Codeine used to treat mild to moderate pain is today the most abused over the counter drug in South Africa.
Codeine (3-methylmorphine) is the most commonly consumed opiate in the world and is mostly used for pain management and cough suppression and it is available in over-the-counter combination preparations with caffeine, paracetamol or ibuprofen or as a prescription medicine.
Misuse of prescription and over-the-counter codeine-containing products is a global public health issue and is on the increase globally.
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.
The problem does not only lie with over-the-counter products where they are available, but also with inappropriate prescribing of codeine-containing medications.
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 in 2017.
Less than 35% of prescribing professionals (mainly general practitioners (GPs)) working in South Africa indicated that codeine dependence could be effectively managed in general practice settings. As a result, individuals who are misusing or dependent on codeine are increasingly being seen in specialist substance abuse treatment centres. Research in SA has indicated that there were 435 admissions to specialist substance abuse treatment centres for codeine misuse or dependence in 2014, translating to ~2.5% of individuals seen in such settings. However, these figures do not include individuals treated at public or private psychiatric treatment facilities.
Sixty percent of medical professionals, in a 2014/2015 SAMRC study believed that 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.
South African pharmacists are meant to keep records of each codeine purchase but this is rare and is in fact, it might be a deterrent to codeine abusers. But 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 the 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.
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.
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 creation of multidisciplinary clinical teams for pain management using pharmacological and non-pharmacological treatments such as cognitive behaviour therapy should be considered.
The area of product manufacture needs to be looked at to ensure innovations such as tamper-proof preparations which should be backed by legislation. 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.
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 to be effective it needed the support from the retail pharmacy sector.
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.
But this would then be putting them out of the reach of the poor and of people requiring a mild painkiller for a few days.