Mind Your Meds
When the delivery room was filled with the first fragile cry of her baby, Ranjita Srivastava slipped into a happy unconsciousness. Six hours after she recovered her senses, she held the newborn in her weak arms. What everyone mostly discussed when they saw him was whether the baby looked more like the mother or the father. He was a healthy boy and they named him Bonney. Five days later, Ranjita had a hard time putting to sleep her otherwise calm baby. He had skin rashes and an upset stomach accompanied by high fever. The baby was injected with antibiotics as precautionary measures after birth. Doctors lost no time to administer the five-day-old with more antibiotics. When one antibiotic did not work, they switched to another in a desperate attempt to save the little one. Nothing worked, Bonney grew weak with each passing day.
On the 10th day, he died. It was found out that the infection which the baby developed was immune to almost every antibiotic. A test confirmed that the antibiotic-resistant bacteria or superbug was passed onto the embryo from the mother.
Suresh Kumar (name changed), a 32-year-old marketing professional in Bengaluru, has never visited a doctor in the last 10 years. Be it a viral or bacterial infection, he has the habit of calling up his pharmacist friend and getting a prescription for his ailments. Based on his friend’s advice, Kumar takes antibiotics and analgesics, and claims there is nothing wrong as he has been doing this for a decade now. He has been suffering from frequent attacks of acidity, diarrhoea, headache and other related problems which, he claims, is nothing serious. Contrary to Kumar’s firm belief, these are nothing but side-effects of analgesic overuse.
If not contained, uncontrolled consumption of antibiotics and other drugs can soon lead to an epidemic. “Yes, this is going to be a ‘super catastrophic epidemic’. When an infectious bacteria-generated epidemic comes, we use antibiotics and stop it. But if antibiotics will not work, the epidemic cannot be controlled and there will be catastrophic results,” says Dr Ashok J Tamhankar, national coordinator for Indian
Initiative for Management of Antibiotic Resistance.
In 2001, eight billion units of these drugs were consumed and the number rose to 12.9 billion units in 2010, which means on an average an Indian took 11 antibiotic pills per year. With the abuse of antibiotics comes the new threat of superbugs. According to experts, on an average 800,000 die in India annually, of which 58,000 were reported to be dead due to superbugs-related complications in 2014. “Superbug is an informal term for a bacterium that has become resistant to antibiotics usually used to treat it, like Methicillin-Resistant Staphylococcus Aureus (MRSA) or any multi-resistant bacterium. Superbugs are drug-resistant, human-killing microbes that modern medicine struggles to combat,” says Dr D S Chadha, Associate Director, Internal Medicine, Fortis Flt Lt Rajan Dhall Hospital, New Delhi. Common bacteria such as MRSA, Escherichia coli (E. coli) and related, Carbapenem-Resistant Enterobacteriaceae (CRE), Clostridium difficile and New Delhi metallo-beta-lactamase 1 are the latest in this group of superbugs .
With antibiotics being the most abused category of medicines—others being pain-killers, antidepressants, cough syrups, abortion pills and anti-allergens—Dr R Sundararaman, general physician (internal medicine) at SIMS Hospitals, Chennai, says people usually tend to self-medicate whenever they develop symptoms of cold, fever or sore throat. “Medication is a gradual process. A patient complaining of sore throat should not be directly put on a course of Penicillin or Azithromycin even if these antibiotics are meant to treat these conditions. These drugs, however, should be saved for advanced symptoms. They have to be given only after the patient is diagnosed properly and doesn’t respond to basic medicines,” says Sundararaman.
At the same time, an inadequate dosage makes the bacteria responsible for the symptoms becoming virulent and resistant to its respective antibiotic. “As a result, a fever which could have been treated with a basic antibiotic will now need a higher antibiotic. The best instance is Ciprofloxacin. The bacteria it was formulated for has become resistant due to indiscriminate usage of the antibiotic. And so have the drugs for tuberculosis. Due to improper dosage of TB medicines, a lot of people are dying of multi-drug-resistant tuberculosis (MDR -TB),” he says.
Just like antibiotics, antidepressants and nonsteroidal anti-inflammatory drugs (NSAID) or analgesics—taken for headaches, fever and pain—which also need a medical practitioner’s prescription to be bought, are easily sold over the counter in pharmacies across the country. “And it is happening even though the sale of sleeping pills without a prescription is prohibited under the Narcotics Act,” says Dr W J Alexander Gnanadurai, psychiatrist and senior consultant at the Institute of Mental Health, Madras Medical College, Chennai.
Sujatha (name changed), a 42-year-old camerawoman working with a television channel in Bengaluru, had the habit of popping analgesic drugs to get rid of her frequent bouts of headache. This turned into a serious issue as continuous use of these drugs led to renal failure. When she was hospitalised, the doctor said her intrinsic problem was rise in blood pressure. Without getting a medical check-up done for a long time and dosages of four-five tablets per day for more than three years had resulted in kidney failure. With none of her family members ready to donate a kidney, she died after some time, leaving behind a five-year-old child.
Rampant abuse of pain management medicines can lead to kidney trouble. “This is something which we generally see in senior citizens as well as in youngsters. Long-term abuse of this medication affects certain other parts of the body leading to unwarranted complications. It is important that the primary healthcare giver makes the patient aware of the dangers of abusing drugs. The doctors themselves should be judicious in the way they prescribe medicines. Since there is no regulation on the prescription and sale of such drugs, there is rampant abuse. If a legislation comes in to regulate the use of medication, pharmacists and doctors will think twice before prescribing such medicines,” says Dr Praveen Kumar G B, senior consultant physician, St. Martha’s Hospital, Bengaluru.
Chemists say they are helpless as a lot of people demand medicines without prescriptions. “It’s difficult to tackle them because they’re adamant about buying what they need. The greatest demand is for Alprax, a drug used for treating depression, anxiety and panic disorders. Usually older people come asking for this but they don’t realise that taking this without the doctor’s advice can prove harmful. Side-effects include forgetfulness, lightheadedness, slurred speech and even blurred vision in some cases,” says pharmacist Sanjay Goel of City Medicos in Dwarka, New Delhi. He further says that Combiflam, used for treating fever and pain, is the other medicine that has a huge demand. “The scariest fact is that parents sometimes give large unprescribed doses of this medicine to their children. It has the same properties such as paracetamol and ibuprofen, and therefore side-effects are similar to ones that you may have when you’ve had an overdose of Crocin. Besides, it’s not advisable for people with breathing problems to take this,” says Goel.
Though Kerala is said to have the best health practice in the country, the irrational or overuse of drugs in the state is reported to be alarming. “Over-the-counter sales of drugs and lack of treatment protocol can be said to have led to the increased use of drugs,” says Dr Althaf A, associate professor at the Thiruvananthapuram Medical College and convenor of IMA Public Health Assurance Committee. “OTC drugs are not banned in the country, which is a great challenge. Apart from this, there is no proper drug quality checking mechanism and no marketing regulations. In developed countries, especially in the UK, no drug can be purchased without prescription. And the prescription also contains the doctor’s code number. When drugs are sold, the stores maintain a record of the names of the doctor and the patient. All these help in controlling the irrational use of drugs,’’ says Althaf.
Even though psychiatrists prescribe antidepressants like Nexito and analgesics for their patients, Dr Gnanadurai says they are strictly given in a measured proportion. “What is horrifying is that patients continue taking these medicines beyond the prescribed dosage. Most of them think stopping their intake will bring the symptoms back. While many use old prescriptions to buy these medicines, others have friends in medicine shops who oblige without much fuss,” he adds.
While the wrong dosage could be harmful and even fatal in psychiatric drugs, Gnanadurai says people often take more than twice the recommended dosage while self-medicating. “The prescribed dosage for Valium (taken for anxiety), for instance, should not exceed over 15 mg per day, but people with addiction take about 40 mg. On the other hand while an average dosage of Alprax, which treats sleeping disorders and anxiety, is two tablets per day, there are people who pop in about 10-15 pills daily,” he adds.
The results of this indiscriminate intake are hazardous. While the side-effects of an improper dose of antidepressants and sleeping pills could result in loose motions, nausea and blood vomiting, an overdose could even cause a cardiac arrest, coma and eventually death in patients, and affect the foetus in pregnant women. A regular intake of these medicines could also make a patient severely addicted to them. “A few years ago, a teenager was rushed to the OT of a hospital I was working in, with palpitation, dizziness and severe chest pain. We later discovered that he was addicted to sleeping pills, which he had been taking for years without consulting a doctor, and just a few days of discontinuing them had landed him in the hospital,” says Gnanadurai.
Besides the unchecked consumption of anti-spasmodic tablets for menstrual cramps, abortion pills are also being sold like candies, even though taking them without a doctor’s supervision could even lead to infertility apart from several other uterine problems. “Many women pop Cytotec and mifepristone pills without any supervision to abort unwanted pregnancies. They should know that abortion isn’t meant to be done over and over again, and when done should be conducted by a gynaecologist. The results otherwise can not only manifest in the form of half-done abortions, but also lead to severe pelvic pains and infertility,” says Dr Kamala Selvaraj, a gynaecologist in Chennai.
Whether it is the promise of quick relief from pain or a desire to self-medicate, people just don’t want to invest time, money and energy in something which, they believe, is under their control. “People have a lower tolerance these days and want immediate relief. Self-prescribing antibiotics is an easy solution as they feel the relief within 48 hours. What they don’t realise is that 48-72 hours is the life cycle of the bacterium in general. What they have treated are only the symptoms. People also believe that antibiotics are a good solution to any ailment. Lack of awareness makes them believe that if a doctor does not prescribe an antibiotic, he is no good. This needs to change. People are also short on time and do not have the patience to sit through OPD working hours to meet a doctor. Also the lack of a good consulting doctor in the neighbourhood is a deterrent and causes them to abuse medication,” says Praveen.
It’s time to pause and ponder before you pop a pill next time.
Abused medicines
Antibiotics
Ofloxacin, Amoxycillin
Anti depressants
Alprazolam, Clonazepam
Abortion pills
Mifepristone, Misoprostol
Analgesics
Paracetamol, Aceclofenac
Laxatives
Lactulose, Bisacodyl
Being Anti-Antibiotics
Antibiotics DO NOT fight viral infections such as colds, flu, sore throats, bronchitis, and several sinus and ear infections. Taking them...
■ Will NOT cure the infection
■ Will NOT keep other people from getting sick
■ Will NOT help you or your child feel better
■ May cause serious SIDE-EFFECTS
■ May contribute to antibiotic RESISTANCE, which is when bacteria are able to resist the effects of an antibiotic and continue to cause harm
POST-ANTIBIOTIC ERA
WHO’s first report on the extent of antibiotic resistance globally warned of a ‘post-antibiotic era’. This survey, which was completed by 133 countries in 2013 and 2014, is the first to capture governments’ own assessments of their response to resistance to antimicrobial medicines used to treat conditions such as bloodstream infections, pneumonia, tuberculosis, malaria and HIV. It summarises current practices and structures aimed to address the issue, and shows there are significant areas for improvement. Following are the key findings of this survey:
Only 34 of 133 participating countries have a comprehensive national plan to fight resistance to antibiotics and other antimicrobial medicines.
Monitoring is key for controlling antibiotic resistance, but it is infrequent. In many countries, poor laboratory capacity, infrastructure and data management are preventing effective surveillance, which can reveal patterns of resistance and identify trends and outbreaks.
Sales of antibiotics and other antimicrobial medicines without prescription remains widespread, with many countries lacking standard treatment guidelines, increasing the potential for overuse of antimicrobial medicines by the public and medical professionals.
Public awareness of the issue is low in all regions, with many people still believing that antibiotics are effective against viral infections.
Lack of programmes to prevent and control hospital-acquired infections remains a major problem.
WHO report 2013-14
with Meera Bhardwaj, Samhati Mohapatra, Ayesha Singh and Prabhat Nair