Why codeine is addictive, by ex-pharmacy chief
by OYEYEMI GBENGA-MUSTAPHA
A Community Pharmacist and exChairman of Association of Community Pharmacists of Nigeria, Lagos State branch, Aminu Abdulsalam, shares some insights with OYEYEMI GBENGA-MUSTAPHA on codeine regulation by the Federal Government. Excerpts:
The Federal Government recently streamlined production and access to codeine cough syrup because of high rate of abuse, what is your view on this?
The way the Minister of Health announced the ban of codeine was not appropriate. Codeine is in the World Health Organisation’s model list of Essential Medicines as an important medicine to be provided in all basic health system. Codeine had been in use for a very long time. Therefore; the problem is not about the availability of codeine, but mainly about the chaotic drug distribution system that predisposes vulnerable people to substance abuse.
I was expecting the Minister to use the opportunity provided by the codeine abuse saga to address the chaotic drug distribution system, which is fundamental to medicine abuse and misuse in Nigeria. We all know that addiction to any substance does not develop overnight, and addiction is not a matter of choice, but a matter of process. Therefore, banning any form of codeine preparations is not a solution to the problem of abuse. It is a well-known fact that there are many banned substances that are still in circulation in medicine distribution chain. As long as the demand is there, and our distribution remains in chaos as we currently have, illegal supplies will find their way to all the illegal drug markets across the country.
How do you think the minister should have handled the matter after the BBC report?
Rather than just placing blanket ban on codeine cough preparations in Nigeria, I expected the Minister to first place a temporary suspension of dispensing use, sales, importation and manufacture of codeine cough syrup so as to pave way for thorough investigation by the relevant regulatory agencies; this should be followed by inventory of the codeine preparations in the value chain. The inventory should include those raw materials already on the way to Nigeria from overseas after the approval has been given. Then a stakeholder forum called, made of representatives of all stakeholders in the distribution chain to brainstorm on the issue and proffer solutions to the problem. The outcome of such forum could have perhaps produced a more objective solution that could save the nation from further embarrassment of such international dimension. The pronouncement of the minister was just an emergency save-face approach which does not solve the problem.
Can you shed more light on what codeine is?
Codeine belongs to a class of drugs called opiate because it was derived from opium poppy plant. It is in the same class as morphine, which is highly controlled, heroin and opium which are classified as illicit or illegal drugs. Codeine is also in the class of Narcotics because it depresses the central nervous system, like other narcotics, it slows down the messages travelling between the brain and the body. Codeine is in the World Health Organisation’s model list of essential medicines as an important medicine to be available in all basic health system. It is considered to be the safest and least addictive among the opiate drugs, which accounts for its being the most widely used medicine within this category of pain killers. Codeine has been in use in Nigeria for a very long time.
Under what condition is codeine useful?
Codeine is a very old medicine. It has been used effectively to treat mild to moderate pain, severe pain when combined with other pain medicines, like paracetamol and ibuprofen. Codeine presented as cough syrup suppresses a dry irritating cough. But we have to know that cough is usually a symptom of underlying disorder, such as asthma, gastro esophageal reflux disorder, and chronic obstructive pulmonary disease, to mention a few.
Where there is no identifiable cause, cough suppressant like codeine cough syrup may be useful, especially when sleep is disturbed. It is important to know that the advantage codeine has in stopping one’s cough can also be seen as its danger, since cough reflex is there for clearing the throat to allow for unrestricted breathing. When this reflex is suppressed unnecessarily through the abuse of codeine, one runs the risk of suffocation during sleep or when lying down on bed. It may also cause sputum retention and this may be harmful to patients with chronic bronchitis, asthma and other related disorders. Codeine has also been used to treat diarrhea. Please note that codeine is relatively safe on the condition that it is used as recommended by qualified healthcare providers.
You said codeine had been in use for a long time, why has it become so bad to have necessitated its regulation by the Federal Government?
As stated earlier, codeine will continue to be of benefit to the users only on the condition that the users adhere strictly to the official recommendation by qualified healthcare providers. Unfortunately, many Nigerians have formulated other benefits that are turning codeine against their own health through abuse. One would not have problem with codeine if used at the recommended dosage, frequency and for a specified duration. It is now evident that the global epidemic of opiate abuse is very much with us, because many Nigerians are now using codeine habitually, not for the treatment of any identified disease but rather to alter mood, consciousness and body functions unnecessarily.
This habit constitutes drug abuse and it is a self-damaging habit, which could lead to tolerance, dependence and addiction. Apart from these, it could also lead to serious physiological injuries, such as damage to body’s vital organs, like liver, kidney and heart or psychological harm such as dysfunctional behavioral pattern and or death. This situation is so bad, apart from the international embarrassment from the documentary on the abuse of codeine.
Substance abuse in Nigeria is now known to be playing significant roles in many social problems, such as drug driving, insurgency, kidnapping, armed robbery, child abuse, rape, loss or missed works and schools, homelessness and other criminal activities. Therefore, there is need for action to save the future of the youths of this country. However, outright banning is far from being the solution.
How tolerance, dependence and addiction are related to drug abuse.
Substance abuse disorder is not a matter of choice, but of process. It is a chain of reactions with one process leading to another. When one keeps taking codeine repeatedly, it can lead to tolerance. Tolerance is said to have developed if there is decrease in response to drug after repeated use. That is, higher dose would subsequently be required to achieve the same effect, leading to taking overdose and consequently toxicity, organ damage and possibly death.
Dependence on drug use is an adaptive state, which develops from repeated drug use, leading to withdrawal effects if the use of such drug is stopped without medical supervision. That is to say, individual who depends on drug would subsequently need one or more drugs to even function normally. After tolerance and dependence, if there is no effort to manage the situation, it will lead to addiction, which is a very serious disease state. Addiction is a compulsive out-of-control drug use despite the negative consequences. Note that craving or intense feeling of compulsion to use a drug is the dividing line between addiction and dependence. An addict can do anything to get the drug he or she is hooked on.
Why is codeine so addictive?
Codeine is said to be the least addictive among the opioids. However, regular use of any product containing codeine in whatever form, tablet or syrup is as dangerous as regular use of illicit drugs like heroin or any other opiate drugs, the difference being that it might take a longer period of continual use of codeine to become addicted compared to heroin. But once addicted, the withdrawals and the road back to where one was before starting the use of codeine is usually arduous and painful and to have successful outcomes, it usually requires professional rehabilitation.
The answer why opioids are so addictive is said to be in human brain. Opioids are known to activate several brain reward systems, including one that motivates a person to take more of the drug. The motivation to take more of the drug is the euphoria associated with the use of the drug. Euphoria is an overwhelming feeling of happiness, satisfaction, joy and a state of wellbeing. People experiencing euphoria may feel care free, safe, bold, confident and free of stress. This emotion can either be a normal reaction to happy events, like sex, delicious meal, achievements, etc, or symptom of substance abuse.
But because we all want to feel good at all time, users get into the habit of taking the drug repeatedly. At the same time opioids cause changes in another part of the brain that limits a person’s ability to stop taking the drugs. The limiting factor here is the uncomfortable withdrawal effects when users attempt to stop taking the drug. Anxiety, profuse sweating, sleeplessness, rigour, pain, tremor nausea, diarrhea, hallucination, psychosis, suicidal and homicidal tendency are some the uncomfortable withdrawal effects that may put the users under compulsion to go back to the drug.
When these two brain processes work in combination, that is, the motivation to take more of the drug in one part of the brain and the limit of person’s ability to stop taking the drug in another part of the brain, the effect is like hitting the accelerator in a car-without having any brakes. A person addicted to codeine feel intense urge to take it again, and also has a hard time resisting that urge.
The longer someone misuses codeine and other opoids the higher the chance of it taking over the chemistry of one’s brain and the less self-control one will have; it gets more and more difficult to resist taking the drug, or to follow through on a resolution to quit. The drugs diminish the person’s ability to make a different choice. Taking the drug becomes a priority and even linked to survival. The brain of such addict is like a car that, besides having no brake, has a steering wheel that works poorly or doesn’t work at all.
Considering all you have said about codeine, what is your advice on its use?
One should always use codeine as prescribed by the authorised healthcare providers because it is an opioid can affect a person in such negative ways to the extent of ruining a bright and promising future, permanent disability and untimely journey to the grave. It is also important parent monitor their children lifestyle and closely mark their relationship with their peers, and report any strange behaviors of their children.
You have said so much about the addictive properties of codeine and the likes, is there any other side of codeine that is important for the public knowledge?
Like many other drugs, codeine is associated with various adverse effects, especially when abused or when an overdose is taken. The common adverse effects associated with the use of codeine apart from euphoria include constipation, urinary retention, respiratory depression, diminished sexual drive, and apathy and memory loss. Respiratory depression (not being able to breathe) is a potentially serious adverse effect. This effect is said to be dose related and potentially fatal consequence of over dose.
Those who abuse codeine cough syrup are also at risk of over dose of other non-addictive components of the preparation which put the vital organs to damage. While it is an effective cough suppressant at low dose it is said to be a weak pain reliever, and needs to be converted to morphine in the liver of the user. According to a report, morphine is responsible for the pain relieving and the euphoria effects of codeine. The report indicated that there is genetic variation in the individual ability to change codeine to morphine. On one side, there are those in the population who have innate ability to change codeine to morphine rapidly, those are more predisposed to codeine toxicity within a short time. At the other end, there are those who are naturally very slow in changing codeine to active morphine, such people are less likely to develop toxicity within a short time of use. Therefore, reactions to codeine abuse vary from individual to individual. In order words, your brother may develop sign of toxicity very much earlier than you, even if you were exposed to the same dose at the same time if your brother is a rapid metaboliser.
It is expected that drug with such a high potential to cause injury to users should be strict controlled. It is obvious there is no adequate measure to control its use…
Honestly, there are adequate control measures in our system to prevent or reduce the extent of abuse of drug. Unfortunately, the problem is poor implementation or enforcement of those measurers. One of the measures was the establishment of the National Agency for Food and Drug Administration and Control (NAFDAC) by Decree 15 of 1993, NAFDAC ACT CAP N1 Laws of the Federal Republic of Nigeria, 2004. The agency is responsible to ensure that foods, drugs, cosmetics circulating in the country are of good quality and safe, and to ensure that all regulated products are used rationally in our communities.
Nigeria is a party to many treaties under various international conventions to regulate the use of narcotics and control substances. The treaties under the various International Conventions are aimed at combating drug abuse by a co-ordinated international action. It is expected that each party gives special attention to substance abuse and take all practicable measures for the prevention of drug abuse and for the early detection, treatment, education, after-care rehabilitation and social integration of the persons involved. NAFDAC is the agency saddled with the responsibility of ensuring that Nigeria fulfills all the control obligations under various international drug control conventions. Unfortunately, there was a square peg in a round hole, as arrowhead, which caused a very serious setback to the good left behind by the late Prof. Dora Akunyili. What we are experiencing today on drug abuse could be a fall out of wrong appointment into the agency, which spanned close to 10years. Honestly speaking, it is quite dangerous to appoint a wrong person into an agency responsible to safeguard the health of the people. However, the current government must be appreciated for correcting the wrong appointment by recently appointing a highly qualified professional person, a pharmacist to the position of the Director-General to lead the agency once again.
There is also the Pharmacists Council of Nigeria (PCN) established by Decree 91 of 1992, now PCN Act Cap P 17. Laws of the Federal Republic of Nigeria, 2004, charged with the responsibility of ensuring that only certified and licensed persons and premises engaged in manufacturing, importation, distribution, sales, and dispensing of medicines.
The National Drug Law Enforcement Agency (NDLEA) established by Decree 48 of 1989, now Act of Parliament to enforce laws against the cultivation, processing, sale, trafficking and use of narcotic drugs and psychotropic substances and to suppress the demand for illicit drugs and other substance of abuse.
The revised National Drug Policy document of 2005 is comprehensive enough to address many of the problems if implemented. Unfortunately, most of the expectations were unrealised due mainly to lack of political will by the past governments and the absence of a well-structured monitoring system.
Government needs to fund and give all the agencies maximum power to enforce the relevant laws. Adequate funding and collaboration among the relevant agencies can make our lot better. It is important that each agency must have adequate power of enforcement. There is the saying that a ‘chain cannot be stronger than the weakest of its links’.
We have heard that chaotic drugs distribution and sales in the open market are responsible for the circulation of fake drugs, irrational drug use and abuse, why has the situation not been addressed?
Acknowledging the fact that the drug distribution system in Nigeria was in chaos and portends serious negative consequences, the Pharmaceutical Society of Nigeria (PSN) has a very long history of tackling the Federal Government to address the distribution problem in Nigeria.
It was not until 2009, when the call for structured medicines distribution in Nigeria by PSN was heeded to, and the process of developing the National Drug Distribution Guidelines commenced as a collaborative effort of the Federal Ministry of Health, Presidential Committee on Pharmaceutical Sector Reform, almost by all the relevant stakeholders in the industry. By the first quarter of 2011, the committee had produced very comprehensive drug distribution guidelines, acknowledged to be well researched and with very broad scope of consultation.
The main attraction of the guideline was that drugs would no longer be hawked, sold in cluster, market places or by unqualified persons, all inconsonance with the National Drug Policy. The guidelines put orderliness in drug distribution in Nigeria. According to the document, the implementation of the guideline was to commence in July, 2012.
While the National Drug Distribution Guideline had gone through several reviews after its production in 2011, the light of implementation has been dimmed by the government persistent lack of political will to address the problem. Between 2012 to date, the goal post of implementation flag-off had been shifted four different times. When 2012 failed, 2014, 2015, 2017 were all target dates of implementation of the guidelines, but respectively, no implementation took place. The new date of flag-off, according to the Minister of Health, is January next year. It is our hope that the new date would be a reality.
Sequel to the BBC documentary on codeine abuse in Nigeria, the senate responded promptly by proposing two bills; Mental Health Bill to establish National Council for Mental Health and Substance Abuse Services and National Drug Control Bill to establish National Council for the Regulation of Control Substances. Do you think such agencies can solve the problem of drug abuse in Nigeria?
We must appreciate the senate for promptly coming up with two bills to tackle the problem. However, as I had mentioned earlier, we already have a system in place to tackle the problem. What the government needs to do is to adequately fund all the relevant agencies: Pharmacists Council of Nigeria (PCN); National Agency for Food and Drug Administration and Control (NAFDAC) and National Drug Law Enforcement Agency (NDLEA) and encourage effective collaboration among the relevant agencies.
Information available is that these agencies are operating far below capacity, as a result of poor funding. Establishing two agencies at the sametime under the Federal Ministry of Health where the existing ones are not adequately funded can be a misplaced priority. The government should also implement all the relevant health and drug policies, including the National Drug Distribution Guidelines.The journey to drug abuse free society starts from a well-structured drug distribution system.