Prescription for better drug control

Second Opinion

Nothing, it appears has happened since then except that the doctor who made the complaint received several death threats. Unlicensed drugs continue to be freely available in the market and what's more, they are even brazenly advertised.

There are remedies for hair loss, male impotence, memory loss and diabetes.

Most of them offer guarantees of cure. Some of them claim to be 'herbal' in origin. And all of them, without exception are expensive. Then, in addition to these pills advertised in the media, pharmacies sell a variety of drugs which are yet to be approved in this country. What is the reason for this deplorable state of affairs?

The Drug Regulatory Authority is the body empowered to license drugs to be sold in Sri Lanka. But it appears that the Authority lacks the legal clout and the manpower that is needed to combat the sale of unauthorised products.

For instance, any distributor can advertise any drug in the media with no questions being asked. The media is not required to obtain proof of the drug being registered in this country before allowing the advertisement. Hence the plethora of advertisements that promise so much for the distressed patient- all of which are illegal.

Then, pharmacies are notorious for doling out prescription drugs without a doctor's recommendation. There appears to be no monitoring of this activity which is good business for the pharmacist but may be lethal for the unsuspecting patient.

Also, there are absolutely no regulations that govern the retail prices of the drugs sold in the country. They vary from brand to brand of course, but even the same brand has a broad price range from pharmacy to pharmacy and hospital to hospital. All this is done with impunity because no one complains. That would be well if it were the case of different brands of soap or even mosquito coils. But these are drugs that can make or break a patient's life and therefore they have to be dealt with more cautiously.

Part of the blame for these problems must invariably lie with the medical profession. They have for long been silent on this issue, preferring the comfort of inaction rather than weather the controversies of confrontation.

This has now even led to allegations that some in the profession are being sponsored by pharmaceutical companies.

Isn't it time then that all concerned- doctors, the Health Ministry and its Drug Regulatory Authority and the pharmaceutical industry- pool their collective resources to formulate guidelines for the sale of drugs in this country? 

Or, in true Sri Lankan style do we wait for a major catastrophe where an unlicensed product takes a toll in lives or limbs before it awakens all those concerned into action?

The family doc

By Dr. Neil Abeysekera, 

A few doctors in the years gone by 
For general practice did say aye 
They opted to use their healing hand 
For their bread and butter and for the love of their land 
He had to take this plunge for better or for worse.
To start a practice which the state didn't re-imburse 
For wealth and power he has no greed 
To his patient he is a friend indeed.
The family doctor has no generation gap 
Grandfather, father and that tiny little chap
Continuity of service plays an important part 
In the judicious rendering of his healing art 
Medicine, surgery, paediatrics and gyn, 
Other fields of medicine and his own discipline. 
A Jack of all trades in the medical field, 
He updates his knowledge to improve his yield. 
He is respected by all, the great and the small, 
At a party, or a game with the bat and the ball 
This friend of the family is always on call 
He believes in ethics and does care for all.
When his colleagues left for greener pastures abroad 
He worked for his country for the biggest reward 
The satisfaction he gets at the end of the day
Is worth millions more than any other man's pay.

Medical news

The publication of the book was sponsored by the World Health Organization and the Ministry of Health and Indigenous Medicine. Copies can be obtained from the Department of Forensic Medicine and Toxicology of the Faculty of Medicine, University of Colombo, Kynsey Road, Colombo 8.

The 26th annual academic sessions of the College of General Practitioners of Sri Lanka will be held on September 30and October 1, 2000. Abstracts of free papers (3 copies) and scripts for College Oration ( 5 copies) should reach the College office by August 10, 2000.

What is this high blood pressure?

But there is some debate among doctors about exactly where normal ends and abnormal begins.

The World Health Organisation, for example, defines high blood pressure as that which consistently exceeds 160/95. What is acceptable can also depend on your age (as our blood pressure normally tends to increase as we get older), and other factors - such as time of the day, stress levels, temperature etc.

Blood pressure is measured as two numbers and there is debate about which of these two numbers is most important. 

The first, known as the systolic pressure, reflects the maximum pressure reached when the heart beats and pushes blood out (this is the pulse or pressure wave you feel at your wrist).

The second figure is the diastolic pressure, or the general pressure in the blood vessels inbetween heart beats when there is no wave of blood being pushed through - this reflects how much the small arteries in the body are resisting the flow of blood into them.

This second figure, the diastolic, is usually most critical and when treating high blood pressure the primary aim is usually to get this number down to below 90. However, systolic pressure can't be ignored and may also be important - there are some instances where it can be harmful if it's raised, even if the diastolic pressure is normal.

So a reading of 190/80 could be normal because the diastolic level is normal.

The raised systolic level (180) may be irrelevant especially if, for example, the person has just exercised. However for some people it may be linked to an increased risk of complications.

In 95% of cases, the cause of high blood pressure is unknown - there seem to be many causes. It may begin doing its damage from birth; by the time it's diagnosed it is probably too late to prevent the structural changes in the heart and blood vessels, which lead to many of the complications of hypertension - and which make it irreversible.

The main long-term risks are:

Stroke 

Heart failure

Coronary artery disease (heart attacks)

Kidney failure and

Retinal damage (to the eye).

In most developed countries about 1 in 5 adults aged over 40 have a blood pressure greater than 140/90. Their risk of stroke is at least twice as high as people of the same age with a blood pressure of 125/75, We do not have reliable figures for Sri Lanka yet to say how prevalent high blood pressure is in this country.

However, the most important factor is that while high blood pressure may never be 'cured', it can easily- with the aid of drugs- be controlled and that will very significantly reduce the risk of all those complications mentioned. Also, once medication for high blood pressure is commenced, in most cases it must be continued lifelong- and that is the advice most patients disregard!

Can drugs help the alcoholic?

None of these drug treatments offer anything like a miracle cure which, on its own, might enable you simply to stop drinking. Neither is there anything like the nicotine replacement therapies used to wean smokers off cigarettes, which could act as an alcohol substitute. But these drugs can help you to deal with some of the symptoms of withdrawal and the craving for alcohol.

But a word of caution: some of the best results in helping people to turn their backs on alcohol are achieved by intensive and carefully structured rehabilitation programmes, in which such drug treatments play a specific but limited part- the greater part is played by the patient's will to give up.

*Tranquillisers: Some tranquillisers such as chlordiazepoxide may be useful to help you cope with the withdrawal effects when you first stop alcohol. In the first week, often referred to as detoxification or detox, you may experience intense anxieties, shakes and tremors, cravings and even hallucinations. You may also have problems sleeping. They are only usually used for this short period of detox. Beta-blocker drugs such as propanolol may also be used at this time to control these symptoms.

*Drugs for alcohol cravings: A new drug has recently been developed specifically to help deal with the intense craving for alcohol that you may experience when you give up. Called acamprosate it may double your chances of successfully giving up.

*Drugs to put you off alcohol: Another medication often used to help people stop drinking is disulfiram. This has a rather strange effect. If you drink alcohol while taking this medication, you feel extremely unwell with intense nausea and flushing. This can help to put you off the idea of a drink but you have to be diligent about taking it in the first place. Occasionally a drug called naltrexone is used. This is actually licensed for opiate addiction. However, under some circumstances it may be prescribed for heavy drinkers.

The good bread and the bad

But there is a demand for 'brown' bread which everyone believes is better for every illness- from diabetes to high cholesterol levels. What exactly is the true picture?

The extra health benefits of brown bread come from the wheat grains which make brown bread brown. Whole-wheat grain is a good source of fibre, protein and B vitamins. In white bread the husk of the grain is removed and only the inner part of the grain is used. But more of the grain is left in when brown bread is made.

However, there are different types of brown bread. Some such as wholemeal and granary contain much or all of the wheat grains (that's why it's called wholemeal) and these are the healthiest.

Other types of brown bread are made from finely milled wheat where all the bran (and therefore most of the protein and vitamins) has been extracted and left out. This bread is not really very different from white bread and it's certainly not worth the battle to get your children to eat this.

But although white bread doesn't contain all the fibre and natural goodness of wheat it's still nutritionally valuable, especially when it is fortified with extra minerals or vitamins. In fact white bread may have twice the calcium of wholemeal bread (although wholemeal has more iron and up to 3 times more zinc).

One ingredient which may not be so good for you though is salt which is present in both types of bread, white and brown. 

High salt intake can lead to high blood pressure, stroke and even some types of cancer. Most people don't realise how much salt is added to bread, so beware.

The real pain in the…

By Chris Fernando

Dr. Maiya says: Anal complaints are very common among people of all ages. They range from bleeding with stools, pain while passing stools with or without bleeding, abdominal pain which is relieved by passing stools or painful lumps in the region of the anus which makes it very difficult to pass stools.

Bleeding with stools is usually due to haemorrhoids, which is commonly known as piles. In such a case, blood would drip on to the stools and there will be fresh blood on the toilet paper. This, if it is purely due to piles, is initially painless. If a patient cannot feel a lump coming out while passing stools and going back in after passing stools, then we are dealing with 1st degree piles, which after an examination with the proctoscope can be easily treated by an injection into the piles. These injections can be repeated until a complete cure is achieved.

If the bleeding pile masses come out on passing stools, and you have to forcibly push it inside after passing stools which can be a very painful exercise, we are dealing with 2nd and 3rd degree piles where surgery is required. If this is neglected further, lumps may come out on passing stools and remain outside leading to a surgical emergency.

The above description is for internal piles, which originates from the anal canal. You can also get a painful bluish lump arising just outside the anus, appearing suddenly which is an external pile mass. This most often does not have anything to do with the internal pile region and can be cured easily by excision under a local or general anaesthetic with immediate relief to the patient and immediate discharge from hospital.

But of course, the important thing is to realise here is that even if you see the piles, you must not conclude that the bleeding is solely due to the piles. There can be another sinister lesion high up in the rectum, from which the bleeding is arising, which can go unnoticed if a flexible sigmoidoscopy or a colonoscopy is not done to exclude a pathology higher up in the colon.

But in your case, I think that we are dealing with 1st degree piles. The cause of the piles cannot really be established but a regular intake of high fibre diet, which avoids straining on passing stools, will contribute to a pile free life. 

If people are habitually constipated, a laxative such as Duphalac is recommended to keep the stools soft and bulky. In the early stages, an acute painful fissure can be treated by local application such as xyloproct, but later, if the fissure becomes chronic with a well-formed edge, then we have to resort to surgery. From what you tell me, you could be suffering from a chronic fissure with piles and some sort of surgery could be indicated in your case.

A fissure, which is a crack at the anal verge and usually located posterially, is caused by hard faecal matter rubbing against and damaging the inner lining of the anus. Now this can cause a lot of pain on passing stools and at times, people with fissures are reluctant to go to the toilet because of this pain and this becomes a vicious circle and causes constipation. A fissure will bleed and a fissure can co-exist with piles. 

Another common painful condition is an abscess or collection of pus in the anal region, which is known as a peri-anal abscess. This is a very painful condition, which requires simple surgery. A fistula is another condition, which can either be painful or pain-free. Fistulas arise from infections of the anal glands and patients with this condition would complain of a discharge of pus on and off from a site outside the anal margin.

This can result following an abscess, which has not been treated or can come on its own. Surgery will cure this permanently.

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