Keeping SA’s children numb
Cheap codeine-containing medicine with soft drinks. By and
prevent opioid misuse from becoming an epidemic as it is in the US, the Pharmaceutical Society of SA and other partners launched the Codeine Care Initiative in 2013.
Opioid abuse is so common in the US that it has contributed to a small decline in life expectancy. In 2018, about 3% of adolescents and 5% of people between 18 and 25 in the US reported misusing opioid pain relievers.
When it was launched nine years ago, the Codeine Care Initiative aimed to be a national database that pharmacists could use to review every codeine purchase someone had made in the past six months, regardless of which pharmacy or chain they had visited.
But because the project wasn’t mandatory, only about 10% of pharmacies opted in, Eksteen says.She adds that Sahpra, as the medicines regulator, has the power to ensure the system is uniformly implemented in pharmacies, which could help to put an end to “pharmacy hopping” (when someone goes to different outlets to get
their fix).
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 is in the patient’s interest to do so.
Most states in the US have similar databases, called prescription drug monitoring programmes, for medicines that carry a high risk of dependence, such as the pain medication oxycodone (OxyContin).
Says Eksteen: “Having a system like this is an opportunity to say: ‘Do you need help? Can I advise you on a different product?’”
Upscheduling vs monitoring
Making codeine-containing medicines available only on prescription is another option, which countries such as France and Australia require. In Australia, upscheduling the products led to 87.3% 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 advised that monitoring the sale of codeinecontaining products would be a better route for South Africa because a change in scheduling would make it impossible for people who can’t get to a doctor easily to access the drug. Eksteen says the pharmaceutical industry, healthcare professionals and regulatory bodies will have to pull together to make this work. This is because there are no guarantees that outlets will use the system. Participation is voluntary and the products tend to be channelled to misusers from community pharmacies with unauthorised personnel. Evidence from the US shows that even prescribers who are authorised to give out these medicines don’t often use monitoring systems.
The Protection of Personal Information Act could also complicate getting South Africa’s database running. Because the act requires organisations to get people’s consent for storing their personal information, the Codeine Care Initiative
would require permission from the customer, says Eksteen.
If someone is 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.
Research from the US shows that pharmacies in rural areas were less likely to participate in a prescription drug-monitoring programme than those in cities or large towns.
An even bigger factor for not using the system was not having internet access. Only one in five workplaces in South Africa’s rural areas has internet access.
Many users have already noticed loopholes like these, including Gordon.
He explains: “I just go down to the [smaller] pharmacies. If I go to [the ones in malls], I’d get denied. Those ones are a last resort.”
These days, Gordon allows himself a cup of lean only when he’s got something to celebrate.
“I know that I can’t do this forever. I want things to happen for me in this life. I can’t let lean distract me like it did in high school.”