Medical Director, Federal Neuropsychiatric Hospital, Maiduguri, Dr Ibrahim Abdu, Wakawa, is an Associate Professor of Neuropsychiatry with the University of Maiduguri and a Chief Consultant Psychiatrist. The UNODC-certified master trainer for drug addiction treatment who has been involved in clinical services and research for over a decade and a half spoke with PEMBI DAVID-STEPHEN on mental health, addiction and ban on codeine by the Federal Government among other matters
How prevalent are psychiatric cases associated with codeine addiction in Nigeria?
It will be very difficult to give a national prevalence rate of psychiatric disorders associated with codeine use in the country since there are regional variations in the use and misuse of the substances as well as only a small percentage of people with substance use disorders present to the psychiatric facilities for treatment. In terms of the regional variations, for instance, alcohol and to some extent, cannabis, tend to be used more in parts of the north-central and southern parts of the country while stimulants, and of recent, Opioid-based substances like Tramadol and Codeine-Containing Cough Syrup (CCCS) tend to be more abused in the northern parts of the country. In terms of presentation to the hospital, most people who abuse codeine do not readily come to the hospital, because: first; drug abuse, generally, is seen as a moral problem rather than a medical problem, hence, they readily present to the clergy either for counselling or deliverance, second, straight forward drug use is not seen as a major problem by most of the populace except if accompanied by comorbid psychiatric disorder, and third, because of the stigma associated with treatment in psychiatric facilities, most people with drug-related problems will not present to the hospital, except if it is the last resort.
Thus, because of the problems enumerated above, coupled with the fact that most researches so far conducted are hospital-based, it will be very difficult to estimate the national prevalence of psychiatric disorders associated with codeine addiction. In our facility, the Federal Neuropsychiatric Hospital, Maiduguri, a recent research we conducted revealed that over 60 per cent of the patients who present with drug-related problems usually abuse an opioid-based drug, that is, either tramadol or codeine. And of this figure, about one-third of them abuse codeine. In terms of psychiatric disorders associated with codeine use, about 40 to 60 per cent of them have comorbid psychiatric diagnoses.
How severe can such mental disorders from codeine be?
The mental disorders associated with codeine use can vary from intoxication due to the intake of an abnormally large quantity which exceeds the usual dose and this can be characterized by staggered gait, slurred speech, irrational speech, and blurred vision. Clients who use codeine could also develop withdrawal symptoms, particularly in those who are addicted, and these include: abdominal cramps, running nose, teary eyes, diarrhoea, etc. In some patients, particularly those who abuse tramadol, they might develop frank seizures like someone with epilepsy. Psychiatric disorders such as depression, anxiety disorders and frank psychosis could also be witnessed.
Is there a possible treatment?
Treatment for opioid- based substances like codeine is available and there are different treatment centres that have been accredited by the United Nations Office on Drugs and Crimes (UNODC) across the country. Treatment consists of two phases or more, basically, detoxification and rehabilitation. Detox has to do with weaning the client off the drugs and managing withdrawal symptoms, while rehabilitation which is a more rigorous process that spans for between three to six months prepares the client for a life without drugs thereafter and how to prevent relapses as well as societal reintegration.
Can you estimate the number of cases the nation records in a year?
Different centres have different databases but, a national database known as Nigerian Epidemiological Network for Drug Use (NENDU) has been established which is domiciled with the Federal Ministry of Health. There, the number of cases that presented to the treatment facilities in a year can be obtained. I think, the credit here goes to the UNODC and the FMOH, under the leadership of Prof. Isaac Adewole for creating the conducive environment for us to have such a national database. We are the first country in the West African sub-region to have such.
When did you begin to notice increasing cases of mental disorder resulting codeine intake?
Actually, mental disorders associated with codeine abuse have been longstanding problems but national consciousness was recently awakened with the recent ‘Codeine Crisis’ in Northern Nigeria particularly in Kaduna-Kano-Jigawa axis.
What do you think is the attraction that draws the youths to this substance?
There is no single factor that could be held responsible for youth attraction to this substance but a combination of so many factors that serve to escalate the epidemic. Opioid-based substances generally give a sense of euphoria and could also sedate. The combination of these factors serve to give the person using it a transient sense of relief from whatever crisis the person might be going through akin to the ‘fools’ paradise’. Other factors such as the availability of the drugs due to encumbrances on the parts of enforcement and regulatory agencies, peer group pressure, youth unemployment, social anarchy and the influences of globalization have also not helped matters.
Is the ban by government enough to stop the consumption of that substance?
The ban on Codeine-Containing Cough Syrup is a commendable step but definitely not enough. Drug addicts have a way of finding alternatives whenever, they could not get their usual drugs. Both CCCS and Tramadol are Opioid-based drugs, now CCCS is banned but Tramadol is readily available, it is just going to be a matter of time before, they switch on to that drug. I think a more holistic approach that encompasses ban on Opioid-based substances should have been more appropriate. Secondly, we have limited number of treatment centres for clients with addiction problems, how do we handle the millions that are already hooked to the drugs. I think earnestly, intervention in phases would have been more humane but definitely, it is highly commendable.
Why do you think youths in this part of the country are mostly exposed to drugs?
The reason is simple, like I earlier mentioned, the drugs are readily available and there are enforcement and regulatory challenges. There is also a breakdown of the societal fabrics, in that, nobody wants to take responsibility for correcting the erroneous child.
In your opinion, who should be held responsible for this?
Everybody is to be held responsible. All hands must be on deck to correct this social ill. From government agencies, non-governmental organizations, school authorities, religious and community leaders, parents, youth groups, as well as law enforcement agencies.
How many affected addicts do you receive in a week or monthly basis?
Let me correct one impression, the term ‘addict’ is derogatory and stigmatizing, we prefer using the term ‘Person with Substance use Disorder’ that boosts their self esteem. It depends, but on the average, we see 40 persons with substance use disorders in a month.
From your records, who is more affected: male or female?
Both gender are affected, but in terms of hospital presentation, males present more. This may be associated with socio-cultural factors such as seeing female drug use as a taboo in our sub-culture as well as the attendant stigma associated with it.
What other substance, from your experience, are Nigerian youths exposed to and abuse?
Many others. I will not like to mention them here in order not to increase the list on their menu for those who do not know some of the drugs yet. But you will be surprised at the list if I mention some of the apart from the conventional ones.
Is the ban on the production and sale of codeine the most appropriate solution to this problem?
It is a step in the right direction but a lot more has to be done.
Which is more effective in the treatment of drug based mental illnesses: the traditional or the modern?
Obviously, as a clinician, I will serve as an advocate for the modern conventional treatment because it has a definitive protocol which is evidence-based and is compatible with global best practices. But I have read of eclectic approaches in other climes that have also been proven to be effective.
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