November issue 2010

Samra’s tragic story graphically illustrates how the abuse of prescription drugs can ruin lives. The once healthy mother of three, with the eldest a teenager and the youngest not even three years old, Samra today is bed-ridden and chronically ill. She has spent more than two years in and out of hospitals, coming close to death on more than a few occasions. With most doctors having given up on her, it is a miracle Samra is still alive.

For over five years Samra was what can only be described as a drug addict. Her choice of self-abuse: a cocktail of assorted prescription medicines that she would gulp down by the fistful a couple of times a day. Worse, in her drug-induced state she began to force her two younger daughters to also down cough medicines in order to “manage them.” Unable to look after her children given her torpor, it was easier to put them to sleep rather than address the chores constituting their daily routines.

After exhausting all other options, Samra’s husband finally cut off her finances. He made sure she did not have access to cash, credit cards or even jewellery, which she had increasingly resorted to pawning for her daily fixes. But even that did not work. “She would steal phone cards and began to sell household items to her domestic staff and random roadside passersby in exchange for a few rupees to buy pills,” discloses a family member.

But nothing made Samra happy. She attempted suicide on a couple of occasions, but was saved each time. Finally, she consumed a dose of poison that almost did the job. She was rushed to hospital, but the attending doctors all but gave up on her. Her esophagus and voice box had both burned, leaving her incapable of feeding or talking, and a very slim chance of survival.

A doctor described her inner organs as a “mesh that were stuck to each other, melted and burned because of the poison.” They put her on a ventilator but advised her family to take her off it because, in their opinion, she would not be able to make it. However, fate had other plans for Samra. Her family declined to take her off the ventilator and opted for exploratory surgery instead. One of the country’s senior-most surgeons agreed to conduct the operation, but made no promises.

Following surgery, Samra was hospitalised for several months. She was unable to feed orally; she could not even take in water, and could barely talk. She gradually improved to the extent that her doctors advised reconstructive surgery. However, because they were not confident enough to handle the complications associated with her case, they suggested it be done abroad. On the day Samra was to leave for her treatment abroad, her sister stumbled upon a packet of injectible anti-depressants, opiates and benzodiazepines — derivatives of the same medicine Samra had earlier been taking, which had pushed her to the brink. It was discovered that she had been bribing the nurses — employed by her family to take care of her — to procure the drugs for her. Furthermore, sometimes she had also made her young son get the medicines for her, telling him they were necessary for her “cure.”

Her family was, understandably, devastated. To compound matters, Samra’s husband was now on the verge of bankruptcy. Devoted as he was, however, he was even willing to sell his house to pay for her treatment.

Samra has had a series of successful reconstructive surgeries. Eighteen months later, she is able to eat again, but is still unable to speak. Sadly, she seems to lack the motivation to get out of the vortex she has landed herself in. Samra keeps attempting to obtain the pills that have cost her so dearly, and alternates between deep depression and terrible withdrawal symptoms. So far there seems to be no light at the end of the tunnel Samra has dug herself into.

Prescription drug abuse — a far more common problem than one imagines — means arbitrarily taking off-the-shelf medication, which would in civilised nations only be available on prescriptions, in dosages other than prescribed. This can produce serious health effects, including addiction. According to Dr Syed Ahmer, assistant professor and residency programme director in the department of psychiatry at The Aga Khan University (AKUH), Karachi, addiction and long-term abuse of prescription medication produces chemical and physical changes equivalent to chronic alcoholism.

Common wisdom in society at large, and even among pharmacists and medical practitioners is that the use of prescription medications is “much safer” than the intake of street drugs, and that the former are “not addictive.” Not surprisingly then, empirical research demonstrates that prescription drug abuse, particularly in Pakistan, can be traced back to doctors who readily prescribe drugs as a first, rather than a last resort.

Take the case of Laila, who at one time was prescribed nine different pills by a general physician for symptoms of mild depression which arguably could have been easily treated by behavioral modification. Interestingly, four of the medicines prescribed to the young woman were banned globally when the side effects associated with their long-term use became known. Unethical medical and pharmaceutical trends, however, prompted their unchecked abuse in Pakistan.

According to a cross-sectional survey of medical students conducted by the AKUH, students reported a basic lack of information regarding their awareness on substance misuse in Pakistan. This could be explained by the fact that psychiatry is not taught as a major subject at the undergraduate level in Pakistan, except in a few medical colleges. Hence, doctors who are less informed than they should be about the ills of this abuse.

According to Dr Ahmer, the most commonly abused prescription medications include opioids ­— prescribed for pain, central nervous system depressants — used in the treatment of anxiety and sleep disorders, and stimulants, used for dealing with problems like ADHD and narcolepsy, as well as barbiturates, amphetamines and tranquilisers. A normal side effect of opioids is drowsiness and constipation, but depending on the amount taken, they can also restrict breathing. Central nervous system depressants slow down brain function and combined with alcohol or other medications that cause drowsiness cause heart rate and respiration to slow down dangerously. Taken repeatedly or in high doses, stimulants can cause anxiety, paranoia, dangerously high body temperatures, irregular heartbeat, or seizures, all symptoms that are evident in Samra’s case.

Dr Ahmer points out that the potential of dependence on benzodiazepines (BDZ) has been known worldwide for almost three decades. As early as in the 1970s, reports suggesting an association between long-term use of these drugs and tolerance started appearing in medical literature worldwide, but they still are the best-selling drugs globally. In 1981, an international study conclusively demonstrated that a physiological withdrawal syndrome could develop with the use of BDZ in doses considered to be in the therapeutic range. The risk of dependence was estimated to be as high as 45% after six months of continuous use. Since then, concerns about dependence and withdrawal have prompted the drug regulatory agencies of many countries to place restrictions on prescribing and over-the-counter sales of BDZ. In many countries they are licensed only for the short-term treatment of anxiety and insomnia, as a pre-anaesthetic and for alcohol detoxification.

Although legally BDZ should only be available for purchasers with a prescription from a doctor, in countries like Pakistan, they can very easily be bought without one. Laws against the unlicensed sale of BDZ are not implemented vigorously and the risk of misuse and dependence on these drugs is very high. Dr Ahmer points out that most of the country’s benzodiazepine consumption — parallel with international trends — was reported among females, especially housewives, presumably as a coping strategy for stress. Another possible explanation for female dependence on these drugs may be the higher prevalence of mood and anxiety disorders in women. Because they are easily available over the counter locally, self-medication is not uncommon. “Both patients and doctors need to be made aware of the risk of dependence associated with the use of BDZ. It is not uncommon in Pakistan for people to start taking a sleeping or anxiety pill themselves or on the advice of a friend or a pharmacy salesman without any need for a prescription,” says Dr Ahmer.

According to international studies, even six weeks of continuous BDZ use has shown significant impaired learning capacities in humans. In a study on the pattern of benzodiazepine use in psychiatric outpatients in Pakistan by AKUH, 45% of the participants were found to be using at least one BDZ. Seventy-three per cent of the users had been using the drug for four weeks or longer, and 87% were taking it every day. In 90% of the cases, the BDZ had been initiated by a doctor, and in 70% of these it was a psychiatrist who had prescribed the drug. Alarmingly, most of the users were taking it for a duration at a frequency which puts them at risk of becoming dependent on BDZ.

Prescription drug abuse is a significant emerging problem the world over. In the US, approximately one in five teenagers has abused a prescription painkiller to get high, and one in 11 has abused over-the-counter products, like cough medicine. Though local statistics are unavailable, doctors believe abuse of prescription medicines is also rampant among Pakistani youngsters. When asked why prescription medicine abuse was increasing among peers, teens cited “ease of access” as a major factor. Specifically, the majority cited parents’ medicine cabinets, and/or medicine cabinets in the homes of friends, as major access points. American data indicates significant and sustained declines in the number of teenagers using tobacco, and noteworthy declines in the number of teens using alcohol. Since 1998, teen attitudes against marijuana — the most widely used illicit drug — have strengthened (i.e., kids see more risk in using the drug, and less social acceptance), explaining a steady decline in the number of kids using marijuana there. However, these stimulants have been replaced by other inhalants and over-the-counter medications — today a significant category of substance abuse in the West.

Several options are available for effectively treating addiction to prescription drugs, depending on the medication being abused. Approaches to treating addiction to pain relievers are drawn from research on treating addiction to heroin, also an opioid, and include medications combined with behavioral counselling.

Social acceptance of the problem is the key to treatment. Take the case of Samra. Her husband has spent millions of rupees on her health expenses, locally and abroad. He has employed a foreign maid to look after her younger daughter and pays the lady over $300 a month, but refuses to take responsibility for his wife’s psychiatric treatment citing lack of time and motivation as excuses.

He is not the only one. Many people do not understand why individuals become addicted to drugs or how drugs change the brain to foster compulsive drug abuse. They mistakenly view drug abuse and addiction as strictly a social problem and may characterise those who take drugs as morally weak. One very common belief is that drug abusers should be able to stop taking drugs if they are only willing to change their behaviour. What people often underestimate is the complexity of drug addiction. It is a disease that impacts the brain and because of that, stopping drug abuse — prescription ones included — is not simply a matter of willpower. Through scientific advances, it is now known how drugs work in the brain. This addiction can be treated effectively in people like Samra only if there is no denial of the issue at hand.