According to the US National Institute on Drug Abuse, in 2012 more than two million people in the US were suffering from substance abuse disorders related to prescription opioid pain relievers. As far back as 2002, death certificates had begun listing opioid painkiller poisoning as a cause of death more commonly than illegal class A drugs such as heroin and cocaine.
As the US National Council on Alcoholism and Drug Defence notes, dependency gives rise to everything from absenteeism and extra sick leave, to injuries, accidents and loss of production, right through to fatalities. Given that prescription drug abuse increasingly forms part of the overall drug abuse picture, it is an issue high on any list regarding employee health and wellbeing.
The situation in Southeast Asia
In our region, the problem is nowhere near the scale seen in the US, but it is a growing one – with worrying consequences for individuals, families and businesses.
Because beyond the extremely serious – possibly fatal – consequences of any drug abuse in the workplace, there are also lesser effects. Yet these still are extremely important. What we’re talking about here is poor decision-making, reduction in efficiency, low morale, and so on. This can also lead to higher turnover and costs.
The International Narcotics Control Board (INCB) put prescription benzodiazepines, which are sedatives, as the third most commonly abused drug in Indonesia, and fourth in China. In Thailand, a community level study suggests that roughly 400,000 people regularly abuse benzodiazepines, and overdoses of these sedatives were estimated by the INCB to cause 260 deaths in the country in 2010. This may not be a surprise when the same community study found that 57% misuse benzodiazepines, 17% abuse them, and 6% show signs of dependence.
In Thailand, a community level study suggests
that roughly 400,000 people regularly abuse benzodiazepines,
and overdoses of these sedatives were estimated
by the INCB to cause 260 deaths in the country in 2010.
The INCB suggests that morphine abuse is prevalent in Malaysia, where it’s also used to treat heroin addiction. A 2015 British Medical Journal study found that around 15% of senior high school children in China use painkillers for non-medical reasons – something that’s also on the rise in Thailand and Indonesia, where there has been a surge in tramadol and codeine abuse among teenagers. These painkillers are mixed into coffee and alcoholic cocktails, and the craze recently forced Thai pharmacies to enforce a 10 pill per customer rule. Reasons for the growing popularity of these drugs are complex, but much of it is to do with the general perception of prescription drugs as safe, as well as the existence of a black market for drugs, many of which are counterfeit.
The reality is that many people are reliant on prescription drugs for good reason. Populations around the world are ageing and need medication to control high blood pressure, reduce risk of strokes and heart attacks, and keep potentially serious diseases such as diabetes under control.
But there are a lot of other realities that clearly show the problems we need to address in our region when it comes to prescription drug abuse – much of which falls on the responsibility of the physician. These include:
- In Indonesia, a high volume of patients and short supply of doctors means the patient-doctor relationship is often compromised and there is a tendency for doctors to prescribe prescription drugs rather hastily instead of spending the necessary time to properly diagnose.
- In markets like Thailand, healthcare is specialist driven, which for various reasons tends to result in the over-prescribing of medications.
- As is the case in the US and other Western markets, physicians across our region often view patients as customers, and they want those customers to be happy. Prescribing medication (and brand name over generic even though generic provide the same relief) is a key part of keeping many of those patients happy.
- Prescription medications are substantial revenue earners for GP and specialist clinics, and with this factor in mind there is no doubt a tendency to very often more readily prescribe medications versus taking a more conservative approach.
- And finally worth a mention: Much of the population as a whole tends now to go straight to antibiotics instead of, for example, reaching first for aspirin or vitamins. In other words, the population as a whole is over-medicated, and to mention just one serious issue that is arising from this reality – we are seeing immunities to antibiotics.
Of course all this aside, the simple reality is this: There are certain prescription drugs – some types of painkillers and other mood-changing medications in particular – that can result in a level of physical and/or psychological dependency. This can and does sometimes turn into abuse. And this is a potentially growing problem we should all be aware of.
The costs of prescription drug abuse
Abuse of these drugs represents a substantial burden, affecting the individual’s health, which in turn affects their home life, their employment and the healthcare system as a whole.
Employment: Drug addiction may also cause a person to be less productive at work and less able to safely drive or operate machinery. One 2014 study by the economic consultancy Analysis Group found that opioid abuse meant a worker lost an average of 13 days extra each year, costing their employer USD 1,200.
One 2014 study by the economic consultancy Analysis Group,
found that opioid abusemeant a worker lost an average
of 13 days extra each year, costing their employer USD 1,200.
Physical health: Long-term abuse of opioids can lead to nausea, bloating and liver damage. Stimulants can cause an irregular heartbeat and ultimately heart failure. But many long-term side effects remain unreported because they are not captured in time-limited clinical trials.
Mental health: Addiction – both physical and psychological – is a key component of much long-term drug abuse. It is both a cause and effect – approximately one in four people who use opioids long-term become addicted. Opioids can result in both physical and psychological addictions. Besides increased tolerance – needing more of the drug to get the same effect – a physical addiction means that people develop withdrawal symptoms, such as sweating, aches and pains and stomach problems, if they try to come off the drug. Other general symptoms of addiction include a change in mood, erratic behaviour, mental cloudiness and confusion, anxiety, and problems sleeping. In the case of stimulants, abusers may also display anxiety, hyperactivity and hallucinations.
Overdose and hospitalisation: Over time drug abusers build up a drug tolerance and so start taking higher and higher doses. This can lead to overdose. In the US, each day roughly 1,000 people end up in hospital for not using a prescription opioid as directed. In 2015, 15,000 people died from opioid prescription overdose. The data in Asia is quite restricted, but in Japan one-quarter of all pharmacists report having dealt with patients who had overdosed on their prescription medication over the previous year. Meanwhile in Thailand, there were 2,439 cases of prescription drug poisoning in 2011.
Family life: Addiction can lead a person to become disengaged with their family and also increases the availability of these drugs in the home. More children end up in hospital due to pharmaceutical poisoning than car accidents. Ninety-five per cent of these cases occur due to self-ingestion, where the child eats the drug like a sweet.
Criminality: Some people are forced into crime to fuel their addiction. It is estimated that 30% of all burglaries are attributable to drug abuse. A study in medical journal Pain Medicine in 2011 reported that criminal justice costs of prescription opioid abuse alone hit the US economy for USD 5bn a year.
Healthcare: The same US study put the healthcare costs of opioid abuse at USD 25bn. Such strains on a healthcare system can create problems for even the richest countries in Asia. In 2000, South Korea underwent a pharmaceutical reform due to the abuse of prescription medication. Under the old system pharmacists were allowed to write prescriptions and doctors could dispense medications direct to their patients, allowing both pharmacists and doctors to make extra profit. Drug abuse became rife and the system changed to enforce the need for prescriptions, which could only be written by doctors. However, an unintended consequence of this change has been the increased cost of pharmaceuticals, raising the likelihood of people with chronic conditions being forced into economic hardship.
A word on antibiotics
As touched on above, antibiotic abuse can lead to resistance to strains of bacteria, but unlike stimulants or painkillers this abuse is not addiction-related. It’s caused, in part, by antibiotic over-prescription by doctors, resulting in overuse by patients, who often wrongly believe that antibiotics treat viral infections. One study of Thai hospitals revealed that despite only 8% of upper respiratory tract infections being caused by bacteria, almost all these patients received an antibiotic.
Nearly three in five Indonesians also self-medicate with antibiotics, mainly for minor conditions that are viral in origin, according to a 2011 study in medical journal BMC Research Notes. This is possibly because 78% of all counterfeit antibiotics are produced in Southeast Asia, which further confounds the problem. The incidence of streptococcus pneumonia, the most common type of bacteria to cause pneumonia, now shows its highest rate of resistance in Asia, especially South Korea, Taiwan and Vietnam. E-coli has a resistance of 95% in some areas. All of this is extremely costly to both life and finances. In Thailand, antimicrobial resistance kills over 38,000 people each year, costing the economy the equivalent of USD 1.3bn.
In Thailand, antimicrobial resistance kills
over 38,000 people each year, costing the
economy the equivalent of USD 1.3bn.
Tackling the problem
So what can be done? A 2014 New England Journal of Medicine paper suggests that a coordinated and comprehensive government effort to address prescription drug abuse should have four key objectives.
- Provide doctors with the knowledge to improve prescribing decisions and ability to identify patients’ problems related to abuse.
- Reduce inappropriate access to drugs.
- Increase access to overdose treatment.
- Provide substance-abuse treatment.
The fact is though, the causes and effects of prescription drug abuse are complex. And tackling them will be a long-term challenge for countries in Asia and others around the world for many years to come. So while it all starts with awareness, we will need to lay down some concrete steps for addressing the issue that factor in the complexities of the medical system as a whole.