BIG LITTLE HIGHS
Are headache powders and three-component painkillers highly addictive?
Annie Wilson tipped her first headache powder onto her tongue as a teen and chased it with cooldrink. ‘I got a lot of headaches after I dislocated and cracked a cervical vertebra in a car crash when I was 18,’ says the now 50-something fashion stylist and designer.
‘Then, at varsity in Stellenbosch, someone said “Take one of these, they’re brilliant!” And they were.’
So brilliant that Annie began knocking one back each time she had a headache. And this grew more frequent. ‘Fifteen years later, when I was living in New York, I was taking one or two every morning with my coffee, and often a third later in the day – pulling out a powder became a bit of a party trick.
‘It went on for 20 years. I’d tell friends visiting from South Africa: “Bring Ouma, Bovril, Provita and my powders.” I went nowhere without them in my handbag.’
Back in South Africa, Annie worked with a photographer who suffered debilitating cluster headaches. ‘One day I was sourcing for a shoot and grew giddy and disjointed. I knew something wasn’t right and told him. He sent me to his neurologist.’
Annie explained about her neck injury causing headaches and what she’d been taking, and the neurologist examined her thoroughly. ‘There’s nothing wrong with your neck,’ he told her flatly. ‘You’re addicted to those powders. It’s a big problem!’
THE PROBLEM
It’s a big problem precisely because it doesn’t strike most of us as a problem at all. Prescription drugs, particularly over-the-counter ones, seem in a different class to street drugs: respectable and safe. And, taken as directed, for specific ailments, in limited dosages for set periods, they are. But popped carelessly or capriciously to chill; sleep better; even for a slight high, painkillers carry potentially fatal dangers.
Internationally, the most commonly abused painkillers are those with opiates (keep an eye out for our in-depth report on this in
an upcoming issue). But even OTC painkillers without opiates can be deadly if we misuse them. The packaging on Annie’s painkillers lists their composition as aspirin, paracetamol and caffeine, and warns not to exceed the recommended dose or use continuously for more than 10 days without consulting your doctor. There’s no mention of side effects – that’s in the insert most of us ignore, in 6-point black on white print that satisfies the requirements of the South African Health Products Regulatory Authority (SAHPRA) but is not easy on the eyes. The side effects include ‘oedema
[water retention], hypertension, cardiac failure’ and ‘peptic ulcers, perforation or gastrointestinal bleeding, sometimes fatal’.
‘The physical effects of overusing OTC painkillers are not just constipation, but perforated gastric ulcers, gastrointestinal bleeding, hepatotoxicity (liver damage) and inflammatory bowel conditions,’ says Siphokazi Dada, a senior scientist at the SA Medical Research Council.
And the risk of experiencing these effects through abuse becomes significant when you can stock up on them not only at any pharmacy, but also at supermarkets, clothing shops and street vendors. They’re also advertised on TV, in radio ads, on township billboards and in branded spazas, as GP and social activist Dr Sindi van Zyl has pointed out in a Twitter thread, where she obliquely refers to the medication as ‘cake’ eaten to ‘help’ with ‘the relief of mild to moderate pain.’
THE STATS
‘While the US has great statistics for prescriptions and dispensing, South Africa has poor control and little in the way of stats, so it’s very difficult to quantify the problem of overuse and misuse of OTC painkillers,’ says Professor Feroza Motara, academic head of Emergency Medicine at the Faculty of Health Sciences at Wits University and Netcare Linksfield’s emergency department head.
It’s also very difficult to get patients to tell the truth if they’re abusing them, she adds. But along with NSAIDS (nonsteroidal antiinflammatory drugs) – those with **ibuprofen and ***diclofenac – the *three-component painkillers are probably the most common medications to cause side effects.
‘They’re easily accessible anywhere and taken by a large number of people for pain,’ Motara says. ‘But necessary precautions aren’t taken – for example, they’re not taken with food and at the correct frequency and dose. This is the most common cause of the side effects of gastritis and upper gastrointestinal tract bleeding, significantly more in the public (government) health sector because they’re cheaper and more accessible than other medications.’
Yet the problem is hidden, as those abusing medicines seldom come forward for treatment because they don’t perceive it as a problem, says Dada. ‘According to the latest SACENDU (SA Community Epidemiology Network on Drug Use) data, treatment admissions for OTC and prescription medicine as a primary or secondary drug of use were 2.9%.’ Dada, like many in her field, believes actual use to be far higher and rising, ‘given the accessibility and affordability of prescription and OTC drugs, and lack of stigma around their misuse and abuse compared to illicit drugs’.
THE EFFECTS
The effects of the combination threecomponent painkillers Annie used hinge on those three components. Aspirin, explains Van Zyl, is a non-steroidal anti-inflammatory used to treat pain, fever or inflammation, and prevent blood from clotting in arteries. Paracetamol is a pain reliever and fever reducer, and caffeine is a natural stimulant of the central nervous system that increases alertness and gives a temporary energy boost. Each of the three ingredients has its uses, she says, separately. ‘It’s combining them in the “cake” that’s the problem.’
When you overuse them, they relieve pain, then worsen it in a rebound reaction where the pain is more intense than before as you build tolerance to the painkillers.
So you need more to relieve it, and find yourself in a vicious cycle. It’s known as ‘medication overuse syndrome’, and is medically recognised, says Dr Roland van Rensburg, registrar of the Division of Clinical Pharmacology at Stellenbosch University.
Though the ‘cake’ comes with a disclaimer not to keep taking it for more than 10 days without consulting a doctor, says Van Zyl, ‘it’s highly addictive – by then you’re hooked’.
I’d tell friends visiting from SA: ‘Bring Ouma, Bovril, Provita and my powders.’
It’s gradual, she says, fuelled by the need to relieve the rebound headache, and by the caffeine.
‘And all the time, the aspirin is doing its work as an antiplatelet, thinning your blood and beginning to irritate your stomach lining,’ Van Zyl adds. ‘I’ve had patients eventually “eating cake” every half hour on bad days – when rebound pain and stomach problems become unbearable – and ending up in Casualty, vomiting blood from a perforated ulcer. When I worked in surgery at Bara [Chris Hani Baragwanath Hospital], we’d see such cases all the time.’
‘It’s a well-known fact that many patients get addicted to OTC painkillers – we mostly deal with gastrointestinal bleeding, either occult (not visible) or from peptic ulcer disease/gastritis,’ says Professor Christo van Rensburg, Stellenbosch University’s head of gastroenterology at Tygerberg Hospital.
Professor Adam Mahomed, clinical head and senior specialist in gastroenterology at Charlotte Maxeke Johannesburg Academic Hospital, estimates that they see five to 10 cases a month of abdominal pain associated with peptic ulcer disease resulting from OTC combination painkillers. And Dr Neil Taverner, a surgeon in a private hospital in Mpumalanga, reports: ‘We get a case of minor bleeding from people taking these painkillers about every two weeks, and big complications, where we have to operate to fix potentially fatal perforated or bleeding stomach ulcers, about every two months. Patients are generally addicted and take massive amounts.’
Clair Hart, a 59-year-old Cape Town home renovator and hiker, started ‘eating cake’ about 10 years ago, for bad sinus headaches. ‘They were the quickest fix, especially on hikes. But I ended up taking them seven times a day to prevent the headaches returning. It’s ironic, because I stopped drinking coffee 25 years ago after a talk at a hydro about what caffeine did, but somehow I didn’t associate this medication with that. They seem so innocuous – they’re everywhere. Then I began having waves of nausea, and went for a gastroscopy. I had three ulcers. I was told categorically that they were linked to the medication.’
Palesa Mnguni, 33, from Joburg, is aware of the dangers but says she’s unable to stop. She, too, started taking the powders about 10 years ago. ‘I had a headache, and my mom and aunt used them, so I knew they must be safe. They gave me energy – I suppose from the caffeine – and helped me concentrate. I felt good, and began taking them as a preventative before going out for a drink. Then I was having one every day. Now sometimes I take three or four a day, and they don’t help when I have a migraine, but I keep stocking up at the garage anyway. A doctor’s told me it’s really bad to keep taking them, and I try to stop, but I can’t. I wish I’d known at the start…’
THE SOLUTION
There have been stirrings of official recognition of the OTC painkiller abuse problem, but only in the case of those containing codeine. To help prevent codeine dependence, South African law has obliged pharmaceutical manufacturers to reduce the size of packages available OTC since 2016, says Marilise van Biljon, operations manager at Medipost Pharmacy. ‘And as it’s a schedule 2 substance, pharmacists must record the ID number, address and phone number of the person they dispense it to, and may not sell the same person more codeine-containing medications within five days.’
But these combination painkillers contain no codeine. So they are neither scheduled nor restricted.
Medipost fund manager Gerda Potgieter says Medipost Pharmacy has introduced an ‘advanced management system’ to detect potential abuse of all medicines, including these three-component painkillers. ‘We have a profile allocated to each person we dispense medication to which includes a record of what they’ve purchased. Any medication bought at frequent intervals will trigger an alert. Pharmacists shouldn’t only supply, but should also educate and advise on the safe and appropriate use of medication, the potential side
effects and the long-term dangers of prolonged overuse. Ultimately, the patient will choose how to use it but this shouldn’t prevent pharmacists from fulfilling their role as custodians of medicine.’
Continuous use of OTC painkillers may not only have adverse effects but can also mask symptoms of more serious underlying conditions, which can be life-threatening if not treated properly, Potgieter adds. ‘When the system alerts the pharmacist, we’ll discuss options with the patient, or advise them to consult a doctor to investigate the root cause of their pain and find a more suitable and sustainable solution.’
Annie stopped using her powders at the neurologist’s urging. ‘He warned me that I could be developing an ulcer or liver problems, and said the only solution was to go cold turkey.’ She booked herself off work for a week and did just that at home, with her husband for support.
Like a heroin addict entering rehab, she cleared out the powders from her bags, bedside drawers and car cubby, and took to her bed – ‘vomiting and drinking loads of water, like the doctor said. I thought my head would split open!’ she says.
After two days it grew easier, and she went back to work later ‘a new woman’. ‘If I had a headache I’d take a Panado and drink water. I haven’t had a headache in years.’
THE QUESTION
The question remains: who will alert the many people just beginning to abuse ‘cake’ – or those at risk of it? The small-print caution not to exceed the recommended dose simply doesn’t cut it on an innocentseeming product that promises relief. And, as Taverner says, even if every pharmacy adopted the Medipost practice, it wouldn’t protect those who buy them at their supermarket, garage or spaza, where they can lay their hands on any amount when their tolerance and ‘need’ grows.
And what of those who don’t read English or Afrikaans (directions are bilingual), or are illiterate? ‘A friend lives on a farm, and these meds are the farm shop’s top sellers,’ Annie says.
For some frustrated medical professionals who deal with the consequences, the solution is extreme. ‘Take it off the shelves’, urges one. But the reality is that while OTC painkillers can be abused, for millions of people they provide a safe, effective, affordable and convenient way to relieve pain. ‘And though there are many stories of significant side effects of these medications, we just don’t have the denominator to this equation: how many people develop reactions to them – or use them more frequently and in large doses – compared to the number of people who use them in total,’ says Roland van Rensburg.
Approached for comment, the manufacturers of Annie’s combination powders said: ‘As it’s clearly stated on packaging instruction for the product, OTC medicines are intended for low dose, short-term use. When used as directed, the product has a well-established safety profile and is approved as being an effective option for the short-term treatment of pain.’
Yet, equally clearly, people need to be better informed about the risks. ‘The manufacturers should ensure there are clear warnings on these products, preferably a simple, bold pictogram, tested on focus groups, that’s understood even by people who can’t read,’ says Mahomed. ‘They should include a toll-free helpline number.’ And if these medicines need to be available outside of pharmacies for public convenience, whoever sells them should have to keep a register, even a rural spaza shop. ‘After all, the dangers for people suffering side effects of misuse there are even higher than in the city.’
‘...we have to operate to fix potentially fatal...bleeding stomach ulcers, about every two months.’
Responsibility lies with manufacturers, says Neelaveni Padayachee, head of clinical pharmacology at Wits. ‘Pictograms and warnings in red are all possible solutions – but is there a will? A mass campaign on better use of these drugs is paramount, to prevent further issues.’
Roland van Rensburg concedes that ‘there’s room for improvement with regard to warnings on the box that are clearer and easier to understand’, and believes the best route to achieve this may lie in pharmacovigilance: the practice of monitoring the effects of medical drugs after they’ve been licensed for use, to identify and evaluate previously unreported adverse reactions. ‘With this, it’s the responsibility of the people using the medications and experiencing these side effects to report them to the manufacturing company or a medical professional.’ Medical professionals need to report these to the National Adverse Drug Events Monitoring Centre (part of SAHPRA), or via the Essential Medicines List Clinical Guide App, which feeds to SAHPRA, he says. ‘This is one of the surest ways to drive policy change to increase warnings and awareness of potential side effects of medications.’
Until then, we all need to start reading labels on anything we put into our bodies, from foods and beverages to medicines (especially medicines), however non-threatening they may seem. We also need to instill this in our families and encourage it in friends and through social networks.
Clair Hart is now on medication for life for her ulcers – yet she still carries powders with her when she goes hiking: ‘They’re my best quick fix. But now I only take the odd one, strictly as needed. I know if I take more, I’ll get more ulcers, and I’ll never risk that! It was a hard lesson, but I’ve learnt it.’