Samuel Adekola is the Chairman of the Association of Community Pharmacists of Nigeria. Adekola, who is formerly the Chairman of the Pharmaceutical Society of Nigeria (Ondo State) and National Vice Chairman of ACPN, talks about contemporary health and pharmaceutical matters in this interview with GBENRO ADEOYE
Lately, there have been several reports about an embarrassing prevalence of drug abuse and misuse in Nigeria, how bad is the problem?
Prescription drugs are intended to help us, but can end up hurting us when misused or abused. What truly is the difference between drug abuse and drug misuse as being witnessed in our climes? When a person misuses or abuses a prescription drug, there is no medical oversight of the risks. For example, a person who misuses or abuses opioids such as codeine-based drugs can die from respiratory failure. Prescription sedatives like benzodiazepines cause withdrawal seizures. The risks from these drugs are worse when they are combined with other drugs or alcohol.
Additionally, when a person misuses a prescription drug, even on a single occasion, that individual might enjoy the experience so much that they begin to seek out the drug more often. Thus, drug abuse and drug dependence are serious risks of misusing prescription drugs. To misuse a drug is to use a drug for purposes it is not intended for. Examples are using codeine-based cough suppressant for a headache, diazepam for nausea, or any other example of people believing a drug can make them ‘feel better’. Misuse involves not following medical instructions, but the person may not necessarily be looking to ‘get high’ from their use. If a person isn’t able to fall asleep after taking a single sleeping pill, they may take another pill an hour later, thinking that might induce sleep.
The features of drug misuse include taking a dose at the wrong time, forgetting to take a dose, stopping a medication too soon, accepting prescription medication from a friend and taking drugs for reasons other than what they were prescribed for. The diagnosis of dependence is clearest with opioids. But what is drug abuse? People who abuse drugs typically do not have a prescription for what they are taking. Not only do they use it in a way other than it is prescribed, they also use it to experience the feelings associated with the drug. Euphoria, relaxation and the general feeling of ‘getting high’ are always associated with drug abuse. The abuse of drugs in the opiate and benzodiazepine families frequently leads to unavoidable side effects, including dependency and addiction. For example, someone taking codeine-based medicines frequently with no prescription, no symptoms and believing they ‘need’ it in order to feel better is an example of drug abuse.
What do you think is responsible for the trend?
We contend with a new systemic collapse or is it outright failure? These youths are unemployed and underemployed, even if there is anything to engage them. Look at what is going on in northern Nigeria with tales of Islamic State’s West African Province (formerly called Boko Haram), killer herdsmen, banditry, terrorisms, kidnapping, armed robberies, assaults, assassinations, gunmen and other men of the underworld who are inflicting terror.
This might just be the beginning of a social revolution. The uneducated children and unemployed youths who have now embraced drug abuse are obviously settling scores with larger society.
Those people who think they are in comfort zones must think twice as this can only spread even to southern Nigeria. This is therefore the time to create jobs, institute welfare programmes and start rehabilitation of drug addicts in the six geo-political zones of Nigeria.
The Federal Government has banned the production and importation of tramadol and codeine but these things still find their way in; from your experience, what is the lasting solution to this?
I do not think the Federal Government has banned importation of tramadol and codeine. What was banned was the sale of codeine-based cough syrups to the consuming public. Codeine is still available in some combination products because it remains a potent analgesic despite the unfortunate abuse potential. The lasting solution is to ensure strict regulation and control in pharmaceutical premises where drugs are stocked and ensure same with drug products available for sale.
In this regard, Pharmacists Council of Nigeria, National Agency for Food and Drug Administration and Control and National Drug Law Enforcement Agency must be structured to collaborate to produce results for us. We must also ensure that the enabling statutes of some of these agencies are strengthened.
Some countries of the world like Saudi Arabia, Indonesia and Singapore have death penalty as punishment for drug trafficking. Do you think Nigeria should go that route to curb the problem?
Capital punishment has never proved to be enough detriment in human history. The strategy is that we must restrict and seriously reduce unhindered access to drugs. The committee on drug abuse led by Gen. Buba Marwa (retd.) posited that there were over one million unregistered premises in Nigeria. These unregistered premises are the sources of fake medicines and places where drug abuse thrives. We must therefore encourage government to be bold enough to deal with this menace by activating the regular ad hoc regulatory platforms.
There have been allegations that some pharmacists now take the role of doctors in some pharmacies, attending to patients and prescribing drugs. What should be the limit of the job of a pharmacist or even a community pharmacist?
There are issues of dispensing doctors and prescribing pharmacists. You cannot therefore blame one of the quarters. We are working on prescription rights and patterns under the auspices of the Federal Ministry of Health.
There are categories of medicines on a global classification and this includes Over the Counter, Pharmacists Initiated Medicines and Prescription Only Medicines. Pharmacists can dispense OTC and PIM in Nigeria.
Various arms in organised pharmacy have been clamouring for the assent of the new Pharmacy Bill. What are the advantages of this to the public?
ACPN has continued to evaluate recent public health concerns with regards to the increasing challenges of drug abuse and misuse in Nigeria. This development obviously further complicates the perennial woes of fake as well as fake drugs in our nation and naturally should bother all promoters of good pharmacy practice in Nigeria. We as part of a global community will continue to collaborate and strategise along the lines of global best practices, particularly with partners, including International Pharmaceutical Federation, World Health Organisation, African Pharmaceutical Forum and the West African Postgraduate College of Pharmacists to clamour for standards and ideals which will ultimately boost consumerism as well as professionalism in Nigeria. One of the major benefit packages of PCN bill is that it opens a unique window of competence driven service rendition at all levels. The new satellite pharmacy concept gives us the prospects of additional pharmaceutical premises in hundreds of thousand range manned by registered pharmacists. The bill provides that any pharmacist who has over 10 years of post-qualification experience can own a satellite pharmacy irrespective of his primary practice option. What this does is that professional service points in pharmacy will increase from about 5,000 we currently have to over 100,000 in Nigeria. The PCN Bill 2017 clearly prohibits sale of drugs in places such as open drug markets. This in essence is in tandem with the National Drug Distribution Guidelines – the official government tool structured to impose decorum in the unwieldy drug distribution channels which Nigeria currently contends with. The PCN bill in question has also removed all ambiguities with regards to offences and relevant commensurate sanctions applicable to all players.
This is particularly significant because owners of unregistered premises, those who sell products they are not legally licensed to sell and those who violate the condition precedence attached to their licensure will better appreciate the consequences of their unlawful endeavors and acts. Flowing directly from above, the PCN bill particularly compels pharmacists to show more responsibility in their professional practice. The need for discipline is showcased at greater heights because the disciplinary tribunal is geared to wield the big stick on erring pharmacists and pharmaceutical premises in the best interest of consumers of health.
The bill also has the unique feature of unhindered empowerment as all professionals and their cadres of practice are registered as distinct legal entities. It will therefore feature for public consumption a gazette of registered pharmacists, pharmacy technicians, registered retail, wholesale, importation, manufacturing and satellite pharmacies. The peculiar registration format will also highlight all patent and proprietary medicines vendors in Nigeria for proper scrutiny. It has also taken care of effective management of resources by presenting a robust yet broad spectrum structure that can work maximally in the interest of the pharma-sector to enhance service delivery at all times. Finally, the ACPN appeals to the Federal Government to heed this clarion call to engender a new agenda of productivity, professionalism, self-sufficiency in local production and regulatory excellence in the pharma-sector. These achievements will change the narratives and place the pharma-sector in good stead to contribute to the National Gross Domestic Product.
NAFDAC has clocked 25 years; in specific terms, what will you consider as the achievements of the agency?
Today, it is apt to laud the modest efforts of NAFDAC under the leadership of Prof Moji Adeyeye with regards to national development by documenting for posterity some obvious areas which include much better management of the internally generated revenue of NAFDAC. The seeming undue political exposure of NAFDAC appears to be drifting now to core professionalism which is the ideal in ultimate public interest. The efforts of NAFDAC under Prof. Adeyeye, who canvassed reduction in drug registration tariffs, are highly commendable, especially because a summation of this and other factors increases drug prices in Nigeria. We must also commend the concession in fees approved for small businesses to thrive. As pioneer players in the quest for a sanitised drug distribution agenda, the ACPN welcomes the collaborations between NAFDAC and PCN as championed through resolutions of the 2018 National Summit of the ACPN. But while we have made some strides in the last 18 months or so, we recognise some challenges that still need to be dealt with. These include non-adherence to designated ports of entries for drugs (both airports and seaports) which still encourages the distribution of fake medicines in Nigeria and continued sale of drugs in places where they are prohibited, including buses and other means of transportation. NAFDAC enforcement agents need to checkmate the influence of the night buses and other illegal modes of freight forwarding deployed to move fake drugs in our country.
It is our expectation that the NAFDAC management will reduce the time spent in the registration of drugs and other products, which appears unduly long as far as the businesses of manufacturers and importers are concerned.
Recently, a former Registrar of PCN was appointed as Chairman of PCN, a decision the Pharmaceutical Society of Nigeria has kicked against. What is the way out of this impasse?
This is a matter the PSN leadership, in conjunction with our contemporary past presidents, is dealing with effectively. We shall resist the temptation to deal with issues as personal matters. For the records, the fundamental issue remains that the Chairman of PCN is the Chairman of Disciplinary Tribunal of the profession. The tribunal has powers equivalent to that of a Federal High Court of Justice. As it stands, if there are disciplinary concerns with a Chairman-designate of the Disciplinary Tribunal, then how will orders and judgments of the tribunal stand in terms of integrity and sustainability, especially if such orders or judgments are challenged in court? Professions are grounded in ethics and therefore requisite professionals must stand on moral high grounds.
If we are desirous of redressing the challenges of value migration in larger society, we must start at the level of professional bodies, community development associations, socio-cultural bodies, and so on.
For us at ACPN we endorse the stand of the past presidents and incumbent president of PSN. Fortunately, dialogue with Federal Government on this matter has been fruitful so far and we shall ensure the spirit is sustained.
Some people are saying the situation shows that pharmacists do not only have problems with doctors, but also have problems with their professional colleagues. How would you react to this?
I do not believe in generalising things. You must resist a tendency to institutionalise pharmacists-doctors face-off. We can be good friends, but it is true we disagree occasionally for common good. If the PSN refuses to endorse a man for a position out of its over 20,000 membership, it cannot amount to conflict among pharmacists. If the man you are referring to is recommended for other positions outside our sector, I am not sure PSN or individual pharmacists will protest. You must however remember that conflicts are part and parcel of human relationships.
In 2018, some pharmacists said there was a dearth of community pharmacists in Nigeria and that the country needed 50,000 in five years. How serious is the problem?
Community pharmacies are health facilities based on the interpretation clause of the National Health Act. Community pharmacies are also the first point of call in all health systems, so Nigeria cannot be an exemption. As it stands today, community pharmacy is not rewarding financially speaking because of the activities of quacks and charlatans who are not restrained. They have actually overwhelmed the government and the regulators despite modest efforts.
The Federal Government needs to compel a joint team of the PCN and NAFDAC to dismantle the plethora of unregistered premises through provision of the necessary logistics, funding and security apparatus.
How has this shortage of community pharmacists affected the country’s healthcare coverage?
Fundamentally, it does in many ways which include the fact that unrestricted access to drugs is catalysed by the involvement of untrained hands in pharmacy. This ranges from auxiliary staff in private hospitals to medicine sellers who just dabble into drug business for financial gains. Primary care endeavours including immunisation, ante-natal care, family planning techniques, and so on would have received a big boost if community pharmacies that are professionally manned are involved.
How do you propose that the problem should be solved?
We need to dedicate more funds to pharmacy education by setting up more Faculties of Pharmacy for training willing students. The Federal Government and the various states governments must also create an enabling environment that guarantees reward for labour for pharmacists.
How would you describe the relationship between community pharmacists and community doctors?
It could be a lot better than what we currently have. The National Prescription Policy, which is binding on the private sector if carefully worked out with inputs from community pharmacists and doctors, will go a long way in bridging existing gaps between these professionals.
Would you say that the relationship and disparity in salaries between doctors and pharmacists in hospitals has now improved or is the situation still the same?
Government has not effectively tackled the welfare package of pharmacists and other health workers which is very sad. There are persisting and outstanding issues with regards to withheld salaries of our members, adjustment of CONHESS salary scale, consultancy cadre for hospital pharmacists and a comprehensive review of the University Teaching Hospital Act.
There is information that the Joint Health Sector Unions which you tend to align with has advanced its course with regards to welfare of public sector health workers. Can you confirm or deny this?
We salute the sagacity of the JOHESU leadership. It is true that the resolutions of the mediation by the Alternate Dispute Resolution have been entered today as consent judgment by the National Industrial Court of Nigeria. There are about 15 of such landmark resolutions, including the resolution to commence immediate implementation of central internship placements for eligible health professionals within four weeks from the execution of terms of ADR.
It is a comprehensive package and I celebrate this modest gain with our colleagues in the hospitals. The way things are going, the expectations of JOHESU members will eventually become success stories.
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