Sedatives – kill the pill

LIFE in modern times is fraught with competition and stress. Gone are the days when people had time to gaze upon the stars and ruminate on Tasavor-e-jana(s). Generally speaking, some degree of stress is good for individual performance. However, rush for gold and achievement is bound to catch up with everyone. Further addition to this mayhem comes from the environment, one only has to read the morning newspaper to get stressed out. A friend of mine, has made it a habit to look at the news only in the evening, that too only skimming the headlines. From trigger happy zealots to incompetent structural engineers, all contribute to the stress of a regular Pakistani. Add to it the poor performance of our hockey team and those jockeying in the political arenas. How do people manage their stress? They do it by popping pills – self- prescription of tranquillisers.

Tranquillisers have become an acceptable component in the lives of a large segment of our population. Most of these are available over-the-counter without any medical prescription. These medications are not without hazardous side-effects and should be prescribed judiciously by a qualified health professional and should not be left to the discretion of shopkeepers. Self-prescription of tranquillisers is a multi-factorial problem with economic, social and psychological roots

By a conservative estimate, around seven to 10 million urban dwellers in Pakistan continue to consume tranquillisers regularly. According to one estimate, psychotropic drug sale in Pakistan for a duration of one year (June 2003-4) was worth 2.76 billion; of these tranquillisers and hypnotics were 1.36 billions with a rising trend of 18 per cent and 137 per cent respectively from previous year. General public, impervious to the risks associated with these drugs continue to pop pills.

The most commonly used tranquillisers are pharmacological compounds called benzodiazepines. Not only in Pakistan but around the world benzodiazepines are among the most prescribed and consumed group of medication. The discovery of first benzodiazepine, chlordiacepoxide, in 1957 by Leo Stern Bach was a landmark in modern psychopharmacology. Chlordiacepoxide was soon followed by a large number of similar compounds, which were quickly introduced in clinical practice, becoming among the most successful drugs ever introduced.

Various compounds from the group of benzodiazepine are available in the market. They are marketed with various attractive names and labels; it is not uncommon to see adjectives like tranquility, serenity and relaxation entwined in the names of some compounds. The most important differences among the variety of benzodiazepines are pharmacokinetic ones i.e. elimination half-life, formation of pharmacologically active metabolites. Established indications are anxiety and sleep disorders, seizures, epilepsy, muscle-relaxation, induction of amnesia, pre-medication and sedation in emergency medicine. What people do not know is that these medicines are not the only option available; there is a wide variety of pharmacological and non-pharmacological behavioral interventions that are far safer and effective for the management of these conditions.

The existence of benzodiazepine dependence was described in the early `60s with a very high dose of chlordiazepoxide but it has become a real concern for the medical community since the late `70s with an increasing number of reported withdrawal symptoms.

Individuals taking these drugs for a month or more may develop symptoms of withdrawal, characterised by anxiety, dysphoria, malaise, depersonalisation, and perceptual changes such as hyperacusis and unsteadiness. Sudden withdrawal of these medications can even lead to epileptic seizures. If the medication is stopped abruptly, it may lead to dysphoric withdrawal symptoms while continuation leads to dependence. It is ironic that the very reasons for which the medication was prescribed may return to haunt the individual.

Another hazardous effect of these medications is muscle incordination and delayed time-reactivity. This can prove disastrously fatal if one is driving a vehicle or operating machinery and for housewives, the use of choppers and blenders.

Once a person is habituated to take these medications, tolerance for the substance sets in i.e. the person no longer gets the desired effect for which he was taking the medication. In order to ward off withdrawal symptoms, people generally resort to increasing the number of tablets.

It is not uncommon for people to get concerned after reaching this stage and seek consultation from a physician or mental health professional. Usually, when they are seen in a clinical setting they are hooked on to take 10 to 15 tablets per day. Inter-dose withdrawal is another phenomenon which might impair day-to-day functioning and work performance.

Like other medication, drug-drug interaction is also another issue with benzodiazepines. If mixed with alcohol consumption, the effect of these medications can lead to life threatening conditions; suppression of respiratory centre in brain stem is just one of the concerns. Possibility of getting choked to death cannot be ruled out either if a person reaches an acute stage of intoxication.

Benzodiazepines are the most favoured medication of self-harm. Perhaps this has stemmed from their status as sleeping pills; in an overdose one would expect a person to sleep forever. There lethality index is very high i.e. when taken alone, dose of multiple grams proves to have fatal consequences.

If we look at the research carried out in developed countries, benzodiazepine overdose is the most common way of self-poisoning among the substance induced suicidal attempts, accounting for about 40 per cent of the total. A study done in Germany reports this proportion to be 32 per cent. The study also reveals that 80 per cent of the drugs used in self-poisoning are prescribed by physicians themselves.

In a study carried out in Pakistan, the proportion of benzodiazepine usage in para-suicide is double the figures quoted in the western data i.e. 80 per cent. In 44 per cent of the cases, these drugs have been bought over the counter.

In the context of Pakistan, general physicians prescribe these medications without educating patients about the potential dependence and abuse. In a group of 475 patients, 38 per cent reported current use of one of these compounds; among them 68.3 per cent used them for sleep, 52.2 per cent for stress or anxiety, seven per cent for depression, 0.8 per cent for fits and 10.2 per cent for other reasons.

On inquiry, 85 per cent of the participants reported that these medications were prescribed by physicians at some point in time. Among these Physicians, 60 per cent were general practitioners while 36 per cent were specialists. One can only speculate about the intention of these physicians; whether they do it out of good will, lack of skills pertinent to mental health or have other ulterior motives.

Multinational pharmaceutical companies, driven by economic gains, market these tablets as ‘absolute recipe for peace of mind’. Most physicians act as ‘agents’ for sales and promotion, with their share in the cake. Ultimately it is the patients and their families who have to pay the price. This is obviously done in the guise of science, technology and promotion of ‘robust’ evidence.

During this survey it was discovered that around 80 per cent of people were aware of one or more brands of benzodiazepines – available over the counter. Among these, 67 per cent had some idea that if these medications are used for a longer duration than they can become a liability.

For drug-naïve patients it is best to stay away from these medications. If confronted with problems of sleeplessness (insomnia) or anxiety there are behavioral interventions which can alleviate the problem.