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Pharmaceutical drugs sold by unscrupulous vendors to youth an emerging danger - Prof Ravindra Fernando
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Like most South Asian countries, Sri Lanka suffers from a deluge of medicinal drugs. While the numbers of these mainly imported drugs have been reduced over the years and drastically so since 2016, the fact is that the public seems to have far more medical drugs than they actually need. Much of the problem arises from the same brand names being given to the same drugs instead of the generic names, which has thrown the public, pharmacists and even physicians to confusion. It has also created certain preferences being given by physicians, especially, in private hospitals to prescribe a brand name of a more expensive drug rather than the cheaper drug in the generic name, due to some vested interests.
Easy accessibility to painkillers like paracetamol and the tendency to misuse antibiotics, has also led to health risks that have put the patient’s life on the line. Antibiotic resistance is today an issue of serious concern among our health officials.
In the wake of the Health Ministry poised to increase local production of drugs at the State Pharmaceutical Corporation by 2018, The Sunday Observer spoke to Chairman National Dangerous Drugs Control Board and Emeritus Professor of Forensic Medicine and Toxicology, Faculty of Medicine, University of Colombo Prof. Ravindra Fernando. He offered us valuable insights into how and why these problems have to be tackled without delay, in order to ensure that every Lankan is assured of the highest quality drugs at the most affordable price.
Excerpts...
Q. Sub standard medicinal drugs have long posed one of the biggest threats to human health, both, in Sri Lanka and abroad. For example, in 2008, it was reported in a leading Sunday paper that more than 35 drugs were found to be sub-standard. These included anti-epilepsy drugs and a number of antibiotics, as well as drugs used to treat brain tumours and rheumatoid arthritis; support labour contraction during childbirth, and stabilize blood glucose levels. Various types of surgical equipment were also on the list of substandard medical products. The same paper also alleged that in 2009, a massive stock of the painkiller pethidine – 360,000 vials – had to be thrown away because it was past the expiry date. Pethidine is favoured by doctors because it is a less addictive drug than other painkillers. As a result of the pethidine shortage, hospitals were compelled to use morphine which is highly addictive in surgery on injured soldiers and civilians. Do you agree?
A. It is not uncommon to receive substandard drugs and medical equipment when we import drugs from various manufacturers from different countries. Although we test the quality of the drugs initially, it is not possible to check every subsequent sample imported, for quality.
Q. It was also found that many brands of the same drug has been registered, causing confusion among both pharmacists and patients.Although the Health Ministry has directed doctors to prescribe generic drugs, rather than brand-name drugs, Sri Lanka has registered a surprisingly large number of brand-name drugs, compared with other countries, e.g. antibiotics, sold only a handful of Amoxicillin brands, while Sri Lanka had hundreds. When local doctors use generic names in their prescriptions, they give unethical pharmacists a chance to recommend expensive brands for their own profit, e.g. the antibiotic Amoxicillin. Whereas in other countries only a few brands are recommended of this antibiotic, in Sri Lanka the number of brands are wide ranging. Is this true?
A. Yes, Sri Lanka has registered many brands of the same drug. Many doctors prescribe generic drugs, but the pharmacies sometimes give branded products. There is no law to prevent pharmacies from doing so.
Q. What are the health implications of drug abuse and antibiotic overuse?
A. Frequent and inappropriate use of antibiotics can cause bacteria or other microbes to change so that, the next time when antibiotics are used, they would not work against them. This is called bacterial resistance or antibiotic resistance. Treating these resistant bacteria requires higher doses of medicine or stronger antibiotics or multiple antibiotics. Because of antibiotic overuse, certain bacteria have become resistant to even the most powerful antibiotics available today.
“Centers for Disease Control and Prevention” (CDC) of the USA calls antibiotic resistance “one of the world’s most pressing public health problems.” Bacteria that were once highly responsive to antibiotics have become more and more resistant. Among those that are becoming harder to treat are pneumococcal infections (which cause pneumonia, ear infections and meningitis), skin infections, and tuberculosis.
In addition to antibiotic resistance, overusing antibiotics can lead to other health problems. Antibiotics kill many different bacteria, even the good ones that help keep the body healthy. Sometimes, taking antibiotics can cause a person to develop diarrhoea due to a lack of good bacteria that help digest food properly. In some cases, bad bacteria, like Clostridium difficile may overgrow and cause infections.
Q. It was also charged that certain doctors and pharmacists were taking advantage of the fact that Sri Lanka had no National Drug Information Centre, unlike in most countries. Hence, the public was generally ignorant about drugs and their proper usage. ?
A. I agree that Sri Lanka should have a National Drug Information Centre. After I established the National Poisons Information Centre in the National Hospital in 1988, I initiated steps to have a Drug Information Centre in the National Hospital. However, two consultant physicians objected stating that there was no need for such a centre and the then Director asked me not to go ahead.
Q. Most countries have drug information centres. These are important for both patients and doctors. Unfortunately, the average Sri Lankan patient knows little or nothing about the drugs he or she is being prescribed. With a drug information centre, patients, doctors and the general public can learn about drugs, online or on the phone, on drugs prescribed, drugs available in the country, and how to use those drugs
A. I agree
Q. It is said that in Britain, a British National Formulary comes out every six months, but that there is no such up-to-date Sri Lanka Hospital Formulary to turn to for reference. Hence doctors who go overseas for training have to bring back used copies of the British National Formulary for reference. The drugs index, which covers all available drugs, registered drugs and new drugs, was last published in 2004. Assurance was given by the Health Ministry that all steps would be taken to track and eliminate sub-standard drugs from hospital stocks and pharmacy shelves, and a revised index on drugs will be made available as early as possible. Has this promise actually been delivered?
A. I think we also should publish a drug index annually. Sometime back I got down the British National Formulary from the UK through the Sri Lankan Doctors’ Association there and distributed them free to our doctors.
Q. A number of changes have taken place since the present government of Good Governance came into power, with the President and Health Minister taking a leading role in calling for low cost affordable quality drugs to be made available to all Lankans. How has this been achieved up to now? Elaborate.
A. .I admire the policy of the government taking a leading role to provide low cost, affordable drugs to patients in Sri Lanka. The Minister of Health has controlled the prices of nearly 50 drugs a few months ago. This must continue.
Q. Despite precautions, paracetamol and other such drugs are being sold in loose form in certain outlets instead of the blister packs. As there are over the counter drugs, studies have found that paracetamol is one of the most commonly used drugs abused by the young and old alike. Your comments?
A. Paracetamol is permitted to be sold as an over the counter drug. Paracetamol is the commonest drug taken for self-poisoning in Sri Lanka. In some countries like the UK, only 16 paracetamol tablets can be sold to an individual from a pharmacy. However, a person who wants an overdose can buy paracetamol from several pharmacies. In overdose, paracetamol is a comparatively safe drug as hospitals have antidotes for paracetamol poisoning. In a study I performed several years ago, only one patient died out of over 600 paracetamol poisoning victims. I say paracetamol is a safe drug because I could save a young girl who ingested 167 paracetamol tablets by giving antidotes early.
Q. What is the practice of over-the-counter drugs issuance in the UK and other countries you have visited in your long years of experience?
A. Many safe drugs are issued over the counter in the UK and other countries. As I mentioned, the numbers sold are restricted for some drugs.
Q. Illegible prescriptions by doctors still a major handicap, especially, in pharmacies which employ pharmacists who are under qualified, due to the dearth of trained pharmacists in the country. The Pharmacology Association has repeatedly stressed they should be upgraded to the same status as that of doctors to overcome this gap. Your comments?
A. I do not think it is possible or desirable to upgrade pharmacists to the same status as doctors as the training of the two professions are markedly different.
Q. What do you see as the main gaps in the present delivery system of drugs? What solutions do you see for filling them?
A. There is no problem of issuing and using drugs prescribed by doctors. However, there is a new danger of abusing pharmaceutical drugs sold by unscrupulous pharmacists. For example, painkiller tramadol, and the anti-epileptic and painkiller pregabalin are sold by these pharmacies to youth without prescriptions for abuse.
They should be sold only for a prescription. The National Medicines Regulatory Authority through Food and Drug Inspectors are prosecuting the pharmacists and closing down the pharmacies selling these drugs.
Q. Your advice to the public and prescribing physicians on drug prescriptions.
A. The advice to the public is not to use drugs without a prescription from a doctor and to use them as advised. For example, if you consider paracetamol, take one or two tablets, three times a day or eight hourly for 5 days as advised by a doctor. Do not keep any drug where children have access to them.