Living Well in Myanmar

Sedative drugs may put you to sleep for good  

Benzodiazepines are a class of medications used to treat seizures, anxiety disorder, and alcohol withdrawal. These are drugs such as diazepam (Valium), lorazepam (Ativan), alprazolam (Xanax) and clonazepam (Klonopin).They have long been part of the pharmaceutical arsenal that doctors use in inpatient and outpatient settings, and, when chosen in appropriate settings, they can be life-saving.

Like all drugs, benzodiazepines have negative side effects. These include daytime fatigue, accidents and falls. Also, this class of medications is addictive and is a well-known group of drugs of abuse. Nevertheless, they are frequently prescribed by doctors and, in some places, such as the U.S., clearly overprescribed. Why?

Doctors and patients use the medications “off-label”, meaning to treat conditions for which the drug is not clearly established to be safe and beneficial. In the case of benzodiazepines, unlabelled prescriptions tend to be offered to patients that are having difficulty sleeping (the medical term is insomnia) or who likely have been given a poorly considered diagnosis of acute anxiety.

A related group of medicines is known as the “Z-drugs”, which includes zolpidem (Ambien) and zaleplon (Sonata), among others. These have similar anti-anxiety, hypnotic, and sedative characteristics, and are mainly used for insomnia. While they are widely marketed as being safer than benzodiazepines, the same side effects should inspire caution among doctors and patients.

Patients taking Valium or Zolpidem on a daily or nightly basis are clearly at risk for sluggish behavior, poor concentration, a lack of motivation, sloppy speech and physical accidents. For this reason they are particularly problematic for the elderly, who unfortunately tend to suffer from sleep disturbances more than the general population. In fact an older (but young at heart) relative of mine was recently prescribed Valium for sleep difficulties, and when we visited her in the U.S., we were surprised by how tired and sometimes unmotivated she was during the daytime. Happily, these symptoms improved when the benzodiazepine was stopped.

While we’ve always known that Z-drugs and benzodiazepines are dangerous on a day-to-day basis, new data is starting to emerge that shows  long-term risk. A large study conducted in the UK and published recently in the British Medical Journal compared 35,000 people taking this class of medication with 70,000 people who were similar in most ways (age, sex, geography, physical and psychiatric disease, etc.) but were not taking a Z-drug or benzodiazepine. After an average of eight years, the patients on the meds were three to four times more likely to be dead. Those who took higher doses more frequently fared even worse.

The next step for research is to confirm this data with additional studies. But the implication is clear: making the decision to use benzodiazepines in a non-emergency setting requires thoughtful consideration and a belief that the patient understands the short- and long-term dangers. The alternatives for treating insomnia are many (see Living Well Myanmar, March 30, 2014) and, really, a variety of things should be tried before introducing this class of medications.

In Myanmar, patients might be recommended one of these medicines from a doctor, but they are just as likely to purchase them on their own. Benzodiazepines, like most other medications, are fairly easily available on the black market. Far from being a dark back alley place to buy illegal goods, the pharmaceutical black market extends into all parts of the distribution chain in Myanmar. From streetside shops where medicines bake in the hot sun and big markets where pharmaceuticals are stacked up into the rafters, to higher-end medical supply stores with trained pharmacists, drugs sourced from dubiously registered channels are for sale.

This means that a drug like diazepam, which is meant to be regulated in Myanmar, can be easily recommended and sold to a consumer who tells the shopkeeper that he or she is having trouble sleeping. Presumably at the time of this transaction there is little conversation around the risk-of-death data presented above.

Creating a strong pharmaceutical regulatory agency is of course one step toward addressing black-market medicine. Even more importantly, empowering the Myanmar Food and Drug Administration would facilitate an initiative against fake medicines, which will one day be acknowledged as a major public health threat. A widespread assumption amongst medical providers that has some degree of evidential support is that a dangerous percentage of pharmaceuticals available directly to the consumer are either completely bogus or contain an inadequate amount of active chemical ingredient.  © Christoph Gelsdorf 2013