Codeine Addiction in SA: New Guidelines to Prevent Abuse News 24
South Africa’s Medicines Regulator – The South African Health Products Regulatory Authority (Sahpra) has released new draft guidelines aimed at curbing the abuse of codeine.
Some people use opioids found in certain pain relievers and cough suppressants to get high.
According to the new draft guidelines; The regulator is the producer of the sales data (and other information); Any scheduled medications may be requested from suppliers or distributors. This allows them “from the manufacturer to the dispensary, the clinic, the pharmacy, the hospital or the doctor’s practice,” Sahpra’s communications officer Nthabi Moloi told Spotlight.
Why is this important?
Until now, health authorities have struggled to detect suspicious codeine sales found in prescription and over-the-counter stores.
This problem manifests itself in two ways.
For one, Recreational users often obtain codeine directly from pharmacies. People are only allowed to buy a limited amount of the drug, but many get around it by buying from different pharmacies. Because there is no centralized data on the drugs people buy among vendors, it is highly unlikely to flag these individuals.
The second problem is related to wholesale. Following the Carte Blanche investigation last year; Sahpra confirmed that the pharmacy group was illegally selling large quantities of codeine-based cough medicines. Although patients can only obtain codeine from a licensed healthcare worker or pharmacist, it is not surprising that it is also found on the black market.
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The new draft guidelines require Sahpra to ask companies and health workers how much codeine they produce. We aim to address both of these issues by allowing you to request information about what is being sold or distributed and to whom. This will “allow Sahpra to detect anomalies in the distribution of drugs of abuse, such as unusually large orders,” Moloi explained.
This is the “first phase” of the codeine care initiative – an effort to centralize data on all codeine sales across the entire supply chain nationwide. The plan is to ensure that the regulator can flag anything from a wholesaler who buys large quantities of codeine to a wholesaler who sells it illegally.
Codeine rehab admissions will triple from 2019.
The draft guidelines, which are now available for public comment, come at a time when codeine addiction rates are rising across South Africa, according to admissions data from drug and alcohol treatment centres. Most rehabilitation centers across the country are linked to a program called the South African Community Epidemiology Network on Drug Use (Sacendu), which collects anonymised patient data from different centres.
Professor Nadine Harker, who oversaw the project, said: “If you look at access to treatment over time, it’s increasing. [in codeine-related admissions] Regularly over the years But sure.”
Indeed, Sacendu’s annual reports say that in the first half of 2019, 277 people who went to Sacendu-linked rehab sites abused codeine. This amounts to 3% of all admissions. But in the first half of 2023, this percentage has tripled to 9%, with a total of 749 people. (The absolute number is slightly less than three times that).
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Even before this happened, health workers were worried. In the mid-2010s, 238 doctors (mostly in the private sector) across South Africa were surveyed. It found that 85% of these colleagues were concerned about the availability of codeine in pharmacies.
Part of the concern is that long-term users of codeine-based medicines can develop health complications, including stomach ulcers and liver damage (especially in medicines with extra ingredients such as paracetamol). Genetic factors play a large role in how codeine affects a person, so some people are more vulnerable than others.
Why is the problem getting worse?
Part of the rise in codeine use appears to be driven by young adults, who sometimes mix codeine-based cough syrups with colds. The combination is often referred to as lean and has become a popular party drug among high school students. Research shows that codeine’s low price and general availability are a factor in its popularity. Harker notes, for example, that children often have access to things at home “they can take out of their mother’s medicine cabinet.”
In other cases, people seem to rely on drugs to cope with emotional distress rather than for recreation. for example, A 2022 study that interviewed women in recovery centers in the Western Cape and Eastern Cape found that many had turned to drugs to cope with grief, from the trauma of losing a child to physical abuse. One woman explained: “I want the pain to go away. I want to cut my mind off… [the tablets] It killed me inside, if I can truly say so.”
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Ignorance of the dangers of codeine also seems to play a role: 94% of doctors surveyed agreed that patients “do not fully understand the risks of sticking to over-the-counter medications with codeine”. A lack of regulatory control may contribute to this perception: a study of South African rehabilitation centers found that “the majority of participants held that view; [over-the-counter] Medicines containing codeine are not drugs.[s] Their sale is guided by their free availability without any real rules or protocols.”
Shouldn’t we make codeine prescription only?
Currently, The law states that codeine-based pills can only be bought over the counter under specific conditions. For one, They must contain another active ingredient, such as paracetamol or ibuprofen, and each pill can contain a maximum of 10 mg of codeine. A person can only purchase one pack and it must contain at least five days’ worth of medication (no more than 80 mg per day). More than that, a script is needed.
Liquid codeine, such as cough syrup, can be bought without a prescription if it contains no more than 10 milligrams of codeine per teaspoon. The bottle should not contain more than 100 ml of solution.
Some researchers who spoke to Spotlight said these restrictions were too lenient and that codeine should be ‘scheduled’; This means that a patient can only get a script, regardless of dosage or combination. By doing so, it becomes more difficult for children to get hold of cough drops for weight loss, and people in general become more aware of drug addiction.
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Indeed, There are some studies that have found this method to be effective in other countries. Research Journal addiction When Australian authorities made codeine prescription-only in 2018; A large national poison information center found a significant decrease in calls (from health workers and the public) about codeine-related incidents.
But there are downsides to this strategy.
For one, As previously reported on Spotlight; Increased regulations could make life more difficult for poor patients seeking pain relief. If you need codeine-based painkillers, you will have to spend more money on the consultation and prescription, it said.
Andy Gray, who chairs the advisory planning committee at Sahpra, elaborated on the second problem: “I don’t believe scheduling is going to solve the problem if we’re dealing with it. [in South Africa] If it’s illegal behavior… [codeine] Whether it’s smuggling from manufacturers or wholesalers, scheduling will make no difference.”
entry of drugs into the black market;
Dr Andrew Scheibe, a harm reduction researcher at the University of Pretoria, said: “If people become dependent on codeine and can’t use codeine. They are likely to switch to opioids. black market.”
Scheibe highlights the United States as an example, where prescription opioids such as oxycodone and fentanyl are at the center of a major drug epidemic.
“When they try to increase the restrictions on those opioids. People started using heroin,” he noted.
According to a 2022 study, Connecticut; This was found among opioid users interviewed in Kentucky and Wisconsin.
However, researchers agree that basic steps need to be taken to educate the public.
Harker says, “Pharmacies, for example, need a lot of different levels of awareness. When someone buys codeine over the counter, it’s important to engage with the pharmacist.” [with them and] If used outside the indicated dose, make the individual aware of the consequences.
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