Codeine abuse accounted for 2.5% of roughly 20 000 admissions to South African drug treatment centres in 2014, according to a South African Medical Research Council (SAMRC) study published in the South African Medical Journal last year.
What’s more, the importation of codeine increased by 50% between 2009 and 2014, the United Nations reports.
The 2.5% translates into 435 admissions and might not sound substantial, but it is probably only the tip of the iceberg of people overusing codeine medications.
Codeine (3-methylmorphine) is the most commonly consumed opiate in the world, and is mostly used for pain management and cough suppression.
In South Africa it is available in over-the-counter combination preparations with caffeine, paracetamol or ibuprofen or as a prescription medicine.
Three-quarters of the admissions in the MRC study involved males, with ages ranging from 11 to 70 years. Most of the study participants reported misuse of tablets and capsules, with just under 20% indicating misuse of codeine-containing syrups.
Codeine products and health consequences
The codeine products most frequently reported by persons in treatment as being misused or causing dependence were Stilpane, Adco-Dol, Benylin syrup with codeine, Myprodol and Broncleer cough syrup.
Codeine has abuse potential because of its opiate effect and development of tolerance in a short timeframe. Prolonged use is strongly associated with depression.
A 2014/2015 SAMRC survey among medical professionals revealed that two out of three of them believed their patients were unaware of the adverse health consequences associated with high doses of medicine containing codeine. Close to 40% said patients’ requests for prescribed medicines containing codeine are increasing.
Codeine can interact with other substances, leading to respiratory problems and other negative effects on the central nervous system. Of particular concern is that long-term or excessive use of combination products containing ibuprofen and paracetamol together with codeine can lead to problems such as gastric ulcers and inflammatory bowel conditions.
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A national SAMRC survey conducted in the same year reported that less than half (42%) of pharmacists believed the level of control of codeine in the pharmacies they worked in was high enough.
Interviews with clients in drug treatment centres in 2015 further revealed that a number of people misusing or dependent of codeine inadvertently fell into habit-forming use of over-the-counter products containing codeine because they didn’t know what addiction was until it was too late.
Others became dependent as a result of being prescribed codeine-containing pain medications and then found themselves unable to stop once the course of treatment had been completed.
South Africa urgently needs interventions to prevent a dramatic increase in deaths and other harms associated with the misuse of medications containing codeine, as has been experienced in the United States and Canada.
The Codeine Care Initiative, which was implemented by the Community Pharmacy Sector and the Pharmaceutical Society of South Africa in 2013, showed enormous promise. But it appears not to have had the level of support from the retail pharmacy sector it needs to be effective.
Dropping codeine levels
In 2014 the Medicines Control Council gave notice of its intention to reduce the amount of codeine in a single tablet to 10mg and to up-schedule narcodeine and acetylcodeine.
There is the very real risk that all codeine products might soon require a prescription, putting them out of the reach of the poor and of people requiring a mild pain killer for a few days.
As part of a three-year, multicountry project funded by the European Union, the SAMRC investigated current best practices in managing such difficulties and possible future innovations.
South Africa needs to consider the creation of multidisciplinary clinical teams for pain management using pharmacological and non-pharmacological treatments such as cognitive behaviour therapy. Pharmacists and medicine prescribers need to be better trained. Patients need better information at the point of sale about the risks of habit-forming use and dependence and harmful patient behaviours need to be better managed.
The most promising innovations appear to be in the area of product manufacture. Tamper-proof preparations should be required and backed by legislation. Smaller packs of codeine should be manufactured, which would give only three days’ supply, and a warning logo is needed on tablets and packets of medication containing codeine.
The abuse risk of codeine should be clearly indicated at the time of prescription and patients discharged from clinics and hospitals should be provided with medicine that does not contain opioids.
South Africa should find ways of keeping over-the-counter preparations available without a prescription. But it cannot be business as usual, because such medications have become far too easy to purchase in large quantities. If we don’t address this situation immediately, the only defendable option will be to make codeine a prescription-only medicine.
Professor Charles Parry is the director of the alcohol, tobacco and other drug research unit at the SAMRC. Dr Tara Carney is a senior scientist in the same unit and Dr Marie Claire van Hout is a principal investigator in the department of health, sport and exercise science at the Waterford Institute of Technology in Ireland.