Publications

In India, majority of the cases of deliberate self-harm (DSH) occur following pesticide poisoning, and this is attributed to low socioeconomic status and a largely agrarian population. The common precipitants for DSH are family conflicts, dowry, and interpersonal issues.1 Poisoning due to drugs was traditionally thought to be a problem in Western countries. However, with rapid urbanization and changing social and economic milieu in India, this is no longer the case. In a vast and diverse country as ours, regional variations in geography, culture, economy, and society significantly shape the toxico-epidemiological landscape. Poisoning with over-the-counter prescription drugs and drugs of abuse, such as benzodiazepines (BZDs), have been steadily increasing in urban areas.2 A cross-sectional exploratory study done in Thiruvananthapuram, Kerala, showed 48% cases of poisoning occurred due to pharmaceutical drugs, while only 11% occurred due to pesticides.3 In the 16th century, the Swiss physician and alchemist Paracelsus gave a doctrine stating, “all things are poison, and nothing is without poison; the dose alone makes a thing not a poison.” This foundational principle of toxicology remains as relevant today as it was then, particularly in the context of BZD poisoning. These drugs, widely prescribed for their anxiolytic, hypnotic properties, exemplify the delicate balance between therapeutic benefit and toxic potential. Ever since BZDs have been introduced in the 1960s, they have been widely used for treatment of anxiety, insomnia, seizures, agitation, and alcohol withdrawal. They remain a popular choice among physicians and psychiatrists owing to its superior safety profile. In the United States, it is one of the most common prescribed psychiatric drug and third most common misused drugs for illicit use.4 Between the late 1990s and 2013, BZD prescriptions rose by 2.5% annually, establishing them as one of the most widely prescribed medications globally.5 With increasing prescribing, the incidence of misuse/overuse has also escalated concomitantly. Of increasing concern is the availability of illicit combination of BZDs with opioids such as fentanyl and “designer BZDs,” such as etizolam, bromazepam, bromazolam, etc.6 Newer research has shown an association of use of BZDs, particularly alprazolam, with increased risk for suicide. An exposure-only within-subject time-to-event pharmacoepidemiologic study by Gibbons et al. showed a doubling in the risk for suicide attempts in patients on alprazolam (hazard ratio = 2.21, 95% confidence interval = 2.06−2.38).7