Where there’s a will there’s a Valium

Lax regulation, pill-prescribing doctors, population prone to self-medication add up to hidden epidemic of addiction.

My friend Samra* was a perfectly healthy girl; beautiful, talented and ready to fall in love.

Born and bred in New York, she would come to Pakistan to meet her Gujranwala based family every summer. During one of her trips, she met a man who was also from Gujranwala but lived in England. They got engaged and she moved back to Gujranwala with her family. As time went by, she realised he was the quintessential male chauvinist as he forbade her from working or even leaving the house until they got married.

Already dealing with the culture shock that had come with moving back to Pakistan, love-struck Samra gave in to his every demand. She held up for a while, but soon her daily routine was reduced to waking up, struggling to get through the day and going back to sleep — with the aid of a lesser-known sleeping pill called ALP. It just kept getting worse as she would get up, pop a pill, watch TV, pop another pill, eat and then sleep after taking yet another pill.

Soon, this bubbly young girl, who was so full of life, was a confirmed addict, measuring out her life in sleeping pills. Extremely disturbed by her behaviour, I advised her to go see a psychiatrist. To my shock, the cure turned out to be worse than the disease; the psychiatrist only prescribed her more pills. I inquired at a few pharmacies about the medicines she had been told to take and found out that the pills Samra was now on were even more addictive and, at Rs20 a strip, also more expensive. Today, she is still waiting for her fiancé to come to Pakistan and tie the knot with her. As she waits, bound within the confines of her home, her addiction has worsened and her former personality is lost beneath a haze of tranquilisers.

“One can find hundreds of such cases in our society,” says psychologist Dr Imrana Lashari. “Psychiatrists, who are out to make money, simply prescribe tranquilisers to patients instead of talking to them and examining their mental state. If they did their job responsibly, they could then counsel the patients themselves or refer them to a psychologist. But since psychiatry is not a lucrative field, many doctors examine at least 20 patients a day just to earn quick money.”

The problem is aggravated because most people do not realise the difference between a psychiatrist and a psychologist in the first place. A psychiatrist is a physician who has received specific training in the diagnosis and treatment of mental illnesses and prescribes medication for a patient’s problems.

A psychologist, however, helps the patient through therapy and counselling. Many a times, people choose to consult a psychiatrist when simply counselling through a psychologist could help them overcome their issues.

Taking that route could have helped 24-year-old Sara*, who lived a perfectly healthy life until her mother passed away when she was just 18. Soon after that, her father fell chronically ill and Sara ended up severely depressed because of these back-to-back tragedies. When she developed insomnia, she consulted a psychiatrist who prescribed her half a sleeping pill every night before going to bed. Today, she takes two to three pills before sleeping and sometimes even pops a few during the day.

“Those within the age bracket of 18 to 25 years never really have an authentic reason for taking sleeping pills,” says Dr Lashari. “People who have crossed their fifties or suffer from depression or persistent insomnia genuinely need these pills.”

This view is corroborated by Dr Mohammad Mujtaba, who heads the department of behaviour science at Rashid Latif Medical College, Lahore. “Many people do not educate themselves about pills before taking them. There is a big difference between a sleeping pill and an antidepressant.”

Sleeping pills such as Xanax and Lexotanil are basically prescribed to people suffering from insomnia, Dr Mujtaba explains. “These medicines are supposed to be taken for a maximum of two to four weeks and if an individual takes them for longer than that, he or she will develop an addiction for them.” On the other hand, antidepressants such as Vivalin and Desyrel are used to alleviate mood disorders and are usually prescribed by psychiatrists, he says.

It is for this reason that antidepressants and sleeping pills are typically strictly regulated in most countries. Laws restricting both the prescription and sales of such drugs exist in Pakistan, but enforcement is patchy though some of the larger stores resist the temptation to sell such drugs to people without prescriptions.

I witnessed one such event only a few weeks ago. As I waited for the cashier to tally up my bill at Servaid, a large pharmacy in Lahore, a boy no older than 16 was begging for some Xanax. The salesman kept refusing, softly but firmly dismissing the boy’s claim that they needed the tranquiliser for his mother whose brother had just died.

“I will not give you the drug until you show me a prescription or bring along an adult member of your family who can verify your claim,” the salesman told him. Disappointed, the boy left the pharmacy but I was left wondering why the salesman had so vehemently refused to sell the drug to someone who was quite obviously desperate to have it.

“This is not the first time we have encountered a situation like this. Every day, we refuse sleeping pills to at least three customers,” says Imran Hassan, the pharmacy’s manager. “Initially, we used to sell pills to such people but then we discovered that they were actually tricking us and popping the pills themselves. Now, we only sell such drugs to the elderly or those with prescriptions.”

As one of the three major pharmacy chains in Lahore, Servaid has obtained a legal certificate from the Federal Ministry of Narcotics Control which bars over-the-counter sale of such drugs but many small pharmacies flout the rules on a regular basis, Hassan says. It gets even worse when you realise pills like Xanax are easily available even at the pharmacy counters of Petrol pump shops.

The next pharmacy I visited offered a perfect illustration of why so many pharmacies are able to get away with violating the law.

“We maintain a register for narcotics but not for sleeping pills,” says Mohammad Naveed, a manager at another well-known pharmacy. “Although we avoid giving sleeping pills, we are not answerable to any authority over the sale of such drugs. We do have a strict check on narcotics such as Ketamine, Morphine and Trimadol etc.”

I then asked to see this register and, instead of the official-looking notebook I was expecting, I was shown an ordinary piece of stationary that you can buy at the corner book shop for Rs100. There was a different section for each drug and the pharmacists are required to put down the patient’s and doctor’s name along with the quantity of drug sold. “A drug inspector visits often to check our records, but there’s no designated time for inspection. They usually show up once every three months,” says Naveed.

By now, I was less than impressed at the state of regulation over the availability of these dangerous medicines and asked Naveed if people came to the pharmacy to buy drugs for non-medical use. “Yes, they do. And most of them are affluent women. They often attempt to bribe us but we refuse for legal and moral reasons,” he tells me. “There have been cases in some pharmacies where salesmen sold these drugs [without a prescription] and ended up behind bars.”

Another well-known pharmacy in Lahore, although licensed, depends largely on customer recognition to ensure that such drugs are not sold for non-medical purposes. “We know our regular patients and by now it has become very easy for us to tell which customer is not taking the drug for medical use,” says manager Javed Iqbal.

“Every pharmacy is issued a license,” he tells me when I mention my confusion over the regulations. “It used to classify drugs into three categories, which have now been merged into two. Sleeping pills fall under Category A and narcotics under Category B.”

But he is also deeply dissatisfied with the official follow-up on the implementation of these regulations. “The anti-narcotics department issued this license many years ago. A drug inspector follows up on the license by conducting a physical check and going through our sale records. But there’s no annual amendment to the license,” he says.

The ease with which such pharmaceutical products are available has led to an increasingly large number of college students turning to such ‘legal’ pills for recreational drug use. Given that pharmaceutical prices are strictly controlled and kept low by the government, these drugs are often cheaper than the illegal variety, resulting in students taking alarmingly high dosages.

“This may appear shocking but in my personal experience, most students do not take one or two pills; they would consume one or two entire strips on a regular basis,” says Dr Lashari, who worked as a student counsellor at Lahore University of Management Sciences for two years.

Some students said they would take the pills to relax their mind after endless hours of study, while others said it helped them improve their level of concentration, she says. Peer pressure also drove many students to use the pill. “Some would just be taking pills to appear ‘cool’ to their friends or because it’s an easily accessible alternative to expensive drugs like cocaine.”

Dr Lashari also dispels the impression that these pills are mostly consumed by members of the affluent class. “Many people in the rural areas are taking these pills. Lexotanil, in particular, is so popular among them that they have coined their own term for it: sukoon wali goli,” she says. Intake may also depend on gender. “Statistically, women are more prone to taking pills while men are inclined towards more dangerous drugs like heroin and cocaine etc.”

Addiction has led to the rise of a new phenomenon called ‘doctor shopping’, which refers to the practice where a patient uses multiple doctors and pharmacies to obtain the same prescription. Multiple prescriptions enable them to buy maximum pills from as many pharmacies.

But some doctors suggest that pharmacies are not the sole source for drugs, which is why insisting on a prescription before selling such medicines may not be a permanent solution.

“A majority of my patients are addicted to hard drugs, not sleeping pills, because there are countless drug peddlers across the country who supply to them,” says Dr Muhammad Nasar Sayeed, associate professor and head of the psychiatry department at Services Institute of Medical Sciences, Lahore. However, these pills do act as gateway drugs, and many young people start by taking sleeping pills but eventually get hooked on to Ketamine, Opium and other drugs, he says.

“There is a dire need for a proper ordinance that considers all these aspects of the problem,” says Dr Sayeed. “The old and insufficient rules must be amended immediately and then the government must ensure that the new and revised laws are implemented.”

*Names have been changed to protect identities

Published in The Express Tribune, Sunday Magazine, October 14^th, 2012.

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