Articles on extensively drug resistant tuberculosis

How Is Tuberculosis Diagnosed?

Dr. Madhukar Pai
Dr Madhukar Pai, MD, PhDDirector, McGill GlobalHealth Programs, McGill University, Montreal, CanadaAssociate Director,McGill International TB CentreIndia alone accounts for a quarter of all TB cases in the world. Over 2.2 million new TB cases occur every year and TB kills nearly 900 people every day in India. The emergence of severe forms of drug-resistant TB has worsened the situation, especially in cities like Mumbai.TB is a bacterial infection caused by Mycobacterium tuberculosis. While TB most affects the lungs, it can affect other parts of the body as well (e.g. lymph nodes, skin, bones, abdomen,urinary tract, nervous system).When should we worry about TB?All persons with otherwise unexplained productive cough lasting two weeks or more, or with unexplained chronic fever and/or weight loss should be tested for TB. Apart from chronic cough and fever, TB causes weight loss, loss of appetite, and tiredness. Night sweats can also occur.What tests are acceptable for TB diagnosis and what samples should be collected?Sputum is the ideal specimen to collect for pulmonary TB. All patients suspected of having pulmonary TB should have at least two sputum specimens submitted for microscopic examination and/or a World Health Organization (WHO) approved molecular test such as Xpert MTB/RIF (also called GeneXpert). Liquid culture is very useful in diagnosing smear-negative TB,and drug-resistant TB.Where are these TB tests available?In the public sector,sputum smears are widely available in designated microscopy centers and DOTS centers. GeneXpert is also available in the public sector, at the district level. Cultures are only available at reference hospitals and medical colleges.All TB tests are free in the public sector.In the private sector,tests such as GeneXpert, liquid cultures and line probe assays are available atmore affordable prices via the Initiative  for Promoting Affordable, Quality TBtests (www.ipaqt.org). More than 115 accredited labs are part of the IPAQTnetwork.What about chest X-rays?Chest radiography is useful but cannot provide a conclusive diagnosis on its own, and needs to be followed by sputum testing. Abnormal X-rays do suggest TB, but other lung conditions can also produce abnormalities on radiography. So, only relying on chest x-ray can result in over-diagnosis. Tuberculosis can only be confirmed by microbiological tests such as sputum smear microscopy, GeneXpert, and cultures.So, it is very important to order sputum tests that can directly detect Mycobacterium tuberculosis.What about blood test sand skin tests?There is no accurate blood test for active TB at this time.  There is no clinical role for blood-based antibody tests (e.g. IgG/IgM ELISA or rapid tests) and interferon-gamma release assays (e.g. TB Gold). They are not accurate and should not be used for pulmonary TB diagnosis.The Mantoux (tuberculin)skin test cannot distinguish latent TB infection from active TB disease, and has no utility for diagnosing pulmonary TB in adults. It has clinical utility in children, along with other tests such as chest x-ray, smears, and clinical history. Tests like Mantoux and TB Gold were designed to detect latent infection, and cannot separate latency from active disease.How is drug-resistant TB diagnosed?Drug-resistance testing can be done using two methods: genotypic and phenotypic. Genotypic methods are based on molecular tests that detect mutations in TB bacteria that confer drug-resistance. For example, mutations in the rpoB gene of Mycobacterium tuberculosis is strongly associated with rifampicin resistance. Examples of genotypic tests include Xpert MTB/RIF (GeneXpert), and Hain Genotype MTBDRplus (a commercial line probe assay). Phenotypic methods are based on detection of culture growth with and without TB drugs added to the culture media. Phenotypic methods include solid and liquid cultures. While solid cultures can take up to 2 months, liquid cultures (e.g. MGIT culture) can produce useful results within 2 weeks. All of these tests are available via the IPAQT network of private laboratories. They can also be accessed for free in the public/government TB program.

Tuberculosis Control Requires New Technologies and Approaches

Dr. Madhukar Pai
Professor Madhukar Pai, MD, PhDDirector, McGill Global HealthProgramsAssociate Director, McGill International TB CentreMontreal, CanadaAlthough much effort has gone into TB control, reduction in incidence has been disappointingly slow. India is a good example. Although India’s Revised National TB Control Programme (RNTCP) covers the entire country, and has met the 2015 targets, India continues to report over 2 million cases every year, and accounts for 1 of the 3 million ‘missing cases’ that are either not diagnosed, or not reported. One reason behind the observed lack of rapid reduction in TB incidence is the inability of programmes to rapidly diagnose and treat persons with TB, before the infection is transmitted to others. In India, a typical TB patient is diagnosed after a delay of about 2 months, and after having seen three different doctors. This underscores the importance of early diagnosis, of engaging private and informal sectors where patients often seek care, and suggests that more intensive efforts are necessary to identify the mission million patients each year.To control TB in India andelsewhere, we need new technologies (including novel tests and drugs), newpolicies, and new healthcare delivery models. We also need TB champions who canadvocate for more resources.New technologiesTB cannot be eliminated using tools that were developed decades ago. Most developing countries, including India, still rely on the sputum microscopy test. This method is more than a century old, and can only detect half of all TB cases. Furthermore, it cannot detect drug-resistance, which is a growing threat in India. Thankfully, new, accurate diagnostics for TB are finally here and are being implemented in India.The GeneXpert test is a rapid molecular test that can detect TB as well as drug-resistance within 2 hours. It is now being scaled up for TB diagnosis (pulmonary as well as extrapulmonary) and drug-resistance detection and over 16 million tests have been used globally. In India, this technology is being used in the RNTCP (which recently purchased 500 GeneXpert systems) as a rapid drug-susceptibility test, along with other WHO-endorsed tools like line probe assays and liquid cultures. In the private sector, these WHO-approved tests are now more affordable and accessible via the Initiative for Promoting Affordable and Quality TB Tests (IPAQT www.ipaqt.org).The IPAQT network has over 115 private, accredited laboratories across India,where WHO-approved TB tests such as GeneXpert and line probe assays are available at nearly 50% the market price. Currently used TB drugs were developed more than 40 years ago. The past couple of years has seen some breakthroughs in new drug development. Bedaquiline, a new drug to treat adults with MDR-TB, is the first new TB drug approved in over 40 years. Another new drug called Delamanid has also been introduced. In addition, efforts are underway to evaluate drug combinations (e.g. combinations containing PA-824, moxifloxacin and pyrazinamide) and these are expected to shorten duration of TB treatment from 6 to 4 months. Shortening TB treatment to even 4 months will increase cure rates, improve adherence, and reduce the risk of drug resistance. Currently, these new drugs are not freely available in India. It is important for India to streamline its regulatory and policy process, so that new drugs can reach the patients who desperately need them.New policies and standardsRecently, two majorstandards were published – the 3rd edition of the International Standards for TB Care (ISTC), and the first edition of the Standards for TB Care in India (STCI). These policy documents are based on the most current evidence, and already incorporate new tools like GeneXpert and newer WHO recommendations on treatment (e.g. acceptance of both daily and thrice-weekly intermittent regimens). These standards aim to inform physicians about the best approaches to TB detection, treatment and follow-up, and their acceptance and widespread use should reduce mismanagement of TB. In India, research studies show that most private practitioners do not follow international or national standards. This can result in poor quality of care, and increase risk of drug-resistance. Indeed, cities such as Mumbai are already dealing with a widespread problem of multidrug-resistant TB (MDR-TB), and even more severe forms of drug-resistance. Thus, it is important to educate the large number of private practitioners about STCI, and to check whether they are following the standards. A new TB book, aimed at private doctors, is now freely available at www.letstalktb.org New healthcare delivery modelsNew tools and new policies will need to reach patients who need them the most. This brings up the relevance of new business models and delivery innovations that can make quality care more affordable and accessible to patients at the base of the pyramid. TB patients need a complete and patient-centric solution, regardless of where they seek care(public or private). Engagement of the private sector for TB control is a key area where newer care delivery models are urgently needed. There are many good reasons topartner with the private sector for TB control. First, half of all patients with TB seek care in the private and informal sectors, and private practitioners (including informal and AYUSH practitioners) are often the first contact care providers. Many patients begin seeking care in the informal private sector, including chemists and unqualified practitioners. So, if we want to diagnose TB early and prevent further transmission, then engagement of such first-contact private providers is the critical. For example, India has over 8 lakh chemists, and many of them directly dispense medications for persons with classic tuberculosis symptoms. If chemists can be educated and engaged to refer such persons for TB testing, they could become a great source of active case finding.Second, there is plenty of evidence that quality of TB care in the private sector is suboptimal. Private doctors prefer blood rather than sputum tests for TB (e.g. TB Gold and TB Platinum) tha thave not been recommended by ISTC or STCI. Even if diagnosis is made correctly,TB treatment in the private sector is highly variable with a variety of irrational drug regimens, formulations and dosages. So, it is important for private practitioners to follow international and national guidelines and use the correct drugs and regimens.Third, even if the correct TB treatment is started, adherence is not guaranteed. All TB patients must complete the full course of treatment. Otherwise, outcomes can be poor. Thus,in the private sector, there is a need create systems to support patients during therapy. Mobile phones may be particularly helpful to send reminders to TB patients, and to make sure they come back for follow-up visits. Fourth, engagement of the private sector is necessary to increase rates of TB case notification. Since 2012, it is mandatory for all TB cases in the country to be notified to local health authorities (e.g. district TB officers). Unfortunately, most private practitioners and private hospitals still do not notify TB cases. Fifth and last, engagement of the private sector is critical to detect drug-resistance and ensure that all patients with drug-resistant disease have access to free second-line treatment that is available in the public sector. If patients cannot afford TB drugs, they should be referred to the public sector.In India, there are good examples of innovative and affordable models in healthcare – from artificial limbs (Jaipur foot), to affordable cataract (e.g. Aravind eye care system in Madurai) and heart surgeries (Narayana Health in Bangalore). There are novel models in the area of TB care as well, including Private Provider Interface Agency (PPIA) models in Mehsana, Mumbai and Patna, and Initiative for Promoting Affordable and Quality TB Tests (IPAQT). These models have used product and process innovations to serve the base of the pyramid.Currently, a Private Provider Interface Agency (PPIA) model is ongoing in Mumbai and Patna, to assess whether interface agencies can aggregate and incentivize private providers,educate them on STCI, improve quality of care and increase case notifications. Another project in Mehsana, Gujarat, is exploring the model of free drug vouchers for patients who are privately managed. These projects have provided free TB drugs to privately treated patients, helped increase notifications, and have also helped improve treatment completion rates. Another project is the Initiative for Promoting Affordable, Quality TB tests (IPAQT), a private lab network that has increased access to accurate diagnostics at lower costs. The government could evaluate these projects, and scale-up aspects that have worked well.Advocating for increased resourcesLastly, we need much more resources for TB control. Otherwise, new technologies and policies cannot be implemented at the scale required. In particular, the RNTCP desperately requires a substantially higher budget, if it has to deliver on the objectives laid out in the ambitious National Strategic Plan, which aims for “Universal Access.” Spending on health itself needs to be increased, given how little India invests in health. Without adequate financial resources, no program can tackle TB. Advocacy, is therefore, crucial –to raise public awareness, and to inspire political leadership. In the past year, TB advocacy has received a tremendous boost. In October of 2014, Satyamev Jayate, anchored by Mr Aamir Khan, featured an entire episode on TB. In December 2014, Mr. Amitabh Bachchan became an ambassador for TB control. A TB survivor himself, Mr Bachchan has featured in a wonderful ad campaign called TB Harega, Desh Jeetega (See YouTube videos at https://www.youtube.com/watch?v=9MiEQ1sqaDE). These are very positive signs, and will hopefully attract increased governmental and private investments in TB control.

Management of Tuberculosis: 10 Common Pitfalls to Avoid

Dr. Madhukar Pai
Indian TB patients get diagnosed after a delay of nearly two months, and are seen by 3 different providers before a diagnosis is made. At the primary care level, patients rarely get investigated for TB, even when they present with classic TB symptoms. Instead, providers give broad-spectrum antibiotics (e.g. fluoroquinolones) and remedies such as cough syrups and steroids. Even when TB is considered likely, private physicians tend to order tests that are non-specific, such as complete blood count, ESR, Mantoux test, and chest X-rays. They rarely seek microbiological confirmation via sputum smear microscopy, culture or polymerase chain reaction tests. Even if the diagnostic hurdle is overcome, TB treatment in the private sector is far from standard. When private practitioners initiate anti-TB treatment, they tend to use drug regimens that are not recommended by WHO or the International Standards of TB Care. Furthermore, private practitioners often fail to ensure treatment completion, and provide adherence support to their patients. This article, one of the chapters of a new TB book called‘Let’s Talk TB’ aimed at GPs in India (published by GP Clinics, available free at www.letstalktb.org) discusses the 10 most common pitfalls that doctors should avoid. Addressing these pitfalls should great improve the quality of TB care in India.Pitfall 1: Not recognizing and suspecting TBDoctors inIndia often miss TB, because they do not suspect TB in patients presenting withcough for 2 weeks or longer.1 Multiple rounds of broad-spectrum antibiotics are tried, but tests forTB are rarely ordered at the primary care level.2 Even when TB is suspected, history taking is often incomplete – familyhistory of TB is rarely elicited, and previous treatment for TB is also missed.2Pitfall 2: Inadequate diagnostic work-upWhen doctorsin India think of TB, they often order non-specific tests such as total anddifferential blood counts (TC/DC), erythrocyte sedimentation rate (ESR), andchest X-ray.1, 2 While thesetests can be helpful, they do not confirm tuberculosis. Abnormal X-rays, forexample, do suggest TB, but other lung conditions can also produceabnormalities on radiography. So, only relying on chest x-ray can result inover-diagnosis. Tuberculosis can only be confirmed by microbiological testssuch as sputum smear microscopy, GeneXpert, and cultures. So, it is veryimportant to order sputum tests that can directly detect Mycobacterium tuberculosis.Pitfall 3: Use of inappropriate diagnostic testsActivetuberculosis is a microbiological diagnosis. Serological, antibody-based tests(e.g. TB ELISA) are inaccurate and banned by the Indian government.3 They should not be used for TB diagnosis. In India, there is growing concern that testssuch as Mantoux (tuberculin skin test) and IGRAs (e.g. TB Gold, TB Platinum)are being misused for active TB diagnosis. These tests were designed to detectlatent infection, and cannot separate latency from active disease. The Standards for TB Care in India (STCI) clearlystates that both TST and IGRAs should not be used for the diagnosis of activeTB in high endemic settings like India.3 If Mantoux and IGRAs are used for active TBdiagnosis, this will result in significant over-diagnosis of TB, because of thehigh background prevalence of latent TB infection in India. In children, STCIsuggests that the Mantoux test may have some value as a test for infection, inaddition to chest x-rays, symptoms, history of contact, and othermicrobiological investigations (e.g. gastric juice acid fast bacilli and XpertMTB/RIF).3Pitfall 4: Not considering the possibility of drug-resistant TB (DR-TB)DR-TB occurswhen patients fail to complete first-line drug therapy, have relapse, or newlyacquire it from another person with DR-TB. All persons who have previouslyreceived TB therapy must be considered to have suspected DR-TB. If patientshave any risk factors for drug-resistance, or live in a high MDR-TB prevalencearea (e.g. Mumbai city), or do not respond to standard drug therapy, they mustbe investigated for MDR-TB using drug-susceptibility tests (DST) likeGeneXpert, line probe assays, and liquid cultures. Indian physicians under-useDST and this can result in mismanagement.Pitfall 5: Empirical management ofsuspected TB with quinolones and steroidsWhen doctorssuspect TB or other lower respiratory tract infections, they frequently usebroad-spectrum fluoroquinolones (e.g. levofloxacin, moxifloxacin) for shortperiods. However, such empirical management with fluoroquinolones willmask and delay the diagnosis of TB. Fluoroquinolones, in particular, arebactericidal for M. tuberculosis complex. Empiric fluoroquinolone monotherapyfor respiratory tract infections has been associated with delays in initiationof appropriate anti-tuberculosis therapy and acquired resistance to thefluoroquinolones.4Doctors also tend to use steroids in individuals with history of chroniccough. Steroids, again, can result in temporary clinical improvement, but delaythe diagnosis and treatment of underlying tuberculosis.Pitfall 6: Once TB is diagnosed, not addressing co-morbidities andcontactsOnce TB isdiagnosed, it is important to make sure the patient is not suffering fromco-morbid conditions such as HIV and diabetes. It is also important to check ifthe patient is a smoker/alcoholic and provide them advice on smoking/alcoholcessation. It is also necessary to ask about TB symptoms among family members.In particular, small children living in the same family as the adult case mustbe tested for TB.Pitfall 7: Use of irrational TB drug regimensEven if the diagnostic hurdle is overcome, TBtreatment in the private sector is far from standard.1 Whenprivate practitioners initiate anti-TB treatment (ATT), they tend to use drugregimens that are not recommended by WHO or the Standards of TB Care in India(STCI). All patientswho have not been treated previously and do not have other risk factors fordrug resistance should receive a WHO-approved first-line treatment regimen fora total of 6 months.4 The initialphase should consist of two months of isoniazid, rifampicin, pyrazinamide andethambutol. The continuation phase should consist of isoniazid and rifampicingiven for 4 months. There is no need to add additional drugs suchas quinolones to the standard drug regimen.4 Also, thereis no need to extend the duration of treatment beyond 6 months, unless there isevidence of treatment failure, or there are complications (e.g. bone &joint TB, spinal TB with neurological involvement and neuro-tuberculosis). Drugdosages should be based on body weight, and daily dosing is preferable.4Some physicians have the mistaken perception that second-linemedication are more potent than first-line medication. In fact they are lesseffective (and more toxic) medications, and should be reserved only forpatients with drug-resistant TB, or first-line drug intolerance.Pitfall 8: Not ensuring treatment adherenceAdherence to the full course of ATT is critically important to ensurehigh cure rates and to prevent the emergence of drug-resistance. But privatepractitioners struggle to ensure adherence. Most do not maintain any medical records,and this makes it very difficult to follow-up patients. Patients often do notreceive sufficient counseling about the importance of completing the fullcourse of ATT. Drug-related side effects (if not adequately counselled on at theoutset) is another common reason for non-adherence, and possible treatmentdefault.Every TB patient should receive counseling atthe start of TB treatment. Bynotifying all TB cases to the local health authorities, private practitionerscan seek help from the public sector to help follow-up patients who default.Physicians can also work with community-based organizations, and enlistcommunity health workers to supervise treatment.Pitfall 9: Not monitoring response totherapy and changing regimens without DSTOnce ATT is started, doctors have theresponsibility of monitoring the patients to check whether therapy is working.This requires follow-up smear and culture testing. Negative smears at the endof therapy is important to ensure cure. If a patient is not responding to ATT,it important to investigate why. Addition ofa single drug to a failing regimen is a big concern. Many physicians add aquinolone to the 4 first-line drugs (HRZE) when the standard therapy does notresult in improvement. This is wrong, and can result in MDR-TB.Sometimes, patients end up moving from one doctorto another, and each time the drug regimen gets modified without adequate drug-susceptibilitytesting (DST) to guide the choice of drug combinations. This creates a perfectenvironment for drug-resistance to emerge or worsen.Pitfall 10: Not notifying all cases and using free publicsector services for vulnerable patientsTB treatment is available free ofcost to all patients in India via the Revised National TB Control Programme(RNTCP).5 So, privatepractitioners can refer all TB patients for treatment through the RNTCP, unlesspatients insist on being treated in the private sector. RNTCP provides a rangeof services such as contact investigation, linkage to free TB drug programs,adherence support, and linkage to PMDT services for patients with MDR-TB.5 By availingthese free services, patients can protect themselves from catastrophic healthexpenditures. Irrespective of where thepatients are diagnosed and treated, it is mandatory for private practitionersto notify all TB cases to their respective District or Corporation TB Officers.REFERENCES1.          SatyanarayanaS, Subbaraman R, Shete P, et al. Quality of tuberculosis care in India: asystematic review. Int J Tuberc Lung Dis2015; 19(7): 751-63.2.          Das J, Kwan A, Daniels B, et al. Useof standardised patients to assess quality of tuberculosis care: a pilot,cross-sectional study. Lancet Infect Dis2015 (published ahead of print).3.          World Health Organization CountryOffice for India. Standards for TB Care in India. URL: http://www.tbcindia.nic.in/pdfs/STCI%20Book_Final%20%20060514.pdf (dateaccessed 7 April 2015), 2014.4.          TB CARE I. International Standards forTuberculosis Care, 3rd Edition. URL: www.istcweb.org  (date accessed 7 April 2015)2014.  (accessed.5.          Sachdeva KS, Kumar A, Dewan P, KumarA, Satyanarayana S. New Vision for Revised National Tuberculosis ControlProgramme (RNTCP): Universal access - "Reaching the un-reached". Indian J Med Res 2012; 135(5): 690-4.This article was originallypublished in GP Clinics as part of a supplement entitled Let’s Talk TB. Other chapters of this book can be downloaded freelyat www.letstalktb.org

Tuberculosis: Correct Diagnosis and Treatment Can Save Lives

Dr. Madhukar Pai
Posted on World TB Day, by:Madhukar Pai, MD, PhDDirector, McGill Global Health Programs, Montreal, CanadaTB is an ancient disease that has plagued humans for centuries. Today, India alone accounts for a quarter of all TB cases in the world. Over 2.2 million new TB cases occur every year and TB kills nearly 900 people every day in India. The emergence of severe forms of drug resistant TB has worsened the situation, especially in cities like Mumbai.TB is caused by bacteria that are spread from person to person through the air. Long-term cough and fever are the most important symptoms of TB. When a person with TB coughs, TB bacteria get expelled into the air. The bacteria can then get inhaled by another person who can become newly infected. TB usually affects the lungs,but it can also affect other parts of the body. TB can affect adults and children, and can affect people from all walks of life. Persons with HIV infection and AIDS are particularly prone to getting TB.The positive news is that TB is treatable and curable. However, unlike most common infectious diseases (e.g. malaria or pneumonia) that require a few days of antibiotic treatment, TB requires several antibiotics and 6 months of treatment. Otherwise, TB bacteria will become resistant to antibiotics. Multidrug-resistant (MDR-TB) refers to TB that is resistant to rifampicin and isoniazid, two of the most critical first-line antibiotics used to treat TB.Accurate diagnosis: the first key stepBecause TB is a curable disease, it is very important to accurately diagnose the disease and to do it early, before severe lung damage occurs, and before other people in the community are infected.All individuals with cough for more than 2 weeks must seek care early and get their sputum tested for TB. Sadly, many persons with chronic cough do not seek medical care,and this results in long delays before a diagnosis is made. Sputum testing can involve microscopic examination for the TB bacteria, culture to grow the bacteria in a tube, or newer molecular tests that multiply and detect TB DNA. GeneXpertis the biggest new advance in TB detection. It is a highly accurate, molecular test that has been endorsed by the World Health Organization (WHO). This technology is completely automated and can rapidly detect TB as well as drug-resistant TB within 2 hours (photograph). Over 16 million GeneXpert tests have been done globally.Thanks to the Initiative for Promoting Affordable and Quality TB tests (www.ipaqt.org), led by the Clinton Foundation, it is now widely available in over 100 labs across India at prices that are 50% less than the market price. Through the IPAQT initiative other WHO-approved TB tests such as liquid culture are also available at subsidised rates.Correct and regular treatment can save livesIf TB is diagnosed, the most important thing a patient can do to is to take all of their medications exactly as prescribed by their doctor. No doses should be missed and treatment should not be stopped early, even if the patients feel better. Patients who cannot afford to buy drugs in the private sector must seek treatment in the public sector where drugs are available free of cost.Doctors have an important role to play in ensuring that their TB patients are treated correctly. Doctors must follow recommended treatment guidelines, monitor patients’ response to treatment, and make sure therapy is completed. Doctors should also avoid starting anti-TB drug treatment without doing any laboratory testing to confirm the disease. If TB is confirmed, they should start treatment promptly and follow Standards for TB Care in India.For regular, drug-sensitive TB, a standard 4-drug treatment must be started, and the total duration of treatment must not be less than 6 months. Drug-resistance usually happens when patients do not complete their full course of treatment; when doctors prescribe the wrong treatment, the wrong dose, or length of time for taking the drugs.If drug-resistance is suspected, it should be confirmed using laboratory tests such as GeneXpert and liquid culture. For drug-resistant TB, second-line drug treatment must be started, and the total duration of treatment must be at least 2 years. Treatment for MDR-TB can be very expensive in the private sector, and such patients can access free treatment in specialized public hospitals that can treat MDR-TB patients.With correct diagnosis and complete treatment, TB can be cured and loss of life averted.Importantly, this will also help control the spread of this deadly infection.

Drugs and 'Spiritual Experiences'

Ms. Raisa Luther, Psychotherapist
Searching for Higher Meaning with Drugs?In 1967 Timothy Leary advised the human race to turn on, tune in, drop out. This was at the peak of the hippie era and he was advocating that people use psychedelic drugs to transcend normal existence. Many followed his advice and the common belief among these LSD users was that they were entering a state where they could develop important spiritual insights. It is this search for meaning that continues to motivate people to use drugs as a means to connect with the divine. The problem is that this use of drugs can also begin to negatively impact the individual’s life – it may cause severe damage to their mental or physical health. These dangers can be eliminated by using more natural methods, such as meditation, to achieve higher mental states. Carlos Castaneda and Don JuanCarlos Castaneda was an anthropologist who helped promote the idea of using drugs as a spiritual tool. His book The Teachings of Don Juan: A Yaqui Way of Knowledge describes his experiences with Mexican shaman known as Don Juan Matus. This spiritual guide introduced Castaneda to a psychedelic drug derived from the peyote plant. In his first book (and the books that followed) he described spiritual experiences and claimed to develop magical powers such as shape shifting. Castaneda’s books were hugely popular in the late sixties and seventies and he sold over 8 million copies. His critics question the veracity of many of his claims – there are even some who would say that he made the whole thing up. There is little doubt that the tales of Don Juan has encouraged many people to experiment with mind altering drugs. Bill W. and LSDBill Wilson was the co-founder of Alcoholics Anonymous. After being sober for almost two decades he began to experiment with LSD. His goal was to reach spiritual states and develop a closer contact with God. Bill was impressed with the results and he continued to experiment with LSD for many years. He believed that drugs worked by damping down the ego which facilitated better contact with the higher power. It is even claimed that he wanted LSD to be handed out at AA meetings. Drugs That Can Induce Spiritual ExperiencesThere are a number of drugs that are said to induce spiritual experiences including:LSDPeyoteAyahuascaPsilocybin (magic mushrooms)EcstasyMarijuanaAyahuasca TourismA growing number of people are travelling to places such as the Amazon in order to achieve spiritual states using drugs. The most popular form of this type of tourism involves use of Ayahuasca which contains dimethyltryptamine (DMT). It has traditionally been used by shamans as part of their religious rites. It continues to be legal for these groups to use this drug in some parts of the world. Ayahuasca Tourism involves travelling to these areas and spending time with the shaman. The goal is that people experience the power of Ayahuasca in a controlled environment and as part of a religious ceremony. There is usually a good deal of preparation before the tourist is allowed to consume the special brew made from the Ayahuasca.Seeking Meaning in RecoveryOne of the key elements in building a successful recovery away from addiction is to find meaning and purpose in life. For many people this means following a spiritual path where the goal is develop a strong connection with a higher power. The spiritual path is not always an easy one to follow and people can be tempted to look for shortcuts. This means that they may be attracted to mind altering drugs as a means to achieve transcendence. Given the history of such individuals it may not be a good idea to once again turn to chemicals to find the answers. There is just too much risk that this could lead them back to substance abuse. The individual will have already tried to fix their problems with drugs and the fact that they ended up in recovery means that it didn’t work. It is good that they are seeking meaning in recovery, but it is better to stick to the well trodden route of sobriety. Dangers of Drug Induced Spiritual ExperienceIt is not recommended that people use drugs to create spiritual experiences. This advice is particularly pertinent to those who are recovering from any type of addiction:These drugs are a short-cut to spiritual experiences. The problem with taking a short cut is that it can allow the individual to experience things that they are not prepared for and some individuals will react badly.Those people who are not prepared for drug induced spiritual experiences may develop mental health problems. There are many examples of people who become delusional after using these drugs.Some people will experience bad trips and these can be terrifying.Some people can trigger an underlying mental health problem when they use these mind altering chemicals.While most of these substances are not particularly addictive it may still be a bad idea for people in recovery to experiment with them. The goal of sobriety should be to deal with life on life’s terms and there are plenty of non-chemical ways to enjoy spiritual highs.These drugs are illegal in many jurisdictions. There can be serious consequences if people are caught with these substances.The individual will have a significantly reduced ability to make good decisions after taking these drugs. This means that they will be at an increased risk of relapse.Natural Methods for Spiritual ExperiencesThe risks associated with drug induced spiritual experiences are too great so it is advisable that people use natural method to achieve such states. There is no spiritual experience that is produced by drugs that can’t be induced naturally. The problem that most people have with following a natural method is that it takes a good deal of time and energy. This is actually beneficial though, because it ensures that the individual is more ready for these experiences when they happen. Some natural methods that can be used for achieving spiritual states include:Meditation has been used for thousands of years as a tool to bring humans closer to the divine. There is no doubt that this path can take the spiritual seeker where they want to go so long as they are steadfast and persistent.Prayer can be another way to experience transcendence. This is because it is possible for people to slip into deep meditative states while they are praying.There are claims that products such as binaural beats or hemi-sync can help people achieve similar states as those produced by drugs.Spending time in nature is much neglected method for developing a deeper connection to a higher power. Many people who report spiritual experiences will claim that it happened to them while they were enjoying nature – even something as simple as starring at the stars.The aim of the 12 Steps is to lead the individual towards a spiritual experience. This is made clear in final step which states, [‘having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs’].Hope Trust’s treatment program is based on the 12 Steps and includes Yoga, meditation and the basic course of Art of Living.

Generously Generic: Know Your Medicines

Dr. Tanoy Bose, Internal Medicine
One fine winter evening when I was consulting a 45 year old obese fair lady who actually forgot to bring her past health records, I enquired about the medicines she is taking on daily basis. She recollected a few brands which I noted down. On asking whether she is on Aspirin or Thyroxine, she denied of such drug but quickly recollected that she takes Eltroxin 50mcg and Ecosprin AV75mg daily. Well, she did not know that the active ingredient of Eltroxin is Levo Thyroxine and that of Ecosprin AV is Aspirin & Ator vastatin combined. The former is given to replace thyroid hormone deficiency to those who are hypothyroid and the latter is usually given to those who are suffering or are at the risk of developing coronary artery disease. If I am not that very wrong, more than 95% of patients do not remember medicines by their generic names. So what difference does it make? Well, it’s the money that matters. For those who are ill-informed, the market prices of most of the drugs of regular as well as special use are tagged with exceptionally high price just for the sake of an industry.The statistics from McKinsey & Co. states that the growth rates of Indian Pharmaceutical Industry is compounding at 12 to 14% per annum since last 5 years and have projected the value of the industry is going to be around $20 to $24 Billion by 2015. This growth would be driven primarily by rising incomes, and be supported by five other factors: enhanced medical infrastructure; rise in the prevalence and treatment of chronic diseases; greater health insurance coverage; launches of patented products; and new market creation in existing white spaces. If we zero down to the basic issue of generics versus branded drugs it is the pocket pinch that matters. I don’t think if quality is assured, people will love to shell out more for a branded drug rather than buying a generic product.What are generics?All drugs are products of research. They are born in a research laboratory and end up in a pharmacy shop. Whatever be the results of the research product in the laboratory, their usage in general public for any particular indication is highly regulated by the US FDA. Financially the companies have to bear a huge burden to research and develop a drug, undergo clinical trials for them in phasic manner and further make them available for general prescription. Further, after the drug is launched and approved by USFDA the company holds a patent for the drug for say tenure of 10 to 12 years. Hence, during this period the cost of drug is very high as the company needs to recover the cost of R&D. However, after lapse of license,the drug molecule is available for other companies to copy and rebrand and bring them into market again. The cost of the drug falls drastically now as the companies now selling the copied drug did not have to spend on the R&D. The only investment for these companies is the price of the molecule and the technology of packaging and marketing. These drugs which are sold under different brand names after the post licensing period of a particular molecule are called generic drugs. However, the qualities of these generic drugs are also under FDA regulation. According to FDA, to substitute a generic for a brand name drug must follow these criteria:It must contain the same active ingredient, the same dosage strength and the same dosage form (e.g. tablets, syrup etc) and have the same route of administration and further it must deliver the same of active ingredient to the blood stream.Hence cheaper does not mean poor quality. The difference from patented drugs is the generics may vary in shape,size, color or taste. They have different inactive ingredients. However, there are authorized generics that need to maintain similarity in these parameters too. Almost 50% of all drugs prescribed in India are generics. Thus generic drugs may cost almost 20 to 80% cheaper than the patented drug.Is the quality guaranteed in a generic formulation?Researchers have compared patented drugs with generic formulation from different companies in a random manner and 36 of 38 studies virtually found no differences in the drug quality control. But, FDA has barred the publication of drug equivalence studies. Hence it is difficult for the prescribing doctor to know whether there had been any difference between the drugs in the equivalence study or not. It’s worth mentioning thatIndia tops the world in exporting generic medicines worth of Rs.50,000 Crores and currently Indian Pharmaceutical industry is one of the world’s largest & most developed.What is the price paid for not using generics? It’s worth mentioning that India tops the world in exporting generic medicines worth of Rs.50,000 crores and currently Indian Pharmaceutical industry is one of the world’s largest & most developed.In spite of being the largest exporter of generics in the world the story behind the screen is very dull. Just have a look at few of the statistics.WHO says that 3.2% of Indians will fall below poverty line because of inflated medical bills.Approximately one third of the rural population do not seek medical treatment due to financial constraints.And about 47% of rural and 31% of urban hospitalizations are financed by loan and sale of assets.About 70% of Indians are spending their out of pocket income on medicines and healthcare services in comparison to 35% in other Asian countries and are still suffering from infectious & communicable diseases due to lack of quality and affordable treatmentWhere do I get the generics?Generic medicines are best bought from the government sponsored generic drug shopped opened under the banner of “JANAUSHADHI”in most of the Indian states. Janaushadhi stores are functioning under the banner of Bureau of Pharma PSUs of India (BPPI) under the aegis of Department of Pharmaceuticals, Government of India. States like Punjab, Delhi, Haryana,Andhra Pradesh, Odisha, Uttarakhand, Chandigarh, Jammu & Kashmir, Himachal Pradesh and Jharkhand have already implemented Janaushadhi stores providing quality generic medicines at a cheap and affordable price. Few states like West Bengal has initiated Fair Price Medicine shops in a Public Private Partnership models to provide generic medicines at a whopping discount of up to 62.7%. They are opened adjacent to or in collaboration with different government healthcare establishment the largest being at the SSKM Hospital, Kolkata.Can we have examples of price comparison?I have made an attempt to compare the prices of the generics available on the website of Janaushadhi to that of branded generics available in the market. In fact I have approached a regular chemist shop and asked for these prices. Also I have reduced the quote by 11%as that particular chemist shop was giving a discount of 11% on any drug bought from the chemist. Now let’s compare the cheapest discounted branded drugs with the Janaushadhi generics. Generics and Branded Generics : The price difference This comparison is bound to raise eye brows. I am sure it’s unthinkable for most of us that we had been buying medicines at such high price and we are at the verge of realization after sucha long period of illiteracy. Do we get all sorts of medicines at these generic drug stores?Well, wish the answer could have been yes. Unfortunately all medicines are not available at the generic drug stores.While scrolling down the list provided by Janaushadhi website I found drugs for treatment of Rheumatoid Diseases are missing. Drugs for treating neurogenic pain, Parkinsonism, schizophrenia, newer drugs for diabetes management,inhalers and insulins are missing. I am sure they will soon be incorporated or might have been incorporated by now. Even without these drugs the net price of the monthly medications fall drastically if purchased from the generic drugstore.Any words of Caution?Well, there has to be some words of caution. The country is lagging in maintenance of quality control and most of the quality control is outsourced. Further, the government not necessarily declares the data of quality check to the general public. Hence, many doctors keep on highlighting the quality of the generic medicines.My recommendation is, whenever you have the opportunity to buy the drugs from a government sponsored stores, consider the quality is guaranteed by the government. Hence, you can very well go and purchase the medicine and use it personally.Adverse Reactions: Unless the drug is too spurious, it is unlikely that somebody will suffer from any adverse reaction. Spurious drugs are usually sold in peripheral aspects of a city or major town mostly is districts and village areas. Hence, one should be very careful about purchasing generic drugs from these areas.What I practice and recommend?When I am sitting in my clinic at Kolkata, I write the composition of the drug e.g. Paracetamol.[ Drug that reduces fever ], Amlodipine [Drug that controls blood pressure] ,Pantoprazole [ An Antacid ] instead of the brand names. This helps the patients in two ways. Either they can go to the Fair Price shop and buy the cheapest ones and save a lot, or they can go to any chemist and ask the chemist to provide the brand which is cheapest for that particular composition. I do practice in districts of West Bengal where there are brands which I have never heard off. In these areas I always write the brand of the drug and tend to keep the price low. In this way the spurious drug sellers can be fended away and I can ensure that quality drug is served and chances of health hazard is minimum.

This Is What Happens When Your Brain Is on Drugs

Ms. Rajeshwari Luther
It is a commonly known fact- supported by years of scientific research- that the use and abuse of any illicit drug or alcohol cause drastic deterioration in the way one thinks, feels, and behaves. Before we talk about this deterioration, let us look at the role our brain plays in our thinking, feeling, and behaving. Every thought, emotion, or action we experience involves our nervous system- our brain, spinal cord, and the nerves that extend throughout our body. The neurons are the millions of cells that are responsible for the functioning of our nervous system. They use positive and negative charges and chemicals (called neurotransmitters) to send messages to and from all the glands and organs to the brain, which in turn evokes responses. Dopamine, serotonin, endorphins, and gamma amino butyric acid (GABA) are the four main neurotransmitters involved in substance dependence. We all know that drugs and alcohol change our mood- they either make us feel extremely happy or depressingly sad or any other emotion that can be encompassed in the spectrum between these two. The question is how do they do it? The simple answer is that the change the actions of the neurotransmitters. Drugs and alcohol could either change the way neurotransmitters are produced, released or sent. OR they could imitate, block or enhance the effect of a neurotransmitter. The result is a change in one’s mood. Thus, thoughts like “I feel good” or “I feel bad” change into “I need a drink” or “I’ve got to have a hit.” An individual gets addicted to a mood-altering substance because it changes the way neurotransmitters work, which leads to intense feelings of pleasure. Scientists believe that people with low levels of dopamine, serotonin, endorphins, and GABA in the “pleasure center” (medial forebrain bundle) of the brain experience a lower level of pleasure. Hence, they seek drugs and alcohol- that work on neurotransmitters- to experience feelings of pleasure. Besides altering the way neurotransmitters work, repeated substance use can change the pathway of dopamine (the “feel good” chemical) through the “pleasure center” of the brain. In simpler terms, it could cause one to either like a drug because it makes them feel happy, want a drug to fulfil their craving, or to absolutely need a drug at a primal level. Once a need pathway is formed, the individual continues to use the substance, despite it not really making them happy or crave it. This makes them believe that they need the drug or alcohol to survive, taking all sense of control away from them. Thus, addicts usually talk about how once they start drinking or using, they cannot stop any more than they can stop breathing. In sum, addiction is not only a disorder or the brain, but also a disease of the body and a sickness of the soul.

Drug Abuse in Teens: Shocking Facts You Didn't Know

Ms. Rajeshwari Luther
It is estimated that 27.2% of high school students use illicit drugs on a regular basis. This is a very disturbing statistic considering the fact that the teenage years are formative in the development of a person’s career, personality and overall success. Adolescence is a very confusing time involving raging hormones, pressure to fit in at school and academic stress. Teenagers abuse and become addicted to drugs and alcohol for many reasons, and it is essential to understand them in order to treat patients successfully in a rehab. Addictions may start young. Many teenagers experiment with drugs and alcohol but don’t get addicted to them. While peer pressure may drive an adolescent to consume drugs or alcohol at parties or other events, other factors are responsible for the mental state of addiction. Trying drugs or alcohol at a party can, however, trigger the path towards addiction. For example, if a teenager has a genetic predisposition to alcoholism and is going through problems because of stress at school, she is likely to crave the relaxing effect of alcohol after she drinks for the first time. With repeated use of alcohol, she will need more of it to feel the same calming effect. This will eventually take her down the path of addiction until she is admitted into a rehabilitation center, and undergoes detox and other therapies. Many teenagers abuse prescription drugs. A popular example of this is stimulant drugs used to treat ADHD (attention deficit hyperactive disorder). These drugs are known to increase focus, thereby enhancing academic performance. This unfortunate phenomenon is aided by the accessibility of such drugs – it is very common for patients of ADHD to sell their prescription medications to other students in their schools. Many rehabilitation centers also report that teenage addicts are aided in their addiction because of the widespread availability of drugs in the form of school supplies – many students sniff glue or whitener. Teenagers are more susceptible to mental illness than any other age category. If a teenager already suffers from a condition like depression or anxiety, a tryst with drugs or alcohol at a party could cause to lead them down the path of addiction. Teenage brains are very different from adult brains from a biological perspective as well, which makes it more likely for them to abuse drugs or alcohol. There are many stressors related to school and peers, which make teenagers turn to drugs and thereby mentally escape from it all. For instance, bullying is very common among teenagers and causes tremendous stress. Disappointingly though, the main cause of a drug addiction in teenagers is ignorance. They believe that marijuana is not addictive, similarly, they do not know the effect of alcohol on the body. Teenagers have a lot to learn, and proper education is essential to reduce the rate of teenage drug and alcohol addiction. 

8 Reasons to Stop Self-Medication (Slow Suicide)

Dr. Nikhil Dhande, General Physician
During self-diagnosis, many a time you may not be fully aware of the kind of illness you are suffering from. In such cases, self-medication can lead to complex problems and you may have to pay the price through both loss of health and money.Wrong dosages during self-medication may lead to complications and can also prolong the recovery process. Infact, it can also lead to, a recurrence of the disease, resistance to  certain medicines, and may also be life-threatening in some cases.Improper usage of antibiotics over a long period of time may lead to the body's resistance to the same antibiotics, as well as combinations of other antibiotics,  thus impeding the process of cure.You stand the risk of suffering from a stroke, allergic, and anaphylactic reaction.The medicines may react with other medicines you are already consuming. You may not know how the new medicines react with your body and the other drugs. Drug interactions affect the body and mind adversely.For people who are diabetic and hypertensive, self and irregular medication may cause uncontrollable reactions.Don't think vitamin tablets are always healthy, as they may lead to toxicity.Over the counter medicines from medical stores on the advice of a pharmacist, and self-medication may save your money, but will not always cure your health-related problems. On the contrary, self-medication may aggravate them.Take Medications As Directed By Doctors Only!