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Still on codeine, prohibition lessons from the United States

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Minister of Health, Prof Isaac Adewole


On May 1, the Federal Ministry of Health ordered NAFDAC to immediately stop the issuance of permits for the importation of codeine as active pharmaceutical ingredient for cough preparations. Health minister, Prof. Isaac Adewole, said the ban was necessary because of the gross abuse of codeine in the country. Instead of codeine, Prof. Adewole ordered that cough syrups should have dextromethorphan, which is less addictive, as active ingredient. Codeine has been the subject of much discussion in recent times because of increasing addiction to the drug. However it was not always the drug of choice for addicts. According to the UNODC, in 2015, 1044 patients were admitted for treatment in the National Epidemiological Network on Drug Use reporting system. 295 of these people had mainly prescription opiate addiction. At the time, tramadol was the clear leader with 210 of these addicts, while codeine accounted for 44 patients, and pentazocine accounted for 30. However, between 2015 and now, codeine has nearly overtaken tramadol as the most abused opiate in Nigeria, hence the ban appears sensible.

But is a total prohibition on codeine the right step to take?
Let us look at another country that once took the route of a total ban on something they considered unhealthy – alcohol.In the United States, there was a nationwide ban on the production, importation, transportation, and sale of alcohol for 13 years from 1920 to 1933. During the second half of the 19th century as America struggled with the effects of reconstruction, the rise of unions and a changing society alcoholism, family violence, and corruption prompted activists, led by pietistic Protestants, to call for an end to the trade in alcoholic beverages as a means to cure the sick society. As a result, many communities in the late 19th and early 20th centuries introduced alcohol prohibition, with the subsequent enforcement in law becoming a hotly debated issue. Prohibition supporters, called “drys”, presented it as a victory for public morals and health.

The alcohol industry, especially brewers, found most of their support in the large German immigrant community. Given their economic leverage, they had funds to fight back against the prohibition movements, but following America’s entry into the First World War on the Allied side, Germans, and German immigrants became demonised and state by state, the legislatures shut down brewers. This culminated in the Eighteenth Amendment in 1919, and the National Prohibition Act, better known as the Volstead Act, came into effect on January 16, 1920. There were some exceptions, for example, the religious use of wine was allowed, but many states banned alcohol outright.

Prohibition while celebrated widely, had some unintended consequences. According to Bryce T Bauer, in the first six months of 1920 there were 7,291 cases for Volstead Act violations. This doubled to 29,114 violations for the whole of 1921, and by 1925, some journalists had begun to openly say that Prohibition was not working.

As more people sought clandestine means to make merry, the profits were too huge to ignore, so criminal gangs took control of the alcohol supply, and names such as Al Capone, devised systems to distribute alcohol that involved major logistics and a lot of violence. He corrupted law-enforcement by bribing policemen, judges and politicians to look the other way while he made a lot of money. At a point, Capone was earning over $100 million a year from his illegal alcohol sales alone.

Towards the end of the 1920s opposition to Prohibition began to mount, and people fingered the Prohibition laws as causing crime and lowering government revenues. Finally, Prohibition ended with the Twenty-First Amendment, which repealed the Eighteenth Amendment on December 5, 1933.

To be clear, the Prohibition succeeded in cutting overall alcohol consumption in America by 50% during the 1920s, and consumption remained below pre-Prohibition levels until the end of the Second World War. This suggests that the Prohibition socialised a significant proportion of Americans to be teetotal. However, overall it backfired spectacularly, and the unintended consequences of increased and more daring crime, and more importantly, lost government revenue, were crucial for an economy which entered into depression in 1929.

The same country tried another form of Prohibition half a century later, this time, on drugs. Talking about how that failed, will be another day, but I believe that the point has been made.

Codeine is listed by the World Health Organisation as an essential medicine. It is also cheap, the 2014 wholesale cost per dose was $0.04 at its lower limit, compared to dextromethorphan’s $0.15. Dextromethorphan is only half as potent, and crucially, is also addictive when consumed in very large doses.

The real issue is not codeine itself. Implementation of the ban will be tricky as our enforcement mechanisms are weak. Think of bans on rice, tomato paste and poultry, and how these items still make their way into Nigeria from other countries. Addressing Nigeria’s codeine addiction problem will take a combination of increased public education, enforcing existing regulations and promoting alternative treatments, but most importantly, studying why many of our young people took to drugs in the first place.


In this article:
Isaac AdewoleNAFDAC
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