On the 16th of November, the unconscious body of 21-year-old Aaron Connor was found in the toilets of a Starbucks cafe in Belfast city centre. He was one of seven people who died of a drug overdose in Northern Ireland over just ten days last month. While it's not yet certain which drugs killed Aaron, it's believed most of these deaths involved heroin in combination with other drugs, most notably a drug originally designed to treat epileptic seizures: pregabalin.
Now increasingly prescribed for nerve pain and anxiety, pregabalin has in the last six years become the second most lethal controlled drug after valium in Northern Ireland. In 2012, the drug was involved in zero deaths, a figure that has risen to 33 – one quarter of all drug deaths – by 2018 in a country with a population of just 1.8 million.
The wider UK is facing a similar problem, not just with pregabalin, but a similar drug, gabapentin, also prescribed for epilepsy and nerve pain.
England and Wales has seen pregabalin-related deaths spiral upwards, from four in 2012 to 187 in 2018, while deaths involving gabapentin have risen over the same period from eight deaths to 93. In Scotland, the two drugs are now a major cause of fatal drug overdoses, implicated in 367 deaths last year. As a result, in April of this year, the UK government stepped up controls of both medicines, reclassifying them as Class C drugs. But as usual, the clampdown has failed to curtail the black market in these drugs.
So why are so many people taking a drug meant for epileptic seizures and back pain and ending up dead?
In Belfast, pregabalin – known to users as "bud" because the blue and red 300mg capsules remind them of the Budweiser logo – has become a staple high among the city's growing number of young, homeless heroin users.
Joey is one of them. In his mid twenties, he lives in temporary accommodation. "Buds give the gear [heroin] a push," he tells me. "I get that warm feeling in my face, I can feel like I'm able to deal with my life." Joey gets his pregabalin mostly from people who are prescribed it, but sell it instead.
Chris Rintoul – a drugs and alcohol consultant at Extern, a Belfast-based social care agency – says use of the drug has risen off the back of an epidemic in the use of diazepam, better known as valium, since the Troubles.
"Pregabalin is a big issue here in Belfast. It’s been driven by historically high levels of diazepam prescribing, which itself was driven by conflict-related trauma," he explains. "When the authorities finally decided to clamp down on prescribing diazepam, the illegal market in that drug stepped in, but then so did pregabalin, which doctors had started to prescribe for anxiety and pain."
NHS data shows prescriptions for pregabalin have increased dramatically over the last decade, from 476,102 in 2006 to 5,547,560 in 2016. In 2015 there were 10.5 million prescriptions for pregabalin and gabapentin combined.
The abuse of pregabalin was originally reported among prisoners, largely as a result of prison doctors prescribing the drug to any prisoner who knew how to fake the symptoms of neuropathic pain. In 2014, prison prescribing was curtailed, but the cat was out of the bag: like valium, pregabalin and gabapentin were easy to get hold of, cheap and potent for people trying to self-medicate untreated mental health problems, or those who just wanted to numb the pains of their daily lives.
Rintoul says heroin users also take pregabalin – brand name Lyrica – because they say it alleviates the lows and intensifies the highs. But using pregabalin and heroin together, like heroin and diazepam, increases the chance of an overdose. Lab experiments on mice have shown that pregabalin exacerbated heroin-induced respiratory depression by reversing heroin tolerance at low doses, and directly depressed respiration at higher doses.
Pregabalin-related drug deaths are almost always in combination with other drugs, most notably opioids such as heroin, which are present in 79 percent of overdose cases. Despite initial claims by makers Pfizer that it was not addictive, many users say they have become addicted to pregabalin, an issue raised by senior doctors in 2017.
Rintoul says it's a hard drug to kick: "Big Pharma was wrong when it said pregabalin was easy to get off. I've not seen anyone get off it after using it for 12 months. There are extremely nasty withdrawals – headaches, nausea, extreme depressive episodes, paranoia, severe confusion, sweats and insomnia. You feel like things are crawling under your skin. It's months of mental hell. The withdrawals are as bad as heroin and benzos, if not worse."
Mark is a 51-year-old from Belfast who has been living with horrific levels of PTSD from the Troubles, after being shot by Loyalist paramilitaries in the early 1990s. He still has severe mobility issues in both legs due to the attack. He was prescribed diazepam to help him cope with PTSD, from the events he had witnessed as well as his own injuries.
"I spent some time in prison," he tells me. "My mental health took a dip pretty quickly while in there in 2005. The prison GP put me on pregabalin to help me with my anxiety. They made me feel human again. I wasn't scared to get out of bed. But when I was released, my own GP refused to prescribe them for me again, so I started buying them on the street."
For a prescription-only drug, pregabalin is not hard to get hold of. A quick online search and I can buy it from websites based in Pakistan, New Zealand and Canada, shipped to my home address within days, without a prescription, for as little as £40 for a 30 x 150mg packet. "You get fakes sometimes, but they're still doing the same thing if you take enough of them," says Mark. "If I don’t have them I can get really aggressive and start acting out. I’ll end up back inside."
Noticing that he winces whenever he moves too far back in his chair, I ask him if the pregabalin helps with pain. "Yeah," he starts. "Well, I don't notice the pain when I have buds in me. It's like heroin – you're off your head, so why would you care? I didn’t want to be alive anymore after I was taken off them last time. I wouldn't wish it on anyone."
As drug overdose statistics have shown, the abuse of pregabalin has been rising across the UK. Michael Linnell, Co-Ordinator of UK & Ireland DrugWatch, says a black market in pregabalin and gabapentin abuse has spread across the country.
"The genie is out of the bottle. It started mostly with inappropriate prescribing," he says. "Once the drug was controlled by the Misuse of Drugs Act, the demand was still there, so the illegal market grew. As with benzodiazepines such as diazepam, heroin users are the main group that use pregabalin, and heroin users exist in pockets all over the country. Pregabalin is pretty much seen as interchangeable with benzos. They will use whatever is about."
Michael says that in Wythenshawe, just outside Manchester, pregabalin users are often caught trying to source pregabalin and gabapentin from pharmacies using fake prescriptions.
"Pregabalin and gabapentin both became class C drugs in April this year. Although there is still felt to be inappropriate prescribing of pregabalin, there are reports of older entrenched users disengaging with services that would not prescribe, just shopping around for someone more willing to prescribe or looking to the illicit market. It's the usual paradox, that curtailing inappropriate prescribing and bringing a drug under the Misuse of Drugs Act has probably led to the growth in the illicit market. We suspect [and are awaiting tests] that much of what is sold is fake, or imported generic brands."
With mental health problems across the UK on the rise and budgets to treat the issue being cut, pills such as pregabalin and diazepam have become a relied upon form of treatment. It's impossible to say the growing addiction rates and number of deaths involving pregabalin are fuelled by a lack of funding for acute mental health services, homelessness or drug treatment services. But the less help people struggling with these serious issues get, the more likely they will be to turn to dangerous, often fake drugs to take away the pain and mollify real life.