Wednesday, May 16, 2012

Buying drugs

As I've recounted in a previous posting, a couple of months ago while in Cambridge I acquired a neurological disorder called lingual dystonia that affects my speech. On returning to Bombay I was fortunate to get a quick and accurate diagnosis from a leading neurologist. However treatment was a different matter. One cannot treat the disorder but only the symptoms. It took more than a month, and two more neurologists, to get the course of medication right. But at the end, when everything seemed under control, I ran into an unexpected problem which taught me something about the law and its "enforcement" in India, and the impact on medical patients. Read on.

The first neurologist prescribed two medicines, one of which is Clonazepam, an inexpensive (Rs 15 for 10 pills) anti-anxiety medication with few side effects that is considered to be always helpful with dystonia. The other medicine, Trihexyphenidyl, is more expensive and specialised, does not always work, and has awful side effects as I can now testify. I bought both of these medicines from one of the row of medical shops right outside Bombay Hospital. The shopkeeper was friendly and even gave me 5 percent off because I was short of cash and he wanted to save me a trip to the nearby ATM! It was my first day back in India and I was delighted at this affectionate and helpful behaviour after cold, clinical England. I should mention that the shopkeeper carried out his legal obligation by carefully examining the prescription and noting down the doctor's details.

Some weeks later I consulted a different neurologist at Jaslok Hospital, who told me to continue Clonazepam and also switched me from Trihexyphenidyl to Tetrabenazine (which also has side effects including depression, which really wrecked me for several days). I had some Clonazepam but needed to buy more of it, and he gave me a fresh prescription. But I found that in the downtown area of Colaba where I stay, the many dozen pharmacies all stock Trihexyphenidyl and Tetrabenazine but not a single one stocks Clonazepam. So I bought it at the same shop as before, outside Bombay Hospital, about 3 kilometres away. The same shopkeeper was again friendly and again took down the doctor's details, carefully checking the spelling of his name (he also seemed to remember me as the person who had run out of cash on the previous occasion).

That was three weeks ago. On my visit to the doctor last week, he agreed to stop the Tetrabenazine which was not helping. But he felt the Clonazepam was working and I was slightly better. So he gave me a new prescription for it, asking me to continue it for a few months. Since I still had some of it left at home, I didn't bother buying a fresh stock the same day.

Now on Sunday I was to return to Cambridge, so on Saturday evening I went to the Bombay Hospital area with my prescription to buy some more Clonazepam to take with me. I thought it would be as simple as before but was in for a huge surprise. The familiar shopkeeper turned rigid when he saw my prescription, looked the other way and said it was out of stock. He refused to talk to me or advise me where else to look for it, except to "try the next shop". I tried all five shops in that row and in all of them, got the same response: Clonazepam (brand name: Epitril or Rivotril) was out of stock. माल नहीं है ("we don't have the stuff"). Try the next shop. 

More surprising was that everyone would freeze and look away when I even tried to discuss the matter, or ask where then I could get my medicine. In desperation I used my mobile to call my neurologist. He thought maybe the shopkeepers would have Lonazep, a different brand that's equivalent, so he suggested I hand my mobile to them so he could explain this directly to them. But they refused point blank to talk to him. They just kept freezing and looking away more and more, and the atmosphere became rather creepy and hostile so I walked away from the area dejected.

My doctor then suggested I try Saifee Hospital, an impressive new hospital a couple of kilometres away where I've always had a good experience. So I took a cab there and entered their neat and small pharmacy, which had an actual pharmacist in uniform. He took my prescription, solemnly checked the stocks on the computer and confirmed that they had Lonazep in stock. His assistant pulled it out of a drawer. And then, just as I thought my problem was solved, he froze. "The prescription is not dated today", he said. "So what?" I asked. "It's just four days old." He replied that I might have filled it elsewhere and be coming to him for more. So I began to understand the issue. Clonazepam, like all benzodiazepenes,  gives one a pleasant and relaxing feeling and is therefore sometimes abused as a recreational drug.

I explained that I was a legitimate patient and hadn't filled the prescription four days earlier because I already had some of the medicine at home. He repeated his objection and said he would not fill a prescription unless it was dated today. I said I understood the concern, but surely even if it was dated today, someone could fill it elsewhere and then come to him and get some more? So the abuse he was worrying about couldn't actually be stopped just by having today's date?

He froze more and more and then rudely told me not to argue with him. He also refused to talk to my doctor on the phone and disappeared into the back of the shop. One more panic call to my doctor. As he practices at Jaslok Hospital, another 3 km away, he kindly phoned the pharmacist there, revealed his identity and verified they had Lonazep and would fill my prescription. So I took a cab to Jaslok. I thought I saw the pharmacist freeze when he saw the name of the medicine, but he slowly regained some mobility and sold it to me. So that was the end of my troubles that day. After another cab ride home to Colaba, I had spent two hours and 250 rupees in cab fare to get 60 tablets of a medicine, collectively worth 90 rupees. This medicine is the only thing that helps my neurological illness, and I have four prescriptions by three leading neurologists all bound neatly in a file, but despite this while shopping for it I had been looked at and spoken to as if I was some sort of drug addict!

 Why did this happen? The shopkeepers would not even talk about it, as I've indicated. But in the past the police have been known to raid pharmacies to check up on the sale of benzodiazepenes. There must have been a raid that day, or recently. Or maybe there was a rumour that there was going to be one. I admit this is speculation on my part but I've never, ever, encountered this kind of reaction when buying any other prescription drug, such as antibiotics or even the awful Trihexyphenidyl.

I was lucky to have the time, the money for cab fare and the energy to travel all over town in pursuit of my medication. But what would happen to another legitimate patient without some or all of these assets? The utter rudeness of all the shopkeepers indicated they must have been terrifed of the police. Also I have never before been told that a prescription can only be filled on the same day. I suspect this "rule" was simply invented by the pharmacist at Saifee. I would appreciate feedback on this from informed readers, because if such a rule does not exist then I'm afraid he behaved unprofessionally and I'd be inclined to complain to the hospital. Though again, the police could be ultimately to blame for his fears.

In the end, recreational users always find shady sources to access their drug, so it's mostly genuine patients who have to put up with the runaround and stress just to buy what they really need. And funnily, one thing that makes neurological disorders worse is stress! In my view there needs to be some kind of legal protection in place for the patient in such cases. If pharmacies are (correctly) penalised for selling certain medicines without a prescription, they should also be penalised for not selling them when there is a valid prescription. And the police, when checking up on medical shops, should be careful and correct rather than intimidate the shopkeepers. They need to think carefully about the potential consequences of their actions on legitimate patients.


Archie said...

Thanks for sharing this. It is a rather pertinent, and often overlooked, point. One of my acquaintances from IIT faced a similar, though less trying, situation when he went out to buy a dextromethorphan based cough syrup and was given curious to curt glances (and eventually refused the medicine) due to frequent recreational abuse of such drugs in student hostels. It earlier seemed like an evil yet necessary precaution but the full magnitude of the problem had not hit me till I read about your experience.

Anonymous said...

I had almost exactly the same experience. I do not recall the name of the medication, but it was a sleeping pill and pharmacists had precisely the same reaction: they would go rigid and suggest I try the next shop. It was finally resolved when I identified myself and explained where I was staying to a shopkeeper who knew my family.

A simple solution would be to have pharmacists cross out a prescription with ink before filling it so it can't be reused.

A slightly better solution could be to set up a website where pharmacists can enter the drug name, quantity sold, doctor's name and prescription serial number prior to filling a prescription. This may help reduce re-use of the same prescription.

The optimal solution is for the prescription to be recorded in a centralized system directly from the doctor's office, and have all pharmacists check the system before issuing any drugs, even if the prescription is for the same day.