Paracetamol over-use biggest threat:

Pain killers can kill

by Carol Aloysius

Sujaya's first reaction when her monthly pre-menstrual cramps became unbearable, was to reach out for her pain killers. Her most frequently used painkiller was Paracetamol, which was always available in her medicine cupboard , and regularly replenished no sooner the stock ran dry. It was also the easiest and most convenient over the counter drug which she could purchase in bulk form without even a doctor's prescription..

So dependent did she become on this painkiller, that she habitually used it for other minor health problems besides easing her monthly discomfort. A mild temperature, headache or joint pain would send her rushing to her medicine cupboard. Often in a hurry to get on with her other chores, she would gulp down several tablets, sometimes combining the drug with similar medications if her supply was low, with abandon and no thought for its dangerous consequences. Little did she realize she was precipitating a pernicious trend- of self medication and antibiotic overdose resulting in disastrous consequences on her health.

Acute reaction

The first sign of paracetamol overdose was when the 46 year- old housewife's tummy started playing up. It started the day she had popped several of the tablets and combined them with a similar analgesic ( pain killer) so as to get fast relief for the excruciating menstrual pain she was suffering. Within forty eight hours, she felt nauseous and began vomiting and developed back pain and fever. When she collapsed, her family rushed her to hospital " The doctors told us that if we hadn't brought her in time to be treated , it could have led to sepsis and death. It was an experience she could have avoided had she listened to our family GP's advice", her husband told this writer.

Sujaya's case is typical of an emerging trend of analgesic ( painkiller) drug overdose which is currently spreading in Sri Lanka. While only those acutely affected and rushed to hospital are reported by the hospital, hundreds of others remain unreported , many even seeking advice from traditional native doctors or those engaged in alternative medicine, to counteract any adverse effects resulting from self medication.

Health officials have however emphasised that early treatment in a hospital setting by qualified medical practitioners, was the most effective means of counteracting any adverse reactions from drug overdose. " The sooner they go to a hospital, the better, since serious complications could set in", they warned.

Study

A new study in the US published by IANS, underlines the danger of antibiotic resistance in kidney infections. "Medication resistant bacteria are now making it more difficult to treat common but severe kidney infection. Pyelonephritis is an infection of the kidney usually by E-coli bacteria, which can start as a urinary tract infection causing fever, back pain and vomiting.

"About half the people infected need to be hospitalized . If not treated with effective antibiotics, Paracetamol Poisoning can cause sepsis and death and liver failure. This is a real example of the threat posed by the emergence of new antibiotic resistant strains of bacterial which could greatly complicate the treatment of infection", the study;s lead author David Talan from the University of California has said.

However , National Poisons Information Unit head, Dr Waruna Gunathilaka countered the charge that paracetamol can cause sepsis, saying " Paracetamol causes liver failure rather than sepsis. It also won't cause immediate death as it acts on a long term basis. Paracetamol Poisoning with serious complications is common in childhood and paediatric age, as well as with alcoholics and malnourished persons in adults".

So how many Sri Lankans are exposed to this danger?

According to the 2015 NPIU Report the number of people currently running risks of an overdrive of medicinal drugs after ingesting excessive doses of pain killers, is increasing by the day.

Take a look

So what medicinal agent accounted for the highest incidence of poisoning?

Paracetamol, says the Report. Its findings revealed that Paracetamol was the commonest ( 36 out of 41 Analgesics) medicinal agent accounted for poisoning. Paracetamol ( 164) was also the most popular drug of choice for poisoning for the majority of patients.

What are Analgesics ? How are they ingested? How do they relieve pain?

Responding to our question, Head of the NPIU, Dr Waruna Gunatileka said, "An analgesic or painkiller is any member of a group of drugs used to achieve analgesia or relief from pain. They act in various ways on the peripheral and central nervous system and are available in various forms - from tablets, capsules and syrups. Paracetamol relieves pain only, and unlike NSAIDs, it does not have any anti-inflammatory actions.

It works by blocking the production of the chemicals called prostaglandins, making the body less aware of the pain or injury. Paracetamol has relatively fewer side effects and is less irritable to the stomach. However, over dosage may lead to liver damage, leading to liver failure, Immediate symptoms are nausea and vomiting. It should not be taken in large doses just because it is a drug that can be bought over the counter." He also stressed, that paracetamol should not be sold in loose form or issued in bulk to patients even in state hospitals as it happens at present when they visit the clinic once a month. " Some of the patients who come from distant areas, often under use the tablets , which is equally bad.

Others share them with family members. My suggestion is to issue the tablets every fortnight and encourage the patient to collect them on the due dates during their clinic visits". He added, selling them in loose form at pharmacies ( private sector) encouraged patients and non patients to buy them in large stocks. " If they sell them in bulk packets, this tendency will be less', he said.

He said, the NPIU would step up its on going awareness programs on the dangers of medicinal drug overuse , among other things, during the forthcoming National Poisons Week from October 17-23.

Hidden facts

Painkillers aside, the Report also unveiled a number of hitherto hidden startling facts relating to medicinal agents used for human poisoning in Sri Lanka. While analgesics led the rest by several margins at 41 out of 228 cases in 2014, the second highest were Antipsychotic drugs ( 25) with the drug Olanzapine rated as the second highest most used drug in this field. The third slot was reserved for Piriton, Folic acid, Resperidone and ingestion of a combination of drugs.

Asked to explain the actions and reactions to these drugs, Dr Gunathilaka said, "?Piriton is a brand of generic medication called Chlorpheniramine. It is an anti- histamine class medication, usually taken for an allergy. The most common side effect of this drug is feeling tired or sleepy.

Children and the elderly are more susceptible to neurological anticholinergic effects and paradoxical excitation", he added. What is troubling is that some people, especially, adolescents are using it to attempt suicide" Folic acid is used to treat mix anaemia deficiency while Respirodone is a mood stabilizer.

"All these drugs , whether the effect is mild or moderate MUST be taken on a doctor's prescription only", he stressed.' Our advice is , " Any drug however mild must be taken in moderation."

Vitamins vs society's demands

If speed is the criterion around which modern society revolves, then popping energizing pills and consuming high energy drinks to match that speed has also become an integral part of this society, today. To keep up with the demands of our fast paced existence, today most people from schoolchildren to young adults to middle aged and elderly persons have fallen into the habit of re-energising themselves with vitamins. Visit any pharmacy and you will find a dazzling array of vitamins promising immediate energy and power to your ailing limbs when you ingest any of these hi energy tablets, syrups, capsules. Health officials however scoff at such claims and say the effects are only temporary and could do more harm than good.

Next to antihistamine ( 13) vitamins( 12) are listed as the commonest abused medicinal agents leading to human poisoning in the 228 listing of medicinal agents.

Diabetes

Other drugs overused or improperly used include ' Anti diabetes drugs . Diabetes is the third highest leading cause of death in Sri Lanka ( 7.9% ) according to the 2015 study on Global Burden Diseases ( GBD), led by the Institute of Health Metrics & Evaluation ( HME), which brought together 1,800 researchers from 130 countries to study Injuries and Risk Factors in countries worldwide including Sri Lanka.

Anti diabetics ( 10) is listed as next to contraceptives ( 8) in the NPIU report on poisoning. Also included are; anti epileptic drugs( 4),cardiac drugs ( 3) and at the bottom of the ladder, steroids, non steroid anti inflammatory drugs and ayurveda oils.

A further breakdown by age and gender distribution in poison exposure patients revealed, that the majority of patients were males ( 74.7% . The youngest groups were under the age of 14 while the adult groups ( 20-60) represented the majority of the patients - 54.7% ( 555 cases out of 1015). In 2013, a total pf 81,471 admissions to state hospitals were due to poisoning with 751 deaths reported from the government hospitals.

Major health concern

"As you can see by these figures, poisoning is now a major health concern in Sri Lanka and the known cause of morbidity and mortality in state hospitals of the country. It is also a burden on our national health budget. Hence, we have decided to focus on Preventing poison during the forthcoming National Poisons Week", Dr Gunathilaka said.

He said, the publication of four books on management of Poisoning by common household products on different subjects covering an entire spectrum of poisoning in Sri Lanka had also been launched in cyberspace last year.

"The rationale of introducing four books for clinicians on management of poisons is in order to practice evidence based information. The books provide quick reference guides of acute management of poisoning by common pharmaceuticals, with updated toxico medical information", he said.

For more information contact the NPIU hotline 0113071073 or access their web page: wwwtoxbaselanka.info