Keywords: Codeine, pentazocine, tramadol, opioids, opiates, intoxication, tolerance, withdrawal, Nigeria.

Introduction.

Codeine/Pentazocine/Tramadol Misuse in Nigeria. What are opiates and opioids? And the effects of opioids in the body? How do opioids affect the brain?  Who is most susceptible to opioid abuse?  Is the abuse treatable?

These substances belong to a class of drugs grouped as opiates or opioids. Both the words opiates and opioids are usually used interchangeably. But they are actually different, even though they behave the same in the human brain.

What are opiates and opioids?

Opiates are actually natural substances extracted from the opium plant called opium poppy. These are also called Papaver somniferum. Opioids are synthetic substances made to behave like natural opium. Some opioids contain both synthetic and natural extracts. In this write up, the two words are going to be used interchangeably. Tramadol and Pentazocine belong to the opioids, while Codeine is an opiate.

These 3 substances are used in the medical world to relieve pain, both acute and chronic pain. They are also used to treat diarrhea, and suppress cough. But unfortunately, these have become increasingly drugs of abuse both globally and locally in Nigeria. About 4.6 million Nigerians abused opioids in 2017. And the abuse cuts across all classes of people in Nigeria. Even the healthcare workers are not left behind. In the southeastern part of Nigeria, 13.6% of health workers in tertiary health institutions abuse opioids. Then, the average age of initiating opioid abuse in Nigeria is 21 years.

1. Tramadol – Codeine/Pentazocine/Tramadol Misuse in Nigeria.      

This drug belongs to the opioid group. Tramadol comes as oral and injectable. Tramadol is the most opioid of abuse in Nigeria, according to studies. It is quite common among male gender in the Niger Delta.  Studies have it that about 85% of commercial bus drivers in Kano state abuse tramadol. In Owerri, 53.4% of undergraduates abuse tramadol.  It is also seen to be abused among secondary school students.

Those with chronic pain of arthritis, abuse it.  And those who do heavy duty work, like masonry, brick layers, herdsmen, farmers, etc. use it to boost their strength. Security officers make use of it to improve their boldness.  While men and commercial sex workers also use it increase their libido and to prolong sexual intercourse. 

And these studies believe that tramadol is a gateway to the abuse of other substances in Nigeria. Unfortunately, those who abuse tramadol in Nigeria, take very dangerous high doses.

2. Codeine – Codeine/Pentazocine/Tramadol Misuse in Nigeria.

This comes from the opium poppy plant. It is used orally to treat pain, stop diarrhea and suppress cough. So it comes as tablets and syrups and can be combined with other pain medications.  Recently, codeine now has an injectable form. Some people crush the tablets so as to snort it. When taken orally, codeine starts working within 30 minutes and the effects can last up to 2 hours.

Studies have it that codeine as cough syrup, is the most abused opioids by students in medical field.  About 96% of students in the medical field abuse formulations that have codeine, in one study in Nigeria. Out of these, 64.4% were medical students. Three million bottles of syrups containing codeine were reported to be abused on daily bases in northern Nigeria in 2018. Students mix the codeine with soft drinks.

3. Pentazocine – Codeine/Pentazocine/Tramadol Misuse in Nigeria.

This is an opioid that comes as an injectable via intramuscular, intravenous and subcutaneous. It can also come in tablets. Ant actually used in the medical field to treat pain, in surgical, obstetrics and orthopedics issues. It is also used for relieve of bone pain crisis in sickle cell disease.  Anesthetists use the medication to induce sleep.  The action starts within 15 to 30 minutes after oral administration. And it can last up to 3 or more hours.

The abuse of pentazocine is quite common in Nigeria, especially among health care workers. Persons living with sickle cell disease also abuse the medicine.

Those who abuse the medication commonly inject it at the buttocks area, upper and lower limbs. Some can even use the neck, chest and abdomen areas for the injection sites. They actually prefer hidden areas that cannot be easily seen by others.

Very dangerous high doses are used in majority of the abuse cases. And some of those suffering from sickle cell diseases may feign bone pain crises in order to get the prescriptions.

Ways Opioids affect the brain.

The actual mechanism of opioids in the brain is quite complex, but a little summery here will suffice. When any of the opiates or opioids is taken via any route, it gets to the brain via the blood stream. Once in the brain, it attaches itself to the receptors of the brain cells. These receptors are known as mu (µ), kappa (ĸ), delta (ɗ).

Once the opioid is attached to the receptors, it causes the release of brain chemical or neurotransmitter called dopamine. This dopamine makes the person have a pleasure feeling or the reward process or the ‘high’ feelng. It is this reward process that repeatedly motivates the person to continue or abuse the medication. This pleasure feeling is also stored in the person’s memory. So, even without pain, once the person is in the environment or with the people where the opioid was taken, the memory area is activated and the person craves for the opioid.

After some time of abuse, the receptors will become less sensitive to the starting dose of the opioid. So it will need a higher dose to get the receptors active again. This is called tolerance. It actually becomes a vicious cycle that higher doses are required to activate these receptors. This can be quite dangerous as the doses increases.

Apart from causing the release of dopamine, the opioids also block the release of a neurotransmitter called noradrenalin. It is the blocking of this noradrenalin that causes drowsiness, reduced breathing, reduced blood pressure, etc. But when the level of the opioid is low in the brain, noradrenalin is released, blood pressure and breathing increases, there is muscle pain, diarrhea, etc.

Intoxication symptoms of opioids.

At high dose, the person becomes intoxicated with opioids. The effects of intoxication include drowsiness, reduced breathing and blood pressure, euphoria (excessive happiness), constricted or pin point pupils, slurred speech, constipation, weight loss, etc. In very high dose, there is confusion, loss of consciousness, and death.

Withdrawal symptoms of Codeine/Pentazocine/Tramadol Misuse in Nigeria.

When a person addicted to opioids suddenly stops medicating self or reduces the dose, withdrawal symptoms occur. These symptoms include wakefulness and poor sleep, aches and pains with cramps, goose pimples, yawning and dilated pupils. . Others include excess tears, runny nose, fever, feeling cold, diarrhea, nausea, vomiting, and tremors. There are also fast breathing raised blood pressure and convulsions or seizures. Also, anxiety, agitation, and restlessness and craving occur.

These symptoms can start within minutes of stopping or reducing the medicine. And it can last up to 14 days or more.  

Who is most susceptible to opioid abuse?        

Actually, dependence on these opioids will occur if the medicines are taken for 4 to 8 weeks continuously. Not everyone who is exposed to opioid gets addicted or becomes dependent on the medicine. Studies have it that only 3% to 19% of people expose to these medicines become hooked.

1. Genetic predisposition.

If any of the parents or close relative abuse any of the medicines, then the risk for inheritance is high.

2. Environmental factors.

a. Psychosocial and cognitive risk factors:

These include being exposed to abuse in childhood such as adverse childhood experiences (ACEs). And these ACEs include community violence. Nigerian children are exposed to physical, psychological, sexual abuse, etc. And presently, they are increasingly exposed to community violence like kidnapping, insurgencies, farmer/herder clashes, etc.

Poor parenting methods can predispose to opioid abuse. Peer pressure is also a risk factor.

Other environmental factors are childhood delinquency, academic failures. Being hyperactive and impulsive or sensation seeking puts one at risk.

b. Economic hardship and unemployment:

 Poor socioeconomic status is also risk factors. Economic hardship and unemployment, or being raised in a family that is poor economically, are risk factors. Nigerians are presently going through economic hardship. Comparing Nigeria with other African countries like Tanzania, Nigeria has the largest number of people living in extreme poverty, i.e. 86.9 million Nigerians. Tanzania has 19.9 million of its citizens living in poverty. According to the National Bureau of Statistics, 33.3% of Nigerians are unemployed, as at end of 2020. The Chairman of the Presidential Economic Advisory Council (PEAC), expects unemployment to hit 40% by the end of 2021.

c. The ease of availability:

This is also risk a factor. Codeine and tramadol are still at easy reach to those who abuse them, despite restrictions. The Nigerian government is making efforts towards the prevention of the abuse of drugs. The National Drug Law Enforcement Agency (NDLEA) are seizing drugs and arresting drug abusers, etc. The Pharmacy Council of Nigeria has banned the open drug markets, etc. The National Agency of Food and Drugs Administration and Control, has banned the manufacturing and sales without prescriptions of codeine. Yet, despite all, these drugs are still accessible to the abusers.

The reason to this is corruption at all levels. This is especially among the custom officials and security agents at the borders and at the air and sea ports. So these drugs can be found in the open markets, where they can get to the pharmacists and patent medicine dealers. Even hawkers sell them at roadside stalls. Dealers may get these drugs in large quantities to the user’s homes.

The doctors and nurses have easy access, to the drugs, including pentazocine. So they can have ease of abuse. The doctors and pharmacists can prescribe for their friends who are abusers. Then the abusers can continue refilling their prescriptions old prescribed sheets. Thus the Codeine/Pentazocine/Tramadol Misuse in Nigeria, still rages.

Complications from Codeine/Pentazocine/Tramadol Misuse in Nigeria.

These include HIV and hepatitis from sharing needles, as well as kidney damage can occur. Mixing opioids with rohypnol, cannabis, water, juice, soft drinks or alcohol, is known as gutter water. These can lead to more deadly complications and death. Death can also come from respiratory depression and hypotension via tolerance or from suicide.

Others include reduced work output, relationship issues, promiscuity or sexual immorality, including teenage pregnancy. Those who abuse these medicines lie, cheat, commit theft, and violence.

The abuse of opioids can cause depressive disorders, anxiety, bipolar disorders, schizophrenia, etc. There are also other stress related issues.

Opioid abuse treatment.   

Those who abuse opioids can receive treatment. The treatment is geared to prevent the withdrawal symptoms which can be deadly. It is also geared to get the abuser stop the abuse and to treat any associated mental and physical illness. Yes, the road to recovery could be long, but it is possible.

The psychiatrist is consulted to administer medications that can prevent the withdrawal symptoms. The psychiatrist to treat any associated mental illness.

A clinical psychologist is to ensure that the patient becomes drug free and stays drug free. The therapist will use different methods to achieve these, such as cognitive behavioral therapy, individual and family therapy. Also motivational interview would be done to encourage the person to makeup his or her mind to stop.

The physician and surgeons can also come in if there are physical health conditions like HIV, organ damage, etc. Even those with chronic pain from surgery or other conditions, may require the services of the appropriate doctor.

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