1

Abuse of Codeine Abuse of Codeine containing cough mixtures containing cough mixtures in Hong Kongin Hong Kong

Dr. CHOI KinDr. CHOI Kin

President, HKMAPresident, HKMA

7 September 20067 September 2006

2

Size of the problemSize of the problem

• Rising trendRising trend• Underestimating the size of the Underestimating the size of the

problemproblem

3

Size of the problemSize of the problem

4

Weight of the problemWeight of the problem

• 1,600 kg codeine imported yearly1,600 kg codeine imported yearly• 22 Manufacturers22 Manufacturers• 56% sold to pharmacies56% sold to pharmacies• 43% sold to doctors’ clinics43% sold to doctors’ clinics

5

Cost of the ProblemCost of the Problem

• 3.6 litres packing sold to clinics and ho3.6 litres packing sold to clinics and hospitals at $420/unitspitals at $420/unit

• Sold to pharmacies as 120 ml bottlesSold to pharmacies as 120 ml bottles• Retail at $50/ bottleRetail at $50/ bottle• 3.6 litres = 30 bottles 3.6 litres = 30 bottles • 30 bottles retail to young addicts yield 30 bottles retail to young addicts yield

$1,500 versus $420 sold to clinics and $1,500 versus $420 sold to clinics and hospitalshospitals

6

Rising cost of cough Rising cost of cough mixturesmixtures

Cost of Cough Mixtures

$60$75

$109 $110

$180

$280

$420

$0

$50

$100

$150

$200

$250

$300

$350

$400

$450

1985 1990 1991 1995 1998 2001 2006Year

Pri

ce

7

Bundling of sales of cough mixtBundling of sales of cough mixtures (1)ures (1)

8

Bundling of sales of cough Bundling of sales of cough mixtures (2)mixtures (2)

9

Survey in folate deficiency and its serioSurvey in folate deficiency and its serious consequences in drug abuse, with eus consequences in drug abuse, with emphasis on cough mixture abusemphasis on cough mixture abuse• There is a definite association between cough There is a definite association between cough

mixture abuse and folate deficiency. Folate defmixture abuse and folate deficiency. Folate deficiency will in turn cause severe damage to oneiciency will in turn cause severe damage to one’s brain and nervous system and even lead to ’s brain and nervous system and even lead to severe permanent disabilities. Pregnant mothesevere permanent disabilities. Pregnant mothers who indulge in cough mixture abuse would crs who indulge in cough mixture abuse would cause severe brain damage to the fetusause severe brain damage to the fetus

(Dr. WY Au from QMH supported by Beat Drugs F(Dr. WY Au from QMH supported by Beat Drugs Fund)und)

10

Cough mixture abuse – Cough mixture abuse – a unique situation of Hong Konga unique situation of Hong Kong

• Young abusers, starting from age 8 Young abusers, starting from age 8 onwardsonwards

• All walks of lifeAll walks of life• Financial situation of youngstersFinancial situation of youngsters• Difficult to quitDifficult to quit• Progress to other drug abuseProgress to other drug abuse

11

Is there a lack of supply in Is there a lack of supply in private doctors’ clinics? (1)private doctors’ clinics? (1)

Dr.York Chow’s reply in respond to DDr.York Chow’s reply in respond to Dr. KK Kwok’s enquiry in the Legislativr. KK Kwok’s enquiry in the Legislative Council on 24/5/06: e Council on 24/5/06:

““ 我們並沒有收到報告指市面上的含我們並沒有收到報告指市面上的含可待因的咳嗽藥物供應未能滿足病人可待因的咳嗽藥物供應未能滿足病人的醫藥需要。”的醫藥需要。”

12

Is there a lack of supply in Is there a lack of supply in private doctors’ clinics? (2)private doctors’ clinics? (2)

As a member of the Pharmacy and As a member of the Pharmacy and Poisons Board for 8 years, I have Poisons Board for 8 years, I have repeatedly reflected to the Board and repeatedly reflected to the Board and the Department of Health that private the Department of Health that private doctors have repeated complaint that doctors have repeated complaint that manufacturers repeatedly could not manufacturers repeatedly could not supply enough codeine containing supply enough codeine containing cough mixtures to private doctors.cough mixtures to private doctors.

13

The role and responsibility of The role and responsibility of the Department of Health (1)the Department of Health (1)

• We find the reply from the SWHF on 24We find the reply from the SWHF on 24/5 irresponsible /5 irresponsible

“ “ 醫生或藥房所選購的包裝類別、定價、醫生或藥房所選購的包裝類別、定價、銷售對象均屬商業決定。…我們的責任是銷售對象均屬商業決定。…我們的責任是確保市民有足夠有效的藥物使用。我們無確保市民有足夠有效的藥物使用。我們無意干預商業運作。”意干預商業運作。”

14

The role and responsibility of The role and responsibility of the Department of Health (2)the Department of Health (2)

• By allowing the quota of codeine to the By allowing the quota of codeine to the 22 manufacturers based on historical 22 manufacturers based on historical reasons, the Department of Health has a reasons, the Department of Health has a responsibility to ensure that supply to responsibility to ensure that supply to doctors and then to patients is secured doctors and then to patients is secured and bundling should not be allowedand bundling should not be allowed

• DH should not be seen to be involved DH should not be seen to be involved with price control by the manufacturerswith price control by the manufacturers

15

Discharging the sale of cough Discharging the sale of cough mixtures to pharmaciesmixtures to pharmacies

• The comment of the SHWF on 24/5/06 about The comment of the SHWF on 24/5/06 about family doctor sending their patients to comfamily doctor sending their patients to community pharmacies with a prescription to bmunity pharmacies with a prescription to buy cough mixtures reveal a total ignorance ouy cough mixtures reveal a total ignorance of the situation in the communityf the situation in the community

“ “ 現時除了醫生診所以外，病人亦可經醫生現時除了醫生診所以外，病人亦可經醫生處方在社區購買藥物。如果家庭醫生認為有處方在社區購買藥物。如果家庭醫生認為有需要，可考慮發處方給病人到社區藥房購藥。需要，可考慮發處方給病人到社區藥房購藥。””

16

Discharging the sale of cough Discharging the sale of cough mixtures to pharmaciesmixtures to pharmacies

• It pushes patients to get cough mixtures It pushes patients to get cough mixtures at a higher fee and force them to waste at a higher fee and force them to waste more time when they are sick to travel more time when they are sick to travel to a pharmacy to get medicineto a pharmacy to get medicine

17

Failure of test purchase (1)Failure of test purchase (1)

• 2006 first quarter : 610 test purchase2006 first quarter : 610 test purchase• No apprehensionNo apprehension

18

Failure of test purchase (2)Failure of test purchase (2)

一名一名 1313 歲少女昨凌晨由較年長的女性朋友帶歲少女昨凌晨由較年長的女性朋友帶往旺角一的士高消遣，期間初嘗往旺角一的士高消遣，期間初嘗 KK 仔後不適，仔後不適，結果暈倒街頭，送院後不治。結果暈倒街頭，送院後不治。 (( 經濟日報經濟日報 ))

19

Failure of test purchaseFailure of test purchase

• 2 raids in Wanchai and Mongkok2 raids in Wanchai and Mongkok• 3,400 bottles of cough mixtures 3,400 bottles of cough mixtures

seized in 4 pharmaciesseized in 4 pharmacies• WHY the DIFFERENCE?WHY the DIFFERENCE?

20

What has been done?What has been done?

• 生署同時增加試買次數，今年首季生署同時增加試買次數，今年首季 610610次的試買行動並未發現違例情況。次的試買行動並未發現違例情況。•採用多元模式，打擊濫用藥物（包括咳藥採用多元模式，打擊濫用藥物（包括咳藥水）的問題。 水）的問題。 •教育方面，繼續與禁毒常務委員會和非政教育方面，繼續與禁毒常務委員會和非政府機構緊密合作，透過多種途徑，包括學府機構緊密合作，透過多種途徑，包括學校學科課程、禁毒講座、宣傳小冊子及短校學科課程、禁毒講座、宣傳小冊子及短片的各種宣傳計劃，向市民灌輸正確的人片的各種宣傳計劃，向市民灌輸正確的人生觀及對濫用藥物禍害的知識。生觀及對濫用藥物禍害的知識。

21

What has been done?What has been done?

• 為了更有效教育青少年對毒品有正確的認為了更有效教育青少年對毒品有正確的認識及價值觀，當局已加強對家長及教師的識及價值觀，當局已加強對家長及教師的禁毒教育，加深他們對濫藥問題的認識，禁毒教育，加深他們對濫藥問題的認識，並鼓勵他們向青少年宣揚禁毒訊息。並鼓勵他們向青少年宣揚禁毒訊息。

• 參考學術界及其他機構所進行有關濫用咳參考學術界及其他機構所進行有關濫用咳藥水的研究報告，將有關的資料納入為宣藥水的研究報告，將有關的資料納入為宣傳教育的材料，並與前線禁毒工作者、社傳教育的材料，並與前線禁毒工作者、社工及醫護人員分享這些資訊，以加深他們工及醫護人員分享這些資訊，以加深他們對濫用咳藥水的認識，及裝備他們處理濫對濫用咳藥水的認識，及裝備他們處理濫用咳藥水的個案。 用咳藥水的個案。

22

What can be done? (1)What can be done? (1)

• ALL codeine containing cough ALL codeine containing cough mixtures should be prescription mixtures should be prescription items only and closely monitoreditems only and closely monitored

23

What can be done? (2)What can be done? (2)

• DH: All GOPD uses only DM DH: All GOPD uses only DM containing cough mixturescontaining cough mixtures

24

What can be done? (3)What can be done? (3)

• Heavy penaltyHeavy penalty