OVERDOSE OF PAINKILLERS CAN KILL
The most commonly misused drugs through self-medication in India, other than antibiotics, laxatives, and acid suppressants, are painkillers, cough syrups, and sedatives. The partial ban of Nimesulide, an NSAID (Nonsteroidal Anti-Inflammatory Drug), by the government of India this week has highlighted the grave problem of casual self-medication and painkiller overdose. Antibiotic misuse and its adverse consequences on public health, agriculture, the economy, and society, and the development of multidrug-resistant bacteria and microbiota dysbiosis were discussed on May 18th, 2025, in my article titled “Antibiotics-a global crisis caused by antimicrobial resistant superbugs” in this paper. Addiction to narcotic painkillers (opioids) and sedatives has been discussed on October 12th, 2025, in this paper. Overdose of narcotic pain killers (morphine, codeine, fentanyl, methadone, tramadol, etc.) as tablets or in cough syrups causes difficulty in breathing and can lead to death. NSAID overdose can be fatal due to toxicity, depending on the drug taken, its dosage, and the period over which it is consumed.
NSAID FOR PAIN, SWELLING, AND FEVER: Commonly used NSAIDs in India are Paracetamol, Ibuprofen, Diclofenac, Naproxen, and their combinations, though most need a prescription and are not to be sold over the counter (OTC) like Paracetamol. Aspirin is not used for fever and pain anymore, due to the high risk of stomach ulcer and bleeding at higher doses. It is used at a low dose as an antiplatelet agent to protect the heart and brain by preventing clots. Its prolonged usage causes vitamin K deficiency, presenting as bruises. Paracetamol is the safest of these for those with acidity-gastric bleeding, cardiovascular, and renal risks or problems. It has a limited anti‑inflammatory effect, hence used for fever rather than for swelling and pain. It has to be used with caution in liver disease or with alcohol. Ibuprofen in lower doses may be sold OTC, but higher doses are by prescription-only. All the rest of the NSAIDs are by prescription only: Diclofenac, a potent anti‑inflammatory drug, is widely used for pain and swelling. It has a risk of gastric bleeding, kidney damage, heart attack, and stroke at higher doses, and with long-term use, compared to ibuprofen, naproxen, or paracetamol. Aceclofenac is a derivative of diclofenac. Naproxen is long-acting, enabling twice-daily dosing. It has moderate gut and kidney risk, low heart risk, and is used for arthritis and severe pain. It is preferred over all the NSAIDs mentioned below. Indomethacin is a potent anti-inflammatory, but has high gut and kidney risks, and moderate heart risk. Ketorolac is a potent painkiller, but has a high risk of gut bleeding and kidney toxicity, and a moderate heart risk. Piroxicam is a long‑acting painkiller, enabling once-daily dosing, but may cause stomach ulcer, bleeding, and has moderate heart and kidney risk. Celecoxib is safe for the stomach and is used for chronic pain, but has a higher cardiac risk than Naproxen. Etoricoxib is longer acting than Celecoxib, is safe for the stomach, and is used for chronic pain, but has a higher cardiac risk than Naproxen. Nimesulide has a high risk of liver toxicity and, hence, is banned in many parts of the world and has never been approved for use in the USA. Its use in children below 12 years of age is banned in India.
TOPICAL (LOCAL) PAINKILLER PREPARATIONS: Gel, cream, and ointments containing NSAIDs, menthol, camphor, and eucalyptus oil are applied directly to the skin over painful areas and provide relief without the side effects of oral painkillers. These can be used for musculoskeletal pain, arthritis, sprains, and neuropathic pain. In excess, they can cause skin irritation and affect the stomach, kidneys, or heart, and should never be applied over cuts, abrasions, wounds, or eczema. Capsaicin ointment is used for neuropathic pain, post‑herpetic neuralgia. Local anaesthetics like Lidocaine and Prilocaine are used as patches, gel, or cream for neuralgia and localized nerve pain relief.
NOT ALL FEVERS ARE FLU: Common causes of fever are viral infections like Influenza (flu), Covid-19, mononucleosis, viral gastroenteritis, dengue, chikungunya; bacterial infections like strep throat infection, pneumonia, urinary tract infections, sinusitis, tuberculosis; parasitic infections like malaria, and toxoplasmosis; Inflammatory autoimmune conditions like rheumatoid arthritis, lupus and Inflammatory bowel disease; heat exhaustion or heatstroke; certain tumours and cancers, and even some medicines. Self-medicating fever as a common flu can prove fatal if the cause is an infection like meningitis.
DRUG SCHEDULES IN INDIA: Drugs are classified into different “Schedules” under the Drugs and Cosmetics Act, 1940, and the Drugs and Cosmetics Rules, 1945. They differentiate everyday OTC medicines from controlled drugs and are designed to balance accessibility with public health protection. Some of these schedules define how medicines can be manufactured, stored, sold, and prescribed. Schedules N, P, U&V, and Y do not concern consumers directly. OTC medicines like paracetamol are outside these strict schedules, but misuse can still be dangerous. Schedule G: Prescription drugs like hormones, certain antihistamines that require medical supervision, and must be taken only under medical advice; their label carries a caution. Schedule H: Cannot be sold without a doctor’s prescription and includes antibiotics, anti-TB drugs, anti-anxiety medications, and, due to their side effects, painkillers like diclofenac, ibuprofen (in higher strengths), naproxen, indomethacin, ketorolac, and piroxicam. NSAIDs in combination with muscle relaxants or proton pump inhibitors (acid blockers) are under Schedule H. Schedule H1: High-risk antibiotics & psychotropics, requiring mandatory record-keeping; to prevent resistance and misuse. Schedule X: Narcotics & psychotropics require strict control, double prescription, and special license. Schedule P: Drugs with limited shelf life that degrade rapidly and require strict enforcement of expiry date. Schedule T: For Ayurvedic, Siddha, and Unani drugs to ensure safety in herbal formulations.
DISSIMILAR DRUGS WITH SIMILAR BRAND NAMES: India has thousands of brands for the same generic drug. Colours and fonts often resemble each other. Several drug brand names in India are easily confused because they look or sound alike, even though they belong to very different therapeutic categories. “LASA” (Look‑Alike Sound‑Alike) problem is a recognized patient safety issue. Illegible handwritten prescriptions add to the problem. Similar-sounding drug brand names can confuse pharmacists, or on an online portal, nurses, and consumers with potentially deadly results, like consuming the drug used for diabetes, “Daonil” (glibenclamide), with “Danol” (Danazol), used for hormone therapy. Taxim (Cefixime), an antibiotic, may be confused with “Taxol” (Paclitaxel), an anticancer drug. If wrongly sold Daonil instead of Danol, or Taxol instead of Taxim, the result can be catastrophic. There are many similar brand names for dissimilar drugs like “Lasix” (furosemide, a diuretic) and “Losec” (omeprazole, an antacid); Loprin (aspirin, an antiplatelet drug) and “Lopamide” (loperamide, an anti‑diarrheal); Norad (noradrenaline, for emergency use) and “Norfad” (norfloxacin, an antibiotic): “Zyloric” (allopurinol for gout) and Zyrorid (cetirizine, an antihistamine). The Drug Technical Advisory Board (DTAB) has recommended banning identical or confusing brand names. Manufacturers are required to upload brand names and formulations to a central portal to prevent duplication. Some use Tall Man lettering (e.g., LopRIN vs. LopAMIDE) to highlight differences.
POOR QUALITY CONTROL: A lack of stringent testing and verification throughout the supply chain can allow contaminated raw materials to reach manufacturers. Insufficient oversight during manufacturing can lead to contaminated batches entering the supply chain. Inadvertent mistakes during handling or processing can also lead to contamination. Some of the states that have offered tax incentives to attract drug manufacturers do not have labs or qualified staff to ensure quality control. Most states have a shortage of drug inspectors, as most of the vacancies have not been filled due to litigation or local political interference, leading to nonenforcement and corruption. States with less robust quality assurance and resources are more susceptible to these issues in unlicensed or unregulated factories that kill innocent children, as has happened many times with contaminated cough syrups, causing loss of trust in, and bringing disrepute to the entire health industry. Drug safety needs to be enforced on manufacturers, distributors, and retailers. Even safe OTC drugs are not harmless and can be lethal in overdose. Pharmacies must not dispense Schedule H NSAIDs and drugs without a valid prescription, as the dose, duration, and patient risk factors need medical supervision. Pharmacies and hospitals must follow scheduled drug rules to maintain licenses. Many prescription drugs are informally sold without prescriptions due to regulatory oversight, and in the absence of a unified OTC list, even though these drugs need strict monitoring. Mixing medications that may interact or counteract each other should be avoided. Herbal & alternative remedies perceived as “natural” can interact dangerously with prescription drugs. Mixing painkillers with alcohol, sedatives, or other medications can amplify toxic effects. Chronic self‑medication can cause ulcers, internal bleeding, fatal liver failure, kidney damage, and heart attacks. The consumer needs to be aware and careful about drug usage, seek qualified medical advice, as casual self-medication with pain killers and other drugs can prove disastrous and lethal.
Dr. P.S.Venkatesh Rao is a Consultant Surgeon, Former Faculty CMC (Vellore), AIIMS (New Delhi), and a polymath in Bengaluru, drpsvrao.com
