viagra

Dr.Joe's Data Base

THE VIAGRA CRAZE

A pill to cure impotence? Afflicted men are saying Yesss! But is
this the end of sex as we know it?

By BRUCE HANDY

Besides its phony name, funny shape and unappetizing color, what's
not to like about Viagra, the new pill that conquers impotence?
Could there be a product more tailored to the
easy-solution-loving, sexually insecure American psyche than this
one? The drug, manufactured by Pfizer, went on sale three weeks
ago, finally giving talk-show hosts something other than Bill
Clinton and Pamela Lee to crack smarmy jokes about.

Spurred, perhaps, by just that sort of publicity, would-be patients
have been besieging urologists' offices and sex clinics--men both
genuinely dysfunctional and merely dissatisfied, skulking around
in hopes of achieving "better" erections through chemistry.
Already, a kind of Viagra connoisseurship is beginning to take
hold. "The hundreds are absolutely incredible," says a very
satisfied user, referring to the drug's 100-mg maximum- strength
dosage, "and the effect lasts through the following morning." What
else can one say but Vrooom! Cheap gas, strong economy, erection
pills--what a country! What a time to be alive!

"We've always been waiting for the magic bullet," says Dr. Fernando
Borges of the Florida Impotency Center in St. Petersburg, where he
has been working with sexually dysfunctional patients for 21
years. "This," he says, "is pretty close to the magic bullet." The
very day Viagra became available, Dr. John Stripling, an Atlanta
urologist, churned out 300 prescriptions with the help of a rubber
stamp he had had the foresight to purchase. At the Urology Health
Center in New Port Richey, Fla., which participated in the drug's
clinical trials, the waiting time to see a doctor for a Viagra
consultation is a month. Not that this has stopped motivated
patients. "We've been inundated with emergencies," says Dr. Ramon
Perez. "Pain in the kidney. Blood in the urine. But when they get
in here, they just want to ask us about Viagra. It's amazing.
These people have been impotent for three years, and they cannot
wait another few days."

"It's the fastest takeoff of a new drug that I've ever seen, and
I've been in this business for 27 years," says Michael Podgurski,
director of pharmacy at the 4,000-outlet Rite Aid drugstore chain.
After a brief lag, the drug is now being prescribed at the rate of
at least 10,000 scripts a day, outpacing such famous quick
starters as the antidepressant Prozac (which went on to become one
of the biggest-selling drugs in America) and the baldness remedy
Rogaine (which has been something of a disappointment after its
initial blaze of popularity).

The run on Viagra has been abetted by the likes of David Michael
Thomas, a Milwaukee, Wis., osteopath who advertises his services
on the Web at www.penispill.com and who allegedly prescribed
Viagra to some 700 patients after cursory $50 telephone
examinations. At a license-suspension hearing in front of
Wisconsin regulatory officials last week, Thomas agreed to stop
the practice. (Normally a diagnosis of impotence involves a
rigorous physical exam, blood tests and an extensive sexual
history.) Other entrepreneurs have been offering prescriptions
directly over the Internet.

Even supporters of the pill worry about hyped expectations. "People
always want a quick fix," complains Dr. Domeena Renshaw, a
psychiatrist who directs the Loyola Sex Therapy Clinic outside
Chicago. "They think Viagra is magic, just like they thought the G
spot worked like a garage-door opener." In the wake of fen/phen
and Redux, the diet-drug treatments that were pulled from the
market last year after it was learned that they could damage heart
valves, caution would be advisable with Viagra. But so far the side
effects seem comparatively slight and manageable: chiefly
headache, flushed skin, upset stomach and curious vision
distortions involving the color blue. Pfizer, leaving nothing to
chance, has even requested and received the Vatican's unofficial
blessing for Viagra. All in all, a happy ending for American men,
their partners and especially Pfizer stockholders, who have seen
the value of their shares jump nearly 60% this year alone.

Yet there's something unnerving about Viagra too, not so much on
the face of it (the drug's merits appear to be manifold; doctors
think it might even improve the sexual response of postmenopausal
women) but in the broader philosophical implications. Is sexuality,
like the state of happiness or male-pattern baldness, just one
more hitherto mysterious and profound area of human-beingness that
can be pharmaceutically manipulated, like any other fathomable
construct of enzymes and receptors? Another looming question: Since
Viagra is taken--at prices ranging from $8 to $12 a pop--not on a
day-in, day-out basis but only when one actually wants to have
sex, will HMOs and other insurers soon be telling us how much sex
is reimbursable? Sufficient? Normal? Necessary?

And what about the impact on the freighted social interactions we
euphemistically refer to as dating? "I bet that within a year,
you'll see women's-magazine articles saying, 'How to Tell If It's
You or Viagra,'" says James R. Petersen, who has written the
Playboy Advisor column for the past 22 years. He adds, "I think
Viagra is going to be as monumental as the birth-control pill." No
less an authority than Bob Guccione, publisher of Penthouse
magazine, believes the drug will "free the American male libido"
from the emasculating doings of feminists. And not only that.
According to Guccione, "the ability to have sex by older men will
make them healthier and live longer. It will fool the biological
clock when men are still active in the later years. It is a very
significant effect of the drug that many haven't contemplated."
There isn't any actual scientific evidence to back up Guccione's
claims, but he does do a nice job of illuminating two important
subtexts of Viagra's appeal: the chimeras of undiminishable power
and perpetual youth.

Of course, the overt appeal is pretty compelling too.

In the past decade there have been great advances in the treatment
of impotence, which is now seen by most therapists, in most cases,
as a physiological rather than a psychological problem, rejecting
the medical establishment's long-held view. The word impotence
itself, like "frigidity" for women, is considered suspect in many
circles; the more politically correct--or at least clinical--term
is erectile dysfunction, or ED, as it is commonly abbreviated.
Inspired by a 1992 National Institutes of Health Conference and
landmark 1994 study on the problem, the diagnosis has been defined
more broadly, from the rather strict criterion of inability to get
an erection, period, to the somewhat more elastic and subjective
criterion of inability to get an erection adequate for
"satisfactory sexual performance." This has led to a tripling of
the number of men estimated to be impotent in this country--some
30 million according to the NIH, half of whom are thought to be
under the age of 65. ED is associated with age; it affects about 1
in 20 men ages 40 and up, 1 in 4 over 65.

From a drug manufacturer's point of view, this burgeoning of the
potential market has coincided quite nicely with the development
of pharmaceutical treatments. (At least two more impotence pills
are in the pipeline from different companies.) Before Viagra, the
most promising therapies involved putting gel suppositories in the
urethra and injecting drugs directly into the base of the penis.
The downside is not hard to grasp. "You can imagine the look most
patients gave when I told them they would have to stick a small
needle into the most sensitive portion of their body," says
University of Chicago urologist Dr. Gregory Bales. The good news
is that the erections resulting from such injections can last an
hour or more, even after orgasm, though depending on one's taste
and circumstances, this too could be a downside. Other treatments,
which involve vacuum pumps, penile implants and penis rings, are
no less awkward or, to get to the heart of the matter, no more
conducive to the spontaneous, unselfconscious, beautiful sex that
Calvin Klein ads imply is our daily right.

The promise of Viagra is its discretion and ease of use. Doctors
recommend taking the pill an hour before sex, which might lead to
some wastage among overly optimistic users but shouldn't otherwise
interfere too greatly with the normal course of coital events. An
even greater advantage, or at least a more naturalistic one:
unlike the injectable drugs, which when efficacious produce an
erection regardless of context (famously proved by Dr. Giles
Brindley, a leading British impotence researcher, who once
demonstrated a successful experimental treatment by dropping his
trousers in front of hundreds of astonished colleagues at a
conference), Viagra merely paves the way for the possibility of
arousal. Erections must still be achieved the old-fashioned way,
whether through desire, attraction, physical stimulation, the
guilty thrill of an illicit affair, page 27 of The Godfather or
what have you.

Loyola psychiatrist Renshaw offers the instructive example of a
couple who came to see her the day after the man had taken Viagra
for the first time: "They went to bed to wait for something to
happen and fell asleep while they were waiting. They forgot to have
foreplay. They expected an instant erection." The next night,
after Renshaw gently reminded them about the importance of
stimulation, they had intercourse for the first time in three
years.

During the drug's clinical trials, which as a rule tend to have
rosier outcomes than real life, Pfizer reported a 60%-to-80%
success rate, depending on the dosage (compared with a 24% success
rate for placebos). The anecdotal evidence is even more compelling,
if one can put up with a certain amount of crowing. Earl Macklin,
a 59-year-old security guard in Chicago, has suffered from
impotence on and off for 10 years as a result of diabetes. The
first two times he tried Viagra, it produced minimal results; the
third time he was able to have intercourse with his girlfriend for
the first time in their four-month relationship. "I've been using
it every day since then," he says (four days later) with a
conspiratorial chuckle. "It makes me feel like I'm in my 30s
again." Macklin's insurance company has notified him that it won't
be reimbursing him, so, he says, "I'll limit myself to 20 pills a
month."

Tom Cannata, a 43-year-old accountant from Springfield, Mass., has
been taking Viagra for the past three years as a trial subject. He
was suffering from partial impotence brought on, he believes, by
years of bicycle riding (an activity, it should be noted, that is
not universally held to be a cause of impotence). Cannata was able
to achieve erections but felt that they "should have been stronger
and much longer-lasting." Viagra worked for him the first time and
has worked ever since. "Not only is the frequency of our sex
greater," he says, "but for me it is much more intense than it was
without the medication. The quality is so much better. Much
firmer, stronger erections. And the orgasm is much more explosive."
So pleased has Cannata been with the results that he was inspired,
he says, to go out and buy a sports car not long after beginning
the drug--indicating, perhaps, a soon-to-boom, Viagra-inspired
market for souped-up cars, Aramis, oversize stereo equipment and
other accoutrements of the virile life-style.

Some patients TIME queried had no reaction to Viagra whatsoever.
Others have had more ambiguous experiences. Consider Irving
Mesher, a 73-year-old retired New York City firefighter, who
currently lives at a family-owned nudist resort in Pennsylvania's
Pocono mountains. He describes himself as "sexually motivated" and
"very active." Thanks to injection therapies (prostate-cancer
treatments six years ago left him "semihard"), he has been having
sex--by his account--as often as three or four times a week with
several girlfriends in their 20s. Still, he was eager to try
Viagra. Taking a 50-mg dose the first time, he was pleased with
the results: "About as hard as it can get." However, a subsequent
experiment with a 100-mg pill backfired, having no beneficial
effect, as did a return to 50 mg. Mesher nevertheless plans to
continue with Viagra, inspired, perhaps, by the example of his
70-year-old best friend Frank, who took the drug last week and
"turned into a monster." The two are planning to invite several
friends to a Viagra party.

As Mesher's story suggests, and many doctors insist, more isn't
necessarily more with Viagra. Known to chemists by the less
evocative name of sildenafil (the word Viagra, redolent of both
"vigor" and "Niagara," had been kicking around Pfizer for years, a
brand name in search of a product), the drug began life as a heart
medication designed to treat angina by increasing blood flow to
the heart. Sildenafil, it turned out, wasn't so good at opening
coronary arteries, but happy test subjects did notice increased
blood flow to their penises, a side effect brought to Pfizer's
attention when the test subjects were reluctant to return their
leftover pills. The medication works by suppressing the effect of
the naturally occurring enzyme phosphodiesterase type 5 (PDE5),
which causes an erection to subside after orgasm by breaking down
the body chemical known as cyclic GMP. It is cyclic GMP that
initiates the muscular and vascular changes that lead to an
erection in the first place. While PDE5 is always present in the
penis, cyclic GMP is produced only during arousal. The catch in
impotent men is that they may not produce enough cyclic GMP to
temporarily "win out" over the PDE5. Thus the efficacy of Viagra:
by strong-arming PDE5, it allows a little bit of one's cyclic GMP
to go a long way.

One more nugget of possibly boring but crucial biochemistry: the
erectile tissue in the penis has a finite number of receptors for
cyclic GMP. This means that a normally functioning man with
adequate levels of the chemical shouldn't get any more bang for his
buck by gobbling Viagra; the variations anyone feels in his or her
sexual response are due to factors outside the drug's purview. At
the same time, Pfizer hasn't done any testing of the drug on
nonimpotent men to prove the point, but it's hard to imagine that
biochemical nitpicking is going to stop people from experimenting.
Certainly it will be hard for wet blankets and smarty-pants to
compete with the siren calls coming out of sex clinics around the
country from men "feeling 18 again."

"If you can have an erection naturally, you probably won't need
Viagra," says Thomas Burnakis, pharmacy clinical coordinator at
Baptist Medical Center in Jacksonville, Fla. "It's not going to
make your erection harder or last longer. But I can guarantee you
that if you walk in and say, 'Doc, I'm having trouble keeping my
flag up,' most physicians are not going to insist on testing.
What's to keep you from using it? Absolutely nothing. And just as
with fen/phen, while a lot of doctors said they would not give that
drug, a lot of clinics were prescribing it. It's going to be a
moneymaking procedure. They'll give a cursory exam, charge you for
that and write the prescription"--a prediction that has already
been borne out on the Internet. According to Pfizer, there's no
evidence that overeager users could develop a physical addiction
to Viagra. But as for a psychological addiction, that is uncharted
territory.

It is because of the potential for abuse and, more to the point,
the traditionally seedy associations that cling to impotence
remedies (witness the ads in the back of low-rent men's magazines
for spurious Spanish fly, hard-on creams and the like) that drug
companies have only recently turned their attention to sexual
dysfunction. This would account for the tone adopted by Pfizer
chairman and CEO William Steere even as he figuratively licks his
chops over the potential market in "aging baby boomers." He is
careful to point out that "quality- of-life drugs are gene-based
just like those for serious medical conditions. In areas like
impotence, aging skin, baldness and obesity, the science is just as
profound as if you were working in cancer, asthma or
anti-infectives." In other words, Viagra is sober stuff and not at
all akin to Sy Sperling's Hair Club for Men.

Along related lines, a brochure for Pfizer employees points out
that while "jokes and puns are often used in conversation about
sexual health topics...you can redirect humorous remarks to more
appropriate discussion by not joining in the humor and pointing out
the seriousness of the subject matter, reminding the people with
whom you speak that ED is a significant medical condition that
affects the lives of millions of men and their partners." This is
true, of course. It also speaks to the tricky questions of taste
and exploitation that Pfizer will have to navigate in marketing
the drug. So far, without an official launch or virtually any
promotion, Viagra is doing fine. But why hold back? Advertisements
will begin appearing in medical journals in about six weeks,
followed by consumer ads this summer. A company spokesman says
they will be "tasteful and emotional, emphasizing [impotence] as a
couple's condition." One can imagine.

At any rate, it's an emphasis that should remind us that human
sexuality is far too rich and complex for the entire subject to be
balanced on the delicate fulcrum of an erection. As with the
debate in psychiatry between traditional talk therapists and their
more pharmacologically minded colleagues, controversy over Viagra
and its cousins may well provoke a rift among sex researchers.
Raymond Rosen, a professor of psychiatry at the Robert Wood Johnson
Medical School in Piscataway, N.J., makes the obvious but necessary
point that Viagra will not be the final word on sexual dysfunction
or dissatisfaction: "There's a danger that we could lose sight of
the fact that a lot of sexual problems relate to poor relationships
or poor self-esteem or anxiety, depression or other factors." Or
as Petersen, the Playboy adviser, puts it, "You can take an angry
couple and give them Viagra, and then you have an angry couple
with an erection." Oddly, that's reassuring.

--Reported by Edward Barnes and Lawrence Mondi/New York, Wendy
Cole/Chicago, Greg Fulton/Atlanta and Arnold Mann/Washington

Discuss Viagra with the experts online Thursday, April 30, 7 p.m.
ET, at time.com

WHAT'S BEING SAID ABOUT VIAGRA BY THE FAMOUS...

--"Even if a man has an erection from floor to ceiling and can keep
it that way for an hour, it will not be pleasurable for a woman if
he is not sexually literate. There has to be an education process
to go with this drug. On the positive side, by the year 2004 there
will be 90 million grandparents in the U.S., and for them, this
will be a boon." --DR. RUTH WESTHEIMER, sex adviser

--"It is frightening to be a male these days. We are a
performance-oriented society, and sex has always been to the
woman's advantage. For sex to occur, all she really has to do is
lie there." --NANCY FRIDAY, author of The Power of Beauty and Men
in Love

--"Feminism has emasculated the American male, and that
emasculation has led to physical problems. This pill will take the
pressure off men. It will lead to new relationships between men and
women and undercut the feminist agenda. It will free the American
male libido much the same way the Pill did." --BOB GUCCIONE,
Penthouse publisher

--"The astounding success of Viagra testifies, I think, to how
integral the erection is to men's self-worth. The penis is a
weapon, and much of society has been aimed at controlling it. But
it is also a lewdly lyrical thing. It is man's most honest organ.
It is either up or down, and you can't lie about it." --GAY TALESE,
author of Thy Neighbor's Wife, is writing a book about the penis

--"The erection is the last gasp of modern manhood. If men can't
continue to produce erections, they're going to evolve themselves
right out of the human species. I want men to re-examine, really
re-examine why they need this pill. Because they do need it, they
need it right now. They need it to bolster themselves. They need it
to stiffen their erections. It's like the steel that they would get
if they were at war." --CAMILLE PAGLIA, postfeminist social critic

...AND THE NOT SO FAMOUS

--"I've waited seven years for a real erection. This little pill is
like a package of dynamite; you don't know if you're going to
diffuse the little sucker or if it's going to explode in your
face." --RONALD MARROCCO, a 55-year-old diabetic from St.
Petersburg, Fla.

--"Not only is the frequency of our sex greater, but for me it is
much more intense than it was without the medication. The quality
is so much better. Much firmer, stronger erections, and the orgasm
is much more explosive, much more satisfying." --TOM CANNATA, a
43-year-old accountant from Springfield, Mass.

--"I've been using it every day. It makes me feel like I'm in my
30s. I don't worry about the risks." --EARL MACKLIN, a 59-year-old
security guard in Chicago

--"There was significantly more lubrication. I did get a slight
headache last night and in the morning, and I had major facial
flushing during sex and afterward." --a Seattle nurse who
experimented with Viagra without telling her husband

--"I hear that it works for 2 out of 3 men. Maybe I'm the one."
--TYRONE, a 48-year-old city employee in Chicago with diabetes who
has tried Viagra twice, so far with no real improvement

May 4, 1998 VOL. 151 NO 17