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03/01/2019

“Pain is the most common medical symptom worldwide,” Prof Truter says. “It intrigues me because it is so common and there is a story behind every pain condition – from physical pain, such as a broken leg or migraine – to emotional pain. There is also a strong addictive component to painkillers such as codeine – a mild, over-the-counter opioid available in South Africa.”

Prof Truter’s specific interest is the central nervous system and associated pain medication. She has done extensive research on combination analgesics, where one painkilling tablet or capsule contains more than one active ingredient, such as a combination of codeine, paracetamol, caffeine and antihistamine.

“Research shows that the widespread addiction to painkillers can start with legitimate treatment for a condition,” Prof Truter explains. “If you have cancer, for example, you might be prescribed a high dose of painkillers for a period which   is correct, but this is very different to routinely taking high doses of painkillers like codeine for no clear diagnosis.”

She says an alarming percentage of South African men and women are addicted to painkillers, and are taking anything from five to 20 or more painkillers a day. What they are not always aware of until it is too late, are the severe consequences, such as kidney and liver damage and extreme constipation.

“It’s essential to educate people better about this,” says Prof Truter, who presented on rational prescribing and best practice use and abuse of combination analgesics at the Pain South Africa Conference in 2017 in Cape Town and at the Pain South Africa regional seminar in Port Elizabeth in November 2017.

She explains that the mass overuse and abuse of painkillers is not just a South African problem, it is a continental problem, exacerbated by a wide range of highly effective adverts promising the end to pain. DURU master’s student, Lauren Campbell, started her research in 2017, which takes the form of a survey in Africa   to look at the prescription and usage patterns of opioids such as codeine.

She and Prof Truter emphasise that many of the combination analgesics are good products; the caveat is that it has to be the right dose for the right condition, prescribed for the right patient. “Currently, it is too easy to go with a shopping list of over-the- counter painkillers without understanding what they are doing to you,” says Campbell.

Pain research, including the many different aspects of pain treatment, pain management and public health, is one of the areas for which the DURU team is renowned.

“Our fourth year pharmacy students are looking at complementary and alternative methods for pain management, such as aromatherapy and homeopathy, as certain aromatic oils and homeopathic products are used for pain management,” Prof Truter explains.

Bernadette Louwrens, who graduated with her pharmacy master’s in 2017, is researching migraines. She surveyed 173 people in the Port Elizabeth, Uitenhage and Despatch districts who went to a pharmacy with a migraine prescription or who went into a pharmacy and said they had a migraine. The trigger factors ranged from red wine and mature cheese to stress, lack of sleep, preservatives, and sitting in front of a computer screen for too long. Louwrens, Prof Truter and statistician Theunis J. van W. Kotze authored a paper, published in 2018 in the journal Value in Health, on the seasonal variations in migraine attacks, with evidence of a rise in migraines as summer transitions to winter and vice versa.

For the rapid treatment of migraines, pharmacies sell over-the- counter migraine cocktails. At least one of the tablets in the cocktail contains codeine, which needs to be monitored, Truter explains. Codeine was rescheduled in South Africa in 2015. You can no longer go into a pharmacy and buy 100 combination analgesic tablets at a time; now you can only buy 40 tablets at a time, 10mg codeine per tablet. The over-the-counter availability of codeine in some other countries like Australia has also recently been changed.

“To limit the problem of multiple purchases of codeine at multiple pharmacies, an initiative known as the Codeine Care project has been proposed, aimed at creating links between pharmacies nationally, whereby if you buy codeine or if you have a prescription, you need to produce ID,” Prof Truter explains. “Your ID number, together with what you bought, when, and where, would then be recorded on a national database. All the pharmacies, clinics and GP practices would work together on this system, which will hopefully be implemented with National Health Insurance.”

A Research Dream

To be elected as a member of the World Health Organisation’s (WHO) International Working Group for Drug Statistics Methodology is to be recognised as a world leader in the field.  Prof Truter received this honour in 2017.

“We are establishing the standard doses of medications worldwide for the WHO’s Collaborating Centre for Drug Statistics Methodology in Norway, which is responsible for developing and maintaining the ATC Codes and DDD for pharmaceutical products globally,” says Prof Truter.

Each and every pharmaceutical product has to be linked to the appropriate Anatomical Therapeutic Chemical (ATC) code and defined daily dose (DDD). For monitoring and comparing drug use internationally it is important to ensure that the data retrieved is comparable. “Having a global standard helps us to set and compare usages and dosages between countries and to adjust doses where necessary,” Prof Truter explains.

An example of this is the research on the antiretroviral medication, efavirenz, by DURU research associate Dr Razia Gaida, who graduated with her pharmacy PhD in 2017. In its prescribed dose efavirenz can have neuropsychiatric side effects in certain patients, such as hallucinations and dizziness. Dr Gaida found that although there are instances of these side effects, the drug’s value currently outweighs these in most patients. In those patients experiencing side effects, these can be managed with adjustments in the dosage. Dr Gaida is now extending this research to TB patients through her postdoctoral work at the Human Sciences Research Council.

Contact information
Prof Ilse Truter
Professor in Pharmacy & Leader of DURU
Tel: 27 41 5042131
ilse.truter@mandela.ac.za