LETTER TO THE EDITOR Year : 2020  |  Volume : 52  |  Issue : 6  |  Page : 529-530  

Tropicamide abuse and regulatory measures in a Sudanese hospital

Elhassan Hussein Eltom1, Mohanad Kamaleldin Mahmoud Ibrahim2, Ekramy Mahmoud Elmorsy3
1 Department of Pharmacology, Faculty of Medicine, Northern Border University, Arar, KSA
2 Department of Pharmacology, Faculty of Medicine, Ibn Sina University, Khartoum, Sudan
3 Department of Clinical Toxicology, Faculty of Medicine, Mansoura University, Mansoura, Egypt

Date of Submission02-Oct-2019Date of Decision19-Oct-2020Date of Acceptance04-Jan-2021Date of Web Publication19-Feb-2021

Correspondence Address:
Dr. Ekramy Mahmoud Elmorsy
Department of Clinical Toxicology, Faculty of Medicine, Mansoura University, Mansoura, Dakahlia
Egypt

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijp.IJP_635_19

How to cite this article:
Eltom EH, Mahmoud Ibrahim MK, Elmorsy EM. Tropicamide abuse and regulatory measures in a Sudanese hospital. Indian J Pharmacol 2020;52:529-30

Sir,

Tropicamide is a widely used short-acting mydriatic with antimuscarinic properties. It is mainly used to dilate the eye pupils for proper eye fundus examination as well as some preoperative and postoperative indications with eye surgery.[1] The misuse of tropicamide ophthalmic solution has been suspected by some pharmacists, who have observed an over sales of the product in Italy and Russia. Many reports emerged after from France, Turkey, and Jordan handling the same problem.[2]

The role of acetylcholine in the pathogenesis of addiction is complicated due to its wide spread effect on the cholinergic receptors in the different brain regions. However, some studies highlighted that acetylcholine played an important role in the addiction of opioids.[3] One study reports an extracellular increases of acetylcholine levels during the withdrawal of morphine, which suggest a role of acetylcholine in opioid unpleasant withdrawal manifestations.[4] This suggested interaction between acetyl choline and opioid addiction and withdrawal is alarming for a potential increase in the antimuscarinic abuse, including tropicamide, among addicts.

An over consumption and utilization of tropicamide eye drop were observed at different premises of our hospital, outpatient clinic utilization had increased by 10 folds weekly, pharmacy shelf refilling also increased by more than 10 folds and some clinics reported missing remnants of the drug bottles where they supposed to be used for patients' examination, this raised a suspicious of tropicamide abuse by some consumers. Those observations lead the medical administration to formulate an internal policies and restrictions on prescribing, dispensing, and diagnostic uses of tropicamide, including adjustment of the bottle doses at the clinics regarding the eye drops used for examination purposes, registration of examined patients number, date, and time of drug usage. The new policy of the medical administration included the special guidelines for prescribing tropicamide for outpatients through attestation of originality of the prescription and accreditation from the medical administration. It included as well, guidelines for dispensing the medicine used internally for the examination purpose through handling the empty bottle first before receiving the new one, after reviewing the usage sheet containing the number of patients and drops used for each patient examination and it must be attested by the specialist in charge. All these policies aimed to raise the awareness and alerting the staff regarding the importance of the problem and therefore pay more attention and contribute in solving this problem.

Upon applying the new legislations, more and more accidents of over shouting and quarreling between some patients and the medical staff at different stations, mainly the pharmacy had been upraising, where the pharmacist insisted not to dispense the drug under investigation without a stamped prescription. The number of dispensed bottles after applying the new polices returned to the standard as before, and the requests for tropicamide were reduced from the unknown outpatient consumers.

To conclude, policy-maker and health-care providers should be aware of this trend to handle the emerging problems of abuse and intoxication of such products. Ophthalmologists and pharmacist should always be concerned with the abuse potential of anti-muscarinic ophthalmic solution before prescribing and dispensing them.

Acknowledgment

We are grateful to the administration and health staff team of Makkah Eye Hospital, Khartoum-Sudan for their moral help.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 

  References 
1.Frost S, Gregory C, Robinson L, Yu S, Xiao D, Mehdizadeh M, et al. Effect of pupil dilation with tropicamide on retinal vascular caliber. Ophthalmic Epidemiol 2019;5:1-8.  
    2.Al-Khalaileh W, Wazaify M, Van Hout MC. The misuse and abuse of ophthalmic preparations: a scoping review of clinical case presentations and extant literature. Int J Ment Health Addict 2018;16:1055-84.  
    3.Hikida T, Kitabatake Y, Pastan I, Nakanishi S. Acetylcholine enhancement in the nucleus accumbens prevents addictive behaviors of cocaine and morphine. Proc Natl Acad Sci 2003;100:6169-73.  
    4.Rada P, Mark GP, Pothos E, Hoebel BG. Systemic morphine simultaneously decreases extracellular acetylcholine and increases dopamine in the nucleus accumbens of freely moving rats. Neuropharmacology 1991;30:1133-6.  
    
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