From prescription to addiction – your painkiller could kill you
Painkillers, sleeping tablets, tranquilisers – doctors prescribe them and pharmacists dispense them every day, but many suffering from pain, insomnia or anxiety are at risk from a “hidden pandemic” of addiction to prescription and over-the-counter (OTC) drugs.
Prescription drug addiction is a growing problem worldwide and the fastest-growing drug problem in the USA.[i] South Africa is not immune, with almost 1 in 5 adults suffering from chronic pain[ii] and up to 7% of rehab admissions being for addiction to prescription drugs.[iii]
In Drug Awareness Week, 20-26 June, pain management expert and South African Society of Psychiatrists (SASOP) member, Dr Shaquir Salduker highlighted that addiction and substance abuse problems are not only linked to illicit drugs such as heroin and cocaine, but also to prescription and over-the-counter drugs trusted and seen as “harmless” by patients.
These include opiate-based pain medications containing oxycodone, fentanyl, morphine or codeine, and many codeine-based OTC cough mixtures and cold and flu medications; benzodiazepines and “Z-drugs” used for anxiety and insomnia; and stimulants such as methylphenidate which should be reserved for the treatment of attention deficit-hyperactivity disorder (ADHD).
Opioid and benzodiazepine “highs”, feelings of euphoria, relaxation, tranquillity and pleasure, and the similar effects of stimulants along with high energy levels, can be highly addictive, and just as addictive as “street drugs”, he said.
“Opiates are the most addictive substance known to humankind. Just because these drugs are prescribed by physicians or stocked in pharmacies does not make the risk of addiction any less, nor are they any less likely than illicit drugs to cause long-term permanent damage to the individual’s brain function, overall mental and physical health, and ability to be a productive member of society,” Dr Salduker said.
Widely available over-the-counter for pain, coughs, colds and flu, codeine is the mostly commonly abused opiate in South Africa and is just as addictive as low-dose morphine,[iv] he said.
“Codeine when swallowed metabolises into morphine, and morphine is a close chemical relative of both opium and heroin. When an individual consumes large amounts of codeine, they are effectively consuming large amounts of morphine, with the same effect as consuming heroin.”
Misuse of pharmaceutical drugs for non-medicinal purposes has increased during the Covid-19 pandemic due to the impact of lockdowns on global supply chains which also affected illicit drug trafficking networks; closure of hospitality venues where “recreational” drugs like MDMA and cocaine are commonly used; and increased stress leading to more reliance on tranquilising drugs such as benzodiazepines.[v]
Overuse of prescription drugs can have similar long-term effects to “hard” drugs on brain function, moods, concentration and thinking abilities, as well as impacting on mental and physical health, with potential long-term organ damage and the risk of premature death by overdose.
Addiction to prescription medications – when an individual consumes the drug for non-medical reasons to the point of physical and psychological dependence – affects the ability to function at work, socially and in relationships, is frequently misdiagnosed as a mental illness, and may need admission to hospital or a substance abuse treatment facility.
Dr Salduker said that prescription drug addictions were difficult to pinpoint as the medication is initially prescribed for a genuine medical reason and addiction develops gradually over time. They are also harder to deal with as the drugs are easily available and cheaper than illicit street drugs.
Tolerance develops with continued use, leading the individual to take increasingly higher doses in order to achieve the same effect, and only realising they may be addicted when they try to stop taking the drug and find themselves unable to function and experiencing withdrawal symptoms.
“It is not unusual for patients to be self-medicating with OTC or low-schedule codeine-containing drugs such as combination painkillers (codeine combined with paracetamol and/or ibuprofen) or cough mixtures, and to have developed an incredible level of tolerance. They could be taking between 20 and 100 tablets a day and still be able to function without being noticed,” he said.
While some may not be aware that their self-medication has reached the level of addiction, others border on the illegal by badgering doctors to issue prescriptions with no diagnosis, persuade pharmacists to dispense without a prescription, go “doctor-shopping and pharmacy-hopping”, or even steal doctors’ prescription pads and forge the doctor’s signature.
These are all warning signs of addiction, Dr Salduker said,
“A key indicator of dependency and possible addiction is needing to take more of the drug to achieve the same effects, taking the medication for uses other than why they were prescribed, and intense cravings when stopping the medication or unable to obtain more. Behaviour such as watching the clock to see when the next dose can be taken, being worried whether one has enough supply and being defensive or secretive about taking the medication, are also critical warning signs.”
Prescription drug addiction can lead to dangerous drug-seeking behaviour – lying, stealing, seeking out illegal supplies – as well as the risk of developing further addictions to other drugs or alcohol, and negative behaviours such as compulsive gambling.
In addition to patients needing to be more aware of the risks of addiction from widely used prescription and OTC medications, Dr Salduker said that greater awareness and training for doctors and pharmacists of pain management and alternatives to opioid painkillers was needed.
“There are large numbers of people receiving codeine-containing analgesics and even stronger forms of opiates on an ongoing basis via prescription for chronic pain conditions without any long-term plan or sustainable option to manage these conditions.
“The entire pain management field is poorly understood and even more poorly managed and this becomes a fertile breeding ground for opiate abuse and dependency and the initiation of a vicious cycle of pain and increased medication.”
He called for a national awareness campaign on the dangers of opiates and benzodiazepines, and raising the scheduling level of opiates.
South Africa is one of few countries in the world where codeine-containing medications are available over-the-counter, with a “triple jeopardy” of being easily available, widely used and tolerance being quickly developed, leading to a high demand for more doses to achieve the same effect.
“While the problem of opiate addiction in the USA is much more pronounced and more widely reported in both scientific and popular media – leading to discussions about policy change and restricting the movement and prescription of these potent analgesics – in South Africa it is an underground problem. Even many medical professionals are unaware of the scale and devastating impact of addiction to these opioid-containing medications,” Dr Salduker said.
For this reason, he said that SASOP was lobbying the SA Health Products Regulatory Authority (SAHPRA) to have codeine-containing medications moved to a higher schedule with greater control over dispensing.
He warned that opioid-containing drugs should not be taken together with other central nervous depressants such as sleeping tablets, tranquilisers or anti-anxiety medication, or alcohol, as this could heighten effects such as drowsiness and potentially life-threatening respiratory suppression (difficulty breathing), as well as increasing the risk of addiction.
Meanwhile, he said, scientific studies have shown that “weak” opioids such as codeine are no more effective than paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs, eg ibuprofen) for pain such as post-surgery, while codeine is just as addictive as low-dose morphine.[vi]
For those suspecting they may be addicted to prescription medications, he advised seeking help and support. Medically-assisted detox and withdrawal might be needed; supported by counselling and psychotherapy to help manage withdrawal symptoms, understand the roots of a person’s vulnerability to addiction and help them get their lives back on track with improved life skills to manage pain and stress.
[i] Substance Abuse and Mental Health Services Administration (USA). Last Updated: 04/13/2022. https://www.samhsa.gov/homelessness-programs-resources/hpr-resources/rise-prescription-drug-misuse-abuse-impacting-teens
[ii] 18% of adults in SA experience pain constantly or on-and-off for 3 months or more.
Kamerman, Peter R, et al. July 2020. “Almost 1 in 5 South African adults have chronic pain: a prevalence study conducted in a large nationally representative sample.” In PAIN, Journal of the International Association for the Study of Pain. Vol 161, Issue 7. https://journals.lww.com/pain/Abstract/2020/07000/Almost_1_in_5_South_African_adults_have_chronic.19.aspx
[iii] SA Community Epidemiology Network on Drug Use (SACENDU). Research Update, March 2022. https://www.samrc.ac.za/sites/default/files/attachments/2022-06-07/SACENDU_Research%20Update_phase%2050.pdf
[iv] Prescrire International. "’Weak’ opioid analgesics. Codeine, dihydrocodeine and tramadol: no less risky than morphine”. 2016 Feb;25(168):45-50. https://pubmed.ncbi.nlm.nih.gov/27042732/
[v] UN Office on Drugs and Crime. World Drug Report 2021. Booklet 5. Covid-19 and Drugs: Impact, Outlook. https://www.unodc.org/unodc/en/data-and-analysis/wdr2021.html
[vi] Prescrire International. "’Weak’ opioid analgesics. Codeine, dihydrocodeine and tramadol: no less risky than morphine”. 2016 Feb;25(168):45-50. https://pubmed.ncbi.nlm.nih.gov/27042732/