Proposed stronger controls on codeine-containing medications will no doubt help many people struggling with codeine dependence. Cape Town addiction counsellor Brenda R* is one of them. She explains that, despite her deep knowledge of pharmacology, she went into full codeine addiction and could only recover after going into a treatment centre.As codeine dependence grows across the country, the South African Health Products Regulatory Authority (Sahpra) is scheduled to enact the Codeine Care Initiative to regulate the over-the-counter (OTC) dispensing of all codeine-containing products to the public.So subtle is codeine’s grip that even as an expert on addiction, Brenda didn’t realise she was becoming increasingly dependent on painkiller Myprodol, which contains 10mg of codeine, 200mg ibuprofen and 250mg paracetamol per capsule and is available OTC in pharmacies.Brenda found she couldn’t just stop taking the medication overnight; withdrawal can mean sweats, body ache, nausea and anxiety and has been compared to heroin withdrawal. This is because codeine is an opioid like morphine, which also comes from opium poppies. Whereas taking paracetamol and ibuprofen generally doesn’t lead to physical dependence, with opioids tolerance can set in, meaning they become less effective and the body needs higher doses for the relief of symptoms. Then can follow dependence, addiction, poisoning and, in high doses, death.Brenda says her path to addiction began when as a teen she had migraines. “I was given Pynstop, which contains paracetamol and codeine. Taking two painkillers every night became a habit but this led to more.” As her tolerance grew she began pharmacy-hopping to get her supply. “They took down my details, but still I could get 30 tablets every 10 days. Some pharmacies in my area don’t require any identity document, name or address to access OTC codeine products. Finally, I was taking nine capsules a day in doses of three.“One night I was trying to sleep but I was sweating, I felt nauseous and my body was sore. I thought, what did I do differently today? I realised I hadn’t taken any codeine tablets. I hadn’t realised my body was addicted to codeine, and I feel silly saying this [because she is an addiction counsellor]. I took two tablets and fell asleep. I contacted my psychiatrist and he said I should wean myself off by gradually tapering the dosage. But I struggled and could not get to zero.”After six weeks in a treatment centre, she’s relieved to be free of the addiction now. “I didn’t use codeine to make me feel high; I used it just to feel normal because if I didn’t take it, just like someone on heroin, if they don’t use, they get sick. [When it comes to addiction], all opioids are the same, whether it be heroin, morphine or tramadol.” I hadn’t realised my body was addicted to codeine, and I feel silly saying this. I took two tablets and fell asleep. I contacted my psychiatrist and he said I should wean myself off by gradually tapering the dosage. But I struggled and could not get to zero.”Had her supply been cut off she would have gone into withdrawal and gone for professional help sooner. “Codeine should be more regulated because of its addiction potential. It should be under prescription only through a GP.”However, doctors who prescribe codeine freely without education about this “dangerous substance” are part of the problem, says Dan Wolf, director of the Houghton House Group of Addiction Treatment Centres. “There may be a legitimate pain, such as after surgery, when the medication is prescribed. However, then it is adopted as a lifestyle and the result is a physical dependence.”Another challenge for people working in substance abuse rehabilitation is perceptions about addiction, in that most middle-class suburbanites don’t align themselves with someone who becomes addicted to party drugs such as cocaine. “Your dealer is someone in a white coat who works at a pharmacy. It’s a different denial to dismantle,” says Wolf.Young people are also finding ways to buy large quantities of codeine-containing cough syrup which they mix with Sprite to make a party drink called “lean”. It’s said to produce a euphoric high and, according to Sahpra, is endorsed by some Hollywood celebrities.Sahpra says the use of lean has reached “epidemic” levels. Two years ago, the body took over the Codeine Care Initiative, initially proposed in 2022 by the Stakeholders Forum on Codeine Care and Medicines with a potential for overuse, misuse and abuse, chaired by Dr Sham Moodley.Tracking codeinePharmacies can now opt in to record dispensing of codeine but this is a blunt tool because there is no central database. The proposed initiative would require all pharmacies and health providers in South Africa to digitally record the ID numbers of patients who bought or collected codeine, with the information feeding into a centralised computer system to help flag patients requesting too much of the drug across different dispensers. The new mandatory system would incorporate all role-players in the codeine supply chain and track the sales of manufacturers and wholesalers to ensure that companies were not supplying the opioid to unregistered outlets.According to Jackie Maimin, CEO of the Independent Community Pharmacy Association (ICPA), ensuring all dispensers of medicines are on the platform is a challenge. “It would need to be made mandatory, which only the statutory councils — the South African Pharmacy Council and Sahpra — can enact.”Initially, the ICPA worked with Sahpra on an implementation plan. “Sahpra then indicated that they required a complete end-to-end view of the codeine medicine market, not just the point of dispensing and not just pharmacies. They require a system that has a view from manufacture and/or importation of the active pharmaceutical ingredient, the manufacture of the medicine, and the distribution channels including distributors and wholesalers,” says Maimin. “Finally, dispensing practices at pharmacy, nurse and doctor level would be monitored, as the larger issue is leakage of the medicines in the supply chain.”Sahpra told Business Day it is working through comments on the proposed initiative. There has been a delay in implementation due to several committee member resignations, competing priorities and limited resources. However, it said the plan will be implemented this year as the body concurs that codeine-containing medicines are vulnerable to overuse, misuse, diversion and illegal distribution, including cross-border trafficking. “The absence of a centralised database and unified tracking and dispensing systems exacerbates these issues. The Codeine Care Initiative seeks to address these challenges by implementing a comprehensive system for monitoring, reporting, and education that engages all stakeholders in the pharmaceutical supply chain.”The initiative will help in reducing incidence of overuse, misuse and abuse; providing comprehensive data on codeine-containing medicine supply chain activity; strengthening regulatory oversight and enforcement; having an empowered healthcare professional at the point of dispensing with patient history and referral tools; enhanced patient education and awareness; promotion of and improved access to addiction support programmes; and preparations for inclusion of other vigilant initiatives.However, implementation is not straightforward as there may be cost barriers for patients. “If the initiative leads to ‘upscheduling’ [making codeine prescription-only], it could increase the cost of care for legitimate patients who must then pay for doctor consultations and prescriptions,” said Sahpra. In addition, the system would be dependent on electronic infrastructure. “The initiative requires licensed sellers to be connected electronically to upload data; those without this infrastructure cannot participate, creating gaps in the monitoring net.”Hopefully, Sahpra will resolve the foreseen challenges and enable stronger regulation to help more South Africans avoid the pitfalls of codeine addiction.* Name withheld.