Johannesburg - After a serious motorbike accident that left him with a fractured leg and sacrum (base of the spine), Kevin* underwent surgery and afterwards was prescribed strong painkillers to manage the pain.
“The pain was extreme at times, and those pills were a lifesaver for me,” he recalls.
The problem, however, was that he became dependent on them to the extent that he was visiting his doctor every month for a new prescription. On the fourth visit, Kevin’s doctor refused to renew the prescription, warning Kevin that he had become too dependent on the pills, which were codeine-based, and offered him a weaker analgesic.
“I got a new prescription, but I was taking Myprodol painkillers as well, which I managed to get over the counter at my pharmacy where I had an old prescription for them. I tried to stick to the directed dosage, but it wasn’t long before I was taking 15, even 20 of them a day,” he says.
What Kevin had developed is an addiction to the codeine contained in his prescription pills. Eventually, the more of them he took, the more he needed to take not only to achieve relief from pain, but for the pleasant feeling of euphoria that opiate-derived medicines can produce.
It is estimated that between 26.3 and 36.1 million people are dependent on opioids worldwide.
In South Africa, nearly 45 percent of people seeking treatment for prescription medicine dependence reported the use of opioid-containing painkillers, according to one Cape Town-based study. This is the tip of the iceberg, however, as countless people are dependent on opioids, but either don’t know it or don’t acknowledge it.
“Much is said about the illegal opiate heroin, but dependency on over-the-counter medicines containing opiates like codeine is actually overtaking heroin,” says Dr Hash Ramjee, a specialist in substance abuse who works for the Houghton House group of treatment centres.
“Our statistics reflect those patients seeking treatment but the problem is far wider than that and growing, and it cuts across the whole population, including all races and ages, even teenagers. The pill-popping elderly lady stereotype is not the reality.”
Opioid dependency ends up as bad as any other drug addiction. Work, family responsibilities and social life suffer, with the abuser spending an inordinate amount of time either trying to obtain the drug or recovering from it.
“I’ve seen patients who are taking up to 100 tablets a day,” says Ramjee. “Their whole day is consumed by trying to get more of the tablets, with patients typically using more than one prescription from two or more general practitioners, then going to different pharmacies. In desperation, some patients forge prescriptions.”
Over-the-counter cough syrup containing opiates is another common way abusers get their fix.
There are a host of serious complications that arise from opioid dependence, depending on the level of addiction.
Codeine can cause depressed breathing, which can be lethal in cases of overdose or combinations with other drugs. Combinations of codeine with other pills can also do serious damage to kidneys, liver and/or stomach.
Constipation, meanwhile, is an ongoing complaint. “Opioids slow down intestinal and bowel movements, creating a blockage,” explains Ramjee.
The situation is alarming, but it’s important to recognise that the problem does not lie with the medicines themselves. For people with pain, opioids like Demerol, Lenadol, Adco-Dol, Myprodol and Syndol are very effective medicines, and most patients do not become addicted.
For some people, however, opioid dependence is an unexpected consequence of proper pain treatment. “The problem comes when someone is unable to stop using the drug after the pain passes. Addiction involves a physical, psychological and behavioural need for the drug,” says Dr Volker Hitzeroth, president of the South African Addiction Medicine Society (Saams).
Hitzeroth explains that opioids are drugs with opium-like qualities that are either derived from opiates or are chemically related to opiates or opium, obtained from the poppy plant.
Opioids act by attaching to specific proteins called opioid receptors, which are found in the brain, spinal cord and gastrointestinal tract. When these drugs attach to the opioid receptors, they block the transmission of pain messages to the brain.
Opioids can also cause euphoria by affecting certain brain regions that mediate what we perceive as pleasure. So after the physical pain has gone, some people continue to use opioids as a behavioural-cum-psychological crutch.
A common remark by someone who is abusing them is “I take these to help me sleep”, or “I take them to relax”.
Another indicator of dependence is frequent headaches, a common symptom of withdrawal, and waking up more than once in the night to take another dose.
“If a patient is using the same painkillers they were prescribed for longer than the directed period, there is cause for alarm,” says Ramjee. “For a mild problem, the directions usually stipulate the medicine shouldn’t be continued after about 10 days.”
Rather than use the word addiction, which draws stigma, doctors call opioid dependence a chronic disease, similar to alcoholism.
This means there is a hereditary factor, but the disease can be managed with a combination of medication and behavioural changes, most effectively in a rehab environment.
Busi Mthali, a social worker at Sharp recovery centre, says patients can take weeks, even months to withdraw from opioid dependency. “If a patient stops immediately, the withdrawal can be very unpleasant, including nausea, night sweats, pain and nightmares,” she says.
The standard treatment at rehab is to wean the patient off with opioid substitutes, such as Methadone or Buprenorphine, which prevent these withdrawal symptoms. “At the same time a therapist works with you to address the underlying psychological issues that led you on this path,” says Mthali.
Pharmaceutically, tablets or capsules containing a small amount of codeine, along with other active ingredients, fall into Schedule 2, which can be purchased without a prescription. Tablets containing higher doses of codeine, and or those containing codeine as the sole active ingredient, fall into schedule 6. Pharmacists are required to record all sales of Schedule 2 products, which should curb the potential abuse of codeine containing products. But this becomes futile if the abuser is using different pharmacies, because the information is not shared between them.
To address this, the Community Pharmacy Sector of the Pharmaceutical Society of South Africa (PSSA) initiated a pilot study titled the “Codeine Care Project”, a registry that helps to identify, screen and refer potential abusers for treatment.
“After we evaluate the results of the pilot study, we will share them with the authorities. We believe that adequate control of potentially abused products will protect the public without denying those consumers who would benefit from their appropriate use,” says PSSA president Dr Johann Kruger.
For those who suspect they may have become dependent, meanwhile, it’s important to realise that this is a long-term medical condition that you can’t tackle yourself, and that there is help available, including out-patient programmes. Some doctors treat opioid dependence in the privacy of their offices. - The Star
You can find out more about your options on pharmaceutical-company sponsored website, http://turntohelp.co.za, as well as www.saams.co.za
* Name has been changed.