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The number of drug abusers in Nepal has been swelling even though sound and subtle narcotic drug policies and strategies have been in place for more than a decade. According to a national drug survey conducted in , there were 91, hard drug users in the country. It has also been revealed that many drug abusers are addicted to pharmaceutical drugs. The main reason is that they are easily available on every street corner, and they can be bought without a prescription. Even pharmacists are sometimes unaware that a certain medicine can be misused as a drug. While law enforcement agencies have traditionally been focusing on controlling regular narcotics and psychotropic substances, the abuse of pharmaceutical drugs has emerged as a big issue in recent years. This is a serious matter indeed. Various studies show that the use of pharmaceutical drugs has risen in the past few years. There is rampant use mainly along the Nepal-India border. Due to the porous frontier between the two countries, people can easily get across to buy drugs. At the same time, drug trafficking has become a source of livelihood. The NCB, the nodal agency for narcotic drug law enforcement in Nepal, has been actively working to control drug trafficking in coordination with different stakeholders. Although a significant amount of hashish and marijuana shipments are intercepted on the Nepal-India border each year, there is much to be done on the over-the-counter drug front. The pharmaceutical drugs that come under substance abuse are basically of three types—opioids used as pain relievers , stimulants and depressants. There are various ways in which people abuse them, but mostly it is through overuse. Over time, the abusers become dependent on them and fall into the drug abuse trap. This has become a worldwide problem these days. According to recent figures, more than 15 million people in the US abuse prescription drugs, which is more than the combined number who reported abusing cocaine, hallucinogens, inhalants and heroin. Prescription drug abuse accounts for the highest number of deaths from overdosing. Of the 22, drug overdose deaths in the US in , opioid painkillers were the most commonly used, accounting for Depressants, opioids and antidepressants were responsible for more overdose deaths 45 percent than cocaine, heroin, methamphetamine and amphetamines combined 39 percent. In the context of Nepal, there is no clear data on deaths due to overdosing. But misuse of pharmaceutical drugs has reached a high in recent years. Globally, an estimated 69, people die from opioid overdose each year, according to a World Health Organisation report. The majority of people dependent on opioids use illicitly cultivated and manufactured heroin, but an increasing proportion use prescription opioids. Due to their pharmacological effects, opioids in high doses can cause respiratory depression and death. In Nepal, there has been a drastic increment in psychotropic substances in the past few years. Codeine-based syrup, Buprenorphine, Diazepam, Nitrazepam and morphine are the common psychotropic substances trafficked and abused in Nepal. Drug trafficking and abuse is a serious threat to national security everywhere in the world. There are social, economic and political costs of drug abuse. On a higher level, it affects national productivity, overburdens law enforcement agencies and harms the healthcare system. At the micro level, it ruins family harmony, strains public security and destroys personal productivity. Trafficking in narcotic drugs and psychotropic substances through the internet and internet pharmacies has not been perceived till now. This trend is increasing in the developed countries, and drug traffickers are supplying their products through door-to-door service. This is something law enforcement agencies must crack down on in time. In the context of Nepal, there is no substantial evidence of such a practice, but it cannot be ruled out. No internet pharmacies are registered in Nepal, nor has any case of drug trafficking through the internet been detected by authorities. Currently, there is no national law or regulation in place that deals with drug trafficking through the internet. The Nepal Narcotics Control Act needs to be amended as soon as possible so that new trends in drug trafficking can be dealt with. The NCB is empowered to investigate and prosecute drug offences. It also acts as a nodal unit to liaise with other international drug law enforcement agencies. The bureau maintains nine satellite stations across the country in all five development regions and at major border checkpoints, including Tribhuvan International Airport in Kathmandu. With drug traffickers using more sophisticated modus operandi, it has become urgent to enhance the capacity of the NCB and its officials. The challenges are daunting. One of the major impediments we have faced in our fight against drug trafficking is the open border between India and Nepal. Free movement across the border makes things easy for traffickers and users, but exceedingly difficult for law enforcement agencies on either side. The cost of intelligence is very high, and the technical and human resources at our disposal are limited. Despite this and many other challenges, the NCB is seriously committed to controlling the drug menace in Nepal. The bureau has been doing its best despite limited resources and varied limitations. It has been steadfastly using its efficient and professional force to control drug abuse and trafficking. The NCB needs the support of all members of society in its fight against drugs. It is not only the duty of the NCB or any particular organisation; it is a matter of consolidation of our society, and making it free of drugs and preventing our youth from falling into addiction of any kind. Therefore, collective efforts are essential, and all stakeholders should play their part. Opinion Double trouble The number of drug abusers in Nepal has been swelling even though sound and subtle narcotic drug policies and strategies have been in place for more than a decade. Published at : June 25, Updated at : June 25, Falling into the trap The pharmaceutical drugs that come under substance abuse are basically of three types—opioids used as pain relievers , stimulants and depressants. Multilevel threats Drug trafficking and abuse is a serious threat to national security everywhere in the world. Apil R Bohara. Read Other Opinions. Editor's Picks.

Adverse events with ayurvedic medicines- possible adulteration and some inherent toxicities

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Official websites use. Share sensitive information only on official, secure websites. This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Grammatical errors and typos have been corrected, especially in the abstract section. The term 'adverse events' has been used instead of 'adverse effects'. Ayurvedic medicine, a traditional system of medicine practiced in the Indian subcontinent is considered to be devoid of adverse events. We report three cases which highlight the possibility of adverse events related with the use of ayurvedic products. A 35 year old woman with hepatitis took ayurvedic powder medicine and swarnabhasma gold salt and had her liver injury worsened, possibly due to alkaloids, and developed nephrotic syndrome, possibly due to gold salt. A 57 year old hypertensive man was taking ayurvedic medicine containing reserpine which had long been withdrawn from the allopathic system of medicine due to wide range of side effects. A 47 year old woman with rheumatoid arthritis was taking an unknown tablet containing steroid as an adulterant for 2 years and developed side effects typical of steroid excess. We would like to highlight the fact that ayurvedic medicines do have propensity to cause adverse events due to adulteration or inherent constituents like alkaloids, and hence may not always be completely safe. Ayurveda is one of the most renowned traditional systems of medicine, and has been widely practiced in the Indian subcontinent, including Nepal, since the 2 nd century BC 1. People have faith with ayurveda as it is based on the use of natural products, and is considered to be devoid of adverse events 2. Allopathic medicines on the other hand are known to have adverse events, and are generally prescribed based on risk versus benefit for a particular disease and patient 3. Alternative forms of medicine like ayurveda are usually thought by patients and ayruvedic doctors alike to be harmless, and are also advertised similarly 2. But it has been proven that certain constituents of ayurvedic products, like heavy metals and alkaloids, can have adverse events, and the possibility of these adverse events needs to be highlighted so that both the practitioners and consumers will become cautious in their use, as with allopathic medicines 4 , 5. Sometimes, patients receive unknown powders adulterated with drugs such as steroids in the name of ayurvedic medicine, prescribed by traditional healers 5. A 35 year old Newar woman from suburban Kathmandu who was a housewife, developed jaundice, vomiting and low grade fever. Family members took her to a local healer who claimed to be an ayurvedic practitioner. Despite the treatment, she became sicker with deepening of jaundice and significant weight loss almost half of her previous body weight in about one week. On presentation to ED, her laboratory parameters, with normal range in parantheses, were as following;. Complete blood count CBC : white cell count Hepatic panel: bilirubin total She was admitted and diagnosed as fulminant hepatic failure with possible infective hepatitis and nephrotic range proteinuria. The powder was stopped, and she was managed with supportive treatment intravenous fluids, intravenous ceftriaxone 1 gm and oral doxycycline mg twice daily for 7 days, daily blood glucose and alternate day hematology, electrolytes, renal and hepatic biochemistry monitoring. She was discharged from hospital in two weeks after she started improving. She recovered, with bilirubin and transaminases falling gradually to normal after three weeks bilirubin-total 1. Her proteinuria also decreased gradually 24 hour urine protein- 0. A 57 year old gentleman from Kathmandu, a teacher by occupation had come for a blood pressure check-up at the medical outpatient department OPD of Patan Hospital, Lalitpur, Nepal in June, Reserpine is not a recommended agent for treating hypertension due to its adverse events such as decreased cardiac output, bradycardia, sedation, depression, diarrhea, and increased gastric acid. Fortunately, our patient had no adverse events attributable to reserpine. We explained to him the risks of the drug he was receiving, then switched him to amlodipine 5 mg once daily. He has been in regular follow up now and his blood pressure continues to be well controlled. A 47 year old Aryan woman from suburban Lalitpur who was a housewife, came to the OPD of Patan Hospital in April, with a complaint of excessive weight gain. She claimed that she was gaining excessive amount of weight despite maintaining her normal diet and physical activity. She also had sore muscles and bruises on her body. On further inquiry, she said that she had been experiencing pain over multiple joints for past 2 years. She was taking some unlabeled tablet Figure 2 prescribed to her by a local practitioner whom she believed to be an ayurvedic doctor. On further questioning as to why she chose this form of medication, she said that she believed the ayurvedic medicine were potentially harmless. The drug was sent for chemical analysis, and it revealed that the tablet consisted of prednisolone, an exogenous steroid. Soon after we stopped the unlabeled medicine, she started to have more pain and swelling in the small joints of both hands and symptoms suggestive of steroid withdrawal were noted. Low dose steroid oral prednisolone 20 mg daily was continued with gradual taper and stopped over 3 months. When last seen 3 months ago October, , her arthritis was well-controlled with DMARDs without steroid preparations or unlabeled medicines. In the first case, the patient with jaundice due to infective hepatitis was taken directly to an alternative medicine practitioner. Jaundice is a problem which most of the Nepalese people in general, regardless of the status of their education, consider as a disease requiring alternative medicine such as ayurvedic medicines. Even if they consult allopathic clinicians first, many take ayurvedic medicines after a period of time as it usually takes many days to weeks for jaundice to resolve; and their faith in ayurvedic medicines gets strengthened. But unfortunately, many plant products contain alkaloids such as pyrrolizidine which are toxic to the liver, and may precipitate or worsen liver injury 4. In our patient, it was not clear whether the medicine she received initially contained harmful alkaloids as the analysis was not done. It was also not clear whether the worsening of her liver disease was caused by the disease process itself or the use of the powder medicine, but we can at least say that these products were not helpful in dealing with her liver problem as is generally believed. We see many patients coming to our clinic with worsened jaundice after the intake of ayurvedic products. Our first patient also received gold in the form of swornabhasma that has been linked with kidney injury and nephrotic syndrome 6. Ayurvedic products contain certain amounts of different heavy metals like gold, lead, mercury, copper, iron, arsenic, zinc, and cadmium that are believed to have therapeutic benefits. Studies have shown that most of the ayurvedic products contain these metals in amounts exceeding WHO permissible limits, and can potentially cause harmful consequences to human health 7. The possibility of the potentially toxic amount of these heavy metals should also be considered and precautions taken. So it is imperative that the amount of such constituents in each of the ayurvedic products be mentioned on the label so that patients have some idea of the substance and the quantity being taken. Our second patient had been taking reserpine in the form of ayurvedic product, as an antihypertensive agent. Though there are studies demonstrating the safety and efficacy of reserpine use as an antihypertensive agent 8 , 9 , the present allopathic guidelines do not support the use of such adrenergic inhibitor as a first line treatment for hypertension, nor is it included among any of the indications for treating hypertension Reserpine causes depletion of norepinephrine, thereby producing adverse events such as decreased cardiac output, bradycardia, sedation, depression, diarrhea, and increased gastric acid. Its wide range of side effects led to the limitation of its use in allopathic system of medicine several decades ago 11 , but it is still used in the ayurvedic system. Moreover, the product Tensarin did not have the exact amount of reserpine and other constituents mentioned in its label. So it was risky to continue the drug without knowing the exact amount the patient was receiving. Adulteration of ayurvedic products has been another alarming issue 12 , We see many patients with arthritis and asthma like our third patient, coming to our clinic with classic Cushingoid character and many of the other adverse events of chronic steroid usage: hypertension, weight gain, hyperglycemia, osteoporosis, bone fracture, muscle weakness, ocular effects, gastrointestinal effects, and electrolyte imbalance 14 , following years of taking adulterated ayurvedic products. Adrenal crisis when stopping these drugs is a potential problem. Most people in South Asia believe that ayurvedic products are safer and more effective for chronic diseases 2. Patients with chronic disease are more vulnerable to mishaps related to ayurvedic products because they want to get rid of their chronic disabling condition, and tend to try alternative medicine products in the hope of safety and cure. Many of these chronic diseases diabetes, hypertension, arthritis, cancer may have no cure in either allopathic or alternative medicine practices, and patients should be counselled regarding this fact so that expectations are realistic. Ayurvedic medicines may be beneficial to health, but are not devoid of adverse events which may be due to adulteration or some inherent constituents like alkaloids. Proper counselling by health professionals, especially regarding adverse events, will play an important role in minimizing harm. Written informed consent for publication of clinical details and clinical images were obtained from the patients. All data underlying the results are available as part of the article and no additional source data are required. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Thank you for asking me to review this interesting paper. My review is brief as most of the issues have been addressed by the other reviewers. In addition, although I have training in pharmacy and pharmaceutics, I do not have expertise in ayurvedic medicine. If the authors would ike to use this term, please provide definition and reference. ADR implies that there is a causality whereas adverse events does not. Ayurvedic medicines may be beneficial to health, but are not devoid of adverse effects. Adverse events may be due to adulteration or some inherent constituents like alkaloids. Finally, for the Discussion section, do the authors have any recommendations or research agenda? I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Corrections of typos and grammatical mistakes have been done in the revised version, especially in the abstract section. Coming to the contents and case reports mentioned in this article, review on this article would be lengthier than the article itself. Ayurveda never considered to be devoid of adverse effects. The classics have vividly explained possibilities of adverse effects and their management systematically. Further, many statements need to be re-written. Ayurveda never used alkaloids exclusively in their formulations. Alkaloids are not sole but, a part of the formulation. The concept of Ayurveda drug formulation is entirely different than as understood by the authors in the manuscript. Withdrawing the drug was a good decision, but patient was put on allopathic medicine again though his Blood Pressure was near normal to his age. Lin et al. Claiming to have achieved normo-tension when patient was already normal with previous medications need attention. Reserpine as an extract is the culprit in unregulated dose, but blame has been put on Sarpagandha and formulations containing Sarpagandha. It is unclear from the discussion whether the patient is taking reserpine or Sarpagandha? What is being used in the formulation? Again, the drug regulating mechanisms existing in the country need a serious retrospective analysis here. The 3rd case again talks about some unidentified traditional healer whom the patient believed as an Ayurveda physician. These cases are treated and reported in Nepal? If, so how the practices are regulated there. It is a matter of series concern. In India, the system is regulated at different levels. The administration at Nepal should take a serious note on such practices and develop a stringent mechanism. The discussion highlighted upon alkaloids like - pyrrolizidine and possibility of hepatic impairment. Which medicine from the three cases being reported in the manuscript contain pyrrolizidine? Hypothetical predictions harm systems. In such cases, it is better generating awareness and implement stringent drug regulating and implementing practicing policies. Blaming a system will not yield anything. Ayurveda concepts of drug administration are quite different than the conventional approaches. Besides other basic requirements; understanding digestive ability, metabolic capability, tolerability of the patient to a specific dose of the drug, psycho-somatic constitution etc. The observations made in the article appears to be illogical and based on inadequate data. They need a further thorough review. A drug can be panacea or poison. Drugs fulfilling the criterion of a standard drug will always become panacea provided, if it is used properly. On the other hand, a poorly prepared or manufactured drug however used skillfully, will always prove to be a poison. Classics of Ayurveda do mention the hazards of drugs, which are not properly manufactured. Seers have prescribed specific processing techniques that remove harmful properties from these drugs. There is no sufficient evidence in the article to confirm the harmful nature of the formulation. Overall, it becomes clear from the manuscript that there is a serious need of looking into the drug regulating mechanisms in the country instead of blaming a system as such. I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. The authors tried to malign the Ayurveda system which is evident from the title of the manuscript it self,which need to be rectified. All natural drugs are not always safe. The medicines mentioned in the manuscript in puriya packet form or unlabelled with out a valid prescription are usually unethical and unlawful. Without a valid prescription and certificate of analysis of the drug it is very difficult to say they were Ayurvedic drugs. Also, without a valid prescription by a registered medical officer they can not be confirmed as Ayurvedic doctors rather the authors could labelled them as Quacks without any medical degree. In case 1, as the base line data of patient who had jaundice before the administration of drug was also not available, which makes it difficult to speculate liver injury caused by Ayurvedic drugs without any histopathology and drug analysis report. Hence, the link between the drug and liver failure can not be linked convincingly. Properly manufactured and prescribed in a therapeutic dose is always safe even in pediatric age group. Genuine Ayurvedic Metallic preparations also can be prescribed as they contains permissible metallic traces. Proper control on manufactuing and Quality control of any drug is the out look of the regulatory bodies of the state 1 Rauwolfia also in a small dose is very good for treating hypertension. The amount of Rauwolfia present and the reserpine amount required to cause the adverse effect needs to be highlighted. Because Rauwolfia contains so many alkaloids apart from Reserpine, which cause less possibility of adv. The authors tried to malign the Ayurveda system which is evident from the title of the manuscript itself which need to be rectified. The revised title does not intend to malign the Ayurveda system, but tries to raise the issues of adulteration and some inherent toxicities of medicines that have given bad name to the system of Ayurveda. The medicines mentioned in the manuscript in puriya packet form or unlabelled without a valid prescription are usually unethical and unlawful. Answer- The traditional healers who claimed themselves to be ayurvedic practitioners prescribed the unlabeled puriyas and tablets to our patients. Analysis of the puriya drug taken by case 1 was not done. However the tablet taken by case 3 was analysed and steroid was found to be present. Hence we have raised the issue of adulteration in the name of ayurvedic medicines, giving bad name to the Ayurveda. Answer- The base line data of the first patient is not available. We have not performed histopathology and drug analysis report. So we are not sure if the drug contained harmful alkaloids, and if the worsening of the liver disease was due to disease process itself or the unlabeled drug that was given. We have mentioned this in our revised manuscript. Here we wanted to focus that at least the alternative drug our patient tried did not help in her liver problem as is generally believed by Nepalese population. Proper control on manufactuing and Quality control of any drug is the out look of the regulatory bodies of the state. Answer- The case 1 also received swarnabhasma gold salt for jaundice, and developed kidney injury. Heavy metals can be beneficial if used in permissible amount, but there are reports of presence of different heavy metals exceeding the maximum permissible amount in different ayurvedic preparations. This raises the issue of possible toxicities of these inherent constituents of ayurvedic medicines. Rauwolfia also in a small dose is very good for treating hypertension. The combination of Rauwolfia with other drugs is usually mentioned in Ayurveda classics and only Rauwolfia is rarely prescribed in Ayurveda. Answer- Although reserpine has safely been used in treating patients with hypertension in some studies in the form of Rauwolfia, the routine use of reserpine as antihypertensive agent has not been recommended by any of the current guidelines of allopathic medicine. Moreover, the ayurvedic preparation our patient was taking for hypertension did not have label regarding amount of reserpine in each tablet. So we have raised the issue about mentioning the exact amount of each chemical constituent in any ayurvedic product so that the patients have some idea about the substance and the quantity being taken. The Authors tried to explain a common scenario of the use of alternate medicine observed by the many clinicians albeit not documented much in Nepal. The case reported is of importance to clinical practice and written well. Ayurvedic medicines have been used in Nepal since the time immemorial. Ayurvedic and herbal medicines are known to cause varying degrees of drug-induced liver injury. Severe liver injury related to Ayurvedic and herbal medicines is studied to certain extent from the Indian subcontinent. Below are my comments for the note of the authors. Case 1: The lady developed features of acute liver failure. Ingestion of gold formulation is known to cause hepatic injury by when the storage capacity of lysosomes exceeds 1. The parenteral preparation can, however, cause acute fulminating hepatic failure 2. Hepatotoxicity by pyrrolizidine alkaloids, often a composition in Ayurvedic medicine has been long recognized. Although the authors presume that the gold or other content of the consumed Ayurvedic medicine is likely to be the factor causing liver failure, the etiology of the liver injury is not clear in this case report. Histopathological study of the liver biopsy would have shed more light to understand the nature of the liver injury. Moreover, analysis of the available sample should have allowed knowing if proposed alkaloids were actually present in the Ayurvedic medicine consumed. Case 2 — Reserpine is no more produced by pharmaceutical companies. It is implicated multiple side effects including postural hypotension, has not been tested as monotherapy in a clinical trial. However, reserpine had been used in large renal disease prevention program in India and was reported to have good blood pressure control without much adverse effect 3. A Chinese study of polypill contained low dose reserpine and had not shown more adverse effects 4. Similarly, reserpine was found to be safe in the treatment of cocaine dependence 5. In this clinical trial the safety results suggest that reserpine was safe and well tolerated by the participants. Case 3: The case exampled the common problem faced by clinical. Adulterated Ayurvedic medicine is a common issue in the Indian subcontinent. In , Ayurvedic research center of KEM hospital Mumbai, India, reported out of the Ayurvedic samples that were analyzed for steroid 96 samples were tested positive. About 18 samples had more than one steroid. This case report may help to create awareness among practicing clinician not aware of the problem or habit of looking into it. Although reserpine has safely been used in treating patients with hypertension in some studies in the form of Rauwolfia, the routine use of reserpine as antihypertensive agent has not been recommended by any of the current guidelines of allopathic medicine. This section collects any data citations, data availability statements, or supplementary materials included in this article. As a library, NLM provides access to scientific literature. Wellcome Open Res. Other versions. Find articles by Buddhi Paudyal. Find articles by Astha Thapa. Find articles by Keshav Raj Sigdel. Find articles by Sudeep Adhikari. Find articles by Buddha Basnyat. Accepted Oct 31; Collection date Version Changes Revised. Amendments from Version 2 Grammatical errors and typos have been corrected, especially in the abstract section. Open in a new tab. Find articles by Phaik Yeong Cheah. Competing interests: No competing interests were disclosed. Phaik Yeong Cheah : Referee. Competing interests: none. PMC Copyright notice. Find articles by Kshirod Kumar Ratha. Kshirod Kumar Ratha : Referee. The first case have taken puriyas possibly a packaging system that dispensed medicines in a paper wrapping from a self-claimed Ayurvedic healer, which contained Swarna bhasma. The medicine was only given in a paper wrapping. In such case, how it was ascertained that the puriya contain Swarna bhasma. The medicine was not subjected to any analysis in order to claim they had Swarna bhasma in toxic levels. Previous disease history or reports are not considered to check the condition of patient prior to medications. When she visited the so called Ayurveda physician; already she was presenting with some liver pathology. In such case, how to confirm that the manifestation is because of puriyas. Further, how many days the puriyas were consumed, what were the doses, how they were administered is unclear. Gold is claimed to be toxic by the authors by citing a reference. It is fine for that specific instance. Processed Gold Swarna bhasma is entirely different than the Gold that is being highlighted by the authors. Please refer: Paul and Sharma 1 and Jamadagni et al. Find articles by Sanjib Kumar Sharma. Sanjib Kumar Sharma : Referee. Associated Data. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel.

Lalitpur where can I buy cocaine