The Perceptions of Health Care Providers on the Current Therapeutic Utility of Codeine Containing Cough Syrups in Askira-Uba Local Government Area of Borno State Nigeria
Uthman Garba Sadiq*, Danjuma Charles Uba
Department of Ethno-Pharmacy, Faculty of Pharmacy, University of Maiduguri, Maidugri, Nigeria
To cite this article:
Uthman Garba Sadiq, Danjuma Charles Uba. The Perceptions of Health Care Providers on the Current Therapeutic Utility of Codeine Containing Cough Syrups in Askira-Uba Local Government Area of Borno State Nigeria. Advances in Psychology and Neuroscience. Special Issue: Substance Abuse: Perspectives, Trends, Issues and the Way Forward. Vol. 2, No. 2-1, 2017, pp. 1-6. doi: 10.11648/j.apn.s.2017020201.11
Received: July 17, 2016; Accepted: July 19, 2016; Published: February 14, 2017
Abstract: The non-medical consumption of codeine containing cough syrups (CCCS) in some communities of Northern Nigeria has become a subject of public concern of recent, largely due to its potential health hazards on the users and socio-economic impacts on the Society. The following work studied the drug prescribers’ and dispensers’ perceptions on the usage of CCCS within Askira Uba Local Government Area (LGA) of Borno State of Nigeria. The work aimed at understanding some health care providers’ views of the therapeutic relevance of CCCS against the background of its abuse in Askira/Uba LGA. A questionnaire based survey was conducted within the study area. Health care providers, categorised into prescribers and dispensers were recruited and administered structured questionnaire. The questionnaire basically addressed demography of health care providers and socio-political factors surrounding the therapeutic utility of CCCS. Data obtained were analysed using simple descriptive and inferential statics. The majority of the prescribers and dispensers were male of six to ten years of practice. The majority of patent medicine vendors did not support the idea of transferring CCCS from the Over-The-Counter (OTC) list to the Prescription-only-Medicine (PoM) list as against the perceptions of the other dispensers (pharmacists) as well as that of the prescribers. On the other hand, the notion of putting a ban on CCCS was supported by the majority of prescribers while the majority of the dispensers felt that a ban might not be necessary. Primary health care providers within Askira Uba LGA of Borno State have supported the idea of reclassifying CCCS from the OTC category to the PoM category with a view of controlling its distribution.
Keywords: Cough, Codeine, Narcotics, Askira-Uba, Borno State, Nigeria, Control Substances, Prescribers, Dispensers, Patent Drug Vendors
The relevance of cough as a useful physiological mechanism that clears foreign material and excess secretions from respiratory passages of human can never be over-emphasized. It should not be suppressed. However, in pathological cough, health care providers often use cough syrups to reduce the frequency or intensity of the cough. A category of such syrups that had gained wide acceptance because of its excellent central effects is the cough syrups containing opioids .
Cough suppression often occurs with lower doses of opioids than those needed for analgesia. A 10- or 20-mg oral dose of codeine, although ineffective for analgesia, produces a demonstrable antitussive effect, and higher doses produce even more suppression of chronic cough . Opioids commonly used in cough syrups include codeine, dextromethorphan, methorphan and other analogs of codeine. The use of codeine containing cough syrups (CCCS) - which is the most common type of opioid cough syrups - is limited by its abuse potential .
The non-medical consumption of codeine containing cough syrups (CCCS) in some communities of Northern Nigeria has become a subject of public concern of recent, largely due to its potential health hazards on the users and socio-economic impacts on the Society . It was reported that CCCS had been subject to abuse by teenagers and college students and fatalities often results after respiratory depression . Chronic CCCS abuse can induce physical and psychological dependence. It may cause serious damage to the brain and neuroimaging may further illustrate decreased striatal dopamine transporters in the brain .
Severe obsessive-compulsive disorder has also been observed among abusers of CCCS . Volume loss and aberrant functional organization in bilateral ventral medial prefrontal cortex (vmPFC) among CCCS users was also reported. Furthermore, the decreased vmPFC GM volume and attenuated functional connectivity of the vmPFC-inferior parietal lobe network were associated with clinical higher impulsivity trait in CCCS users .
An outcome of a national epidemiologic survey on codeine and related opiods in China, revealed that high prevalence of psychiatric disorders among nonmedical opioid users, particularly women .
In Nigeria, a press bulletin reported that the abuse of CCCS in Kano, especially among students and pupils in both secondary and primary school is quietly spreading like a wild fire on a wheat farm. Their mothers and aunties are major culprits too .
To curb this epidemic, the National Agency for Food and Drug Administration and Control (NAFDAC) is currently embarking on grass root awareness creation and sensitization campaign to warn the public of the risks of abuse/misuse of CCCS through campaign and talks in Schools and the use of Broadcasting media all over the Nation.
The Agency admitted that it has been confronted with rising cases of young persons and women abusing some cough syrups, especially codeine to get high.
The Federal Government of Nigeria had further enacted an act that ensured the transfer of CCCS from the ‘Over the Counter’ (OTC) list to the ‘Prescription only Medicines’ (PoM) (schedule) list. This invariably means that CCCS can only be obtained on presentation of genuine prescription from medically qualified personnel. However, the acceptability and impression of primary drug prescribers (medical doctors and community health extension workers) and dispensers (pharmacists and patent drug vendors) on the reclassification of CCCS to the scheduled list need to be ascertained so as to have a good idea of primary health providers’ perspective of the health dilemma.
The following work studied the drug prescribers’ and dispensers’ views on the usage of CCCS within Askira Uba Local Government Area (LGA) of Borno State of Nigeria, with the aim of understanding the primary health providers’ perspective of the menace.
2.1. Study Area
Askira/uba is one of the biggest LGAs of Borno State in North-Eastern Nigeria. The Headquarter is located in the town of Askira. It has an area of 2,362km2 and a population of 138,091 by 2006 preliminary census. Dominated by the Marghi tribe, it has a sizable population of Fulani tribes and others. It shares border with Chibok Local Government Area of Borno state from the North, while Hawul and Michika Local Government Areas from the West and East respectively. Hong Local Government Area of Adamawa State borders it from the South .
2.2. Study Population and Design
Health care providers practicing within the study area were recruited based on voluntary sampling for the survey. They were classified as either prescribers or dispensers. Prescribers were described as medical doctors and in some cases community health extension workers were included. Dispensers were defined as registered pharmacists, pharmacy assistants and patent medicine dealers. An observational descriptive design was adopted in the study.
2.3. Data Collection
Structured, mixed and non-disguised questionnaires were administered to the enrolled health care providers. The first part of the questionnaire addresses the demography and characteristics of respondents while the second part addresses the practices and opinions surrounding the therapeutic utility of CCCS under the present policy that is meant to address distribution.
2.4. Data Analysis
Data were grouped and presented in the form of frequency tables. Data was further analyzed by use of Statistical Package for Social Sciences (SPSS) version 16.0®. Chi-square analysis was used to test for statistical significance between categorical variables. A p-value of ≤ 0.05 was considered statistically significant.
The majority of the prescribers and dispensers were males of six to ten years of practice. The majority of patent medicine vendors did not support the idea of transferring CCCS from the OTC list to the PoM list as against the perceptions of the other dispensers (pharmacists) as well as that of the prescribers. On the other hand, the notion of putting a ban on CCCS was supported by the majority of prescribers while the majority of the dispensers felt that a ban might not be necessary.
|Area of practice|
|Number of years in practice|
|Reason for prescribing CCCS|
|Frequency Physicians prescribe CCCS|
|Frequency Physicians come across deliberate abuse by clients|
|Should CCCS be made POM|
|Should CCCS be Ban|
|Area of practice|
|Number of years in practice|
|Frequency Pharmacist come across CCCS Prescription|
|Perception of Pharmacists on Frequency clients that Visits Premises without prescription|
|Perception of Pharmacists on Age group of Clients that patronize Pharmacy|
|Perception on Gender that patronize Pharmacy more often|
|Category||Number of Bottles per Day||No of Pharmacy Shops||Percentage (%)|
|Turn-over Rates of CCCS|
|Should CCCS be made PoM|
|Should CCCS be Ban|
|Age of Drug vendor|
|20 & below||2||13.3|
|51 & above||1||6.7|
|Number of years in business|
|Number of bottles||14||1||6.7|
|Should CCCS be Ban||Yes||3||20|
Out of the 9 prescribers, of which they were all medical doctors, seven (77.8%) were males. The prescribers were fairly distributed between the clinical sub-units of general practice, gynaecology, dentistry and two specialists. The majority (55.6%) had 6 to 10 years of clinical experience (table 1).
Most of the prescribers recommends CCCS in managing patients presented with dry cough and this class of patients are not often seen (table 2). However, going by the report of Elwood (2002) users of CCCS on insurance, have learned which symptoms to describe to get a prescription for cough syrup . The majority of prescribers admitted coming across cases of deliberate misuse of CCCS by patients. All the prescribers supported the transfer of CCCS from the over the counter (OTC) list to the PoM list and 77.8% of them went ahead to support the idea putting a ban on the use of CCCS (table 2).
The Dangerous drug act of Nigeria classified Opioids and related drugs as schedule drugs (PCN 1990). Meaning that certain regulatory measures must be observed in their distributions and therapeutic usages. The quantity of codeine in CCCS was considered too little to warrant its inclusion in among the schedule drugs. Recently however, the Federal Government of Nigeria have reclassified CCCS as a schedule drug under the Dangerous drug act of 1990 to curtail its excessive abuse .
Of the 10 pharmacists enrolled in the study, only 1 is female. Half (50%) of the enrolled pharmacists have had 6 to 10 years of practice and 80% were in community pharmacy practice. The majority (70%) of the pharmacists described their encounter with cases of patients requesting CCCS without accompanying prescription paper as ‘not often’ and that 80% of the total request of CCCS were from the 20 to 30-year age category and they were all male. There was variable turnover rate of 5 to 30 bottles per day irrespective of the weather condition. All the pharmacists were of the opinion that CCCS should be maintained in the ‘PoM list’, 60% of which argued further that its usage should be banned. However, Howard and Huda believes that CCCS still has a place in managing pathological coughs .
Out of the 15 patent medicine vendors enrolled for the study, 10 (66.7%) were male. They mainly fall within the 21 to 30 age category and have been in business for 1 to 10 years. They have varying educational background ranging from primary school leaving certificates to diplomas (nursing, health technology, etc) and degrees. Those with degrees constituted the majority (26.7%). On the encounter with cases of patients requesting CCCS without prescription, 53.3% claimed that it is not often seen, despite the fact that they gave an estimated sales of 35 to 38 bottles per day. Most vendors (80%) do not see any need for transfer of CCCS from OTC list to PoM list and same proportion did not support the idea of putting a ban on sales of CCCS.
The selling of patent medicines appeared to be a lucrative job judging from the fact that degree holders with no health-related training have dominated the business and moreover, the majority thought that reclassifying CCCS to control drug category and/or putting a ban on it, is inappropriate. This popular idea of the patent medicine vendors might have been born out of fear of decreased turnover of sales of CCCS if reclassified. Statistical significant (p<0.05) correlation have been demonstrated between the two form of dispensers and the support of ban or reclassification of CCCS. None of the other demographic variables of the volunteers showed any statistically significant relationship with either the decision of reclassification and/or ban on CCCS.
Primary health care providers within Askira Uba LGA of Borno State have supported the idea of reclassifying CCCS from the OTC to PoM category with a view of controlling its distribution. Some, advocated the concept of putting a total ban on it. However, patent medicine dealers perceived such move as unhealthy to the overall well-being of the Society.