Non-fatal overdoses on prescription meds outnumber illicit drugs

The dangers of illicit drugs are hammered into our minds as young children, but when it comes to prescription medications, their use comes without a second thought.

Data from the ministry for social solidarity, forwarded to MaltaToday show that more people were admitted to Mater Dei hospital between 2011 and 2014 with non-fatal overdoses through prescription medications than with non-fatal overdoses of illicit drugs.

In 2014 alone, 74 people were admitted to Mater Dei hospital with non-fatal overdoses resulting from prescription pills, compared to 21 illicit drug users, which might lead one to wonder about the dangers of prescription medication.

“From my point of view, such figures are not surprising, and they should in no way suggest that illicit drugs are less hazardous than prescription medication,” psychiatrist Anthony Zahra told MaltaToday. 

Zahra said the figures could be attributed to various reasons, not least of which is the availability of such medications with a wide range of them naturally being offered on the government’s formulary list, and the majority of them not being particularly expensive.

“Another reason for higher hospital admissions is that illicit drug users are often scared of taking their friends to hospital or of even reporting potential overdoses for fear of getting caught by the police,” he said, adding that many illicit drug overdoses tended to be fatal precisely for this reason. 

Zahra also explained that prescription pill overdoses were normally the result of people taking a ‘cocktail of medications’ or even mixing them with alcohol.

“Prescription pills don’t have a ‘junky’ sort of following, but they are often used for specific and particularly trying times,” he said, adding however, that many make chaotic use of medications, mixing both illicit and prescription medications, or taking more medications than their prescription advises.

“Illicit drugs will always be more dangerous to human health, and they are illicit precisely because they are addictive and offer very few benefits to human health,” Zahra said.

“However,” he added, “Some medications may have abuse potential, in particular those kinds of medications which have an effect on our emotional state, or which relieve particularly unpleasant states, such as persistent pain.”

Zahra explained that in and of themselves, prescribed medications are not intentionally addictive but that some of them may cause an effect in the person that would be desirable (such as the resolution of pain), or in some cases, inadequate control of the symptoms might bring about a higher use of the medication, or difficulties when attempting to reduce the dose of medication. 

“Addiction to these medications happens when there is no further therapeutic indication for taking the medication, yet the person experiences the compelling need to continue, to the point that it may interfere with usual everyday functioning,” Zahra explains.

Some of the most commonly misused prescription meds fall into three main categories: Opioid painkillers such as morphine and methadone among others, Central Nervous system depressants (locally referred to as kalmanti or tranquillisers) such as benzodiazepines, as well as stimulants which have both legal forms such as caffeine and nicotine, and illegal forms like methamphetamines and cocaine. 

Zahra sais that some opioid pain relief medicines might sometimes function beyond their role as pain relievers, and cause a state of emotional well being. 

“This positive emotional state is medication induced, and thus may lead a person to have more and more of the medication to artificially induce this chemical high once again.”

The American Society of Addiction Medicine says a shocking 46 Americans die everyday day from prescription opioid overdoses. Clinical director of Agenzija Sedqa, George Grech confirmed that painkillers can be very addictive if taken for long periods of time, or when they are taken for the wrong reasons. 

Grech said that the misuse of painkillers has become a major problem in terms of morbidity and mortality. 

“The problem is compounded further by the fact that people who misuse these pain killers usually abuse alcohol and other psychotropic medication besides.”

Indeed sedatives and tranquillisers, or CNS depressants, are the main types of drugs abused in Malta. 

Anthony Zahra explained that tranquillisers are often used as anxiety medication, known scientifically as benzodiazepines such as diazepam (Valium) and alprazolam (Xanax) and lorazepam (Ativan) among others.

Although 2014 data reveals that a mere 0.26% of the population had sought assistance from public entities for benzodiazepine addictions, the true extent of the addiction might not be visible from these figures given that they do not include private facilities.

Asked about the potential hazards of benzodiazepine misuse Zahra explained that any medication that is taken unnecessarily can have potential consequences, and that this particular class was no exception.

“In the short term, a person will experience sedation, lack of concern for everyday activities and responsibilities, slowed reflexes and mental activities, with possible unpredictable emotional states,” Zahra said.

“In the longer term, there appears to be a link to cognitive impairment, such as memory problems and difficulties in other areas of mental functioning,” he said, adding that over the past years, researchers found an association between benzodiazepine use and the risk of developing dementia five or six years down the line. 

“Taking the medication for more than six months was associated with an 84% increased risk of having an Alzheimer’s type dementia,” he said, adding however that the findings showed an association, but not a definite causation. 

He explained that the early signs of dementia may include problems with sleep and anxiety, and thus the benzodiazepines possibly would have been used to address these symptoms.

Zahra added that further research into the matter is warranted but that long term prescription in older persons was not considered best practice anyway, in view of other complications, such as the risk of falls, fractures and clouded thinking.   

He said that these medications are meant to be closely monitored, with regular prescriptions being recorded on a sheet the patient has to present to the pharmacist to help them monitor patterns of possible escalating dose or frequency of use. 

“They are typically prescribed in situations where the person is suffering from an acute stress or anxiety reaction, and current guidelines recommend use for a few weeks,” he said, adding that the medications are not inherently harmful. 

“However, in my work with adults and older persons, I often come across instances where a person would have been having the medication for several years.”

Substance abuse psychologist and ‘Dwarna’ presenter Mariella Dimech added that very often patients stand to benefit from these medications, but only if they are taken in line with therapy. 

“Medication would be much more effective if people use the time they are feeling better to learn how to think on a more positive level and perceive things differently in order to change the way they feel,” she said, stressing the need for psychiatrists and doctors to refer people to therapy more readily.

Dimech added that medication was absolutely necessary for people who suffered from conditions known as ‘psychoses’, that is where people are not aware that they are hallucinating, but that people who suffer from conditions classified as ‘neuroses’, like anxiety, depression, obsessive compulsive disorders or even post traumatic stress disorders, would not necessarily require medications depending on the severity of their condition.

“A number of patients become addicted or dependent on medication and it may be very traumatic to stop or change medication,” she added.

“This process really needs to be monitored carefully as the patient may relapse into the same problems prior to receiving the necessary treatment.”

Asked why the medications could lead to dependence, Zahra said that this could stem from a combination of factors, including the direct effect of the medication, which resolves anxiety symptoms.

“An anxious person experiences multiple unpleasant symptoms, ranging from dry mouth to palpitations to shallow breathing, to a sense of impending doom and panic, so the rapid and effective reduction of these symptoms is naturally very tempting.” He added however, that the medications tend to be effective at symptom control but not so effective at preventing further episodes from recurring.

Asked whether some people were more susceptible to prescription pill addictions than others, Zahra said that well-recognised risk factors include a family history of addiction, male gender, and the easy availability of addictive substances among others. 

“However,” he added “the development of an addiction is ultimately a very personal story, with genetic, developmental, social and psychological factors weaving to form different coping strategies.”