South Africans youngsters have found a new high: it’s cheap and easily accessible over the counter, but is costing them dearly, write Zano Kunene, Linda Pretorius and Joan van Dyk for Bhekisisa.
It’s good old-fashioned codeine, found in mild painkillers and cough syrups, and sometimes mixed with Sprite, raspberry-flavoured cool drinks, or alcohol, to make a drink called “lean”.
A study of 31 countries found that South Africa made up a third of all over-the-counter (OTC) codeine sales between 2013 and 2019. Although one in five people in the country experience persistent pain, experts worry that misuse of codeine is driving sales as well, particularly among young people.
More and more adolescents are showing up at drug treatment centres to try to kick the “lean” habit.
There are systems in place to monitor codeine abuse at pharmacies, but the loopholes in such safety mechanisms are getting wider, and teenagers are paying the price.
“Lean” is a typically purple drink made by mixing alcohol or a soft drink with codeine-containing medicine like cough syrup. It also commonly goes by the name purple drank or “sizzurp”.
Codeine makes your brain release feel-good chemicals, which is exactly what happens when you mix 100ml of codeine-containing medicine with two litres of soda. It’s a difficult trap to escape: opioid drugs like codeine, morphine and heroin are addictive and over time the brain needs more and more of it to get the same high.
A 2020 study among 144 schoolchildren aged 14-17 from two townships in Mpumalanga and the Free State showed that South African teenagers are using/abusing “lean”.
Adolescents are particularly vulnerable to addiction, as the part of the brain that controls rational decision-making is not yet fully developed.
A codeine high is not only cheap (R20-R30 for a 100ml bottle of the pain medication Stilpane or cough syrup Broncleer plus R20 for a bottle of Sprite), but also easy.
The pain/cough syrups are available over the counter at chemists and pharmacies, with little oversight of who buys them. Teens who participated in the local study on cough syrup misuse reported that “you just go to the pharmacy and buy”.
While it’s mostly codeine-containing syrups being misused, tablets have as much potential for abuse. In a study on codeine abuse in South Africa, a third of the participants reported abusing codeine tablets like Stilpane and Adcodol.
But it shouldn’t be that simple, says Mariet Eksteen, professional development officer at the Pharmaceutical Society of South Africa.
Broncleer and Stilpane syrups are Schedule 2 medicines in South Africa because they contain little enough codeine to be safe if used as intended. The higher a drug’s schedule, the more restrictions on how and when it can be dispensed.
But even though Schedule 2 medication can be bought over the counter without a prescription, the dispenser must record the name, ID number and address of the person to whom it was sold. (Codeine on its own is a Schedule 6 drug, because of its potential for addiction if used at more than 20mg per dose).
Still, a pharmacy is not a kiosk, Eksteen says. Pharmacists are supposed to make sure patients know how to use self-administered medicines safely. “You don’t just hand it over.”
Research across 31 countries found that South Africa (the only African nation in the study) accounted for almost a third of all over-the-counter sales of codeine, almost one and a half times as much as the second highest consumer, France, between 2013 and 2019.
So where is it all going?
Many people are, of course, buying these medicines because they’re in pain – nearly one in five people in South Africa experience constant discomfort, mostly in their backs and limbs, reports a 2020 study of more than 10 000 people.
But health professionals and regulators worry that the amount of codeine consumed in the country isn’t all for legit uses. And, says Daphney Fafudi, manager of regulatory compliance at the South African Health Products Regulatory Authority (SAHPRA), their data show that most of the misused codeine products come from pharmacies.
SAHPRA tracks every batch of codeine-containing painkillers, from when it’s made to when it’s sold. It does this by taking stock at the manufacturers and wholesalers to ensure what comes in tallies with what goes out and dropping in on randomly selected pharmacies to check their orders for codeine-containing products against stock in store and sale records.
That’s how they noticed something dodgy happening at some dispensaries in 2019. “You wonder (why) when a person should be getting one bottle, the establishment is giving a box or more than one box,” says Fafudi.
Not only was codeine being sold in bulk, some pharmacies were not recording the details of the people to whom they sold the products, she adds.
But it doesn’t seem to be pharmacists as such who are dishing out codeine indiscriminately; the issue seems to be at outlets where there’s no pharmacist on duty.
In 2019, the South African Pharmacy Council investigated 14 chemists nationwide for allowing unauthorised personnel to do things only a pharmacist should, like dispensing over-the-counter medication and offering health advice to patients. This was the highest number of this sort of contravention in five years.
More and more codeine-dependent teenagers are also beginning to show up at South Africa’s drug treatment centres, says Siphokazi Dada, a researcher formerly at the South African Community Epidemiology Network on Drug Use. In 2016, about one in five people admitted for codeine dependency was between 10 and 19-years-old; by 2019, this number had jumped to about one in three.
A possible solution – with some loopholes
To try to stem the codeine abuse and help prevent opioid misuse from becoming an epidemic as in the US, the Pharmaceutical Society of South Africa and other partners launched the Codeine Care Initiative in 2013.
In the US, opioid abuse is so common it has contributed to a small drop in how long people in that country are expected to live. In 2018, about three in 100 adolescents and 5% of people between 18 and 25 in that country reported misusing opioid pain relievers.
When it was first launched nine years ago, the Codeine Care Initiative was supposed to be a national database where pharmacists could see every codeine purchase made in the previous six months, regardless of which pharmacy chain the person had visited.
But because the project wasn’t mandatory, only about 10% of drug stores in the country opted in, said Eksteen. SAHPRA has the power to ensure a system like this is uniformly implemented in pharmacies nationwide, she says, which could help to put an end to “pharmacy hopping”.
If the system alerts a pharmacist to a customer who’s been using codeine products regularly, they’ll be able to talk to them about the risks or suggest a medicine that doesn’t contain the drug. Dispensers can also refuse to hand over a medicine if they think it’s in the patient’s best interest.
Most American states have similar databases, called prescription drug monitoring programmes, for medicines carrying a high risk of dependence, such as oxycodone.
Upscheduling vs monitoring
Making codeine-containing medicines available only on prescription is another option, used in France and Australia. In Australia, upscheduling the products led to almost 90% fewer sales of low-dose codeine medicines in the next year and cut the monthly number of overdoses by half.
SAHPRA has considered changing the schedule of the products here too, but local experts said monitoring the sale of codeine-products would be a better route because a change in scheduling would put the painkiller out of reach for people who can’t get to a doctor easily.
Eksteen says the pharmaceutical industry, healthcare professionals and regulatory bodies will, however, have to unite to make this work.
Why?
For one, because there’s no guarantee outlets will use the system. Participation is voluntary and the products tend to be channelled to misusers from community pharmacies with unauthorised personnel. US evidence shows that even prescribers who are authorised to give out these medicines don’t use monitoring systems often.
The Protection of Personal Information Act could also complicate getting SA’s database running. Because the Act requires organisations to get people’s consent for storing their personal information, the Codeine Care Initiative will require permission from the customer to take part.
So if someone’s planning to misuse the medicine, they’re unlikely to allow their purchasing record to be saved. In this case, the pharmacist may still note on the registry that the patient declined to participate, but without any details as to who the customer was.
US research shows pharmacies in rural areas were less likely to participate in an online prescription drug monitoring programme than those in cities or large towns. But an even bigger factor for not using the system was not having internet access.
Only one in five workplaces in rural South African areas has internet access. Unfortunately, many users have already noticed loopholes like these.
See more from MedicalBrief archives:
SA under-prepared for rising codeine addiction
Addiction epidemic sees Nigeria ban cough syrups containing codeine
Opioid painkillers to carry prominent addiction warnings in UK
The African opioid epidemic you haven’t heard about