Codeine (3-methylmorphine) is an alkaloid morphine derivative found in opium. An alkaloid is a group of naturally occurring compounds consisting mostly of nitrogen atoms. Codeine is an opiate medication in the same class as other narcotic agents such as morphine and diamorphine (heroin). It has weaker analgesic and sedative
properties than morphine (its parent compound) and is commercially available as an antitussive (cough medicine) and painkilling remedy in single preparations, and in combination with other agents.

Pharmacokinetics Codeine is metabolised to morphine in the body by the cytochrome P450 enzyme (CYP) 2D6. As a narcotic medication, the mechanism of action of codeine is similar to other opioid drugs. It binds to specific (opioid receptor) sites in the brain with specialised receptors for endogenous (naturally occurring) neurotransmitters such as endorphin and dopamine. Codeine interacts with these receptors to block pain signals,
suppress cough impulse and act similarly to these endogenous neurotransmitters to achieve analgesia, reduce the sensation of fatigue and produce feelings of euphoria, relaxation and overall well-being.

Codeine is generally not addictive when used (intermittently) as a cough suppressant and for short-term relief of moderate to
severe pain. More prolonged use of larger quantities may, however, induce significant physical and psychological dependence on the drug.

The pleasure-inducing effect of opioid drug-use contributes significantly to the
potential of these substances to lead to dependence in the longer term. Codeine has become an extremely popular recreational drug among the youth in developing countries such as Nigeria. This article discusses a range of policy instruments useful for tackling the problem of codeine addiction and opiate misuse in Nigeria.

A conspiracy of ignorance Abusers of codeine and similar opioid substances tend very often to offer justification for their ostensibly “harmless” indulgence on the grounds of symptom-relief, a desire to gain more
energy and to “feel good” about themselves.

These justifications are reflected in a variety of articles written on the subject and shared across a wide range of demographic distinctions, for example, students and adult
professionals using codeine as a stimulant for “boosting” energy levels, and individuals taking advantage of its aphrodisiac properties! They conveniently ignore the addictive and anti-social consequences of drug misuse and focus erroneously on the illusory benefit supposedly derived from the illegal consumption of codeine and similar substances.

Education and public awarenessA concerted drive towards public education and
population awareness if successful would serve to dispel any misconceptions about the use of codeine. Community stakeholders, private organisations, schools and places of public worship (churches, mosques and others) must
be furnished with accurate information about the dangers of codeine dependence and thoroughly supported in the dissemination of this information throughout the community.

Healthcare professionals must actively
engage with the community in the propagation of these public awareness messages and seek to improve their knowledge for the benefit of patients and the public.

Re-classificationDoctors Without orders/Médecins Sans Frontières (MSF) maintain the argument that access to “essential medicines” such as painkillers should not be regarded as a luxury, especially in developing countries.

However, the scale of the problem that exists in Nigeria suggests an urgent need to achieve regulatory control and restricted access to codeine on the open market. The purpose of such restriction must not be to instigate a ban on the use of codeine as such extreme measures would serve only to drive an already dangerous trend further underground!

A system of drug re-classification has been applied to good effect in other countries where the clinical and socioeconomic impact of substance misuse has been deemed at some stage, sufficiently damaging to justify appropriate regulatory intervention and control.

re-classification of codeine as a scheduled controlled drug offers a unique opportunity to achieve regulatory control by transferring administrating responsibility to a system of governance procedures, accredited prescribers (doctors) and pharmaceutical providers, supported by a controlled drug register to ensure strict monitoring of prescribing patterns, compliance, inventory and safe disposal of all forms of opiate and controlled medication.

In conclusion The misuse of codeine and related opioid medication is a significant public health challenge in Nigeria in 2018. Tackling the problem will require a coherent and coordinated response, involving a collaboration of government agencies, private citizens and community stakeholders, each assuming responsibility for supporting a strategy of enhanced public education, robust pharmaceutical governance and effective regulatory control measures for the administration of codeine and opioid-related medicines throughout the
health sector