Addiction to Codeine SA: New guidelines aim to prevent abuse | News24
South Africa’s medicines authority – the South African Health Products Regulatory Authority (Sahpra) – has released new draft guidelines, which it says will help prevent codeine abuse.
Opioids, found in certain pain relievers and cough syrups, are used by some people in large doses to get high.
Under the new draft guidance, the regulator can request sales data (and other information) from manufacturers, distributors or distributors of any prescribed medicine. This would allow them to monitor the flow of codeine everywhere «from the manufacturer to the medical facility, be it a clinic, pharmacy, hospital or doctor», Sahpra’s communications officer, Nthabi Moloi, told Spotlight.
Why is this important?
Until now, health authorities have struggled to detect the questionable sale of codeine, which is found in prescription and over-the-counter medicines.
This problem manifests itself in two ways.
For one, recreational users can often get a continuous supply of codeine directly from pharmacies. Although people are allowed to buy only a limited amount of the drug, many ignore this by buying different drugs. It is mostly impossible to identify these people because there is no central data on which medicines people buy from suppliers (although efforts have been made to solve this problem).
The second issue is related to wholesale supply. After a Carte Blanche investigation that flew last year, Sahpra confirmed that the pharmacy group was selling illegal quantities of codeine-based cough syrups. Although patients are only allowed to obtain codeine from a licensed health worker or pharmacist, it is therefore not surprising that it can also be found in the black market.
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The new guidelines aim to address both of these problems by allowing Sahpra to request information from companies and health workers about how much codeine they produce, sell or provide and that to whom is it given. This can «enable Sahpra to detect discrepancies in the distribution of drugs that may be abused, such as unusually large orders from institutions», Wizard explains.
It’s the «first step», he says, of the codeine monitoring process – an effort to centralize data on the sale of codeine throughout the entire supply chain across the country. The idea is to make sure that the regulator can flag anything from someone who buys large amounts of codeine from wholesalers to a dealer who sells the drug to illegal dealers.
Codeine rehab admission three times since 2019
The guidelines drawn up, which are now available for public consultation, come at a time when the rate of codeine addiction is on the rise across South Africa, according to data from people admitted from drug treatment centers and alcohol. Many rehabilitation centers across the country are linked to a programme, called the South African Community Epidemiology Network on Drug Use (Sacendu), which collects anonymised patient data from different centres.
Professor Nadine Harker, who is in charge of the project, says: «If you look at people receiving treatment over time, there has been an increase. [in codeine-related admissions] over the years – slowly, but surely. «
Indeed, Sacendu’s biannual reports show that, in the first half of 2019, 277 people who went to Sacendu-affiliated rehab facilities said they had abused codeine. This amounted to 3% of all admissions. But, in the first half of 2023, this percentage had tripled to 9% – a total of 749 people. (In absolute terms the number is slightly less than three times).
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Even before this process, health workers were worried. In mid-2010, surveys of 238 doctors (mostly in the private sector) were conducted across South Africa. It found that 85% of these doctors were concerned about the easy availability of codeine in pharmacies.
Part of the concern stems from the fact that long-term users of codeine-based drugs can develop a number of health problems, including stomach ulcers and liver damage (especially hallo when the medicine contains other substances such as paracetamol). And some people are more vulnerable than others, as genetics play a large role in how codeine affects a person.
Why is the problem getting worse?
Part of codeine use appears to be driven by a trend among young people, who sometimes mix codeine-based cough syrups with soft drinks. This compound is often called lean, and it has become a popular party drug among high school students. Research shows that codeine’s low price and general availability is another reason for its popularity. Harker, for example, notes that it is often found at home, where children «can take it from their mother’s medicine cabinet».
In some cases, it seems that people depend on the drug not for relaxation, but to cope with stress. For example, the 2022 survey, in which women were interviewed at health centers in the Western Cape and Eastern Cape, found that many turned to pharmaceutical products to deal with everything from the trauma of physical abuse to the grief of losing a child. One woman explained: «I wanted the pain to go away.» [the tablets] he actually made me die inside if I do say so.»
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A lack of awareness of the dangers of codeine also appears to play a role: 94% of doctors surveyed agreed that patients «do not fully understand the risk of becoming dependent on over-the-counter medicines containing codeine». A lack of regulatory control may contribute to this perception: one study of South African rehab centers found that «many participants felt that [over-the-counter] Medicines containing codeine were not drugs[s] per se due to their free availability to purchase without any real regulations or protocols guiding their sale”.
Shouldn’t we just do a prescription for codeine?
Currently, the law states that codeine-based pills can only be bought over the counter under certain conditions. For one, they must contain another active ingredient, such as paracetamol or ibuprofen, and each pill can contain a maximum of 10 milligrams of codeine. One can only buy one packet and it must contain five days’ worth of medicine (not more than 80 milligrams per day). Everything and script is required.
Liquid codeine, like cold syrups, can be bought without a prescription if it contains no more than 10 milligrams of codeine per teaspoon (the maximum daily dose is 80 milligrams). The bottle itself may not contain more than 100 milliliters of syrup.
Some researchers who spoke to Spotlight argue that these restrictions are too lenient, and that codeine should be «up-scheduled», meaning that it will only be available if the patient has a prescription, regardless of dose or combination. By doing this, children may find it more difficult to handle non-fat cough syrups, and people in general may be more aware of the drug’s addictive nature when used. for a long time.
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In fact, there are other studies that have found this method to work in other countries. Research published in journals, addiction, found that when Australian authorities made codeine prescription-only in 2018, the country’s main poison control center began receiving significantly fewer calls about codeine-related incidents (both from to health workers and members of the public).
But there are also potential downsides to this strategy.
For one, as Spotlight previously reported, increased regulation could make life more difficult for poor patients seeking pain relief. This is given that they will have to spend a lot of money for a consultation and a prescription if they need codeine-based painkillers.
Andy Gray, who chairs the scheduling advisory committee at Sahpra, elaborates on the second issue: «I’m not sure that scheduling would solve the problem if we were to deal with it. [in South Africa] it is illegal behavior… If [codeine] is being smuggled out of manufacturers or retailers, scheduling won’t make a difference.»
‘Obtaining opioids on the black market’
Dr Andrew Scheibe, a harm reduction researcher at the University of Pretoria, notes a third related potential problem: «If people become dependent on codeine and cannot get codeine, they may turn to use opioids … the black market.»
Scheibe points to the United States as an example, where prescription opioids, such as oxycodone and fentanyl, have been at the center of a major drug epidemic.
«When they try to increase the restrictions on getting those opioids, then people start using heroin,» he says.
A 2022 study found that this was the case among opioid users interviewed in Connecticut, Kentucky and Wisconsin.
Regardless of the answer, researchers agree that some basic steps should be taken to educate the public.
Harker said: «A lot of precautions need to happen in different settings, for example in pharmacies. When someone buys codeine over the counter, it’s important that the pharmacist is involved. [with them and] identify the consequences for each person if they use it outside the indicated doses… And we do not do that enough from a medical or pharmaceutical point of view.»
*This the brute first published by Shine – life journalism for the public good. Subscribe to Newsletter.
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