Kieran Gordon* awoke dazed and cold. He was in his underwear on the floor of a friend’s living room in Johannesburg.
Someone was fumbling with keys by the front door, waking up a few of the other partygoers who were still asleep.
That’s how they discovered something fishy going on at some dispensaries in 2019. “You wonder why, when a person should get one bottle, the establishment gives a box or more than one box,” Fafudi says.
Not only was codeine being sold in bulk, but some pharmacies were failing to keep track of who purchased the drugs, she adds.
However, it does not appear that pharmacists are indiscriminately dispensing codeine. Instead, the problem appears to be at locations where there is no pharmacist on duty.
In 2019, the South African Pharmacy Council investigated 14 chemists across the country for allowing unauthorised personnel to perform tasks that only a pharmacist should perform, such as dispensing over-the-counter medication and providing patients with health advice. This was the most of this type of violation in five years.
According to Siphokazi Dada, a former researcher at the South African Community Epidemiology Network on Drug Use, an increasing number of codeine-dependent teenagers are beginning to show up at South Africa’s drug treatment centres. In 2016, one in every five people admitted for codeine addiction was between the ages of 10 and 19. By 2019, this figure had risen to roughly one-third.
When a fix can make or break you
Gordon was about 16 years old when he was at home trying to make a stronger lean drink. Instead of just one bottle of syrup, he poured two into two litres of Sprite — effectively doubling the strength.
He realised he needed to lie down after a few moments.
“I couldn’t talk,” he realised after accidentally overdoing. I was paralysed. “I couldn’t feel my heartbeat,” he recalls.
Overdosing on codeine can result in respiratory and kidney damage, as well as unconsciousness, a weak pulse, and a slow heartbeat.
Gordon, on the other hand, was unfazed by the incident. He continued to drink about four litres of lean every day, which equates to about 14 bottles — nearly one and a half litres — of cough syrup per week. Over-the-counter codeine has a safe maximum adult daily dose of 80mg. A full bottle of cough syrup can contain up to 200mg of codeine, which means Gordon, as a teenager, could consume up to 400mg of the drug per day, which is five times the recommended safe dose in this form.
Gordon’s codeine addiction ruined many aspects of his life.
“I was on the verge of failing Grade 11.” I couldn’t study while on lean because my mind wasn’t in the right place. “I couldn’t sleep without it,” he admits.
His relationship with his parents was also tested. His mother once discovered 30 empty Stilpane bottles in a bag in his cupboard and threatened him with rehab.
So he made the decision to “put his head down and stop for a while.” But regaining his parents’ trust was difficult.
“If I poured myself a glass of cooldrink, my mother would make snide remarks like, ‘What’s in that cup?'” he smirks.
A possible solution with some flaws
To combat codeine abuse and prevent opioid misuse from becoming an epidemic in South Africa, the Pharmaceutical Society of South Africa and other partners launched the Codeine Care Initiative in 2013.
Opioid abuse is so common in the United States that it has contributed to a small decrease in the average lifespan. In 2018, approximately three out of every 100 adolescents and 5% of people aged 18 to 25 in that country reported misusing opioid pain relievers.
The Codeine Care Initiative was supposed to be a national database where pharmacists could see every codeine purchase someone had made in the previous six months, regardless of which pharmacy chain they visited when it was first launched nine years ago.
However, because the project was voluntary, only about 10% of the country’s drug stores participated, according to Eksteen.
As the medicines regulator, Sahpra says she has the authority to ensure that a system like this is implemented uniformly in pharmacies across the country, which could help put an end to “pharmacy hopping” (when someone skirts suspicion by going to lots of different outlets to get their fix).
If the system alerts a pharmacist to a customer who has been using codeine products on a regular basis, the pharmacist will be able to talk to the customer about the risks or recommend a medicine that does not contain the drug. Dispensers may also refuse to hand over a medication if they believe it is in the best interests of the patient.
Most states in the United States have similar databases, known as prescription drug monitoring programmes, for medications that have a high risk of addiction, such as the pain reliever oxycodone.
“Having a system like this is an opportunity to say: ‘Do you need help?'” says Eksteen. ‘May I suggest a different product?'”
Monitoring vs. scheduling
Another option, which countries such as France and Australia have pursued, is to restrict the availability of codeine-containing medications to prescription only. In Australia, rescheduling the products resulted in nearly 90% fewer sales of low-dose codeine medicines the following year, as well as a 50% reduction in the monthly number of overdoses.
Sahpra considered changing the product schedule here as well, but local experts advised that monitoring the sale of codeine-products would be a better route for South Africa because a change in scheduling would put the painkiller out of reach for people who couldn’t easily get to a doctor.
According to Eksteen, the pharmaceutical industry, healthcare professionals, and regulatory bodies will all have to work together to make this work.
Why?
One reason is that there is no guarantee that the outlets will use the system. Participation is voluntary, and products are typically channelled to misusers via community pharmacies staffed by unauthorised personnel. Evidence from the United States indicates that even authorised prescribers do not frequently use monitoring systems.
The Protection of Personal Information Act may also make it more difficult to launch South Africa’s database. Because the act requires organisations to obtain people’s permission before storing their personal information, the Codeine Care Initiative will require customer permission to participate, explains Eksteen.
As a result, if someone intends to misuse the medication, they are unlikely to allow their purchase record to be saved. In this case, the pharmacist may still record on the registry that the patient declined to participate, but without providing any information about the customer.
According to US research, pharmacies in rural areas are less likely than those in cities or large towns to participate in an online prescription drug monitoring programme. However, a more significant reason for not using the system was a lack of internet access.
In South Africa, only one out of every five rural workplaces has internet access.
Many users, including Gordon, have already discovered such flaws.
“I just go down to the [smaller] pharmacies,” he explains. I’d be denied if I went to [the ones in malls]. Those are only used as a last resort.”
Gordon now only allows himself a cup of lean when he has something to celebrate.
“I know I can’t keep doing this forever.” I want things to go my way in this life. I cannot allow lean to distract me as it did in high school.
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