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Gabapentin misuse

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By Professor Saman Gunatilake

Consultant Neurologist

As prescribing physicians, we should be happy about the initiative taken by the State Minister of Pharmaceutical Production and the Sri Lanka Pharmaceutical Manufacturing Corporation (SPMC) to produce essential drugs, locally. This would definitely help our patients if the quality is assured and also help the country save millions of rupees currently spent on purchasing them from foreign vendors. The newspapers this week reported that the drug, gabapentin, had been produced by the SPMC. I am intrigued. Why gabapentin was the first choice to be produced locally? It has been mentioned that Rs. 65 million is spent on this drug annually, the implication being that this is an important and widely used drug. As a practising neurologist, well aware of the prescribing habits of doctors, I would agree that it is widely prescribed, but most of the times unnecessarily. Whether this drug is so important as to be made here for wider use is debatable, and the general opinion of the international experts is that it is a drug very extensively misused. In this country, too, large sales of this drug are due to its use for conditions and situations where it is really not indicated. The pharmaceutical industry and its representatives have promoted this drug for use in many conditions where it is not licensed to be used. Our drug market is flooded with generic products of this drug with different brand names, imported from several countries.

The misuse of medicines is defined as use of a substance for a purpose not consistent with legal or medical guidelines, such as taking another person’s medication or taking a higher dosage than prescribed. The Prescription drug misuse is a problem, especially psychoactive drugs such as opioids, benzodiazepines and more recently gabapentinoids the class of drugs gabapentin belongs. Pregabalin, the other drug in this group, may have a higher misuse potential than gabapentin due to its rapid absorption and faster onset of action. In the UK, gabapentin use has increased by 350% over five years. In 2016, gabapentin was the 10th most commonly prescribed medication in the United States. This trend is likely due to using gabapentin to avoid the use of opioid analgesics which are strongly addictive. Opioid addiction is a major problem in many countries in the West and also leads to many avoidable deaths from overdose, etc.

Gabapentin was first licensed as an adjunctive treatment for epilepsy in 1993 and later approved for treatment of pain in diabetic neuropathy and post herpetic neuralgia. Diabetic neuropathy is when patients develop pain and uncomfortable sensation in their legs due to nerve damage due to poor control of diabetes. Post herpetic neuralgia is distressing pain that follows herpes zoster (Shingles). However, off-label prescribing (using a drug for other conditions for which it is not licensed by a regulating body like the Food and Drug Administration Authority of USA) of gabapentin increased in 1990s due to extensive marketing campaigns in violation of US Federal regulations, promoting it for use in other pain conditions, and psychiatric disorders. Neuropathic pain can be very difficult to treat with only some 40-60% of people achieving partial relief. In Sri Lanka, too, these drugs are now freely available and the drug market is flooded with so many generic brands. Although we have no published data available, it appears that gabapentin and pregabalin are widely used mostly for off-label indications. It is not uncommon to see our doctors use gabapentin as first line for chronic back pain, headache and other musculoskeletal pains, but there is no evidence to show that it works. Prescribers should be aware that even when used for neuropathic pain over half of those treated with gabapentin do not have worthwhile pain relief but may instead experience adverse effects. So, gabapentin is not a very effective medicine and, therefore, not an essential drug.

The use of gabapentin for non-neuropathic pain is unlicensed and ineffective. Patients inappropriately prescribed gabapentin or pregabalin may not benefit and may be exposed to potential harms, which broadly fall into two categories. First, by causing an adverse drug reaction or toxicity e. g. nervous system effects (headache, visual disturbance, drowsiness, agitation, delirium, lethargy); cardiac effects (rapid heart rate and slowing of heart rate); disturbances in muscle control and movement, and gastrointestinal symptoms. Second, gabapentin or pregabalin prescription may result in drug misuse or diversion (the transfer of any legally prescribed substance from the individual for whom it was prescribed to another person for illicit use.)

We, as prescribers must be conscious of the potential to do harm, both to our patients and society as a whole. Therefore, we must carefully select the patients who will benefit from these drugs. These medicines are licensed to be used in treating neuropathic pain, epilepsy and anxiety, but illicit use of the drugs has increased in recent years. Data from Scotland revealed that gabapentinoids had been prescribed prior to a fifth of drug-related deaths in Scotland in 2016. In this country, too, some medicinal drugs like strong pain killers are abused and a part of the illicit drug trade.

In the UK, from 1 April 2019, gabapentin and pregabalin were made Schedule 3 controlled drugs under the Misuse of Drugs Regulations 2001, and Class C of the Misuse of Drugs Act 1971. Under these regulations prescriptions of gabapentin and pregabalin will be limited to 30 days’ treatment and repeat prescriptions without seeing a doctor will not be issued. Any prescription received have to be dispensed within 28 days. In Sri Lanka, too, it is time to tackle the problem of overuse of gabapentinoids by limiting their use to approved indications. This will bring down the number of prescriptions issued and also the money spent on purchasing or producing this drug.



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Features

Vesak celebrations … with Cuteefly

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Perfect for celebrations, gifts, and meaningful occasions // Gift pack

I would describe Indunil Kaushalya Dissanayaka as innovative and creative, and she operates under the name of Cuteefly.

Indunil always comes up with something novel to celebrate special occasions, and she does it with candles … and that’s her profession.

She was in the spotlight when she created a happening scene, with candles, for Christmas, Sinhala and Tamil New Year, and Valentine’s Day.

As lanterns light up Sri Lanka for Vesak, the Colombo-based candle maker is quietly turning wax and wick into little pieces of the festival.

Candles reflecting Vesak themes

Her candles reflect Vesak themes – light, peace, remembrance, giving, etc., to enable you to fill your Vesak celebration with devotion and beauty.

Among her Vesak creations is a lotus-shaped soy candle, scented with sandalwood, lavender, etc., meant to burn during this Vesak Poya Day.

Indunil Kaushalya Dissanayaka: Customers
praise her for her creativity

These handcrafted Vesak candles are perfect for offering at the temple, she says.

What makes her creations so novel is that they come in different shapes, scents, themes, and all are handmade.

What’s more, her customers have heaped praise on her for her creativity.

According to Indunil, her creations are perfect as a thoughtful gift … to bring beauty, unity, and light into every moment.

Says Indunil: “Our beautifully handcrafted Unity candles are designed with premium detail and love, making them perfect for celebrations, gifts, and meaningful occasions.”

Cuteefly, says Indunil, is available online.

Readers could contact Indunil on 0778506066 for more details.

He Facebook Page is: Cuteefly.

Handmade with love

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Features

Dark Spots …

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Yes, dark spots do crop up on the skin, especially with sun exposure and, of course, as the skin ages.

However, these tips should be of immense benefit to those who are faced with dark spots.

Lemon and Honey Glow Mask:

You will need 01 teaspoon lemon juice and 01 teaspoon honey.

Mix the lemon juice and honey well and then apply this mixture, only on the dark spots.

Leave for 10–15 minutes and then rinse with cool water.

Benefits:

Lemon helps brighten pigmentation.

Honey moisturises and heals skin.

Gives a natural glow.

* Aloe Vera Gel Treatment:

All you need is fresh aloe vera gel.

Apply the gel apply on dark spots, before going to bed.

Leave overnight and wash in the morning.

Benefits:

Reduces acne marks and pigmentation.

Soothes irritated skin.

Helps skin repair naturally.

Turmeric and Yoghurt Paste:

You will need 01 teaspoon yoghurt and a pinch of turmeric

Mix the yoghurt and turmeric into a smooth paste and apply on affected areas.

Leave for 15 minutes and then wash gently with lukewarm water.

Benefits:

Turmeric brightens skin naturally.

Yoghurt removes dead skin cells.

Helps fade dark spots gradually.

Use these packs 02-03 times a week as results are generally seen over time.

You can also try this out: Mix a ripe papaya into a smooth paste and apply to the face, or directly on to the dark spots. Leave for 15-20 minutes and then wash with lukewarm water.

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Features

The rupee is warning us again

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Speak the truth, before the crisis does

The Sri Lankan rupee is not merely depreciating. It is sending a warning. Once again, the country is being reminded that recovery is not the same as stability, and that an IMF programme is not a substitute for disciplined national economic management.

Beneath the casual conversations of scholars lies a serious argument: Sri Lanka is not yet out of danger. The country may have escaped the worst of the 2022 collapse, but it has not escaped the habits that produced it: delayed decisions, weak communication, excessive import appetite, fuel-intensive lifestyles, and a political reluctance to tell citizens the hard truth.

The vicious cycle

The latest pressure on the rupee should, therefore, not be dismissed as a temporary market fluctuation. It reflects a familiar and dangerous sequence. When the rupee begins to fall, exporters hold on to dollars in expectation of a better rate. Importers rush to buy dollars before costs rise further. Banks become reluctant to release foreign exchange. The interbank market tightens. Anxiety feeds behaviour, and behaviour feeds anxiety. That is how a currency problem becomes a confidence problem.

Sri Lanka has seen this movie before, precisely during 2020-2022. The names, personalities, and policy language may have changed, but the underlying pattern is recognisable. First, the exchange rate comes under pressure. Then the authorities speak calmly. Then temporary measures are discussed. Then import restrictions are considered. Then citizens are told certain goods are “non-essential.” Finally, when pressure becomes unbearable, the truth emerges: the country had less room than officials implied.

The danger today is not that Sri Lanka is exactly back in 2022. It is not. The fiscal position is stronger. The IMF programme is in place. The Central Bank has more credibility than during the worst period of denial. But that is precisely why complacency is dangerous. A country that has just survived a crisis should be more alert, not less and announce “there is no problem”.

The IMF tranche expected shortly may calm the market. It may bring dollars into the system. It may help the Central Bank reassure banks, exporters, importers, and investors. But IMF money is not a national economic strategy. It is breathing space. If that breathing space is used merely to postpone difficult choices, then the country will have learnt very little from its own trauma.

The most dangerous illusion is that import controls can solve the problem. They cannot. They can delay pressure, redirect it, and make the government look active for a few weeks. But they do not eliminate underlying demand. If people cannot import vehicles, the credit and purchasing power do not vanish. They move elsewhere: housing, construction, consumer goods, machinery, travel, or other import-linked spending.

Vehicle imports illustrate the dilemma. They consume foreign exchange and increase future fuel demand. But they also generate large tax revenue and support leasing, insurance, repairs, spare parts, logistics, and employment. A crude ban may reduce one form of dollar demand while damaging revenue and pushing economic activity into other channels. The correct answer is not panic prohibition. It is intelligent demand management.

Fuel is the real battlefield

Petroleum is one of the country’s largest import burdens, yet Sri Lankans still behave as if fuel consumption is a private matter with no national consequence. It is not. Every unnecessary trip, every idle engine, every fuel-inefficient commute, and every avoidable private-car journey becomes part of the country’s dollar problem.

If fuel prices are artificially softened, people continue as before. If the rupee falls further, the eventual pain comes through every channel at once: fuel, electricity, food, water, transport, and imported inputs. The country then discovers that avoiding one price increase only produced a larger national price increase later.

Poor households must be protected

That is why targeted support is essential. Public transport must be supported. But subsidies should not be thrown blindly across the economy. They should be directed through systems that can be monitored: Aswesuma for vulnerable households, route-based support for buses, and transparent cash or coupon mechanisms linked to actual public service.

Sri Lanka should be making public transport the patriotic option, not the poor man’s punishment. If citizens are being asked to reduce fuel consumption, they must be given a credible alternative. That means better buses, cleaner buses, more AC services, higher frequency, safer routes, and regulations that reflect reality rather than outdated assumptions.

Transport system management is vital

Discussions about metro-style bus services is important for precisely this reason. If commuters are willing to stand in an air-conditioned bus because it is cleaner, quieter, smoother, and more comfortable than the ordinary alternative, policy should expand that service. Do not suffocate better service with rules written for a different era. Regulate for safety, yes. But do not block improvement in the name of procedure.

Rail is even more important. A serious country does not solve urban commuting only with buses and private vehicles. The railway should be the backbone of mass commuting into Colombo. Trains move more people with less fuel per passenger. They avoid road congestion. They reduce import pressure indirectly by reducing fuel demand. But this requires frequency, rolling stock, signalling upgrades, centralised control, digital systems, and operational seriousness. Sri Lanka cannot talk about saving dollars while tolerating a transport system that pushes citizens into private vehicles.

Hello, please speak the truth

The government’s communication failure is equally serious. Leaders in India and Singapore have been willing to tell citizens that conditions are difficult and that behaviour must adjust. Use public transport. Reduce unnecessary consumption. Work from home where possible. Conserve fuel. Be careful with imports. These are not signs of weakness. They are signs of mature leadership.

In Sri Lanka, the message remains too soft. Officials appear afraid to say plainly that the country is not yet secure. The public is allowed to behave as if recovery means normalcy. Fuel is consumed, imports resume, roads fill, luxury vehicles appear, and private lifestyles continue with little sense of national constraint.

This is irresponsible. Citizens cannot be expected to act prudently if the state refuses to speak honestly. Economic management is not only about interest rates, reserves, and IMF reviews. It is also about shaping expectations. If leaders do not explain the seriousness of the situation early, the market will explain it later through far more painful consequences, such as runaway inflation and shortages of essential goods.

There is also a deeper governance problem. The issue today may not be crude corruption of the old kind. The more immediate danger may be hesitation. The government appears too slow in making necessary decisions. It overthinks. It delays. It waits. It consults. It hesitates. Meanwhile, markets move.

Delay is very expensive

In economics, delay is not neutral. Delay has a price. A decision postponed in May may become a crisis measure in August. A reform avoided today may become a forced adjustment tomorrow. The market does not wait for Cabinet comfort, bureaucratic neatness, or political messaging.

This is where Sri Lanka must learn from Vietnam, which did not become an investment magnet through speeches about development. It made decisions. It signed trade agreements. It improved investor access to land. It aligned policy with competitive advantage. It pushed digitalisation. It treated investment facilitation as practical statecraft, not ceremonial rhetoric.

Sri Lanka remains trapped in procedural delay. Land acquisition takes too long. Export-zone facilitation is too slow. Intellectual property reforms remain incomplete. The Madrid Protocol issue is not a minor technicality. For exporters and investors, brand protection, product security, and legal alignment with global systems matter. A country that cannot protect intellectual property cannot expect higher-value investment to arrive simply because officials request it.

The lesson is blunt: Investors do not reward potential. They reward execution. Sri Lanka has potential. It has always had potential. That is precisely the problem. Potential has become an excuse for underperformance. Vietnam converted potential into policy. Sri Lanka converted potential into discussion.

Disciplined adjustment means telling citizens the truth before the crisis does

If the country responds with another cycle of reassurance, delay, temporary restriction, and vague optimism, then the recovery will remain fragile. If, however, the government uses this moment to speak honestly, manage fuel demand, strengthen public transport, target subsidies, speed up reforms, and treat policy execution as urgent, the rupee’s warning may still be useful.

The choice is not between panic and denial. The choice is between disciplined adjustment and forced adjustment. Disciplined adjustment means telling citizens the truth before the crisis does. It means asking those who can work from home to do so. It means encouraging public transport while improving its quality. It means protecting the poor without subsidising waste. It means recognising that every unnecessary dollar spent today weakens the country’s room for manoeuvre tomorrow.

Forced adjustment is what happens when leaders avoid these choices. Then the exchange rate makes the decision. Prices make the decision. Queues make the decision. Import shortages make the decision. Public anger makes the decision, similar to Aragalaya in 2022. Sri Lanka has already paid once for denial. It should not pay again for hesitation.

The rupee is not only a price. It is a signal of trust. When it weakens, it tells us that markets are uncertain, citizens are unconvinced, and policy has not moved fast enough. The correct response is not to blame exporters, importers, consumers, or global conditions alone. The correct response is to govern. The country does not need another explanation after the damage is done. It needs timely action before the damage spreads.

That is the real message of this moment: the rupee is warning us again. This time, Sri Lanka must listen early.

(The writer, a senior Chartered
Accountant and professional banker,
is a professor at SLIIT, Malabe. Views expressed in this article are personal.)

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