Prescription Drug Misuse/Abuse In India

Have you ever been refused medicines at the pharmacy because you forgot the doctor’s prescription note? Chances are maybe once or twice. So, why is it that some medicines can be bought only with a prescription note and some without? Here’s the difference.

A prescription drug is a medicine that one can only buy with a written prescription by a doctor. Prescription medicines are specially formulated for a specific purpose. On the other hand, over-the-counter medicines are generally considered safe for most people and maybe formulated to help with a variety of minor health issues.

Medicinal drugs have been misused and/or abused since ancient times. Cannabis was one of the most sacred plants mentioned in the Vedas; it was widely known for its healing properties and was used as a medicine. However, it was and is still being abused for attaining a trance-like state or a high.

Today, substance abuse and addiction are two of the biggest healthcare issues challenging the world today. India too has seen a rise in substance abuse, especially misuse/abuse of prescription drugs.

The terms ‘Misuse’ and ‘Abuse’ are not the same and are not interchangeable. Knowing the difference between the two terms is crucial to understanding the problem of prescription drug misuse/abuse in India.

Prescription Drug Misuse vs. Prescription Drug Abuse

Misuse of prescription drugs can be described as consuming medicine in a way or dose other than prescribed. It can also include using someone else’s prescription, even if it’s for genuine medical issues like migraine or pain.

Abuse of prescription drugs can be defined as consuming drugs in a way or a manner that causes one to get high, and eventually get addicted.

Let’s explain this further in a real-world situation.

Patient A is a 45-year-old woman who has Insomnia (a sleep disorder in which one has trouble falling and/or staying asleep) and is prescribed sleeping pills. She has been asked to take one pill an hour before sleeping. However, since the last few days, Patient A hasn’t been able to fall asleep with the prescribed one pill, so she started taking two pills instead, thinking it will help her fall asleep. This is misuse of prescription drugs.

Let’s assume that Patient A has a teenage son who is unable to keep up with his academic demands and his social life. He starts taking his mother’s sleeping pills to ‘zone out’ from his problems. This is an abuse of prescription drugs.

It is important to note that both misuse and abuse of prescription drugs are harmful and at times can be life-threatening too.

Most Commonly Misused/Abused Prescription Drugs

The Ministry of Social Justice and Empowerment, in collaboration with the National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi carried out a National Survey on Extent and Pattern of Substance Use in India in 2019. The report highlighted that around 1 per cent of the population, aged 10-75, had misused pharmaceutical opioids in the past year and that an estimated 0.2 per cent of the population (2.5 million people) were suffering from drug use disorders related to pharmaceutical opioids.

The three classes of medication most commonly misused are Opioids, Central Nervous System [CNS] depressants and stimulants.

Opioids are a class of drugs derived from the opium poppy plant and are often used as medicines because they contain chemicals that help relieve pain. Prescription opioids are often used to treat moderate to severe pain. These prescription drugs can make people feel very relaxed and “high” and are the reason why it is misused and abused. Opioids are highly addictive and an overdose can cause death. Some common prescription opioids that are abused are Hydrocodone, Oxycodone, Oxymorphone, Morphine, Codeine and Fentanyl.

Central Nervous System [CNS] depressants are medicines that include tranquillizers, sedatives, and hypnotics. These drugs help slow brain activity and are suitable for treating anxiety, panic attacks, acute stress responses, and sleep disorders. Tranquillizers as the name suggests brings tranquillity or “the state of being calm” and are prescribed to treat anxiety or to relieve muscle spasms. Sedatives and hypnotics can induce sleep and are used to treat sleep disorders. Diazepam, Alprazolam, Zolpidem, Phenobarbital are some of the CNS depressants that are widely misused/abused.

Prescription stimulants are most often prescribed to treat attention-deficit hyperactivity disorder (ADHD) as well as narcolepsy (uncontrollable episodes of deep sleep). These drugs help increase alertness, attention, and energy. The most common prescription stimulants are dextroamphetamine, dextroamphetamine/amphetamine combination product and methylphenidate. In popular slang, they are also called Speed or Uppers as they give a feeling of “intense rush” (euphoria).

Prescription Drug Misuse/Abuse In India – Statistics

According to the “Magnitude of Substance Use in India” report submitted by the National Drug Dependence Treatment Centre (NDDTC), there is a rise in prescription drug abuse/misuse over the years.

According to the report, approximately 2.6 crore people in India have used or use opioids and over 60 lakh people in India suffer from Opioid use disorders. The most common drug used is Heroin followed by Pharmaceutical opioids and Opium. Uttar Pradesh, Punjab, Haryana, Delhi, Maharashtra, Rajasthan, Andhra Pradesh, and Gujarat contribute to more than half of the people suffering from Opioid abuse.

Approximately 1.18 crore people use sedatives and inhalants out of which 4.6 lakh children and 18 lakh adults need support as a result of addiction to inhalant use. Uttar Pradesh, Madhya Pradesh, Maharashtra, Delhi, and Haryana have a very high child population in need of help as a result of an overdose.

Over 8.5 lakh people inject drugs into themselves and are addicted. The most common drugs injected are Heroin (48%) and Buprenorphine (46%). Uttar Pradesh, Punjab and Delhi top the numbers.

Risk Factors And Symptoms Of Prescription Drugs Misuse/Abuse

Prescription drugs are misused/abused in many ways. Some take a larger dose than prescribed, some crush the pills, dissolve it in water, and inject the liquid into a vein and some snort the powder.

Opioid and CNS depressants misuse/abuse can cause slowed breathing, which may lead to hypoxia (a condition arising when too little oxygen reaches the brain). Hypoxia can have short- and long-term psychological and neurological effects, including coma, permanent brain damage, and even death. Over abuse of prescription stimulants may lead to an abnormally high body temperature, an irregular heartbeat, heart failure, and seizures.

The most common physical symptoms of Opioid and CNS depressants misuse/abuse include slowed breathing rate, drowsiness, confusion, poor coordination, and memory problems. The common physical symptoms of stimulants misuse/abuse include anxiety, paranoia, insomnia and high blood pressure.

People misusing/abusing prescription drugs may showcase other non-physical symptoms like withdrawal from friends and family, borrowing prescription drugs from others, stealing prescription pads, visiting multiple doctors for prescription notes and also ordering prescription drugs from illegal internet pharmacies.

Prevention Of Prescription Drugs Misuse/Abuse

The age-old saying of “Prevention is better than cure”, is apt when we are dealing with the probable misuse of prescription drugs. Doctors, pharmacies and patients and their families can all play a significant role in identifying and preventing misuse/abuse of prescription drugs.

Doctors have an advantageous position when it comes to identifying a patient’s misuse of prescription drugs and can take immediate steps to prevent it from becoming a substance abuse disorder. If the patients are regularly asking for new prescription notes or higher dosages, or if the medicines have stopped being effective, then the doctor needs to step in and take action.

Preventive measures could include having a frank but a compassionate conversation with the patient, asking the patient’s partner/children/close family member for any physical symptoms or social change in behaviour, as well as giving the patient a complete physical and medical examination to verify symptoms of possible misuse. As these prescription drugs are an important part of the patient care regime, the doctor has to balance the genuine medical needs of the patient with the potential risk for misuse and related harms.

Pharmacies or ‘Chemist shops’ need to keep an eye out for fake, forged, altered or old prescription notes. They are the first line of defence when it comes to the misuse/abuse of prescription drugs. Pharmacists may proactively inform the patients about the prescribed dosage and the harmful effects of overdosing. They should also at all costs avoid selling prescription drugs without a prescription note. Also, according to the Schedule H1 of Drugs and Cosmetics Act (DCA), pharmacists have to maintain a record of all habit-forming medicines and potent third- and fourth-line antibiotics for a minimum of three years.

Patients should always take their prescription medicines as per the dose prescribed. If visiting a new doctor, they need to inform them about all the prescriptions drugs, over-the-counter medicines, and dietary and herbal supplements they are currently taking or took in the immediate past. They need to keep themselves aware of possible interactions with other drugs as well as alcohol. Patients should also never share their prescription medicines with others or hoard medicines to take them in one go. Patients should also make sure that their prescription drugs are only accessible to them and not left lying around at home or office. Also, it is important to discard expired prescription drugs in a way that it cannot be fished out from garbage bins by drug addicts. You can also give your expired or unused prescription drugs back to the pharmacy and they will discard them safely for you.

Treatment Of Prescription Drugs Misuse/Abuse

Years of research have proved that substance abuse problems often involve mental ailments that can be treated effectively. Treatment should take into account the class of drug used and the medical needs of the individual. Successful treatment often involves a holistic approach that includes detoxification, counselling, and medications that are not addictive.

Patients suffering from prescription drug abuse can seek Cognitive behavioural therapy (CBT) to help identify the root cause of their addiction. CBT has been established to be effective for a wide range of problems including depression, anxiety disorders, alcohol and drug use problems, eating disorders and severe mental illness.

Recommending treatment through medication for prescription drugs abuse may seem counter-intuitive. However, there are a few drugs that prevent other opioids from affecting the brain or relieve withdrawal symptoms and cravings, thereby preventing relapse episodes.

The Future Of Prescription Drugs Misuse/Abuse In India

The Narcotic Drugs and Psychotropic Substances Act, as amended in 2014, recognized that the need for relief from pain was “an important obligation of the government.” The revised law created a class of medicines called the “essential narcotic drugs” list, which included morphine, fentanyl, methadone, oxycodone, codeine and hydrocodone. This loosening of prescription opioid laws has left India’s sprawling cash-fed health care system ripe for misuse.

Drugs that are now routinely prescribed for chronic pain, were first approved for use by cancer patients only. One of the earliest formulations of fentanyl, for example, was a lollipop because chemotherapy left many cancer patients severely nauseated to eat. In India, pain physicians now prescribe fentanyl patches to patients with chronic muscular pain. Tramadol was touted as a less addictive painkiller and had fewer restrictions on its sale. However, it was found that addicts of heroin took Tramadol when they couldn’t find or afford heroin.

The Indian government is aware of prescription drug abuse in India and regularly updates drug wholesalers on which drugs they can stock and which they cannot. In 2018, the Ministry of Health and Family Welfare prohibited the manufacture for sale, sale or distribution for human use of 328 Fixed-Dose Combinations (FDCs). Over 6000 brands of drugs were affected by the ban including the popular painkiller Saridon and the widely used cough syrup, Corex. However, pharmaceutical companies are a powerful lobby and they will keep demanding more relaxation of laws on the sale of prescription drugs.

In the end, it all comes down to the right intent. Doctors need to prescribe medicines with more care, patients need to be careful with their medications and the pharmacies need to stop dispensing prescription drugs like candies. The road ahead is long but it is a battle that can be won.