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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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Suppressing the struggle: Education and the Discourse of Class

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A file photo of the military presence at Galle Face during Aragalaya

By Anushka Kahandagamage

Protesters defeated the dictatorial Rajapaksa regime, making the Rajapaksas resign from their positions, premiership and presidency, of the government. After the collapse of the dynasty, Ranil Wickremesinghe, a Rajapaksa puppet, came to power with the support of a distorted majority in Parliament. Having got himself appointed as President, without a people’s mandate, Wickremesinghe began to suppress the struggle—the very struggle that led to his ascendency. Hours after Wickremesinghe took oath as President, at midnight, when the protesters were preparing to disband the major GotaGoGama (GGG) protest site, the military stormed in, violently assaulting some protesters, including women and people with disabilities. The military attacked media reporters, including BBC journalists, and destroyed the structures built on the location, prompting many to go to the GGG site in support of the protesters. A witch hunt would soon unfold, and, today, just weeks after Wickremesinghe came to power, arbitrary arrests are commonplace in Lanka, most recent and prominent, that of the trade union activist Joseph Stalin.

The Classed nature of the Discourse:

The Double Standard

National as well as international activists, academics, journalists, students, condemned the arbitrary violent attack on the GGG site. Social media was swamped with video footage of the attack, and posts, condemning the government’s moves. Many social media posts pointed fingers at the military, which was to be expected. But a notable and recurring theme was the link made between the military’s behaviour and its low education level – “Eighth grade passed Army”. Meanwhile, politicians from the ruling party (and others) publicly condemned the protesters’ actions, even calling them drug addicts (kuddo). The social media discourse targeting the military (low education) and the protesters (drug addicts), although coming from very different places, was steeped in a classed and classist language, and reduced their actions—whether of the protesters’ or of those suppressing the protest —to their level of education or social class.

Yet, there were surprisingly few discussions regarding the education level of the President, who commanded the attack on the protesters. There is no doubt that Wickremesinghe, whose past is linked with horrendous acts of violence, commanded the military to attack GGG. He is also behind the arbitrary arrests of protesters, the very people who placed him in power. While people are aware of Wickremesinghe’s violent tendencies, these inclinations are not discussed in relation to his education level. During the protest, when his house was set on fire, along with his personal library, many condemned the burning of the library, emphasizing the importance of ‘reading’ and ‘knowledge’. Ranil Wickremesinghe is seen as an ‘educated’ politician, well-read and knowledgeable about foreign policy and politics. A double standard manifests itself where the violent acts of the military (by no means am I trying to glorify the military) are criticized on the grounds of their ‘low’ education level, while the violence of Wickremesinghe garners little comment.

Violence and Education

There is no essential link between violence and education, rather capitalist structures have conditioned us to associate violence with under privileged groups and lower levels of education. Formal educational structures sustain hierarchies, power and, in our context, neo-liberal market economies. Education socialises the individual in such a way s/he/they come to embody dominant society’s values, beliefs, and attitudes. Educational institutions are particularly efficient in legitimising the current social order since they play a role not only in training workers in the strict sense of providing them with skills to be productive but also in the naturalization of social relations of production. Education thus entrenches the status quo, and, in that sense, is not an innocent space, rather a space where inequality and hierarchies are sustained and reproduced.

We associate ‘low’ educational levels, and underprivilege, with violence, as we are trained to do so by the political-economic structures which glorify the ‘learned’ and ‘wealthy’. While the military should not be glorified, under any circumstances, it should be understood that the soldiers, who attacked the protesters, on the ground, represent the disadvantaged classes, carrying out their ‘duty’ as commanded by a supposedly ‘educated’ President. It is an irony that society sees people who are directly involved in violence as the generators of violence, rather than the decision-makers who perpetrate violence.

Formal educational institutions, driven by capitalist values, serve to produce, reproduce and sustain such hegemonic narratives. Indeed, there is a link between our pathological social condition and our education system. While our mostly market driven education is trapped in narratives of employability, efficiency or productivity—needed to understand a phenomenon beyond what is given—human values and critical thinking remain neglected on the back burner. Under these circumstances, there is a great need for alternative education forms.

Counter narratives and alternative

forms of Education

Education has been crucial to the struggle to depose the dictatorial Rajapaksa regime. In this context, I am referring to the ‘education’ initiatives that have been a key element of the Aragalaya: education on democracy, the constitution, history of struggles, economy and so on. In the GGG site, groups connected to the protest as well as other initiatives organized debates and discussions to raise awareness about economic, political and social issues, to learn about how to utter the correct slogans and how to steer the struggle in the ‘right’ path. In doing so, hundreds of webinars were organized, numerous articles and posts written and videos uploaded. In the GGG main protest site, a library, university, college, and an IT centre were established to support ‘educating’ the people.

‘Education’ was a thread that wove the struggle together. There were (and are) different debates on education at various levels of the struggle where alternative forms of education were discussed, challenging hierarchy and institutionalized education. The protest has opened up a space for people to pursue alternative educational structures and build counter narratives. Unfortunately, most of these efforts ultimately fall, directly or indirectly, in to hegemonic educational structures, where hierarchy and Sinhala Buddhist hegemony are sustained in different forms. Similarly, the activists and academics, among the protesters, who tried to introduce alternative education forms and counter narratives often fell into capitalist hierarchical structures. The majority of the webinars and awareness raising forums were top-down in nature and were held in one language, discriminating against other language groups.

Furthermore, these forums were frequently clogged with ‘experts’ or the kind of academics who preach their opinions to the ‘uneducated.’

In conclusion, existing capitalist educational frameworks train one to discriminate, based on class and educational levels, normalizing certain ways of life and being. For example, it’s fascinating to see how Wickremesinghe was removed from the violence and education discourse while the military was at the centre of it. Alternative forms of education are needed to question and challenge these hierarchies.

(The author is a Doctoral Candidate in School of Social Sciences, University of Otago)

Kuppi is a politics and pedagogy happening on the margins of the lecture hall that parodies, subverts, and simultaneously reaffirms social hierarchies.

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Prioritising protection of Government over the people

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by Jehan Perera

According to the philosopher Thomas Hobbes, the natural condition of mankind was a state of war in which life was “solitary, poor, nasty, brutish, and short” because individuals are in a “war of all against all.”  Therefore, it was necessary for them to come to an agreement. The philosopher John Locke called this the social contract. Social contract arguments are that individuals have consented, either explicitly or tacitly, to surrender some of their freedoms and submit to the authority of the ruler or magistrate (or to the decision of a majority), in exchange for protection of their remaining rights. Constitutions set out the rules by which societies are governed.

 The evolution of constitutional thinking  since the 17th century that Hobbes and Locke lived in has been to find ways to regulate the powers of the rulers and protect the people from the rulers. Those who have power need to have checks placed on them. They need to be held accountable. If those who are rulers are not checked or held accountable, they invariably abuse their powers. That power corrupts and absolute power corrupts absolutely has been a truism. Over the past 74 years we have seen that the rulers have used their power indiscriminately some more than others. PTA is an example of a law which was instituted to deal with the Tamil separatist insurgency over 40 years ago, but it still remains-to protect power of the rulers. In the past three years when the rulers of Sri Lanka held virtually absolute power by virtue of the 20th Amendment to the constitution, the situation in the country deteriorated. The country became bankrupt for the first time ever.

 The current debate over the 22nd Amendment is to ensure and enlarge the role of civil society to mitigate the powers of the politicians who are rulers. A key question now is with regard to the three civil society representatives who will be in the Constitutional Council. The present formulation of the amendment is that the civil society representatives will have to be acceptable to the majority in parliament (thereby giving the government final say). Unfortunately, Sri Lanka’s experience with constitutional reform has been  in the direction of further strengthening of the powers of the rulers against the people. The so-called reforms have invariably strengthened the hands of the rulers against the people and justified that it is being done for the sake of the people.

 ERODING CONTROLS

 The 1972 Constitution replaced the constitution that the country had inherited from the British colonial rulers. It ensured the independence of the judiciary and of the civil service and also had special protections for human rights and non-discrimination between ethnic communities. However, these protections were removed from the 1972 constitution that sought to empower the ruling politicians on the justification that they embodied the will of the sovereign people. It was argued that the elected politicians were closer to the people than unelected judges and civil servants. But being away from the people makes them non partisan, a value less understood. Judges were sacked when the new constitution came into operation and treated shamefully. The 1978 constitution repeated the activities of the 1972 constitutions. Judges were once again sacked and treated shamefully. At a later point they were even stoned.

 It is these cultures we developed that have led to the present crisis of lack of values beyond the economy itself and formed the base for Aragalaya. The 1978 constitution took the centralisation of power in the 1972 constitution even further and centralized it in the  office of one person, the executive president. He could now be even above the law, like the kings of old before parliaments that represented the people came into being. The first executive president of Sri Lanka, J R Jayewardene, said that the only power he did not possess was the power to turn a man into a woman and a woman into a man. It is not surprising that with this power going into  the hands of the elected rulers, that the abuse  of power and corruption should grow without  limit. From being  a country  near the top of Asia at the time of independence, Sri Lanka  is today nearer the bottom. The life savings of its people have been halved in half a year and not a single politician has faced a legal accountability process.

 The 22nd Amendment belongs to the family of constitutional amendments  that began with the 17th Amendment of 2001. This  amendment was  agreed to by the then president due to the weakening of the government at that time. The  JVP  then,  as now, the party of the disadvantaged in society, gave the lead. The amendment resulted in the reduction of the power of the president and sharing those powers with parliament, state institutions and with civil society. The idea behind the 17th Amendment was to strengthen the system of checks and balances and thereby promote good governance in the national interest. The 19th Amendment that resembles it was the work of a coalition of parties that had opposed the abuse of power of the rulers they had just deposed through an electoral mandate.

 HIGH CORRUPTION

 However, the limitation on the powers of the rulers has never been acquiesced by those who would be rulers or belong to their party. The 17th Amendment was overturned in 2010 by the 18th Amendment that gave back to the presidency the powers it had lost plus some more. When this led to an increase in the abuse of powers by the rulers, the  successor government brought in the 19th amendment to once again reduce the powers of the presidency. This was in pursuance of the mandate sought at the presidential election of 2015. But once again in 2019, those who formed the next government overruled the 19th Amendment and with the 20th Amendment and gave back to the presidency its lost powers plus some more.

 It is under the 20th Amendment which is about to be repealed that the corruption and abuse of power in the country reached its zenith and plunged the people into unprecedented economic hardship and poverty. It is these hardships that gave rise to the Aragalaya, or protest movement, that culminated with the physical storming of government buildings and the forced resignations of the president, prime minister and cabinet of ministers. The shrinking of the middle class who have toiled a lifetime are now falling between the cracks and joining the poor and vulnerable created by the government in less than three years. Yet highlighting the priorities of the rulers, no  one of the seem to be thinking of compensating those who have lost their savings, only of compensation of what happened to a few of the rulers and their henchmen during the 2015-2019 period  or the Aragalaya period in which the houses of the rulers, much beyond their known sources of wealth and income were burned down.

 An Indian political analyst Dr Maya John, has written, “Although the Aragalaya targeted not only individual politicians like the Rajapaksas but also the wider ambit of corrupt political forces – as evident in the parallel slogans of “GotaGoHome” and “225GoHome” – the bulk of people’s energy was overtly focused on dislodging certain individuals from political power; indicating the tendency for the ruling establishment to still hold sway with the ouster of particular politicians. As the well-known Sinhalese proverb goes: inguru deela miris gaththa wage (exchanging ginger for chilli), we have simply got rid of something bad and got something worse in return. So, the Rajapksas have been replaced but the same ruling clique and political system remain intact; in fact, in a more offensive reincarnation.”

UNEQUAL TREATMENT

 The protest movement was a reaction to the social  tolerance limits, economic hardships, shortages, queues and steep price rises that in effect halved the general income of the people, with some suffering more than others. But the crackdown on them by the rulers has been both subtle and harsh in the present period. Those who gave it leadership are being picked off one by one, put into jail or being put on bail so that they dare not protest again. The unequal and discriminatory treatment of the protest movement is given the veneer of law which the government would he hoping would get it through the monitoring of the UN Human Rights Council next month and preserve the economic rewards of the EU’s GSP Plus, which is given to country’s that are making a genuine effort to improve the lot of their people, poor people not only the rich.

 In 2018, parliamentarians who attempted to stage a constitutional coup (which failed because the judiciary stood firm) sat on the chair of the Speaker of parliament whom they had forcibly chased off. They flung chairs and wrenched microphones out of their sockets. But none of them were punished even when the coup failed. However, those who joined the protest movement and sat in the chair of the president are being houndeds one by one and arrested. A protester who took the beer mug of the deposed president has been arrested. But ministers who are accused of corruption, accused reportedly even by diplomats accredited to the country, and ministers who have been convicted by the courts, sit on, in government. Such unequal and discriminatory treatment is likely to cause the sense of grievance to grow especially when the people are faced with price rises and shortages. They form the basis  to cause another Aragalaya.

 The current version of the 22nd Amendment which gives the rulers the power to pick the civil society members who will be in the constitutional council is not a sign that the government will heed the voice of the people. In this reluctance to be held accountable and to use power in a just manner, is a recipe for confrontation between the rulers and people in the future in which repression will be the response of the rulers who disregard the people. It may explain  why the military budget continues to take first place despite the economic collapse. Unless the people’s voices are represented truly in the parliament and the political processes, which can only come through a fresh set of elections, it is difficult to expect accountability in the system which is a formula for disaster sooner or later.

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Doing it…dad’s way

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Yes, of course, the older folks would all remember Edward Joseph; the young ones may find the name unfamiliar as Edward now lives in Germany and does his thing in that part of the world.

Better known as Eddy, he was with the leader of the group Steelers and they were big in the local showbiz scene…many, many years ago.

While Eddy is now busy, operating as a singer/guitarist/songwriter, in Germany, his daughter, Samantha, has decided to follow in her dad’s footsteps…as a singer/guitarist.

According to Eddy, Samantha decided to get actively involved, this year, and started performing with him, at various gigs,

A few weeks ago, she had the opportunity to perform with dad, to a huge crowd, on big stage, and after her impressive performance, she was asked to come for a casting by the State Jazz band of Frankfurt, whose conductor was in the audience.

She was also discovered by another promoter of a big TV Channel, in Germany, called RTL.

Says Eddy: “So, hopefully, things will work out for her. I never pushed her to do music because I know how hard and competitive, and dangerous, the industry has become.”

The proud dad went on to say that he only gave her the tools of advice, and tips, in singing and playing instruments.

“From that point, onwards, it was all her effort,” he added.

Samantha, originally, was keen to become a Music Teacher, says Eddy, rather than a performer, but now she is gradually getting the taste of the crowds.

“I am grooming her and supporting her in every way I can and hope that she will get better opportunities, in this business, than I had.”

Eddy says that if he was born and bred, in Germany, he, probably, would have come a long way, by now.

“But I am very happy with my life, the way it is.

“I still have my loving mom and dad, a fantastic daughter, a caring partner, my friends and family, and God, on my side, and I am now totally at peace with myself.

“I can proudly say that God has given me the path to be one of the most booked musicians, in my region.”

Most musicians, over there (born and bred in that region), according to Eddy, do find the going pretty tough, where work is concerned, due to the pandemic, and the Ukraine-Russia war, resulting in a food and fuel crisis.

Hopefully, if the scene brightens up, we may see father and daughter, in action, here!

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