Codeine ban: Know the new 'bride' dextromethorphan

Following the widespread abuse of codeine in the country, the Federal Ministry of Health recently directed the National Agency for Food and Drug Administration and Control (NAFDAC) to ban with immediate effect further issuance of permits for the importation of codeine as active pharmaceutical ingredient for cough preparations.

The ministry said, “Codeine containing syrups should be replaced with dextromethorphan which is less addictive.”

Dextromethorphan is an over the counter medicine that is chemically similar to prescription medicines for pain, like codeine and morphine. It suppresses the central nervous system (brain and spinal cord); it is a key ingredient in most over the counter cough medicines and also present in other medications, but can cause death in very high doses, according to experts. 

Dextromethorphan can also make people ‘high’ (feeling of euphoria) like codeine.

 According to Dr Adebimpe Alder, a psychiatrist with Melville Healthcare Resources, a mental health facility in Abuja, cough syrups containing dextromethorphan are also abused. She said it is far more likely that people will turn to dextromethorphan once the codeine base isn’t available.

“People abuse them also because they can also give an euphoric feeling and dissociative feeling,” she said.

How does this new bride resemble or differ from codeine? 

Pharmacist Lawrence Ikhide said in normal doses both codeine and dextromethorphan act on the central nervous system, and dextromethorphan produces more psychological effect and dependence than codeine. But it has less physical addiction when compared with codeine. 

Dependence, he said, is psychological and occurs when someone thinks he or she cannot do without a thing. For instance people believing they need to depend on drugs to cope with heart break, unemployment and to have confidence or boldness among others.

On the difference between codeine and dextromethorphan, he said the former depresses the respiratory system (affects breathing system) but that dextromethorphan doesn’t have that much effect on the respiratory system. However, it does have effect on rare occasions.

He said one major characteristic of dextromethorphan is that it causes ‘multiple behavioural syndrome’, that is it makes you have multiple personality.

“I can be a very good boy now but when I am under the influence of dextromethorphan, I can behave in three to four different ways: I can be very violent, do something devilish and unprintable but may not remember doing any of those things  when I come back to my senses. These are documented side effects when people abuse the drug or take it to get ‘high’,” said Pharmacist Ikhide.

He said dextromethorphan has been used as a recreational drug like codeine and is one of the most widely abused drugs in the United States of America today where it has nicknames such as Triple C, Skittles and Red Devils. 

In the US, he also said, overdose with dextromethorphan increased by 100% between year 2000 and 2003, adding “obviously they were controlling other drugs and left dextromethorphan. The mistake they made is what we are trying to repeat here.” 

He said some studies suggest that the effect of dextromethorphan is half that of codeine, meaning if one bottle of codeine gives an effect, it will take two bottles of dextromethorphan to give that effect.

The degree of the effect of drugs also varies from one individual to the other, adding that the effect of the abuse of dextromethorphan is worse than kidney and liver damage as it affects the whole system and causes the individuals to lose their personality, humanity and sense of responsibility.

The American College of Medical Toxicology said symptoms of  taking too much dextromethorphan are dependent on the amount ingested.  “Symptoms range from feeling more stimulated (lower doses); to euphoria, hallucinations, and out of body experiences (moderately high doses); to coma and even death (extremely high doses). Symptoms begin within a half hour of taking dextromethorphan and can last up to six hours or more.” 

Will codeine ban and introduction of dextromethorphan check the drug abuse situation in Nigeria?

Pharmacist Ikhide said banning codeine and introducing dextromethorphan  is not a solution to the abuse of drugs and substances amongst the populace. He said if you ban codeine, addicts look for the next available options. “If you bring dextromethorphan that is abused in countries where they have strong regulation, how can that be a solution here?” he said.

He said pharmacists have been working hard towards addressing drug abuse and sold codeine, which should ordinarily be N200 or N300, at N1500 and N2000 and that codeine containing cough syrups are not available in many pharmacies anymore.

However, he said Nigeria has porous borders and most addicts patronize the black market. He said the ban on codeine is akin to depriving local manufacturers and giving more money to those in the black market. 

“It is estimated that in Kano and its environs alone 4 million bottles of codeine are sold almost daily. If someone makes N500 from a bottle, multiply that by four million bottles, it runs into billions of naira, and many of these products come through the porous borders. So if you ban products from bodies you can regulate what of places where they come from where you cannot regulate?,” he said.

He said addressing the causes of addiction such as unemployment, watching the borders and increasing education on the dangers of addiction are the better options.

 “Statistics shows that a lot of youths have lost their jobs and many are unemployed. We should create job opportunities and a better environment for our youth. Let us also have a curriculum on drug addiction and its effects right from primary to secondary school. Let them know they are killing themselves.

Dr Albert Kelong Alkali, national chairman of the Association of Community Pharmacists of Nigeria (ACPN) said the ban on codeine will not do much except the open drug markets in the country are closed and the National drug Distribution Guidelines implemented.

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