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Codeine abuse, pharmaceutical industry and official overreach


Recently Codeine has been in the news, essentially for the wrong reasons. Codeine which came into use in 1832 has been a very useful medication for treating pain and more recently as a cough suppressant in cough syrups. Codeine or 3-methyl morphine is an alkaloid found in the opium poppy- Papaver somniferum. In 1848, a German Pharmacist discovered how to isolate morphine from the opium poppy, which eventually gave rise to the discovery of Codeine by Pierre Robiquet, a French Chemist in 1832. Subsequently, Codeine was extracted from the black tar opium which constantly put the drug manufacturers in constant conflict with illicit drug cartels, but later was now synthesised from coal-tar. 
According to the World Health Organisation (WHO), Codeine is the most widely and commonly used opiate in the world and is also regarded as the safest of all the opioids and seen as least addictive as well. The most common medical use of codeine is related to its ability to suppress chronic cough, hence it is regarded as an antitussive. Additionally like other opiates, it helps to reduce nausea and diarrhea and being the weakest opiate, it is used in many of the compounds and will treat these symptoms without causing as many side effects and has a lower probability of physical addiction. Some of the side effects, especially in children include unusual sleepiness, confusion and difficult breathing. In many countries throughout the world, Codeine is regulated by Narcotic control laws, but some countries do allow its purchase over the counter, without a prescription, which as we have seen can readily lead to abuse or addiction.
In Nigeria codeine has been freely available either as pain relieving tablets or in cough syrups since early 20th century. It was classified as an over the counter (OTC) product, which meant that you did not need a doctor’s prescription to obtain the product. However, in the last couple of years, following reports of increased abuse of cough syrups containing codeine, the National Agency for Drugs Administration and Control (NAFDAC) reclassified it and made a product that can only be accessed through a doctor’s prescription or pharmacist’s recommendation. Beyond this restriction on consumer access, importation of the product as raw material for manufacturers became controlled and in the last 10 years or so, manufacturers have had to obtain import permit.

In the recent months, there have been reports in the media of increasing abuse of cough syrups containing codeine in Nigeria, just as it is happening globally. I am not aware that Nigeria’s government took any actions to see how to deal with what has become a growing social malaise. Indeed, the reports indicated a growing incidence of drug abuse and drug addiction especially among the youth and women. Rampant use of illicit drugs like Cocaine, Heroin, LSD, etc has been reported by the National Drug Law Enforcement Agency (NDLEA) and other reports have indicated very disturbing trends in antisocial behaviour. People are reported to be inhaling all types of gases some from nauseating sources like Pit latrine or Lizard dung so as to get high. Beyond traditional abuse of alcohol and other stimulants, people abuse other pharmaceutical products especially pain killers, including the well known Paracetamol and such stronger analgesics like Tramadol.
The Pharmaceutical Society of Nigeria (PSN) has over the years drawn the attention of the government to the growing twin menace of drug misuse and abuse and often made far-reaching recommendations on how to curb the social malaise. But much of these recommendations have been ignored by successive regimes as both the Federal Government and some state governments have continued to put revenue generation above the safety of the people. Additionally, the governments have chronically failed to involve the experts on drug matters which are primarily pharmacists and pharmacologists when policies and decisions regarding medicines and drugs are being made.
This failure to consult experts in a proactive manner became very evident and injurious in the recent precipitate, knee-jerk response of the Federal Government. The British Broadcasting Corporation (BBC) ran a documentary on the abuse of cough syrups containing Codeine in parts of Northern Nigeria. Based on this documentary, the Federal Government immediately banned the use of Codeine in Nigeria. Immediately, NAFDAC moved on to seal up the syrup lines of some pharmaceutical companies producing cough syrups containing codeine, the most prominent being Emzor Pharmaceutical Industries Ltd. After taking these precipitate actions, both the Federal Minister of Health and the Director General of NAFDAC travelled outside the country, keeping the operations of the affected companies paralysed. I am even told that some pharmaceutical inspectors are beginning to go to retail shops to either seize all codeine containing products or to incriminate pharmacists who run those retail shops. All of a sudden, the pharmaceutical supply chain is in panic leading to unnecessary disruption.
I hear that a meeting is being called involving the Pharmaceutical Manufacturers Group of the Manufacturers Association of Nigeria (PMG-MAN), the Pharmaceutical Society of Nigeria (PSN), NAFDAC and the Ministry of Health. What is the purpose of this meeting? Perhaps to discuss how to manage the disruptions and damage already caused by the knee-jerk reaction of the Federal Government. Would it not have been better if this kind of meeting was held before the hasty action of government? First, I do not think it is right for government to take such precipitate and far-reaching action based on a documentary from a media house. It was not even as if the report showed anything that was previously unknown about codeine. The documentary did not show any new adverse or dangerous actions of the drug. It only highlighted the level of abuse, much of which has always been associated with the drug. In normal circumstances, even if there was a report in the media of newly discovered adverse effects of any drug, the line of action would be for the government to set up a team of experts to investigate the matter and submit a report. If some credibility is established, then the government would do a detailed study to establish with verifiable data that the adverse effects outweighed the beneficial effects of the drug and then a rational decision would be taken to restrict or withdraw the product.
Thereafter, the government would invite the stakeholders to discuss the findings. At such meeting, notice is given to manufacturers as to the plan to restrict, withdraw or ban such product. Then current stock of raw materials and goods in the pipeline are considered and the quantity of products in circulation estimated. A withdrawal plan is then agreed that will ensure minimum disruption to all stakeholders. No sudden media announcements are made to minimize panic and irrational patient response. This procedure is most appropriate when the real reason for the ban is that a drug is being abused not because it is causing much harm to those who are using the product rationally as prescribed or recommended. Even if the drug had become very dangerous or poisonous, an ordered recall procedure is worked out. Nothing is ever done in the manner we have just done with this codeine matter. Typical Naija!
Right now, we have caused unnecessary disruption in the economy. The normal patients and consumers who are using this product now have their drug regime disrupted. The companies that are producing this product are in agony. What will they do with their stock of raw materials and finished goods especially since the market has been agitated and confused? Most traumatized are the companies whose plants have been shut as if they were carrying out illegal business. Beyond financial losses as with other manufacturers, their apparent victimisation will affect their corporate image. The question is, why should government treat ordinarily respectable companies this way? How does this kind of treatment attract new investors into a country that claims it is looking for investors? Doing business in Nigeria is already a very tough proposition, investing in manufacturing is seen as both risky and unprofitable and when government goes to shut companies, not necessarily because they offended the law but because of consumer abuse of their product worsens our national competitiveness. May be tomorrow, if one media house releases a documentary on how beer is being abused by some consumers, the government may shut down the breweries!

Right now the professional community pharmacists are in panic with the rumour that inspectors are going round shops seizing products. And soon, a new grey market for codeine will emerge and begin to flourish. Here, both the good and the bad will mix to create a situation that may be worse than what we are trying to deal with. A nation that cannot prevent the smuggling of arms (AK 47 etc) and cannot stop Muamar-Ghadaffi’s trained soldiers from crossing our borders at will to kill Nigerian citizens cannot stop black-market trade in Codeine from neigbouring countries where sale of cough syrups containing codeine is legal. This official overreach needs to be reviewed for the good of our economy and the right procedure adopted. Most countries have only restricted the use as prescription- only product, only few have gone this road of outright ban. We need to find out the real economic and social factors that are driving some of our populace to drug abuse, addiction and violence and deal with them. Otherwise we may soon ban pit latrines and lizard dung!
Mazi Ohuabunwa, OFR.

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Codeine abuse
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