BEIRUT: Once upon a time, or so the anecdote goes, alprazolam (aka Xanax) and anti-anxiety medicines of its ilk were passed around Beirut’s Civil War parlors like after-dinner mints. Today, psychotropic drug regulations have largely curtailed such blatant self-medication, and yet pharmacists still report rising demand for prescription benzodiazepines, or tranquilizers, and experts say their misuse remains rife.
Widad Hachem, who runs a pharmacy in Beirut’s Downtown, said she was approached at least three times a week by individuals seeking prescription anti-anxiety medicines.
Hachem refuses to fulfill such requests, recommending herbal medicines as an alternative and advising the individual to go and consult a doctor.
She feels that although some ask for a specific product by its trade name, “most are not conscious that it is dangerous to take [these medications] without guidance.”
Hachem also pointed out that those seeking the medications were not from one particular age group.
Likewise, a Mar Mikhael pharmacist told The Daily Star that an increasing number of people were coming to ask her for alprazolam and diazepam (sold under the trade name Valium), but insisted she did not sell these drugs without first seeing a prescription.
While antibiotics are easily acquired over the counter in Lebanon, stricter regulations do appear to have taken a widespread toll on pharmacists’ willingness to sell designated psychotropic drugs to individuals without prescriptions.
Of the five pharmacies The Daily Star approached to purchase such medication, just one agreed to sell the drugs – and only after some cajoling.
The pharmacist in question did initially ask for a prescription, but eventually agreed to hand over a 30-pill packet of alprazolam with the plea that not more than half a tablet be consumed at a time.
At the other pharmacies, the response was clear: “Not without a prescription.”
While most simply turned down the request, one Ashrafieh pharmacist went so far as to suggest to The Daily Star a number of nonprescription anxiety treatment options and also offered to recommend a doctor.
Pharmacists’ strong unwillingness to sell psychotropic drugs is likely directly linked to the close monitoring of sales by both the Health Ministry and the Pharmacists’ Syndicate.
Every prescription filled must be recorded in a special book, said Rabih Hassouneh, president of the Pharmacists’ Syndicate. These books are audited regularly by the ministry, he added. Pharmacies found in violation are issued warnings and sometimes closed down, he said.
Hassouneh, however, also noted that pharmacists are still approached by patients without prescriptions.
Hachem backed up his account of the enforcement of prescription regulations, saying that every month her record books were inspected.
Even the pharmacist that eventually sold The Daily Star a packet of Xanax said he would have to fiddle his books to account for its sale in the absence of a doctor’s note.
But while such prescription medication may have become less easy to acquire over the counter, they are still widely misused.
Professor Elie Karam, a psychiatrist and the head of the Institute for Development, Research, Advocacy and Applied Care, argues that even through many patients taking psychotropic medications now do so under prescription, they may still be taking them inappropriately.
It all comes down to the type of doctor consulted, he said, explaining that nonmental health specialists often prescribe these drugs incorrectly.
“If people go and see psychiatrists more commonly than not they end up taking antidepressants for depression, but if they see a nonpsychiatrist, more commonly than not they end up receiving tranquilizers,” Karam said.
Karam, who said the IDRAAC would release data supporting this claim within the next few months, explained that this happened largely because unspecialized doctors acted to treat patients’ immediate symptoms.
“The fact is,” he said, “that most people who have depression have some anxiety symptoms.”
Doctors prescribe drugs to treat these symptoms of anxiety, and patients feel some relief as a result but over the long term the treatment won’t yield results, Karam emphasized.
“If you have a mood disorder, like a depression or something related ... if you take benzodiazepine or a minor tranquilizer you’re going to be doing yourself a big disservice,” he said.
“You go into a practice and see the doctors who are not specialized, they seem to be giving minor tranquilizers to both anxiety and mood disorders. That’s the problem ... they didn’t make the right diagnosis.”
Hassouneh confirmed that any licensedphysician could legally issue a prescription for the drugs in question.
But while he admitted drugs could be wrongly prescribed under the current system, he was clear that “the issue now is with the physicians,” saying that audits and controls need to be introduced at their level.
Karam, meanwhile, said education was now needed to change the stigma surrounding consulting psychiatrists and mental health specialists.
“Now if I come and tell them, ‘Hey, you need to go and see a psychiatrist’ ... they’ll punch me in the face, they’ll say ... ‘you think I’m crazy!’ That’s the stigma,” Karam said
He likened people’s current attitudes to mental health problems to our forebearsefforts to hide physical sicknesses like cancer and heart disease because people would perceive them as “unreliable.”
The answer to this predicament is more knowledge, Karam said.
“We need lots of education. It takes lots of education over several generations for us to believe and to trust and to really interject in our own consciousness that anxiety and depression are disorders and are not necessarily a weakness or a fault.”