Increase in codeine abuse among SA youth sparks concern

This mixture, when used recreationally and in large amounts, can cause feelings of euphoria and may lead to dependence and substance abuse disorders. Picture: Martin Sanchez/Usplash

This mixture, when used recreationally and in large amounts, can cause feelings of euphoria and may lead to dependence and substance abuse disorders. Picture: Martin Sanchez/Usplash

Published Jan 23, 2024


Fuelled by popular music, the promise of escapism and the fact that it’s relatively cheap, some of South Africa’s youth have become increasingly addicted to codeine-based over-the-counter products which can be purchased without a doctor’s prescription at a pharmacy.

Products such as cough mixtures and pain medications can innocently lead to abuse as they contain codeine due to its sedative properties.

“Lean”, as it is typically called among users, along with other popular names, is usually taken as a mixture of a soft drink and prescription-strength doses of cough syrup that contains codeine and often promethazine.

This mixture, when used recreationally and in large amounts, can cause feelings of euphoria and may lead to dependence and substance abuse disorders.

David Bayever, chairperson of the International Society of Substance Use Professionals (ISSUP), has raised concerns about a surge in opioid abuse in parts of Africa.

"We have seen a similar outbreak in abuse in our neighbours to the north of the continent, but with the primary substance of abuse being tramadol in North, West, and Central Africa," Bayever said.

Bayever emphasises that substance abuse is less about the specific substance and more about the behaviour of the people involved.

"The environments of poverty, crime, and stress prevalent in South Africa can drive more people to become chemically dependent on substances in the first place," he explains.

According to the United Nations Office on Drugs and Crime, opioids, including codeine, are increasingly popular recreational drugs in Africa.

The continent accounted for more than half of the global amounts of pharmaceutical opioids confiscated between 2016 and 2020, indicating the rapid spread of the epidemic in Africa.

Bayever warns about the dangers of codeine abuse, stating that when taken in large amounts, it can lead to severe health complications and even death due to its strong sedative effects.

Furthermore, the legal status of opioid medications can reduce the stigma associated with illegal street drugs, making it even more challenging to address the issue.

Cipla South Africa CEO, Paul Miller. Picture: Paul Miller/Supplied

"During the Covid-19 pandemic, we saw a much higher incidence of mental health illnesses, and people who realised the soothing effects of these medicines would have come to rely on them rather than trying to find other coping methods," Bayever says, highlighting the detrimental effects, especially on young people whose brains are still developing.

Bayever also raises concerns about the accessibility and monitoring of opioid medications.

He points out that even though pharmacies are required by law to control the sales and monitor patients' use, there is no central database to store and make available the information pertaining to these sales.

The increasing incidence of opioid abuse in South Africa calls for heightened awareness, monitoring, and control to address this escalating public health concern.

The Codeine Care Initiative, initially launched in 2013, is undergoing vital revisions to gain greater support and impact in addressing codeine abuse.

Enforceability challenges across various pharmacy outlets have hindered the initiative's effectiveness, leading to limited traction.

The Independent Community Pharmacy Association (ICPA) is working on revamping the initiative to empower pharmacists in monitoring and recording purchasing behaviour related to products containing codeine.

The goal is to create a national database that links all codeine-containing product sales to enable informed decision-making by pharmacists.

"The intent of the Codeine Care Initiative is to raise awareness about the potential development of physical dependence and addiction, rather than to punish individuals," states a representative from the ICPA.

The initiative aims to provide vital information at pharmacy level, facilitating early intervention for those at risk of developing dependence or addiction to codeine. This proactive approach seeks to reduce the harm associated with misuse and abuse of the medication.

The enhanced system will identify patients demonstrating potential signs of substance use disorder, such as frequent visits to multiple pharmacies within a short period or purchasing excessive amounts of codeine-containing products.

This would prompt pharmacists to be informed of the issue and employ their judgement to address the situation, possibly through a “red flag” notification.

Pharmacists will be able to override the system in cases where a patient requires more than the normal dosage of codeine to treat specific conditions, such as neuropathic or nociceptive pain, under the guidance of a healthcare professional. However, all such overrides are recorded.

The programme will be implemented within the confines of all the necessary regulations to ensure the protection of personal information.

“As a manufacturer of affordable, quality medicines and with an ethos of ‘caring for life’, ensuring that these products are used in a safe, responsible manner is absolutely critical,” said Cipla South Africa CEO, Paul Miller.

“We therefore support the initiative to have stricter control around codeine-containing products to tackle the problem of addiction associated with non-therapeutic usage.