Former President of Nigerian Association of Pharmacists and Pharmaceutical Scientists in the Americas (NAPPSA), Dr. Nkere Ebube has called for urgent action on drug abuse, describing it as a global crisis that transcends age group, gender, sex, ethnic group, political affiliation and economic class. Ebube who is also an Adjunct Professor of Pharmaceutics and Pharmaceutical Technology at Roosevelt University, USA in this interview with GABRIEL IFINNWA, said that opioid abuse has assumed epidemic proportion and advised the Nigerian Government to improve the healthcare delivery system in the country. Excerpts:
What is your opinion on opioid addiction?
Opioid abuse and addiction is a global crisis with epidemic proportion. It transcends culture, gender, and socio-economic class. Opioid epidemic is nearing a global pandemic, if not curtailed. In recent times, opioid abuse and addiction in Nigeria has seemingly attained a national crisis. It is on the verge of imploding into a pandemic of unprecedented proportion with some severe but crippling consequences, if drastic measures to check this epidemic is not taken. Some of the ensuing economic burden would include prohibitive cost of healthcare, loss of productivity, addiction treatment, and severe impact and drain on the criminal justice system. Opioids are a diverse class of drugs used for the treatment of moderate to severe pain. They include oxycodone (OxyContin& Percocet), hydrocodone (Vicodin), codeine, morphine, heroin, tramadol and a potent synthetic analogue, fentanyl.
The potency and availability of these drugs made them popular for use as formal medical treatments and recreational drugs, notwithstanding their abuse potential and substantial risk of overdose. Opioids produce sedative effects on the part of the brain that regulates breathing, and thus in high doses they may lead to respiratory depression resulting in respiratory failure and death. According to the United Nations Office on Drugs & Crime (UNODC) data, the estimated consumption of Cannabis among the population is 10.8%, followed by psychotropic drugs such as benzodiazepines and amphetamines (10.6%), heroin (1.6%) and cocaine (1.4%) in both urban and rural areas. Drug abuse appears to be more common in males (94%) than females (5.8%). In the United States, it is estimated that 115 Americans die every day from opioid overdose. This has been recognised as a national crisis that affects the public health as well as the social and economic welfare. The estimated economic burden in United States is $78.5 Billion a year. I am certain that accurate statistics on the effect of opioids abuse and misuse in Nigeria, when compiled and made available, would be equally devastating or even worse, on a relative term.
What measures can be put in place to prevent over prescription of opioids pain Killers and curb drug abuse?
This is a loaded question with no simple answer or resolution. The solution to this institutional endemic problem is as diverse as the root causes of the opioid epidemic, preponderance of recognised procurement and distribution channels of the drugs to the end users and abusers, paucity of effective drug laws and government regulations, surveillance of ethical professional practices amongst pharmacists, doctors, health administrators and allied key stakeholders to get these drugs out of the hands of abusers, state of the criminal justice system to persecute offenders – stiff penalty for illicit drug peddlers, quality of health education targeting schools, churches, mosques, etc., enforcement of drug screening programmes at the work place, availability of drug rehabilitation/ counselling centres at multiple locations in the country, and ability of government to provide alternatives – jobs, vocational training, etc. Succinctly, I would recommend a two-phase approach to addressing the problems of opioid abuse and addiction –
Overhaul the drug laws – no one can get a pain medication with potential for abuse without a prescription.
Pharmacists must keep records of all opioid drugs procured/ dispensed – records must be submitted to drug enforcement agency quarterly/ reviewed annually. Pharmacies must be equipped with a functional surveillance camera and must apply for annual quota based on projected sales volume.
Mandatory drug screening at the work place – coordinate unannounced screening with stiff penalty for abusers including termination.
NAFDAC must increase surveillance at the point of entry as well as track/ have records of drug distribution pathway. For drugs manufactured locally, the manufacturer must keep record of the API procurement and finished product distribution channels. Opioids cannot get to the hands of street drug peddlers.
Empower the criminal justice system – stiff penalty for drug abusers and peddlers. Medical professionals indicted for aiding drug abusers will be penalised including loss of license to practice.
Health education programmes – targeting churches, mosques, schools, etc. must be encouraged with opportunity to establish accessible drug recovery outposts.
Create jobs and alternative recreational activities for the youth – sports centres, computer centres, vocational centres, after-school programmes, etc.
Drug Enforcement Agency must be under NAFDAC to streamline drug regulation, closely monitor and control drug procurement, manufacturing and distribution.
Establish multiple centres for drug abuse treatments, counselling and rehabilitation – this must be mandatory for each State/ Local Government.
Create a mechanism to reward States with the least incidence of drug abuse through incentives programmes.
NAFDAC will partner with Pharmaceutical Companies/ Manufacturers to develop drugs with abuse resistance properties without compromising on the therapeutic benefits of the drugs. Opiates with proven abuse and alcohol resistant properties will receive accelerated approval/ release as an incentive to the manufacturer/ vendor.
Abuse of opioids such as Tramadol is on the rise in West Africa. How can the Government, particularly in Nigeria control this?
Tramadol is an opioid analgesic used for the treatment of moderate to severe pain. It is considered a relatively safer alternative to the other narcotic analgesics such as oxycodone, hydrocodone and methadone. However, it can produce euphoria like oxycodone and other opioids. The abusers appear to prefer Tramadol because of the perceived feeling of numbness from pain by the abusers. Moreover, the price of Tramadol is relatively cheaper than most of the other opioids. A 10-tablet strip of 100 mg Tramadol may cost approximately 100 Naira; whereas, it was reported that a strain of Marijuana may cost approximately 15,000 Naira for a small sachet. I believe that Nigerian Government can work with other West African countries to enact strict drug laws with stiff penalties, as well as create a mechanism to share intelligence information related to drug trafficking.
West African countries can pull together to create a drug trafficking & control patrol unit with a mandate to minimise drug trafficking and abuse across the entire sub-Saharan region. Nigeria can play a lead role with a centre at Abuja. This unit will monitor and track all opioids getting into the sub-continent by working very closely with appropriate local/ primary regulatory and drug enforcement agencies. A fundamental step towards truly curbing the opioids epidemics in Nigeria is to first recognise that this is a national crisis, more than anything that we have ever faced in the past. The threat is real and our future and survival as a country is at stake. The government and policy makers need to give the opioid epidemic adequate attention by providing necessary resources, framework and infrastructures to tackle this problem before it becomes a pandemic. The opioid epidemic presents a unique opportunity for Pharmacists and Doctors, both in Nigeria and the diaspora, to work closely together and with the rest of the medical community, legislatures, religious leaders, other key stakeholders, and the government to control the devastating menace and spread of this evil in Nigeria.
Russel Brand on alcoholism and drug addiction says –“The mentality and behaviour of drug addicts and alcoholics is wholly irrational until you understand that they are completely powerless over their addiction and unless they have a structured help, they have no hope.”
We should strive to offer hope. Hope comes through our collective resolve, structured and systematic engagements to make a perceptible difference in the fight against the opioid epidemics and abuse. Ironically, the grips of opioid epidemics transcend culture, religion, colour, race, gender, profession and political affiliations, or socio-economic strata. Perhaps, through our genuine efforts and resilience, we can offer hope and balance to our brother, sister, friend, father, mother, and neighbour. We can proudly hand over a clean, drug-free and prolific society and country to the future generation.
Some stakeholders have condemned the recent federal government ban on the production and sale of codeine cough syrup in Nigeria, citing that it would likely increase the boom of black market. What is your take on this?
Codeine, as indicated earlier, is an opioid analgesic. It is also used to reduce cough due to its antitussive properties. Like the opioids, it is addictive and when taken in excess can cause schizophrenia and organ failure. In Nigeria and across Africa, codeine syrup has been reported to be mixed with soft drinks and consumed by students and other abusers. It was estimated that over 3 million bottles of codeine syrup are consumed every day in just 2 states, Kano and Jigawa. In India, multiple brands of codeine cough syrup have been banned following reports of abuse and addiction. Following the recent BBC report and public outcry, codeine syrup was banned in Nigeria by the drug regulatory agency along with the ministry of health. I feel that the measure was a logical first step. This would enable the agency and the government to thoroughly evaluate the risks and safety of using this drug, and perhaps, put proper steps in place to adequately regulate the manufacture, importation and distribution of the drug. The health and safety risks associated with the use of the codeine syrup must outweigh the fear of the drug being sold in the black market. A thorough risk assessments, as well as risk-to-benefit evaluation must be performed. In United States, the Food and Drug Administration (FDA) is investigating the possible risk of using codeine syrup to treat cough and cold in children under the age of 18 years due to its serious side effects, including slowed or difficult breathing.
The drug regulatory agency (NAFDAC) should institute adequate surveillance and control at the points of entry to minimise illegal importation of the drug into the country. Similarly, NAFDAC should work with the law enforcement agency as well as ministry of justice to impose stiff penalties against anyone involved in unauthorised importation, manufacturing, and distribution or dispensing of codeine syrup. This is a matter of saving the lives of our children and the health of our nation. These cannot be compromised; our future as a nation is at stake.
TO BE CONTINUED NEXT EDITION