Monday, September 2, 2013

Maggie will not die without her Xanax

I am often a little behind on television. This is due, in large part, to the fact that we don't actually own a television. I share this to clarify why my husband and I are currently watching the very beginning of Season 1 of HBO's acclaimed drama The Newsroom, while the rest of you are watching the end of Season 2.

Back here in Season 1, during a very sweet scene, my attention was drawn to an awkward piece of dialogue--it first caught my ear because the writing was oddly stilted and then held me because the content was downright infuriating.
http://buzzhub.files.wordpress.com/2012/08/newsroom-hbo.jpg
http://buzzhub.files.wordpress.com/2012/08/newsroom-hbo.jpg

It went something like this:
The smart young protagonist runs outside to the back patio in the midst of a full-blown panic attack. Her unrequited love bends down to comfort her. In between a series of witty and tender words in which he skillfully calms her anxiety, he manages to say, "Maggie, where's your Xanax?" She tells him she forgot it at home, and he responds with a furrowed brow, "You must always have your Xanax with you for moments like this. You need it. Don't ever leave home without your Xanax."

Uh oh. Red flag. Big red flag. GIANT red flag.

First, Xanax (and its generic equal alprazolam) is one of the most addictive and, frankly, troublesome medicines I prescribe. Sure it has its place, but it is not the equivalent-- as implied in this scene--to an epinephrine pen, which would be essential in the case of an allergic reaction. Maggie might very well feel like she may die, she might even call 9-1-1, but a panic attack, though frightening, is not actually life-threatening. I assure you, Maggie will not die without her Xanax.

Second, Xanax is a brand name drug that is actually now available in generic form. There is no reason for the screenwriters to use the brand name unless they are advertising the brand.  Hmmm. . .is drug-brand name-dropping on TV legal? Should it be? Is it ethical?

Third, are you agitated? Because I am. I think I need a Xanax.

Xanax for president?
Xanax (pronounced ZAN-ax) is the number one prescribed psychiatric medication in our country and has been in the number one position since 1988. In 2012, there were more than 47 million Xanax prescriptions written in the US. Forty-seven million! Most experts believe it to be the most successful anti-anxiety medicine on the market because of aggressive marketing by its maker, Upjohn. Upjohn has convinced patients and physicians alike that Xanax is the most effective treatment for panic attacks and panic disorder. That's why Maggie is taking it.

Xanax is a member of the benzodiazepine family (affectionately called "benzos" in the medical world). The benzos are a class of medicines used to treat anxiety that also includes lorazepam (aka Ativan, ranked #4 on the list of top psychiatric medications), diazepam (aka Valium, #9 on the list) and clonazepam (aka Klonipin). All of the benzos work on the brain's GABA receptors, which essentially are our "downer" or "quieting" neurons. Xanax activates our "downer" neurons, thereby turning down and quieting our anxious selves. Got that?

Even though you and I are supposed to believe Xanax is better than the other benzos for panic, a 2011 review of studies comparing Xanax to the other benzodiazepines found that Xanax was not, in fact, superior to any of the other benzos for panic disorder (see this link, if you are interested in the actual analysis). Xanax has also been shown to be notably inferior to two better treatment choices for panic: Cognitive Behavioral Therapy (CBT) and antidepressants (specifically, selective serotonin reuptake inhibitors, like Prozac and Zoloft, as well as tricyclic antidepressants, like Elavil).

CBT is a specific type of therapy that has been shown to be particularly effective in panic disorder--73% of patients are panic free after three to four months of CBT (I'll write about CBT in a future post). Studies of anti-depressants also show them to be effective (61% of patients are panic-attack free after 12 weeks of one of these medications). Okay, so admittedly neither of these treatment choices are foolproof (I, too, would like to see the results closer to 100%), but they do help a lot of people.


http://cdn1.tauntr.com/sites/default/files/BOSH-Xanax.jpg
http://cdn1.tauntr.com/sites/default/files/BOSH-Xanax.jpg

The reason people like Xanax for panic is similar to the reason my husband likes his albuterol inhaler for his asthma: it works fast. Unfortunately, however, both Xanax and albuterol do little, if anything to prevent the next attacks. And Xanax does worse than doing nothing; in fact, Xanax leads to a triple whammy of benzo-badness: 1) It is addictive, 2) It causes rebound anxiety, and 3) It turns your brain into mush.
Sound enticing?

Just to be clear, my issue with Xanax is not specific to Xanax, it's just that Xanax is the incumbent benzodiazepine and has held that office for much longer than two presidential terms-- Xanax has been top dog since George Bush Senior was elected President.

Addiction
Okay, so there is a lot of tiptoeing around in the world of addiction medicine around semantics. Care is often taken to distinguish "dependence" from "addiction". "Dependence" is a term used to describe "physical dependence"-- that is, bodily adaptations that result in withdrawal when drugs are discontinued (e.g. If you stop drinking your two cups of coffee cold turkey, you'll probably get a really bad headache). "Addiction" is a term used to refer to "the loss of control over the intense urges to take the drug even at the expense of adverse consequences" (e.g. You lost your home and got divorced as a direct consequence of your gambling addiction).

Scientists all agree that Xanax leads to physical dependence. It changes the brain, at least during the time you take it, and perhaps forever. In fact, withdrawal  from any benzodiazepine can kill (unlike withdrawing from Prozac or morphine, both of which can make people miserable but won't actually kill them). Almost everyone who takes a daily or twice daily dose of Xanax develops dependence; not everyone gets addicted. There is a certain subset of people who can take Xanax on a regular basis without it having adverse consequences on their lives, but the risk of physical dependence leading to addiction is high.

Xanax is also a known drug of abuse. National rates of hospitalizations due to all benzodiazepines actually tripled between 1998 and 2008 (see national data). Benzodiazepines are often abused in combination with alcohol or other drugs (like opiates). In fact, benzos were recorded as contributing causes in 30% of prescription painkiller overdose deaths in 2011. Large numbers of high school students admit to having tried a benzodiazepine, most commonly Xanax. Some clinic systems have even stopped prescribing Xanax altogether because of drug-seeking behaviors (see story in NY Times from 2011).

Please remember that benzodiazepine withdrawal can be deadly. If you have been taking regular benzos for any length of time and you decide you want to stop taking them, you should work closely with your physician to do so. Don't stop them on a whim.

Rebound Anxiety and Rebound Insomnia
We have known since the benzodiazepines came on the market that they cause what we call "rebound anxiety" and "rebound insomnia". This basically means the more benzos you take, the more anxiety you have. Bummer. And not exactly what you were hoping for.

Brain Mush
Known effects of the benzodiazepines include sedation, decreased attention, and anterograde amnesia. In simpler terms, benzos make you sleepy (which is why they are used by anesthesiologists to put you  to sleep for surgery); they make you a little less "tuned in" (which is excellent for panic, not so excellent for driving your kiddos to school); and they make you lose your ability to create new memories during the time the medication is working (looking to forget what is just about to happen to you?).  Another bummer.

http://notdabblinginnormal.files.wordpress.com/2010/02/cornmeal-mush-hasty-pudding-recipe3.jpgIt's also pretty clear that some combination of those effects lead you to be a little less cognitively sharp. Brain mush is a very technical term for the dulling effects of benzodiazepine use; there is convincing evidence that long-term use of benzodiazepines causes people to score lower on neuropsychological tests. The longer you are on them, the worse you score (see here for study). Same is true in elderly people (here is that study).





Is there an appropriate time for benzos?

Yes, I think there is a time and a place for benzos, but they must be both prescribed and taken with care. You should work closely with your provider to discuss the risks and benefits and really take benzos only when absolutely needed. And, please, don't share them with your neighbors-- this is not a neighborly good deed.

Examples, in my opinion, of appropriate uses of benzos:
  • I had a patient recently flying back East to her 50th high school reunion. She is terrified of flying and even more terrified of seeing her former classmates. I gave her a few tablets for the flight, both ways. I'm stingy, I think I gave her 6 pills.
  • I have a patient with advanced dementia who gets super anxious before coming to any dentist or doctor's appointments. Her son gives her a baby dose of lorazepam before the visits, and we avert hours of drama for her and him.
  • I had a patient recently assaulted at the transit center. He is having some flashbacks and panic when getting on the bus in the evening to go home. He is working closely with a therapist and considering starting an antidepressant, but he really needs to keep riding the bus to work in spite of his current symptoms. This is a temporary and urgent fix.
What about Maggie?
Well, let's be clear here. I am not Maggie's doctor. I don't have a relationship with her, nor do I know her well enough to know why she is taking Xanax and whether or not it is an appropriate choice. I have not probed her psychiatric history, I don't know her substance abuse history, and I don't know what other prescription or recreational drugs she uses. I can make an educated guess, from this scene, that she experiences panic attacks. In this context, it's hard for me to make a therapeutic decision for her.

I would say, if she has simple panic attacks that are random and infrequent, then yes, Xanax (or any of its equivalents) is probably an okay medicine for her. For very occasional use and only in combination with an adequate trial of cognitive behavioral therapy. I would also like to know what she is doing for her own self care (she has a super stressful job) and how she intends to manage stress going forward. I'd be worried she may have some underlying anxiety disorder that isn't be addressed. If she gets panic attacks any more often than infrequently, she should probably consider a trial of an anti-depressant.

I'd also say that Maggie shouldn't be advertising her Xanax to you. Decisions about your diagnosis and which medications are appropriate for you should be a matter of discussion with your primary care provider, not some pharmaceutical advertisement. Or some cute smart girl you see on TV.

Now let's talk about product placement (aka 'name dropping') of pharmaceuticals
I am not that media savvy. I'm forever missing references to pop culture, and I can never confirm or deny a particular star's presence in a film. So maybe it is not shocking that I had no idea that pharmaceutical product placement was "a thing" until I watched the Xanax scene. When I started researching material for this post, I found that others have been talking about the topic for years; the earliest policy research dates back to 2005. Have you ever noticed a drug-name being dropped on your favorite show?

I could take this opportunity to launch into a diatribe about direct-to-consumer advertising to patients (Cut to commercial: music plays, previously incontinent grandma cured by the magic medicine runs through an open field and hoists her grandchild above her head, huge smile on both faces, music fades.). But direct-to-consumer advertising is a big topic for another day. For today, I want to consider specifically the issue of pharmaceutical product placement in TV and movies. Should it be allowed?

According to Nielson Media, product placement is defined as "any verbal or visual integration of a brand into a plot line". Examples of common products intentionally placed in the way of TV and movie cameras include Mercedes-Benz vehicles (the 2012 winner for making the most big screen appearances), Apple computers (a close #2), Budweiser beer, and the classic example of E.T.'s Reeses Pieces.
http://blog.candy.com/wp-content/uploads/2010/11/et.gif
http://blog.candy.com/wp-content/uploads/2010/11/et.gif

Turns out one of the first pharmaceutical product placements was in 2005 by the pharmaceutical company, Organon, which placed posters for Nuvaring, a birth control method, in the background of episodes of Scrubs and King of Queens. Soon after, analysts started noting Zoloft (an antidepressant) and Lap-Band (a patented procedure for gastric bypass surgery) being dropped into certain daytime soap operas. Even though I love birth control, I want people to know about anti-depressants and gastric bypass surgery, this still seems wrong.

Marketers are banking on our emotional relationships to some fictional character in some fantasy world to subtly persuade us that the medication our favorite character is taking is what we need too. This doesn't seem like a good way to get educated. 

In contrast to the examples mentioned above, some viewers might assume that the inclusion of medication brand-names in screenwriting is unavoidable. Some might argue that using brand names captures "how doctor's speak" or literally "how patients talk about their medications." What do you think?  If a scene is going to realistically cover a health issue, must the writer specifically mention a medication by name? Does it make the dialogue more real? Does it lend credibility? Or is it merely advertising?

I can share with you that, as a physician who cares about the undo influence of pharmaceutical companies on my practice, I very consciously try not to use brand names when speaking with patients or other providers about medications. In fact, writing "Xanax" over and over for this story is killing me. I do firmly believe that the more I see, write, read, and say a name, the more likely I am to prescribe and use that drug (rather than generic or equivalents that may be less expensive and just as good). I also know that I am human, my patients are human, and marketing works on humans.

There is no way to confirm that the name dropping is actually funded by the pharmaceutical companies because transactions between private companies and the media outlets are not privy to public information. So we won't really know. But we can guess. And my guess is that the makers of Xanax paid for Maggie's scene.


The practice of pharmaceutical product placement is also questionable from a legal perspective. The FDA has strict guidelines about what information needs to be included in pharmaceutical advertising (that's why we always hear that raspy voice at the end of the TV commercial reminding us that, "in rare circumstances we could die or lose our fourth digit on our left foot by taking such-and-such medication"). But, does the FDA consider this advertising? As far as I can uncover, the FDA, FCC and FTC currently do not have specific guidelines to address the use of prescription drug references in fictional entertainment. This gap clearly leaves some space for abuse-- and puts us at risk for some serious manipulation.

After all, if the cute smart girl is taking Xanax, why wouldn't I want it too?
________________________________________________________________________

Additional  references on benzodiazepines:
http://www.psychologytoday.com/blog/how-everyone-became-depressed/201306/benzo-hysteria
http://psychcentral.com/lib/top-25-psychiatric-medication-prescriptions-for-2011/00012586

Additional references on product placement
http://www.pharmalive.com/sites/default/files/blogs/attachments/product-placement.pdf
http://www.marketingpower.com/AboutAMA/Pages/AMA%20Publications/AMA%20Journals/Journal%20of%20Public%20Policy%20Marketing/TOCS/summary%20spring%2008/Pharmaceuticaljppmmay08.aspx
http://www.rxentertainmentinc.com/what-we-do/product-placement/

25 comments:

  1. As someone who has worked in television writers' rooms since 2008, I can tell you the only reason the brand name "Xanax" is used instead of "Alprazolam" is that viewers wouldn't have a fucking clue what drug you're referring to if you called it "Alprazolam." That's why other brand name drugs are referenced in shows -- the most important thing is that the viewer know what you're talking about. You'll also notice that TV show characters used to refer to "Prozac" when that was the hot anti-depressant of the moment and then that reference was replaced by "Zoloft" in subsequent years. Again, TV writers just trying to stay relevant. I've heard characters refer to taking Klonopin, which is also very trendy right now -- and much more longer lasting and seemingly scarier than Xanax.

    Shows are only offered brand sponsorships in their second season and then they are usually for Subway sandwiches and innocuous products like that. Any brands shown visually (Coca Cola cans, etc.) must be legally approved and cleared by the corporation. The same, however, is not true in dialogue. You can mention any name brand in dialogue and the company has no legal recourse unless the reference is disparaging. I know this because I handle the legal clearances for my show.

    Many of the TV writers I know are on anti-depressants and many suffer from panic disorder because they are highly sensitive (which is why they are writers in the first place). Xanax is probably being referenced because compared to Ativan, it is their benzo of choice, and a more effective one at that, speaking from personal experience...

    As someone who has successfully managed panic disorder since 1997 through CBT, Elavil and the occasional Xanax. I keep one in my purse at all times and just knowing the safety hatch is there means I never need to take it. (Maybe that's what the Newsroom character was referring to...) And if I do take it, and it keeps me from running from the office like a crazy person and enables me to sit still and act normal, then thank god someone invented that drug. As someone on a daily dose of Elavil, I can tell you that sometimes an anti-depressant is not enough to prevent panic attacks.

    According to Michelle G. Craske, PhD of UCLA, one of the leading panic disorder researchers and author of Mastery of Your Anxiety and Panic, CBT is mostly effective for the first two years after treatment. The majority of patients relapse, as I did, two years after CBT treatment (with Kraske's book). I never developed a physical dependence on Xanax, despite being on it for an entire trimester of college when first learning how to manage my anxiety. It enabled me not to drop out of college. To sit still through a class I would have otherwise ran out of.

    I weaned off my small dose of .25 mg (3x per day) after the trimester was over. I had little problem with this because I am not an addictive personality. I can have a Xanax in my purse and not take it for months. Some people can't do that. So clearly whether you're an addictive personality has as much to do with it as the drug. Not everyone can handle having a glass of wine once a week and feel the need to do it every day or multiple times per day (and many folks with anxiety disorders become alcoholics). Again, that lies in predispositions and whether the patient is willing to work hard to fix their mental illness.

    ReplyDelete
    Replies
    1. Thanks, Nicole, for your thoughts. I totally love the idea of people with panic having their "benzo of choice" in the purse as a safety valve-- in fact, I had a patient just last week that told me when she was doing her best, she just had to have her lorazepam in her car's glove compartment. Just knowing it was there helped her avoid a panic attack. As I said in the piece, I do think there is a time and place for these meds, but unfortunately, I think many physicians hand them out without really probing their risk for addiction and without making a plan with individual people about how to really address the panic. And, you're right, sometimes anti-depressants and CBT aren't enough. But there is also a ton of abuse and misuse. . .Thanks, too, for your thoughts on the product placement bit-- it's obviously not something I know a ton about, but it still strikes me as odd.

      Delete
  2. Xanax
    Learn How to Get Xanax with a Prescription. Find about how you can get a Xanax prescription from your doctor and buy Xanax online in a legal way.
    Elspeth Smith
    2827 Summit Park Avenue
    Livonia, MI 48150
    elspetsmith.13@gmail.com
    248-982-9401

    ReplyDelete
  3. Buy originally manufactured xanax without RX
    We sell both brand and generic xanax
    We also sell related medicines like valuim, ativan, clonazepam, restoril

    All our medications are originally manufactured we source them directly from pharmaceutical companies .
    Shipping is fast, discreet and guaranteed we package in vacuum sealed papers.. Smell proof
    Payment is secured
    Visit our website to order www.guaranteedmeds.com
    Call or text +1408-657-8662

    ReplyDelete
  4. Online shop where you get 100% authentic products from pharmacies. We have the following products in stock: pain medications, Anti Anxiety, Adhd/Add, Weight loss, Sleeping Aids, injections, ED pills and Cough Syrups and many other Pharmaceutical products at attractive prices. Email (bodybuildingpharma59@gmail.com)

    Oxycodone, Roxicodone, Xanax 1 mg ksalols blues, Anesket Ketamina 1000 mg/10 mL, Flunitrazepam (rophynol) Methadone, Xanax 2 mg Bars, Oxycontin, percocet, MDMA, Meth, Adderall, Medical Marijuana Strains, Nembutal, Diluadid, Actavis etc

    TEXT OR CALL US (325) 261-0302
    VISIT HERE; https://www.allmedspharmacy.site123.me

    ReplyDelete
  5. Easily Boost Your ClickBank Traffic And Commissions

    Bannerizer makes it easy for you to promote ClickBank products by banners, simply visit Bannerizer, and grab the banner codes for your chosen ClickBank products or use the Universal ClickBank Banner Rotator Tool to promote all of the available ClickBank products.

    ReplyDelete
  6. Great job....You have beautifully presented your thought in this blog post. I admire the time and effort you put into your blog and detailed information you offer. xanax

    ReplyDelete
  7. TEXT +1 (253) 881-5330 OVERNIGHT DELIVERY FAST AND SECURED FOR XANAX,OXYCODONE,PERCOCET,MORPHINE,HEROIN,PERCOCET,AMBIEN,NEMBUTAL

    We are reliable for a long term,communications & transactions are secured . - Offer safe and discreet overnight shipping (24/H) to clients depending on location. - Finest and fast services to all our clients, and we make sure they are treated like family. - We offer a Full Refunds on any Package that does not make it to its destination. Below is a list of some of our product:

    CALL OR TEXT TO ORDER: +1 (253) 881-5330

    EMAIL: healthcarepharmacy47 @gmail.com

    WHATSAPP:+12538815330

    WICKR ME:Healthcare3

    AYURVEDIC UREA GROW TALLER HERB, LIQUID AND POWDER.
    Actavis Codeine Syrup
    Zopiclone 7.5mg
    Oxycodone 30mg
    Suboxone strip 8mg
    Ritalin 20mg
    Adderall 20mg
    Rohypnol Flunitrazepam 2mg
    Oxycotine 40 -80mg
    flunitrazepam 2mg
    Xanax 2mg
    Zohydro ER 20/ 50MG
    Dilaudid 8mg
    Winstrol Stanozolol 10mg/50mg
    Hydrocodone 500mg
    Percocet 10mg
    MDMA 50 mg
    Tramadol 100mg
    Rohypnol 20 mcg
    Tilidin 100/8mg
    Concerta XL 18-36mg
    Morphine 15mg
    Opana 10mg
    Norcos 10mg
    Oxynorm 20mg
    Mandrax (Quaalude) 300mg
    Diazepam Valium 10mg
    Lortab Watson 7.5mg
    Dilaudid 8mg pill
    Fentanyl 100mg Patches
    Stilnox 10mg
    viagra 1000mg
    methadone 10 mg
    Subutex 8mg
    lyrica 300mg
    vicodine5-10mg
    seconal 15mg
    Dexedrine 15mg
    Alprazolam 2mg
    Ambiean 10mg
    Rivotril 2mg

    Our services...
    -no prescription required
    -Express prior overnight or next day delivery
    -packing is highly discreet sealed, wrapped with an aluminum foil, safe and secured
    -no signature required upon arrival of parcel
    -100% customer care and support.
    -Money back guarantee

    Bitcoins Payments Now Acceptable. Pay for your medications with any cryptocurrencies

    CALL OR TEXT TO ORDER: +1 (253) 881-5330

    EMAIL: healthcarepharmacy47 @gmail.com

    WHATSAPP:+12538815330

    WICKR ME:Healthcare3

    We have a 100% record in successful deliveries. Contact us for more information.

    ReplyDelete
  8. TEXT +1 (253) 881-5330 OVERNIGHT DELIVERY FAST AND SECURED FOR XANAX,OXYCODONE,PERCOCET,MORPHINE,HEROIN,PERCOCET,AMBIEN,NEMBUTAL

    We are reliable for a long term,communications & transactions are secured . - Offer safe and discreet overnight shipping (24/H) to clients depending on location. - Finest and fast services to all our clients, and we make sure they are treated like family. - We offer a Full Refunds on any Package that does not make it to its destination. Below is a list of some of our product:

    CALL OR TEXT TO ORDER: +1 (253) 881-5330

    EMAIL: healthcarepharmacy47 @gmail.com

    WHATSAPP:+12538815330

    WICKR ME:Healthcare3

    AYURVEDIC UREA GROW TALLER HERB, LIQUID AND POWDER.
    Actavis Codeine Syrup
    Zopiclone 7.5mg
    Oxycodone 30mg
    Suboxone strip 8mg
    Ritalin 20mg
    Adderall 20mg
    Rohypnol Flunitrazepam 2mg
    Oxycotine 40 -80mg
    flunitrazepam 2mg
    Xanax 2mg
    Zohydro ER 20/ 50MG
    Dilaudid 8mg
    Winstrol Stanozolol 10mg/50mg
    Hydrocodone 500mg
    Percocet 10mg
    MDMA 50 mg
    Tramadol 100mg
    Rohypnol 20 mcg
    Tilidin 100/8mg
    Concerta XL 18-36mg
    Morphine 15mg
    Opana 10mg
    Norcos 10mg
    Oxynorm 20mg
    Mandrax (Quaalude) 300mg
    Diazepam Valium 10mg
    Lortab Watson 7.5mg
    Dilaudid 8mg pill
    Fentanyl 100mg Patches
    Stilnox 10mg
    viagra 1000mg
    methadone 10 mg
    Subutex 8mg
    lyrica 300mg
    vicodine5-10mg
    seconal 15mg
    Dexedrine 15mg
    Alprazolam 2mg
    Ambiean 10mg
    Rivotril 2mg

    Our services...
    -no prescription required
    -Express prior overnight or next day delivery
    -packing is highly discreet sealed, wrapped with an aluminum foil, safe and secured
    -no signature required upon arrival of parcel
    -100% customer care and support.
    -Money back guarantee

    Bitcoins Payments Now Acceptable. Pay for your medications with any cryptocurrencies

    CALL OR TEXT TO ORDER: +1 (253) 881-5330

    EMAIL: healthcarepharmacy47 @gmail.com

    WHATSAPP:+12538815330

    WICKR ME:Healthcare3

    We have a 100% record in successful deliveries. Contact us for more information.

    ReplyDelete
  9. Buy Adderall online without doctors prescription
    Buy Adderall overnight shipment
    Buy Adderall with credit card
    Buy Adderall cheap online
    Buy Adderall online Canada
    Buy Adderall online COD
    Buy Adderall in Spain
    Buy Adderall online Sweden
    Buy Adderall online Norway

    ReplyDelete
  10. Buy Adderall online without doctors prescription
    Buy Adderall overnight shipment
    Buy Adderall with credit card
    Buy Adderall cheap online
    Buy Adderall online Canada
    Buy Adderall online COD
    Buy Adderall in Spain
    Buy Adderall online Sweden
    Buy Adderall online Norway

    ReplyDelete
  11. Best Research chem is one of the best research chemicals sites online We are the USA and Europe's based company specializing in wholesale distribution of the best Research Chemicals. Note: We don't manufacture this chemical we buy them from a network of highly qualify and trusted manufacturers.


    Buy 3-MMC Online
    MDPV crystal for sale,
    APAAN POWDER For sale online,
    Buy 2'-OXO-PCE Drugs,
    Buy 4-Aco-DMT online,
    Buy 4-CL-PVP Crystal for sale,
    Buy 5-MeO-pyr-T online store,
    Buy Alpha-PHP Quality Online,
    Buy Alprazolam Powder Online,
    Buy Dibutylone Crystal online,
    Buy heroin powder online,
    Buy SR9009 Powder Online,
    Fentanyl Powder online,
    JWH-250 For sale,
    MDMB-CHMINACA Online,
    Buy 100% Pure Caffeine Powder,
    BUY ERIMIN 5 MG TABLETS,
    Buy Flubromazepam Powder,
    Buy Nitrazolam Powder online,
    buy phenazepam online,
    Diazepam Powder for sale online,
    Diclazepam Drug for sale online,
    Flubromazepam for sale,
    Buy AKB-57 Quality drug,
    Buy NM-2201 Cannabinoid,
    Buy SGT-78 Quality Online,
    Buy MDMA Crystal online,
    Quality molly pills online,
    Buy 4-MEC online,
    Buy A-PVP Crystal Online,
    Buy Amphetamine Powder online,
    Buy Butylone crystal online,
    Buy FUB-AMB Online,
    Buy N-ethyl-hexedrone online,
    Buy Methylone Crystal online,
    Mephedrone for sale,
    Buy Ketamine powder online,
    Buy Cocaine Drug online,

    Visit our website. https://bestresearchchem.com/

    ReplyDelete

  12. ( 1 ) Mephedrone , methylone , methaphentamine , Mathedrone ,Mdma ,
    BK mdma Methoxetamine , Methathinone , MBDB , Mdai. , mdpv .
    ____________________________________________________________________________

    ( 2 ) Buphedrone , butylone , Eutylone ,Pentylone , NAPHYRONE ,
    detrophetamine

    Ethcathinone , Dimethocaine , Dimethylcathinone , Diethylpropion ,
    ____________________________________________________________________________

    ( 3 ) 3-MMC , 3-MEC , 3-EMC , 3-EEC , 4-EMC , 4-EEC , 3-MOMC , 2-FMC
    , 2-FEC , a-PVP 3-FMC ,

    3-FEC , 3-CMC , FPVP , 3,4-DMMC , 4-MePPP , MOPPP , FPP , MPBP , MPHP
    , MDPPP , MDPBP.
    ____________________________________________________________________________

    ( 4 ) 2CI , 2CP , 2CE , 2CB , 2CD , 2FLY , 2CC , 2CP , 2CT21 , 2CT4 ,
    2CTT , Fantanyl heroine ,

    cocaine powder , crystal cocaine
    ____________________________________________________________________________

    ( 5 ) JWH-018 , JWH-250 , JWH-018 , JWH-073 , JWH-200 , JWH-250 ,
    JWH-240 ,J WH-350.

    ____________________________________________________________________________

    ( 6 ) AM 2201 , AM 2202 , AM 1220 , AM 122 , AM 2021.

    ____________________________________________________________________________

    ( 7 ) 5-Meo-DMT , 4-Aco-DMT , 4-Ho-MIPT , DMT , BOMO GRAGON FLY
    ,4-MeO-PPC DOC, DOI.

    _____________________________________________________________________________

    Call/Text;(405)-283-6382 and other countries contact us on whatsapp on (405)-283-6382

    WICKR ME,.......MedsPharma

    Email..............tropicpharma3 @gmail.com

    ReplyDelete
  13. Buy Roxicodone, Xanax, Ketamine, Ambien , Methadone, Oxycontin, DMT, LSD, Percocet, MDMA, Coke, Heroin, Adderall, ETC
    ============
    Contact Securely for Orders / inquiries:
    Telephone / +1 (405)-283-6382
    Mobile: +1 (405)-283-6382
    WhatsApp: +1 (405)-283-6382
    Wickr: Medspharma
    __________________________________________________________________________
    __________________________________________________________________________
    Email us via: ========= medspharmacy99@ yahoo.com ==========
    Website Address ==== https://medspharmaceuticals.site123.me ===========
    Tel ================ +1 (405)-283-6382=============================

    I will supply you the best quality of the following medication and more:

    Medical Marijuana (Sinaloa Kush, Strawberry Kush, OG Kush, Arizonan western light purp, Afghani #1, Northern Lights etc)
    Ketamine vials (FOR DEPRESSION)
    Xanx: Pfizer Long Bars
    Fentalyn patches
    Nembutal (Pills, Liquid & Powder)
    Klonopin
    Ativan
    Dilaudid
    AMBIEN
    Oxycontin
    Percocet
    Roxicodone
    Quaaludes - Methaquallone pills

    Ketamine crystals,
    ketamine vials,
    Actavis promethazine
    Cough syrup with Codeine

    OXYCONTIN,
    ADDERALL,
    ACTAVIS,
    OPANA,
    XANAX,NORCO,
    DILUADID,
    METHADONE,
    RITALIN ,
    HYDROCODONE,
    SUBOXONE,
    SUBUTEX,
    IBRPOHEN ,
    ADVIL PM,
    VIAGRA GOLD ,
    LO LOESTRIN FE,
    EPHEDRINE,


    FENTANYL ( brand name: duragesic 5-12 12.5 mcg/hr patches box),
    DEMEROL ( Meperidine HCL) caps 8,
    AMBIEN 10MG,
    MORPHINE 30MG,
    VICODIN 5MG,
    VICODIN ES 7.5MG,
    EPHEDRINE 30MG,
    CELEBREX 100mg,
    CODEINE 15mg, and
    many more not mentioned

    My services are available for both clients with prescription and those without prescription


    ===============================================
    Contact Securely for Orders / inquiries:
    Telephone / +1 (405)-283-6382
    Mobile: +1 (405)-283-6382
    WhatsApp: +1 (405)-283-6382
    Wickr: Medspharma
    __________________________________________________________________________
    __________________________________________________________________________
    Email us via: ========= medspharmacy99@ yahoo.com ==========
    Website Address ==== https://medspharmaceuticals.site123.me ===========
    Tel ================ +1 (405)-283-6382=============================

    ReplyDelete
  14. Best Research chem is one of the best research chemicals sites online We are the USA and Europe's based company specializing in wholesale distribution of the best Research Chemicals. Note: We don't manufacture this chemical we buy them from a network of highly qualify and trusted manufacturers.

    Best Research chem is one of the best research chemicals sites online We are the USA and Europe's based company specializing in wholesale distribution of the best Research Chemicals. Note: We don't manufacture this chemical we buy them from a network of highly qualify and trusted manufacturers.
    Wickr ID: Spidoplug
    What's App: +1 (972) 360-8189
    Email: joeernest194@gmail.com

    We supply good quality meds worldwide.
    All parcels are shipped discretely and tracking details are provided
    Weed,
    Oxycodone,
    Adderall,
    Cocaine,
    Crystal Meths,
    Fentanyl/Carefentanil Powder etc...

    Delivery is overnight and parcel is delivered directly to your nominated delivery address.We ship overnight and discreetly as well.
    Delivery is 100% successful and guaranteed worldwide, Discrete delivery available in vacuum sealed crush proof containers to any location

    ReplyDelete
  15. Cocaine for sale | buy fentanyl | buy dmt | buy mephedrone | buy ketamine

    Buy pure cocaine online, Buy cocain,cocaine,crak cocaine.Order powder cocaine.Cocaine
    for sale.buy fentanyl, buy lsd, buy mama, buy dmt, buy crystal meth, buy mephedrone,
    buy ketamine,buy heroin online, buy mephedrone online, buy mephedrone for sale

    Website https://www.albertdrs.com/
    Whatsapp +1 901-504-5215
    Email contact Info@albertdrs.com

    ReplyDelete
  16. Cocaine for sale | buy fentanyl | buy dmt | buy mephedrone | buy ketamine

    Buy pure cocaine online, Buy cocain,cocaine,crak cocaine.Order powder cocaine.Cocaine
    for sale.buy fentanyl, buy lsd, buy mama, buy dmt, buy crystal meth, buy mephedrone,
    buy ketamine,buy heroin online, buy mephedrone online, buy mephedrone for sale

    Website https://www.albertdrs.com/
    Whatsapp +1 901-504-5215
    Email contact Info@albertdrs.com

    ReplyDelete
  17. Buy high quality real and fake passports online

    What's App: +1 (972) 360-8189
    Email: firstclassdocuments20@gmail.com

    We produce Documents with Best Quality Novelty both fake and original.
    All our produce are undetectable and will pass all UV light Test
    such documents includes:
    -Passport
    -Drivers License
    -National Identification Card
    -Resident Permit
    -Visa/Invitation
    -Diploma Certificate
    -Counterfieted Money
    -Bank Statement and many more

    Buy fake/genuine Passports,Driver’s License,ID Cards,IELTS,(firstclassdocuments20@gmail.com),Visas,SSN,SSA,SIN,Green Cards,Fake Money,
    Buy Passports,Id Cards(pvc), Driver Licenses, Visas, Resident Permit Cards, Green Cards, Passport Cards, Marijuana Cards, Check Counterfeiting(Check Washing), DBR forms, CRB checks(standard, enhanced and enhanced with list checks),Certified Management Accountant(CMA), Certified Meeting Professional(CMD),Certified Medical Dosimeter, Birth Certificates, College degrees,School Certificates,IELTS, TOEFL, ESOL and all Other English/French Language Certificates,Training Certificates, Attestations, Private Cards, Student Cards, Diplomas, SSN, Marriage Certificates, Credit Cards, Counterfeit Money, Clear Criminal Records And Many Other Documents For Sale (firstclassdocuments20@gmail.com).

    Buy Passports,Driver’s License,ID Cards,Refugee Cards,Visas,SSN,SSA,SIN,Green Cards,Fake Money, criminal records brureau checks, disclosure and barring services checks.We Also sale Chemicals Like SSD Automatic Solution For Cleaning Black Currency.We are the best producers of high quality fake/novelty documents, with over a billion documents circulating around the world.We offer only original high-quality passports,driver's licenses,ID cards,birth certificates,stamps,visas,universities diplomas and other products.

    Buy genuine Training Certificates, GCSE, A-levels,High School, Diplomas, Certificates, GMAT, MCAT and LSAT Examination Certificates, School Degrees all in an entirely new name issued and registered in the school's, institution's, college or university's database.
    We Produce Real registered IELTS, TOEFL, ESOL without you sitting for an exam. We are here to help you get your documents easily and save your precious years and time.Once you submit your information and do your payment, your Certificate will be produce and registered. you will be able to verify and see your result at (firstclassdocuments20@gmail.com)

    We produce certificates for various language test world wide, including the ; IELTS, TOEFL, TOEIC, CaMLA, EFSET, ECCE, ECPE, MELAB, MTELP, ESOL Test of Proficiency in Korean Language Proficiency Test, Hanyu Shuiping Kaoshi (HSK), CNaVT, NT2, DELF, DALF, TNF, Deutsches Sprachdiplom Stufe I and II , TestDaf, NTD, CELI, CILS, PLIDA, Certificate Examinations in Polish as a Foreign Language, DELE, CELU, CELPE-Bras, CAPLE, TORFL, JLPT and NNS and The European Language Certificates (TELC) Website Link: https://bill-pay.ltd/

    ReplyDelete
  18. I was able to get rid of my herpes virus last year,i was diagnosed of herpes virus since late 2017 and i was on my doctor prescription ever since, I wasn’t satisfied i needed to get the virus out of my system,i was going through a blog to find new informations about the Herpes Simplex Virus i came across a review of a lady who was cured by (doctordohgo@gmail.com)I contacted the herbal foundation and they guided me on how to purchase the herbal formula.the herbal products las me for 3 weeks which helps me to get rid of the virus totally.

    website ; doctordohgo.wixsite.com/herbs

    whatsapp/call +2347062142293

    ReplyDelete
  19. Bitcoin Crypto Investment
    Hello! I'm Aulakh K Rupinder from Victoria Australia. I am a professional binary options broker/trade expert, I coach/mentor aspiring internet entrepreneurs on how to build a stable and steady source of passive income through online trade. I will like to know if you are familiar with Binary Options trade? Kindly contact aulakhkrupinder@gmail.com to get/learn more about Binary Options trade, how it works, it's benefits and how you can get started.

    ReplyDelete
  20. MedsPlugging  is one of the best underground drugs source where you can get quality products delivered to you discreetly.We have Anabolic steroid products such as Injectable steroids,Oral steroids,Hgh etc and we also have in stock Opioids,Pharmaceutical medications for depression,Panic attack,insomnia etc. ((Pain killers, anxiety medications))etc.With MedsPlugging you can Buy cheap Hydrocodone online,Buy steroids online with Bitcoin,Buy opiates online no RX,Buy strong painkillers online USA,Buy pain relievers online without RX,Buy pain relievers online legally,Buy benzos online without RX,How to purchase opioids online,Buy opioids online without RX,Buy opioids online with Bitcoin,Buy Xanax 2mg online,Buy Oxycodone online,Buy Oxycontin online cheap,Buy hydrocodone online,Buy opioids online cheap USA,Buy hydrocodone online USA,Buy dilaudid 8mg online USA,Buy Pain relievers online with Bitcoin,Buy Pain relievers online with,Where can i buy Oxycodone online,Buy cheap hydrocodone online USA,Buy cheap Xanax 2mg online USA,underground steroids sites online,Anabolic Steroid Suppliers Uk,legit steroid sites that accept bitcoin,Buy steroids online EU with bitcoin,Buy steroids online Europe with bitcoin,Buy steroids online Europe,Buy steroids online Canada with PayPal,Buy steroids online Australia with bitcoin,Buy steroids online USA with bitcoin,Buy steroids online UK with bitcoin,Buy bodybuilding steroids online with bitcoin USA,Steroid websites that accept bitcoin,Buying steroids online with bitcoin,Buy steroids online with PayPal,Buy real steroids online USA,Buy Hgh online USA,Buy Hgh online with PayPal,Buy Painkillers online with PayPal,Buy anabolic steroids online with PayPal.

     Below is a list of some of our product available in stock ;

    MDMA
    Percocet
    Ultram/Ultracet Dangers & Addiction
    Xanax 1 mg Upjohan footbals
    XANAX 1 mg (blue Ksalol)
    Xanax SR 2 mg (brand Upjohn)
    Xanax 2 mg (Pfizer LongBars)
    Valium 10 mg
    AMBIEN
    Lorazepam 2.5 mg (Ativan)
    Clonazepam 2 mg (Rivotril)
    Nitrazeoam 5 mg (Nipam)
    Bromazepam 6 mg (Lexotan)
    Percocet
    Phentermine
    Adderall
    Codeine 30/500mg
    Cialis
    Demerol (meperidine hcl) caps
    Diazepam
    Dilaudid
    Soma -generic
    Ketalar injection
    Ketamine
    Ritalin
    Vicodin
    Opana
    Hydrocodone 10mg/500mg
    Roxicodone 30mg
    Clonazepam (klonopin)
    Viagra
    Testosterone
    Methylene
    Fentanyl patches
    Oxycontin
    Methadone
    Seconal (chemical name-secobarbital)
    Oxycodone
    Vailum
    Suboxone
    Subutex
    Meth Crystal
    Nembutal......etc

    SHIPPING IS WORLDWIDE).

    SHIPPING:
    -Stealth Packages
    -Vacuum sealed thick plastic
    -Fast and Reliable delivery -#Tracking Available!
    -No signature required upon arrival of parcel
    -We offer safe and discreet overnight shipping (24/h) to clients within the US, and 3-4 business days shipping to clients in EU.
    -We also offer the best discount for bulk purchase on any of our products.
    -We offer the best of services to all our clients, and make sure they are
    treated like family.
    -We offer a FULL REFUND on any package that doesn't make it to its
    destination.
    Contact us:
    Website:https://medsplugging.com
    Text or Call:+1(786) 864-3313
    Wickr App:Genlabs
    SnapChat ID: Jammieooxx
    Email:medsplugging@gmail.com

    ReplyDelete
  21. 💯Fast stealth Secure delivery
    #GHB (gamma hydroxybutyrate) Rape pills
    #MDMA 86%
    #ket
    #METH
    #LSD
    #ESCTASY
    #Xanax
    #Adderall
    #Fentanyl  
    #Roxy 30mg  Other Pain Pills💊
    WICKR ID/ calismokee 
    WhatsApp+1(815)2900660
    Telegram @Empiremarketdr 
    Telegram Channel @pillsXtc
    Web: https://medsaustralia.com/
    Everything discreet and legit

    ReplyDelete
  22. Interesting Article. Hoping that you will continue posting an article having a useful information. Phenazepam Buy

    ReplyDelete
  23. I was diagnosed as HEPATITIS B carrier in 2013 with fibrosis of the
    liver already present. I started on antiviral medications which
    reduced the viral load initially. After a couple of years the virus
    became resistant. I started on HEPATITIS B Herbal treatment from
    ULTIMATE LIFE CLINIC (www.ultimatelifeclinic.com) in March, 2020. Their
    treatment totally reversed the virus. I did another blood test after
    the 6 months long treatment and tested negative to the virus. Amazing
    treatment! This treatment is a breakthrough for all HBV carriers.

    ReplyDelete