Tuesday, May 1, 2018

NIGERIA AND HER DEADLY CODEINE BASED COUGH SYRUP EPIDEMIC

Picture of bottles of codeine
Bottles of Codeine syrup (Picture from www.bbc.com)



WARNING: If you are a pharmacist or other healthcare worker, you might not like what you are about to read. You are free to disagree with my opinions and state yours but you are not free to insult me or any other professional. 

So BBC carried out an investigative piece on the scourge of codeine syrup epidemic in Nigeria and indicted some people/persons and people are having issues with the piece. Personally, I was super happy about it because it gave me evidence to back my hypothesis on the cause of this problem.

The genesis of this epidemic is from the pharmaceutical companies, pharmacy owners (who can be pharmacists, doctors, nurses or any healthcare worker or anybody with money), pharmacists/pharmacy assistants and pharmaceutical representatives. Yes! I said it. And I will say it again and again. Why did I say this? Let me give you all a back story… 

I was born into the world of pharmaceuticals and growing up, I was accustomed with only one brand of codeine based cough syrup and that was Benylin. While in pharmacy school, the Parkalin brand of cough syrup was introduced into the Nigerian market but it took quite a while for them to produce their own brand of codeine cough syrup. By the time I finished pharmacy school, I knew just two brands that were producing the syrups. When I started my internship at a community pharmacy, I was shocked to see that Emzor pharmaceuticals was also producing codeine based syrup. Why? I did my 6 months Industrial training at Emzor and during my time there, it had not yet been formulated. I also noticed that some other brands had started producing codeine syrups but they were about 5 in number. 

Fast forward to 2017/2018, you can imagine my shock to see that every Tom, Dick and Harry pharmaceutical company that has the facilities to produce syrups is making their own brand of codeine based syrup. Why? GREED!! It is that simple. People are thirsty for money. And they don’t care whose life is damaged while doing it.

I remember in 2009 when this addiction was slowly creeping into the Nigerian system, I heard people were mixing the syrup with alcohol, soft drinks, energy drinks and even heating it up and injecting it. I made a personal decision to always ask questions whenever someone requested for a syrup with codeine. Based on their answers, I will determine if you needed it or not and convince you to try another syrup that is non-codeine based. There was a particular client that I noticed came to the pharmacy to request for the syrup on a daily basis. After a few confrontations and some walking off by the client, I decided that I didn’t have the energy for anymore confrontation. So whenever I sighted the client, I simply hid the bottles and straight up lied (yes I did) that we didn’t have any stock in the pharmacy. I will then advise that the client to try the non codeine based alternative. In my over 2years experience as a community pharmacist, I can say I barely sold/dispensed up to 15 bottles of codeine based syrups. 

That was my decision and thankfully my boss trusted me to do what was right. However that cannot be said for some other people. There was a staff member who knew that people were addicted and started increasing the price of the syrups and sold without any restrictions (when I was off duty). I also noticed that the client stopped coming when I was on duty. The client probably came when I was off duty or went to another pharmacy. So while I was trying my best to help prevent the epidemic, some people due to greed were fanning the flames.

Now this issue has blown up in our faces. According to reports, the epidemic is at a critical high in the Northern region of Nigeria. I don’t get how 10000 bottles can be sold within a short period of time. That is 1,000,000mls of codeine based liquid!! Outrageous!! In 2009/2010, Benylin with codeine was about 350 – 400 naira (Benylin was the premium brand), now Coflin (a more likely generic brand) costs 1500 naira (last time I checked). Can you see why I said greed?

The investigative report by BBC incriminated a pharmaceutical rep from Emzor who went to a hotel room to sell 60 bottles of codeine based syrup. Like Boy!!! Are you freaking crazy? What differentiates you from the street drug (narcotics) peddlers? I am still trying to understand what he was thinking.

Now some pharmacists are having their panties in a bunch because they feel the report was indicting. Like I said while I was trying my best to do my part, some pharmacists were selling more than 2 bottles at a time to patients/clients at that time. I can’t even begin to think about how much they are selling to people now. Some of the pharmaceutical reps because they must meet their sales target sell to every street corner shops. Hey, the goal is to meet the target, get that commission and be promoted. Some pharmacy owners don’t even care as long as the money is coming in. 30 bottles of codeine syrup at 1500 naira amounts to 45000 naira/day and in 24 days in a month that is about 1,080,000naira in sales. Cha ching!! Big bucks in this harsh economy, right? But as long as we are not the ones using it, it doesn’t bother us, right?

I once heard that we all need to work together to improve our society because if we think that we are far up in the society with our money and moral standards and don’t help others to be better, one riff raff or deviant can show up and turn your world upside down. It is not hard to imagine one addicted person taking up armed robbery or stealing to support his addiction and having an encounter with you. You get my drift?

So now that we acknowledge that we (especially pharmacists/pharmaceutical reps) have been part of the problem, it is time to end the problem. We need to employ both upstream (prevention) and downstream (management/curative) interventions in order to tackle this epidemic.

I will list the interventions that I believe might be effective, hopefully it might be valuable when drafting some policy decisions (that is if this piece ever reaches the policy makers).

1.       Restrict the amount of companies that can produce codeine based syrups. According to the BBC reports, there are about 20 pharmaceutical companies that produce codeine based syrups in Nigeria. Why is it that much? The federal government through NAFDAC and its other drug agencies can restrict the companies that produce the syrups to about 5.
2.       Close every importation loopholes. Our borders are too darn porous! All the stakeholder agencies need to work together to prevent an unreasonable influx of the syrup because once there is a restriction on production, the greedy people will try to import them.
3.       Restrict the amount of bottles produced and sold per transaction. No company should produce above a predetermined amount of bottles per batch and a predetermined amount of batches per month. Sales to licensed pharmacies/hospitals should be appropriate to the size of the pharmacies. For instance if a singular pharmacy is sold 10 bottles/transaction with a restriction of 3 sales within a month, I don’t expect a pharmacy that has a chain of 10 shops to be sold just 10 bottles/transaction. It should be relative to the size of the pharmacy chain.
4.       The federal government can encourage the formulation of non codeine based syrups by reducing some of the policies involved in production or registering of new products and giving discounts or incentives to the companies who have been restricted from producing the codeine syrups and now produce non codeine based cough syrups.
5.       Carry out an intensive health awareness/advocacy campaigns on the dangers of abusing codeine syrups (as well as other narcotics) across all demographics based on age, sex, income status, education.
6.       Equip most hospitals and psychiatric health institutions (both private and public) with the facilities needed to cope with the aftermath of codeine withdrawal symptoms. I particularly am interested in public hospitals having enough space/facilities to accommodate the likely influx of patients that might be referred there especially in the North. The dedication of a lot of wards/pharmacies/consulting rooms in a dedicated building as is seen in University of Uyo Teaching Hospital, Uyo will be more capable of coping with any influx of potential patients than the 8 bed allocation in the Nervous disorder ward of Lagos state university teaching hospital.
7.       Stop the silly glorification of codeine or drug abuse by Nigerian singers! I have never heard the Science student song but people have written that it was glorifying codeine syrup drinking. How did that song get approved for goodness sake?

Whew! That was a long write up. I hope people will take a few minutes to read it. It sure feels like a school assignment (theory of public health essay)..lol

Well, let us get the conversation started. What do you think about the whole codeine syrup issue? Do you have any suggestion on how this epidemic can be stopped? I will love to read your thoughts. Please leave your comments below.

Thanks for stopping by.

Luv ya,
Petite Diva

P.S: Here is the link to the BBC article http://www.bbc.com/news/world-africa-43912282

P.P.S: I wrote this piece before I saw reports that the federal government has banned the production of codeine containing syrups in Nigeria.

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