Codeine's Global Influence: From Pain Relief to Concerns

Cough syrups are used by many of us during the winter when coughs and colds begin to reappear. However, some cough syrups have unfortunately caused a crisis in multiple countries in Africa due to the lack of testing in clinical trials, leading to many deaths and addictions amongst young people.

Throughout Nigeria, there are thousands of young people addicted to what is meant to be used as a cough suppressant - codeine cough syrup.

Codeine is an opioid which acts on the central nervous system to relieve mild to moderate pain. When it enters your body, it is broken down and converted into morphine. Codeine cough syrups only work when the body has broken it down to morphine, resulting in pain relief and the treatment of dry cough. However, some people’s bodies convert codeine to morphine faster than normal leading to high levels of morphine in their blood. This can lead to some severe effects such as breathing difficulties that could result in death, especially in children and young people below the age of 18. This addictive painkiller can also cause organ failure including the kidneys and trigger schizophrenia and hallucinations.

So, what has caused this epidemic of addiction all over Nigeria?

The sweet strawberry-tasting medicine has become a street drug all over the world but has particularly affected Nigeria. Young people mix the highly addictive cough syrup with drinks and even drink it by itself, as it leads to an elated mental state through intoxication. Dealers target schools, where young people are hooked once get a taste of it. According to the BBC, 3 million bottles were consumed in just 2 states, every day in 2018. There are a wide variety of reasons for why young people are addicted - many are depressed, whilst others succumb to peer pressure and the desire to be ‘trendy and cool’. Before 2018, codeine cough syrup was legal, but it was against the law to sell it to people who didn’t have a pharmaceutical licence or a prescription from a medical professional. However, on May 1st, 2018, the National Agency for Food and Drug Administration (NAFDAC) banned the production and importation of codeine-containing cough syrup. This occurred after the BBC exposed an executive of one of Nigeria's largest pharmaceutical companies, Emzor Pharmaceuticals, who was showing off about how he could sell 1 million cartons of the cough syrup in a week. This ban was attempting to reduce the widespread use of street drugs amongst young people and prevent pharmaceutical companies from illegally selling the syrup on the black market.

More recently, the World Health Organisation has become involved in this cough syrup crisis. In 2022, 66 children in The Gambia died due to cough syrup related injuries. These children consumed medicines such as Promethazine Oral Solution, Kofexmalin Baby Cough Syrup, Makoff Baby Cough Syrup and Magrip N Cold Syrup which were all manufactured by Maiden Pharmaceuticals Limited (Haryana, India). These syrups have potentially caused acute kidney injuries and many deaths causing the world to cast an eye on where these cough syrups are being manufactured - India.

The WHO had analysed the 4 products mentioned above and the conclusion was that these samples contained unacceptable amounts of diethylene glycol and ethylene glycol as contaminants. The company that manufactured these substandard products are Maiden Pharmaceuticals Limited - located in Haryana, India - and they were questioned by the WHO on the safety and quality of these products. They have not made any comments in regard to the syrups exported to The Gambia and how they failed to meet medical specifications. The risks of diethylene glycol and ethylene glycol in cough syrups given to young people are fatal as they can cause abdominal pain, vomiting, diarrhoea, altered mental states (e.g depression, delirium, and dementia) and acute kidney injuries resulting in serious injury and sometimes even death, in the case of the 66 children in The Gambia.

Indian authorities did shut down Maiden Pharmaceuticals, but this didn’t stop the substandard medicines being distributed to The Gambia which raised a question on India’s drug regulation. Despite this lethal scandal, India’s pharmaceutical industry is in full force which is concerning as India accounts for 20% of the global demand for drugs and 60% of vaccines used worldwide, and supplies about 50% of all of Africa's demand for generic medicine according to India’s Finance Minister, Nirmala Sitharaman.

These scandals show us that there still needs to be a lot done in the global pharmaceutical industry regarding regulation and the exportation of drugs containing harmful substances by healthcare companies, as it has had deadly consequences for the young people in Africa. There needs to be a closer examination done of large pharmaceutical companies in developing countries that are letting drugs sell without prescription and spurring addiction, causing hundreds of deaths and ruining lives.