The dose makes the poison

 By Tablo Mohammad:

According to World Health Organization (WHO): “Pharmacetical products (more commonly known as medicines or drugs) are fundamental components of both modern and traditional medicine. It is essential that such products are safe, effective and of good quality, and are prescribed and used rationally” .

With these few lines is clear that different factors must coexist in order to achieve the goal which is the prevention, cure and treatment of a disease. In the past century much progress was made in the pharmaceutical field and, thanks to this, it is now possible to treat diseases which were lethal only a few decades ago (just think about the introduction of Imatinib for Chronic Myeloid Leukemia).

Simultaneously with development of drugs with such a big impact on terminal patients’ lease of life, another category was making big progress: the analgesics. The purpose of these drugs is not that of curing the cause of a disease, instead they treat the effect of it, the pain.

They can be classified in different ways and various classes, however the most commonly used are Paracetamol and the Nonsteroidal Anti-Inflammatory Drugs (NSAID) wich include Aspirin and Ibuprofen among others. In many part of the world these drugs can be got without a medical prescription and, considering their effectiveness and relatively low cost, they are largely appreciated and utilised by patients. For these very same reasons they have found success in South Kurdistan too.

Our region still bears the scars of many years of war, embargo and poverty. We are still in a process of development, both socially and culturally . From a medical point of view, years of war and poverty have led to:

1.  a general self-negligence that is now coming to the surface with multiple health related problems;
2. lack of understanding of the importance of a correct diagnosis and cure of a disease;
3. a health care system that is still unable to sustain the demands of a growing and heterogeneous population and, therefore, a general dissatisfaction and lack of trust in our doctors among the population.

A mix of all of these factors has served to boost the idea of self-medication with painkillers. These are medicines that the population could benefit from, if properly educated about the risks and the limits. However, the general feeling among patients in South Kurdistan is one of lack of information and frustration.

I had this particular feeling when I met a man in Sulaymanyiah suffering from rheumatoid arthritis, a chronic inflammatory disease which needs to be followed over time and treated. Sadly this man was tired of running after medicines that were not always available in the public hospitals and so he was opting for the treatment of his chronic pain with almost daily intakes of Ketoprofen.

That same sense of frustration manifested by the patients sometimes leads to unnecessary prescriptions by doctors too.

What is being tremendously underrated is the many complications that the misuse and abuse of these drugs can bring. They are commonly known as innocuous (and they are, if taken with caution) but less known are the effects of a long term therapy or the effects of an overdose.

Many scientific studies in the last decade have shown how the foremost cause of acute liver failure in the Werstern World is Paracetamol toxicity. Other complications include: abdominal pain, easy bleeding and hepatic encephalopathy which can lead to coma and death. This situation can also be complicated by a simultaneous renal failure. The daily dose of this drug should not exceed 4000 mg for an adult, however, whenever there’s not a strict medical control of the correct use and dosage, it’s easy for this limit to be surpassed. As a result there are many medical emergencies which are sometimes lethal for the patient and, especially in the most rural parts of Kurdistan, they are difficult to manage due to the lack of adequate medical structures.

Another category of drugs that has had enormous popularity is that of the Nonsteroidal Anti-Inflammatory Drugs (NSAID). Among these we can find Aspirin, Ibuprofen, Ketoprofen and many others. Those are all well known names, and especially Aspirin is largely used for its anticoagulant effects in patients with a high cardiovascular risk. The administration of this product should be accompanied by that of gastroprotective drugs (such as Omeoprazole or Lansoprazole), but this won’t always happen for many reasons such as the costs of the therapy or the fact that the complications that might come are often uderrated.

Still their use is the most common cause of acute gastritis; other symptoms may include: nausea, vomiting and gastric ulceration/ bleeding. Furthermore they are also associated with renal adverse drug reactions, which lead to decreased renal function and hypertension (which increases the cardiovascular risk).

Analgesics are handy, helpful, effective and relatively harmless drugs whenever used with common sense; however a medical supervision should be ensured for patients with chronic pains; they should be avoided when possible and it needs to be clear to the patient that the dose should not be exceeded.

Most importantly, wherever possible, we must treat the cause of the pain rather than the pain itself.

In order to reduce the complications that come from wrong management of these drugs we should focus on:

1.  ensuring that patients are followed over time by the same doctor (or team of doctors) which permits a deeper knowledge of the patient’s clinical and pharmaceutical history;
2. education about the correct use of drugs, from analgesics to antibiotics. When unnecessary they should not be used (this also means that doctors should refrain from prescribing them).

Paracelsus, a Swiss doctor, said in the 16th century : “All things are poison, and nothing is without poison: only the dose permits something not to be poisonous”, or, more commonly: “ The dose makes the poison”.

Tablo Mohammad was born in Slemani and grew up in Italy where she is a medical student. For the last two summers she has trained for a few weeks in Slemani’s hospitals.  She has plans to go back to Kurdistan after her graduation and hopes to help with the improvements and changes that our health system needs. 

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