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Logo of Phnom Penh Post newspaper Phnom Penh Post - Over-the-counter addiction

Despite existing laws that say so, prescriptions are not needed to buy potentially addictive and deadly drugs from most any streetside pharmacy in the Kingdom. VicToria Mørck madsen
Despite existing laws that say so, prescriptions are not needed to buy potentially addictive and deadly drugs from most any streetside pharmacy in the Kingdom. Victoria Mørck Madsen

Over-the-counter addiction

Prescription painkillers and anti-anxiety drugs are notoriously easy to come by in the Kingdom. Many here from abroad take them recreationally, tempting addiction or worse

The pharmacy is overflowing. Behind a white-coated clerk, a row of shelves are stocked with cartons arranged in precariously leaning stacks.

The glass counter in front of the pharmacist contains an even larger bounty. Here, there are potent drugs for every ailment: depression, anxiety, insomnia, back pain.

Their titles read like a medical school exam answer sheet: Dicodin, codeine, Valium, Zolnox, clonazepam, alprazolam. In much of the developed world they are called “prescription” pills – psychotropic drugs intended for medical use and available from a pharmacist only with a doctor’s prescription.

But in the Kingdom, the label, while legally binding, is in practice merely superficial – one needs only money to buy them. 

In the West, the abuse of prescription pills has reached near epidemic levels, and brought with it serious dangers – in the United States, prescription drugs account for more deaths annually than heroin and cocaine combined.

For some foreigners coming to Cambodia, popping potent drugs bought over the counter for fun remains an occasional recreation. But for others, the easy accessibility of such mindbending pills is seriously damaging.

“The first prescription I did was codeine, and I remember that it was pretty cool,” said Ragnar*, 19, an Australian backpacker who has visited the Kingdom twice.

After discovering the ready availability of prescription drugs here during his first visit in 2013, he began regularly abusing a wide range of psychotropics.

“After the first trip, I started looking up opiates in the year that I was back in Australia,” he said.

Ragnar returned to Cambodia last December, excited to experiment with more drugs.

They were easy to obtain, he said, from the pharmacy across from his hostel. They were cheap too: $4.50 for 16 pills of codeine – an opiate painkiller and his drug of choice. But things went downhill fast.

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Several local pharmacists said that prescription painkillers like codeine were mostly bought by expats. Victoria Mørck Madsen

One night, while relaxing with friends in their hostel room, the backpackers ingested a cocktail of psychotropic drugs: Xanax, codeine, Valium, dihydrocodeine and Zolnox. “Not at the same time but at varying times during the night,” said Ragnar.

After his pals passed out from the potent mix, Ragnar lay on his bed and continued the prescription binge.

“I took too much. My kidneys failed and I got a compression of my sciatic nerve – a nerve in your back that controls your lower body.”

Ragnar passed out and when he awoke the next morning he could not move his legs. For two days he remained in bed, popping pills and trying to “sleep it off”.

On the third day of paralysis, his friends carried him into a tuk-tuk and headed to a clinic. The nurse there told Ragnar to visit a hospital immediately.

“My friends were freaking out, but I wasn’t so much because I was still inebriated,” he said.

Ragnar’s mother, who was in Thailand at the time, flew to Phnom Penh and transported him back to Australia, though not before dishing out five grand to a Phnom Penh hospital for Ragnar’s five days of board and dialysis treatment. Nearly a year later, he is still recovering from the close call.

“I’m walking now but it’s just a bit sloppy,” relayed the teenager from Australia. “I still can’t move my ankles.”

The type of binge popping that Ragnar participated in represents one danger presented by the easy availability of prescription pills. The other, and more insidious danger, is addiction.

According to Nick Barton, an MA holder in clinical psychology and chief executive of the UK-based anti-drug NGO Action on Addiction, dependencies on prescription pills, most commonly opiates (painkillers) and benzodiazepines (mood alterers), “is believed to be a growing problem across the world”.

“[Addiction] often starts with a prescription for a physical ailment like pain relief … then people develop a habit and become dependent and addicted to them.

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A typical Phnom Penh pharmacy, overflowing with pill boxes. Victoria Mørck Madsen

The reason that they started taking them may disappear, but then they’re [still] taking them. One problem is replaced by another,” Barton said.  

Under Cambodian drug laws, most prescription painkillers and benzodiazepines medications can only be bought with a doctor’s note. Since 2005, Cambodia has been a party to the UN-approved Convention on Psychotropic Substances of 1971, which requires signatory states to ensure such drugs are used only for medical and scientific purposes.

But Cambodia’s pharmaceutical industry is under-regulated and over-saturated with distributors: there are about 600 pharmacies in Phnom Penh alone, according to Dr Chroeng Sokhan, who served as director of the Essential Drugs Bureau for the Ministry of Health’s Department of Drugs and Food until his retirement in 2011.

Many pharmacies don’t have licensed pharmacists, and while laws pertaining to prescription pills exist, officials simply lack the resources to properly enforce them, he said. 

But ultimately, prescription pills are not regarded as a major concern by the government. While the abuse of prescription pills is rampant in the West, the idea of using medicine recreationally is simply not known among most Cambodians, said Sokhan.

This is in contrast to Cambodia’s expat community, where prescription pill popping is widely known and hardly eyebrow-raising. 

“If you’re trying to explain why some people use these drugs,” said Peter*, 33, a long-time Phnom Penh resident, “I think the more interesting question is why some people don’t.

“I would say it’s not considered strange [in the expat community].” 

Peter first came to Cambodia in 2006. He has since returned periodically for work, splitting his time between Cambodia and his home country of Australia.

It was not until 2008, when relaxing in a now-shuttered backpacker hangout at Boeung Kak lake, that he heard of the pharmacies’ lax prescription practices.

A longtime drug experimenter, Peter expressed interest in trying out the prescription pills and a friend wrote him a list of psychotropics to buy.

He took a liking to tramadol, a synthetic opiate which produces body-numbing effects similar to codeine. He started taking them initially to take the edge off hangovers, but soon began regularly ingesting. 

At a Phnom Penh bar one evening last week, Peter said, “Do you want to see them?” Reaching into his shorts pocket, he extracted two blister packs of tramadol and diazepam and laid them on the table.

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Nick Barton, chief executive of Action on Addiction. Photo supplied

The back of one pack showed that the drugs had been produced in the Himalayan state of Uttarakhand in India, a nod to the fact that most psychotropics here are imported. Several pills were missing from each silver strip.

“Maybe I’ve been lucky or maybe I’m just smart about it, but I’ve mostly been able to avoid having a problem with them,” said Peter. “Except for one time when I got mildly addicted to tramadol.”

It was in 2011. Peter had been undergoing a “personal crisis”, and went on a bender. He’d returned to Australia and brought a cache of “trams” with him from the Kingdom.

“For a while I was doing too many too often. When I ran out I faced the issue of the ‘comedown’, then a decision of ‘Do I ride out the comedown or go and find an alternative opiate?’ – which is problematic in the West because the alternative you have to get most likely is heroin.

So it leads to a kind of problematic situation. Do you ride the comedown or avoid it by going to a harder version? I chose to ride the comedown,” said Peter.

“It wasn’t pleasant – no energy, I struggled to face the world, diarrhoea, throwing up,” he remembered. The misery continued for three days.

But it could have been much worse. According to Barton, while the comedown from prescription pills differs depending on the drug, all are thoroughly unpleasant:“For opiates [like tramadol], withdrawal tends to be shivers and sweats, sometimes a bit of cramping.

For the benzodiazepines it can be extremely dangerous, because you can have seizures and sometimes those can be fatal. It’s quite similar to people coming off alcohol,” he said.

Despite suffering the pains of withdrawal himself, Peter did not think that the easy availability of prescription pills in Cambodia was a problem, nor did he think that enforcing existing laws to limit their availability would keep interested users from becoming addicted.

 “If people are inclined to addiction, there’s a hundred ways they can be irresponsible,” he said.  

“There is no problem accessing drugs in any Western country. If somebody hasn’t taken drugs yet in their home country, it’s probably because they’ve made a conscious decision not to use drugs,” he continued. 

The teenaged and still slightly handicapped Ragnar, looking back on his own experiences, was a bit more critical of Cambodia’s easy accessibility of prescription pills.

“It was a stupid thing to do,” he said. “But it was an accident, you know? Sh— happens sometimes.” 

“I’ll probably come back to Cambodia one day,” he concluded. “But not for the drugs.”

*Names have been changed.

Additional reporting by Vandy Muong

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