Tackling Nigeria’s codeine crisis is a marathon, not a sprint

“…drug abuse is with us. It’s happening closer to us than we can imagine. It’s wrecking our youths, our future, our pride. All hands must be on deck towards solving this problem.” – Pharm. Chijioke Onyia

One of the most talked about issues in the Nigerian health sector today, is the codeine crisis in Nigeria, and the government’s reaction to the issue. The story, an investigative documentary was aired by BBC Africa two weeks ago after correspondent Ruona Meyer went undercover to learn how the cough syrup turned street drug was getting into the black market. The documentary revealed how Meyer and her team unravelled the underground trade and highlighted how cough syrup was being sold by representatives of three major pharmaceutical companies in Nigeria. One of the representatives with Emzor Pharmaceutical boasted in the documentary that he could sell 1 million cartons of codeine containing cough syrup a week. This damning revelation quickly had the company distancing itself from the sales executive, who has since been fired. Meyer’s reason for investigating this issue was hinged partly on her brother’s experience as a codeine addict.

This piece of exceptional investigative journalism has stirred up vigorous debate in the country about the codeine crisis, which, although evident for years in some parts of Northern Nigeria, has not received the priority it deserves. The discussion has been particularly virulent on social media, and people did not hold back their feelings about the crisis.

In reaction to the release of the BBC video, the Minister of Health Professor Isaac Adewole, on May 1, 2018 announced that the Nigerian government had banned the issuance of permits for the importation of codeine. In addition to the ban, the National Agency for Food and Drug Administration and Control (NAFDAC) shortly afterwards announced the shut down of the three pharmaceutical companies indicted in the BBC video for their alleged involvement in codeine syrup black market sales; Emzor Pharmaceuticals Industry Limited, Peace Standard Pharmaceuticals Limited, and Bioraj Pharmaceuticals Limited. Emzor has since come out on social media to say that NAFDAC has only temporarily sealed one of its production sites, the liquid line.

Since the news of the ban was announced, there have been several online and offline arguments across Nigeria. The discussions have been centred on the ban imposed on pharmaceutical companies and whether the ban was the right solution to end the codeine crisis in Nigeria.

We ran a poll on our Twitter platform to gauge what people thought about the ban. More than a few comments also surfaced online as people debated the issue.

While these are compelling and critical discussions, it is not enough for us to spend too much time debating the narrow issue of whether the government should or should not have placed a ban. There are deeper issues involved, that we must resolve if we are to find a solution to this growing crisis.

Following the several conversations and our review of the situation, we have highlighted three key areas that may contribute to a final solution to the Codeine crisis in Nigeria.

Defining the size and dimensions of Nigeria’s codeine problem

Our first priority is to ascertain the size and distribution of the problem. The data flying around, including by officials on the Nigerian Senate has stated that 3 million bottles of codeine syrup are consumed daily in Kano and Jigawa states alone. However, it is unclear exactly where this data is from or how accurate it is. What are the national figures? Who is collecting the data? How is the data collected? Are there different patterns in different states? Are there particular age, gender or socioeconomic groups affected? What other data can we use to define the problem – school absenteeism? Hospital consultations? While anecdotal and other suggestive evidence indicate that the problem is entrenched and growing, working towards a solution requires accurate data to reveal the real magnitude of the problem. With credible data, we will be in a position to examine and make projections about the long-term impact of this problem. Some of these questions can be answered through relatively rapid to deploy well designed quantitative and qualitative studies, but it is critical that there are evidence-base underpinning proposed solutions. We cannot manage what we do not measure.

Defining a coherent and broad prevention strategy

The government’s ban, while understandable, should only be a first step in addressing the problem and should reflect the evidence base around the effectiveness of the prohibition of illicit substances and should, if deployed only be part of a wider strategy to address the problem. With better understanding of the magnitude of the crisis, backed by better data, we must then put in place a framework of primary, secondary and tertiary prevention strategies. Primary prevention will focus on stopping new cases of codeine abuse. We must begin a thoughtful, well-designed risk communication campaign communicating clearly to the public the dangers of codeine abuse, and saturating the airwaves and public spaces with anti-codeine abuse messaging, much as we have done with anti-tobacco messaging. Can we enlist some of our celebrities and public figures who are widely admired in the fight as Egypt has done with the footballer Mohammed Salah? Secondary prevention needs to focus on early detection and treatment of people who are affected and can be achieved by educating the public and clinicians about the early signs of codeine abuse or addiction. We should ensure that doctors and other health workers understand the problem, are able to educate their patients about the harm of codeine abuse and possess the right information to support or refer them for specialist help if needed. The education system should also play a role- we should think critically about how to train and support our teachers and educational institutions to respond to this crisis.

The government’s ban will not do away with the need by those who have already developed a problem from needing to use codeine. We must seek to understand the underlying reasons for people being drawn to abuse codeine- there are suggestions that undiagnosed mental illness, genetic predisposition and chronic pain may all be factors.

Regulation, of course, is an important part of any prevention strategy. Beyond banning the importation, perhaps this may be an opportunity for the government to improve the regulation and enforcement of existing regulations on sales of medicines, especially in open markets in Nigeria. Clinicians need to carefully assess patients’ legitimate clinical needs for sedatives, opioids and stimulants, to ensure that these medicines do not get into the wrong hands.

A cohesive prevention strategy will allow the country to tackle this problem from various angles. This will yield both short and long-term results.

Defining an approach to manage the existing problem – it will not disappear on its own

In the meantime, there is an existing crisis. For thousands of those suffering from codeine addiction, the ban only means that codeine syrup is bound to become scarce and even more expensive. We must, therefore, look at access to rehabilitation and treatment support services- are they enough? Are they well distributed across the country, matching the areas of need? Do they have the resources they need? Are they providing evidence-based care? The sight of patients chained up in the BBC documentary suggests there are clear areas for improvement. Are they effectively using substitution, treatment and societal reintegration to rehabilitate addicts? Civil society organisations such as Federation of Muslim Women Association of Nigeria (FOMWAN) and Youth Awareness Forum Against Drug Addiction (YAFODA)  in Kano, are already intervening with community-based approaches, and seeing some success. Can the lessons learned and models used be evaluated and spread more widely?

Members of Jajircewa group of Kwanar Dala with officials of FOMWAN Dala LGA and Kano state Amirah of FOMWAN. Photo credit: Nigeria Health Watch

Ultimately as a country, we must understand that this race to rid our nation of codeine abuse is a marathon, not a sprint, and not expect one-stop answers for such an entrenched problem.

Meyer says in the BBC Africa documentary; “Some journalists pursue stories for fun or for money; I am pursuing cough syrup, in anger, in rage, in love.” As a country, we must join Meyer to pursue this codeine addiction crisis out of Nigeria… in anger and rage against what it is doing to the next generation… out of love for our country’s young people and our nation’s future.