it is a major move."

Beyond its therapeutic benefit, Viagra has become a cultural phenomenon. It has been hailed in various circles as the harbinger of a new sexual revolution, fuelled by men freed from worry about performance in much the same way that the revolution of the '60s and '70s was spurred by women freed by the birth-control pill. "Viagra," says counsellor Sue Johanson, host of the popular Sunday Night Sex Show on the cable network WTN, "could give new meaning to the phrase, 'Don't worry, dear, I'm on the pill.' "

No other drug has entered the common parlance so quickly. In boardrooms and around watercoolers, on late-night talk shows and in stand-up routines, Viagra - a drug that addresses a problem, and a part of the body, that many people are still uncomfortable talking about - has become the inspiration for tittering and locker-room jokes. Even men who use the drug are getting in on the comedy act. One satisfied Canadian Viagra user, who also invests in Pfizer stock, says he made $30,000 on the company's soaring share price over the past year. "So I got a bonus," he says with a laugh, "to go with my boner!"

Funny stuff? Not to Bob Carter. To him, the snickers over Viagra undermine the gravity of a condition that has ruined the relationships and shattered the egos of millions of men - including himself. Now 37 and a financial analyst in Toronto, he has suffered from erectile dysfunction for his entire post-pubescent life. In high school, when other guys were trying to get their girls into the backseat, he shied away from any sexual possibility - "I avoided everything." His first marriage, in his 20s, ended in divorce in part because of his dysfunction, he says. And although he has since remarried and has a good career, the jokes still rankle. "When mutual fund reps come into the office and talk about Pfizer," Carter says, "the girls are laughing and the guys are looking down at the floor. People just can't deal with this."

Carter, who says his second wife, Cindy, pushed him to get treatment, has tried just about everything to help him get an erection. Yohimbine, an herb-based prescription drug, "didn't do anything," he says. And injection therapy was "uncomfortable, very invasive and not spontaneous - just a general pain in the butt, as well as other places." Earlier this year, he was even considering the radical step of surgical implants. Then, in mid-April, he heard about Viagra. Armed with a prescription from his urologist, Carter and his wife drove to Lewiston, N.Y., across the border from the Lake Ontario resort town of Niagara-on-the-Lake. "We tried three or four different places, and nobody had it," he recalls. "Finally, we went to another store and they had some. The pharmacist said, 'You're the eighth guy we've seen from Toronto this week.' "

Carter bought 10 pills at a total cost of $160. After he tried it, he figured it was money well spent. "It works very naturally - I took the pill and a couple hours later I was ready to go," he says. "About 2 in the morning, my wife and I couldn't sleep, because we were laughing and crying and holding each other, and wondering how many other people had gone through exactly the same things we had."

The short answer is, a lot. Experts estimate that between one in 10 and one in eight men will experience total erectile dysfunction by age 60. It can be caused by a host of physiological conditions, all of which tend to impede blood flow to the penis. Among the most common are diabetes, hypertension and blood-pressure irregularities; men who have had surgery for prostate or colon cancer are also at risk. Alcoholism is a factor, as is smoking. A range of psychological problems, from stress and fatigue to depression, can also cause erectile dysfunction. Traditionally, because of the stigma attached to impotence, very few sufferers - at most 10 per cent, specialists say - get help.

Viagra seems to be changing that. "I get stopped everywhere," says Dr. Sidney Radomski, a urologist at The Toronto Hospital. In his clinic, Radomski says he has fielded "tons" of requests for the drug. "People are coming out and saying, 'I have a problem and I want the pill and I want to be treated.' "

But the interest in Viagra is also creating a problem for sufferers and their doctors, simply because the drug is not yet approved in Canada. Last November, Pfizer Canada, based in Montreal, filed an application for Viagra with the Bureau of Pharmaceutical Assessment, the division of the federal Health Protection Branch that approves and monitors new pharmaceuticals. That was only a month after Pfizer filed an application with the bureau's U.S. counterpart, the Food and Drug Administration. In Washington, the drug qualified for a fast-track approval - hence its April release. In Canada, the criteria for the fast track are more strict: the drug has to address a life-threatening or seriously debilitating condition. Although Pfizer requested that Viagra be given quick consideration, Canadian health authorities turned the company down.

How much longer it will take Ottawa to approve the drug is unclear. Mary Carman, director of the Bureau of Pharmaceutical Assessment, says the entire process usually takes 18 months. But that depends, she adds, on the quality of the data the drug company has presented and on the allocation of resources from Health Canada. Right now, the bureau is conducting safety reviews of Viagra. Nothing is certain in the world of drug approval, but the time frame for review is 300 days from the date the Health Protection Branch accepts the drug company's application, which was last December. That might mean Viagra will be approved by September - or not. "We piece together the puzzle by analyzing and validating the outcomes of the tests," says Carman. "These are very detailed studies."

For Toronto Hospital's Radomski, whose impotency clinic is participating in the drug trials, that is not good enough. He calls Health Protection Branch officials "a bunch of bureaucratic idiots" for not putting Viagra on the fast track. "Here I am, one of the researchers in the study, and I can't prescribe the drug because the Health Protection Branch doesn't want to get off their butts," Radomski fumes. "And yet some Joe Blow family physician or urologist in the States, who's never worked with the drug before, can prescribe it till the cows come home. It just doesn't make any sense."

In the U.S. communities that dot the border with Canada, dealing with Viagra fever has become something of a cottage industry. Dr. John Pettit, who runs a urology clinic in Bellingham, Wash., about 20 miles southeast of where the interstate highway crosses into British Columbia, says about two dozen Canadian men - most in their 60s and 70s - have come to see him since April. Pettit insists on a medical evaluation before he will prescribe the drug, and he forwards the test results to the patient's Canadian physician. Typically, the consultation costs between $145 and $175, and the patient leaves with a couple of sample tablets and a prescription for 10 or 20 more. Pettit says he is careful to ask patients what other drugs they are taking - especially cardiac medications like nitroglycerin, which is contraindicated for Viagra. A handful of those coming to see him, Pettit adds, have been healthy men who simply wanted to experiment with the drug. "I've turned away a few," he says.

Just to the north, in the town of Ferndale, another Washington business caters to the Canadian demand for Viagra in a different way. Like a growing number of U.S. pharmacies in North Dakota, New York, Michigan and other states, Ferndale Drugs will honor prescriptions written by Canadian doctors. Behind the counter, Steven Erickson, one of the store's four pharmacists, says he has seen "quite a few" Canadians looking for Viagra - although even more place their orders without bothering to come to Ferndale at all. "We get a lot of mail requests," says Erickson. "They'll have their doctor phone or fax a prescription to us. We get one of those a day." Most Canadians, Erickson adds, pay by credit card. The price for a five-pill prescription, including shipping: between $95 and $100.

There is nothing illegal about Canadians buying non-approved prescription drugs in the United States, as long as they are only for personal use. But for Canadian doctors, the ethics of prescribing Viagra are dicier. Some will not do it. Dr. Thomas Elsdon, a urologist in Windsor, Ont., says he gets 10 or 12 patients asking for Viagra every day, and he refers most of them to a physician in nearby Detroit. "I probably refer six or eight a week to this urologist, and I'm not the only one sending guys over there," Elsdon says. "We have to provide access to the drug somehow, because patients have just demanded it."

Other physicians say the best way to ensure their patients are properly monitored while on Viagra is to write the prescription themselves. But with the high demand for Viagra, some doctors are worried that it will be misprescribed - an especially serious problem in cases where erectile dysfunction is the result of a more grave condition such as diabetes or a pituitary gland tumor. "The hype could contribute to this," says Toronto endocrinologist Dr. Jerald Bain, medical director of Toronto's Health Institute for Men. "Patients will demand it and doctors will say what the heck? They'll write the prescription for Viagra, but it might be masking some underlying pathology, even if it works."

Another concern: some doctors may not have all the information they need, because Canadian law prohibits pharmaceutical manufacturers from distributing information about a non-approved drug. Viagra is still considered experimental in Canada, and if something goes wrong, doctors who prescribe it could be open to legal action. The College of Physicians and Surgeons of Ontario is advising doctors to exercise caution - and consult their lawyers - before prescribing Viagra. "What if someone has an adverse reaction?" says CPSO spokeswoman Jill Hefley. "Physicians need to know what their responsibilities are."

Those concerns were thrown into new light earlier this month with reports that six men in the United States died while on the drug. In response, FDA authorities said it was unclear whether Viagra had anything to do with the deaths. Pfizer, meanwhile, reiterated the warning that the drug not be prescribed to men taking nitrates such as nitroglycerin. Other observers pointed out that men suffering from erectile dysfunction tend to be older, and six deaths among a million users may not be significant.

But they were enough to make at least one Canadian sufferer think twice. Bob, a 43-year-old self-employed computer specialist from eastern Quebec, was all set to order Viagra over the Internet. (A handful of ethically questionable Web sites cater to the non-U.S. market, offering customers "on-line" medical consultations and drug prescriptions.) Now, he is reconsidering. "There have been FDA boo-boos before," says Bob, who has been using injection therapy about three times a week for the past two years, with few complaints. "I'm kind of glad other people are trying Viagra out before me."

Since its U.S. release, dissenting voices about Viagra have been rare. But recently, a handful of doctors and other experts - many of them female - have begun to question its long-term implications. For years, therapists have been preaching that there is more to healthy sex than penetration, that intimacy, touching and feelings are the important things. But much of the fervor over Viagra - and its emphasis on the primacy of a hard penis - runs counter to that message. "Viagra's going to be great for a lot of people," says Sue McGarvie of the Ottawa Sex Therapy Clinic. "But the issue has always been that sex has less to do with the in-out, repeat-as-necessary, than with what's going on between the ears."

Traditionally, women have been more concerned than men with the emotional and psychological aspects of intimacy. And Viagra raises the spectre of a man who wants penetrative sex - and is determined to get it, whatever his partner's feelings. McGarvie recently counselled the wife of a man who had purchased Viagra in the States. "They hadn't been having intercourse for years, but they were having other types of sexual activity," McGarvie says. "She was quite happy with that. But now, she's like, 'What was the problem?' " Another woman who may have cause to regret Viagra's introduction is Roberta Burke, 61, of New Jersey. Last week, she filed a $2.8-million palimony suit against her former partner, claiming that the drug led the 70-year-old man to infidelity and destroyed their 10-year relationship.

Despite such problems, Toronto sex therapist Marianne Keystone says Viagra will be a big help "to a small percentage of men" with erectile dysfunction. For the rest, the problems go deeper - beyond the plumbing of male genitalia and into psychology. "I think people are being misled, to think that we are getting a new sexual revolution just because we have a pill to give men erections," adds Keystone. "I wonder if we'd say that if it was a pill for women instead of men."

Well, they're working on it. At Vancouver Hospital, sexual medicine specialist Dr. Rosemary Basson - who took part in Viagra testing for men - is now conducting a small study of the drug on women. "The [female] physiology is much the same as a man's," she says. "The enlargement of the clitoris is based on the same nerve response." But she points out that "with women, there isn't that objective evidence of sexual response that there is in men." Basson adds that it is too early in the study, in which some women are on a placebo, to say much about the drug's effectiveness. "Some women are reporting effects," she says. "But how can you tell whether they're on the real drug or not?"

For now, at least, taking Viagra is pretty much a guy thing. And with men like Bob Carter and Mike in Regina swearing by the drug - and looking south of the border to get it - it seems clear that the fever over the so-called potency pill will rage on. Amid the hype and the titillating testimonials, perhaps the sanest advice comes from sex educator Johanson. "What I'd like Canadians to do while they're waiting for the pill to arrive is learn more about sex," she says. "How about getting some counselling? How about solving your relationship problems first?" Because when and if the drug is approved in Canada, the real question may not be whether Viagra is ready for men - but whether men are ready for Viagra.

Maclean's June 8, 1998