May 6, 2018

CODEINE CHAOS: How disorganised sector fuels abuse, addiction — Top pharmacists

CODEINE CHAOS: How disorganised sector fuels abuse, addiction — Top pharmacists


By Chioma Obinna

Codeine-containing cough syrup has a soothing taste that may lure you to want to take it all the time. But how lasting is the taste?  Ordinarily, codeine alone is a very bitter medicine which users may find uncomfortable to take. But in recent times, the abuse of the drug has made it look as if it has sweet taste.

Meanwhile, the attraction to this deadly drug, according to medical experts, when used without prescription, continues to defy sound reasoning.   Unconfirmed reports say Nigerian youths now use it, just like cocaine, heroin or any other hard drug, to get ‘high’.

Even before now, Nigeria has been battling codeine cough syrup abuse and tramadol but the undercover report by the BBC confirmed the fears of Senate Leader, Ahmed Lawan, that the rate of the misuse of codeine- containing cough syrup is so high that almost every family in Nigeria has an addict.

It has always been available in the ‘black market’ for young and old Nigerians alike to get high.   Findings have also shown that between Jigawa and Kano states alone, over three million bottles of codeine are consumed on daily.   Health watchers fear that Nigeria is gradually building a nation of drug addicts if not checked.

Sunday Vanguard examines the effect of codeine on abusers and implications of the recent ban of the product by government.


For years, codeine addiction has been widespread not only in Nigeria. In many countries of the world, it remains a prescription drug while some have stopped its use in cough syrup. Also in the country, codeine was a controlled substance until recently when people took advantage of the chaotic drug distribution system in the country to give the drug that should be prescribed by doctors to students and minors in the name of making money.

Codeine is often prescribed by doctors to assist with pains resulting from injury, trauma or illness.   It also have antitussive benefits, preventing harsh coughs, and very common in prescription cough syrups. Studies have shown that the drug is also effective when used as an anti-diarrhea cure.

Despite these benefits, the product also has its disadvantages when wrongly used.

Only last year, the National Agency for Food and Drug Administration and Control, NAFDAC, issued an alert about the restriction of codeine and tramadol medicines use. Sadly, many Nigerian youths can no longer cope without indiscriminate use of these classified drugs. While the youths say it makes them high, experts say they are digging their graves.

Overdose of codeine, medical experts say, can lead to schizophrenia (mental instability) and organ failure.

According to them, it can also lead to side effects such as life-threatening respiratory depression, severe low blood pressure and adrenal insufficiency. Also, accidental ingestion of codeine can result in fatal overdose.

For addicts, it can lead to physiological harm.

According to the immediate past Chairman of Lagos State Association of Community Pharmacists, ACPN, Abiola Paul- Ozieh, some addicts may end up having psychiatric problem while some may develop kidney or liver damage.

“Some addicts may develop seizure. Somebody that is not having epilepsy before may begin to have seizure and high blood pressure”, Paul-Ozieh said.

She said the effect may be so bad that abusers could even go into coma.

‘Never satisfied’

Explaining how it affects abusers, the ACPN Chairman said because it is a drug of addiction, as a person uses it and gets ‘high’, he will feel he is no longer in the world and sleep off. “With that, it looks like his problems are solved only to wake up to realize that he is still in the world. As a result, he is never satisfied and, with time, he demands for more. That is what we call tolerance. Then he begins to need higher doses.

“Then he moves from that level to what we call dependence. Now he cannot do his job or normal activities without taking it. And as he consumes the drug, it gives him euphoric feeling, a feeling of relaxation and confidence. That is why you see that the people in entertainment industry are the first set of people into this habit of taking drugs because of the problem of facing the crowd.   In drug abuse, we have tolerance, dependent and addiction.

“Addiction is when the abuser now has a compulsive desire to always take this drug of abuse and live as if his life depends on it. He knows know this thing is damaging his life but somehow he cannot get off it. Drug abuse changes dreams and cuts lives short”.

Pharmaceuticals misuse

In a related development, health watchers are worried that pharmaceuticals are becoming more of a problem than illicit drugs.

For instance, a 2017 study in Australia showed that prescription or over-the-counter drugs are misused more than all illicit drugs except cannabis.

The research published in the Medical Journal of Australia found the rate of codeine-related deaths in Australia more than doubled between 2000 and 2009.

But, in Nigeria, there is no data to show how many of the youths may have lost their lives while unconfirmed reports say a handful of these Nigerians lose their lives on daily basis.

Stakeholders in the pharmaceutical industry believe that government should be held responsible for the continued abuse of pharmaceuticals.   They argue that government delay in closing open drug markets and implementing the National Drug Distribution Guidelines, NDDG, that would have corrected the chaotic drug distribution system while bringing about easy recall of defected products remained the root cause of drug abuse in Nigeria. The stakeholders maintain that if nothing is done to arrest the situation now, the country will be breeding sick leaders in future.

Controversial ban

The BBC report showed how pharmaceutical companies aid in the circulation of classified drug products. Since the report, there has been a furore.

Even the temporary ban placed on codeine by government in an effort to save the situation has run into a controversy. Government had claimed that the ban was due to what it described as ‘gross abuse’ the product has been subjected to in the country.

But a cross-section of Nigerians and pharmacists who are custodians of drugs believe that the ban was not a solution to the problem on ground. According to them, outright closure of open drug markets scattered all over the country would stop abuse and guarantee the safety of Nigerians.

The nation’s drug industry, in their opinion, has been neglected for decades, a situation that led to charlatans and hawkers taking advantage of the lapse to carry out illicit trading in medicines.

The National President of the ACPN, Dr. Alkali Albert Kelong, said the decades of neglect of the distribution system had resulted in this sad abuse of codeine containing cough syrup and other controlled medicines.

“Another point of concern is the hazardous effect street medicine hawkers have on poor unsuspecting Nigerians”, Kelong stated.

To him, government should ensure that facilities dispensing prescription medicines or controlled medicines should have pharmacists and the National Prescription Policy must be reactivated.

“There should be full implementation of the National Drug Distribution Guidelines, NDDG. We need to see action now to ensure that the deadline of January 1, 2019 is met. Public or private facilities that do not have pharmacists in their employ should send their prescriptions to a community pharmacy for dispensing”, the National President said.

He regretted that the Board of Pharmacists Council of Nigeria, PCN, which should regulate pharmacy practice, three years after, is yet to be reconstituted.

“Our streets should be free of street medicines hawkers and stiff penalties to be meted out to defaulters”.

Paul – Ozieh echoed similar position, saying the codeine ban, which she called a fire-brigade approach by government, will only worsen the situation.

“I would have expected the Minister of Health to have considered immediate closure of open drug market places because that is one of the things causing rapid transportation and movement of some of these things. If that has been done, it would have been easy to clamp down on the distribution chain that is promoting this illegal use of drug”, the Lagos ACPN Chair said.

“For long, government has turned its eyes the other way and things got this bad. It is so unfortunate that until this revelation by the BBC, our government appeared to be doing little or nothing.”

Dangers and implications

While maintaining that the ban on codeine was against the UN position on narcotics, which provides that narcotic drugs could be used within the framework of medical purposes, she said codeine is not only used as a cough suppressant but can also be used as a pain reliever.

She said the major implication was that those addicted to the drug will become desperate and may become violent and desperate.

“They would do anything to try to get it, and that would put pressure on the distribution system such that they would be willing to pay anything to have it”, Paul-Ozieh said.

“There is the likelihood of the influx of counterfeit codeine products in the country and these addicts would begin to use it because they are already hooked on it”.

The ACPN Chair, who further accused government of paying lip service to the fight against drug abuse, said government lacks the political will to put order into the chaotic drug distribution system.

“Can you imagine that for three years that this government has been in place, they have not constituted the Boards of Pharmaceutical Council of Nigeria, Medical and Dental Council of Nigeria among others? All these Council Boards had been dissolved and government has not reconstituted up till this moment.”

“There is need for the country to address the issue of drug abuse holistically and find ways of rehabilitating these Nigerians like they did for HIV victims. These are the issues that the Minister has not put in place. The holistic thing would have been to check distribution and reduce demand for codeine. The government should have put in place structures that would say, ‘look if you know you are addicted to this drug, just come and we would help you’.

“There could be violence in the streets because of people that are hooked on it. We have had cases of people going to community pharmacies to grab the product. We have the issue of porous borders; I want to believe that the so-called three million bottles being consumed in Kano and Jigawa are not coming from Nigeria. I want to believe that there can be an influx of imported codeine products coming in through land borders, there could even be cloning of these codeine products.

“These are the issues government, the Ministry of Health, regulatory agencies must address and not putting the cart before the horse.   There are so many things the government ought to have done over the years which they have not done.

“Parents too must be aware of what is happening to their children, they cannot just look the other way. It is of recent that I heard that people put codeine inside Coca cola bottle and you think they are taking soft drink not knowing they are taking codeine. I don’t think passing blame would solve the problem but for all hands to be on deck to rescue the youths and future generations.

“For the companies that have been caught in illegality, doing things against the oath they swore to which is to prioritize the health of patients, there should be a tribunal that will evaluate it and take proper action. The Council has the power to strike the name of such pharmacists off the register. The situation has turned Nigeria to a community without a king and everybody does what pleases him or her.”

What is drug addiction?

Addiction is a chronic disease characterized by drug seeking and use that is compulsive, or difficult to control, despite harmful consequences. The initial decision to take drugs is voluntary for most people, but repeated drug use can lead to brain changes that challenge an addicted person’s self-control and interfere with his ability to resist intense urge to take drugs. These brain changes can be persistent, which is why drug addiction is considered a “relapsing” disease. People in recovery from drug use disorders are at increased risk for returning to drug use even after years of not taking the drug.

It’s common for a person to relapse, but relapse doesn’t mean that treatment doesn’t work. As with other chronic health conditions, treatment should be on-going and should be adjusted based on how the patient responds. Treatment plans need to be reviewed often and modified to fit the patient’s changing needs.

What happens to the brain when a person takes drugs? 

Most drugs affect the brain’s “reward circuit” by flooding it with the chemical messenger, dopamine. This reward system controls the body’s ability to feel pleasure and motivates a person to repeat behaviours needed to thrive, such as eating and spending time with loved ones. This overstimulation of the reward circuit causes the intensely pleasurable “high” that can lead people to take a drug again and again. As a person continues to use drugs, the brain adjusts to the excess dopamine by making less of it and/or reducing the ability of cells in the reward circuit to respond to it.