Hawkers in bars sell anti-impotence drugs, whispering that they have "blues" available for $5 a pop.
Friends pass their pills to other friends, and drug users take them to counter the effects of methamphetamines or ecstasy, which can leave them unable to get an erection.
And Web sites sell the drugs or counterfeits to almost anyone who requests them.
At the same time, the makers of erectile-dysfunction drugs are running racier marketing campaigns that stray from the depictions of the drugs as medicine. "Get back to mischief," woos the latest Viagra slogan, with devil's horns seeming to emerge from behind a middle-age man's ears.
These are all part of the changing image of erectile-dysfunction drugs. Since the first impotence drug, Viagra, debuted in 1998, sister drugs Levitra and Cialis have been used increasingly by healthy younger men for perceived performance enhancement or as psychological life-preservers to alleviate performance anxiety.
"When Viagra first came out, the whole emphasis was on older men, with Bob Dole doing the marketing and the age group being around 70," says Dr. Abraham Morgentaler, a urologist and associate professor at Harvard University. "Now we're seeing the bar lowered, not just for men wanting it, but for physicians giving it out to those who are younger and less severely affected."
One concern is that the drugs may be psychologically addictive, says Morgentaler, author of The Viagra Myth, a book about the common misperceptions surrounding the drug.
The wrong idea
Many men seem to have gotten the wrong idea about what the drugs can do. One cardiologist tells of a healthy man in his 20s with no apparent functional problems who asked for a prescription to help him celebrate his anniversary in Las Vegas. A sex therapist reports that men as young as 16 have sought her help, thinking they need Viagra to have sex or that it might compensate for having a small penis.
Still, many doctors and drug companies say they don't think the drugs are being overused, and in any case see little danger in them. About 75 percent of erectile drugs are prescribed by general practitioners rather than urologists or cardiologists.
Dr. Louis Kuritzky, a clinical assistant professor at the University of Florida's department of community health and family medicine, says he generally gives a prescription when asked. "There's no way to prove they have (erectile dysfunction) any more than a woman having menstrual cramps or headaches. We trust them unless there's reason to believe otherwise," he says.
Even if the cause is psychologically rooted, Kuritzky says, many people can't afford the money or time therapy would require. The pills can offer a temporary quick fix to restore confidence, which may be all that's needed, he says.
Users getting younger
Pfizer, which sold $1.9-billion worth of Viagra last year and says 23-million men worldwide have tried it, maintains that it is not promoting the drug for enhancement purposes. Spokesman Daniel Watts says that if a man is troubled by erection problems, he should consult a doctor about a possible underlying condition.
Carole Copeland, a spokeswoman for Eli Lilly, which makes Cialis, says the company "strongly discourages" use by those seeking enhancement only. "It's just not safe. People who don't have a condition that necessitates it shouldn't use any drugs," she says, noting that erectile dysfunction drugs can be deadly if taken with nitrates.
Dr. Sanjay Kaul, a cardiologist at Cedars-Sinai hospital in Los Angeles, questions whether some of the purported need for the drugs has been drummed up by the drugmakers' advertising and reports that 30-million men in the United States may suffer from erectile dysfunction.
There's little doubt that the age of erectile drug users is getting younger. Express Scripts, one of the nation's largest managers of employee prescription-drug benefit plans, said the fastest-growing segment of users who applied for reimbursement of Viagra prescriptions was men 18 to 55 during 1998 to 2002.
The number of men younger than 45 using the drug tripled during that time, although it is still small compared with the majority of users, who are older than 50. Pfizer says the average age of men taking the drug is now about 53. As of earlier this year, about 8 percent of prescription Viagra users were age 34 to 40, about 26 percent were in their 40s, 36 percent in their 50s and 22 percent in their 60s, Pfizer's data shows.
Some healthy men who have used the medications say the drugs enable longer-lasting and firmer erections and reduce what is known as "refractory time," the amount of time between erections.
Dr. Ira Sharlip, a urologist and clinical professor at the University of California, San Francisco, who serves as spokesman for the American Urological Association, says the drugs "can't make a superman out of a normal man." Although middle-age men who have seen firmness decline may note an improvement with the drugs.
But Kuritzky, the Florida physician, says that because the brain is such a critical element in sexual functioning, the so-called "placebo effect" can play a big role for some men.
The Food and Drug Administration and physicians say the drugs are safe for most men if used as directed, with the exception of those taking nitrates or those with poor cardiovascular health.
They acknowledge that some men experience headaches or flushing and in rare cases extended and painful erections that won't subside, a condition called priapism.