The New Straits Times, September 20, 1996
Q: A friend of mine consumed several light orange tablets which he said was Erimin, together with beer and immediately fainted.
Each tablet is about 8mm in diameter with the number '5' inscribed on one side with an unidentifiable logo and '028' on the other. What are these tablets and what are the risk associated with them?
A: The description clearly identifies the drug as nimetazepam which belongs to the benzodiazepines group. The product comes in two different strengths, namely Erimin 3mg and Erimin 5mg with the latter being used in the above self-poisoning case.
Benzodiazipines are classified as depressants as these compounds inhibit the central nervous system leading to the slowing down of the system. In Malaysia, they are only available as prescription drugs and are indicated in the relief of anxiety, irritability and tension to relieve nervousness, relax muscles, relieve muscle spasms and for the symptomatic treatment of insomnia.
In many developed economies, benzodiazepines are considered to be the most common prescription drugs taken in overdose due to its supposedly wide safety margin.
Oral ingestion of up to 1,500mg of another benzodiazepine, diazepam, ahs been reported with minor toxicity. In such instances, the available data seems to suggest that extra precaution should be taken when consuming this drug as large differences were noted in the number of fatal poisonings of different benzodiazepines as well as the administration of these drugs with another depressant compound such as alcohol.
For example, over a period of 10 years in the United Kingdom, 1,512 fatal poisonings have been attributed to benzodiazepines with or without alcohol.
In the non-pharmacological use of benzodiazepines, tolerance to the intoxicating effects develops rapidly, leading to progressive narrowing of the margin of safety between an intoxicating and lethal dose. The abuser who is unaware of the dangers of increasing dependence will often increase the daily dose up to 10 or 20 times the recommended therapeutic level. The source of supply may be no further than the family medicine cabinet. Depressants are also frequently obtained through theft, illegal prescription or purchase on the illicit market.
Illegal users often resort to the use of the drugs as self-medication to smooth jangled nerves brought on by the use of stimulants, to quell the anxiety of 'flashbacks' resulting from prior use of hallucinogens or to ease withdrawal from heroin. The dangers, it should be stressed, are compounded when depressants are used in combination with alcohol or other drugs. Chronic intoxication, though it affects every age group, is most common in middle age. The problem often remains unrecognised until the user exhibits recurrent confusion or an obvious inability to function. Depressants also serve as a means of suicide, a pattern particularly common among women.
The abrupt cessation or reduction of a high-dose depressant intake may result in a characteristic withdrawal syndrome which should be recognised as medical emergency more serious than that of other drugs of abuse.
An apparent improvement in the patient's condition may be the initial result of detoxification. Within 24 hours however, minor withdrawal symptoms manifest, among them anxiety and agitation, loss of appetite, nausea and vomiting, increased heart rate and excessive sweating, tremors and abdominal cramps. The symptoms usually peak during the second or third day of abstinence from the short-acting benzodiazepines; they may not be reached until the seventh or eighth day of abstinence for long-acting benzodiazepines. It is during the peak period that the major withdrawal symptoms usually occur.
The patient may also experience convulsions indistinguishable from those occuring in epilepsy. More than half of those who experience convulsions will go on to develop delirium, often resulting in a psychotic state identical to the delirium tremens associated with the alcohol withdrawal syndrome. Detoxification and treatment must therefore be carried out under close medical supervision. While treatment techniques vary to some extent, they share common objectives; stabilisation of the drug-dependent state to allay withdrawal symptoms to prevent their recurrence.
In cases of benzodiazepine poisoning, moderate poisoning closely resembles alcoholic intoxication. The symptoms of severe poisoning are coma, cold clammy skin, a weak can rapid pulse, and a slow or rapid but shallow respiration. Death will follow if the reduced respiration and low blood pressure are not counteracted. An antidote, flumazenil, has been shown to reverse the toxic effects of benzodiazepine poisoning. There are scientific reports which indicate patients with pure benzodiazepine poisoning showing full consciousness within minutes. Those who respond only partially would be considered as having a mixed drug overdose.
Although generally believed to be a safe drug for the treatment of anxiety, benzodiazepines still present potential hazards. True physical dependence can emerge from chronic therapeutic use. Thus, if possible, the introduction of no-pharmacologic treatments for anxiety such as relaxation training, cognitive restructuring and problem-solving techniques many be helpful.
