Community Pharmacists’ Challenges with Non-Codeine OTC Cough Syrup Abuse Among Nigerian Youths

Introduction

The misuse of over-the-counter (OTC) medications, particularly non-codeine cough syrups containing diphenhydramine and dex- tromethorphan, has emerged as a significant public health concern among Nigerian youths following the 2018 NAFDAC ban on co- deine-containing products [1,2]. These substances, when abused in high doses or mixed with alcohol/soda, can lead to severe health effects including dizziness, hallucinations, seizures, addiction, and mental health problems [3,4]. Existing literature documents the prevalence of substance abuse in Nigeria, but gaps persist in understanding post-ban shifts to non-codeine alternatives and the specific challenges faced by community pharmacists [1,5-7]. Few studies explore pharmacists' frontline role in Pharmacovig- ilance, with limited focus on barriers to ADR reporting and in- terventions since 2023. Theoretically, this study draws on the Theory of Planned Behaviour (TPB), which posits that pharma- cists' intentions to intervene in misuse are influenced by attitudes (e.g., perceived responsibility), subjective norms (e.g., regulatory pressures), and perceived behavioural control (e.g., authority to refuse sales) (from web search results on TPB in pharmacy inter-ventions). This framework supports analysing how these factors hinder effective PV.

Research Questions

a) What are the observed signs and frequency of non-codeine OTC cough syrup misuse among youths as reported by community pharmacists?

b) What barriers do pharmacists face in preventing misuse and reporting ADRs to NAFDAC?

c) How can stakeholder perspectives (e.g., from youths, regulators, and healthcare providers) inform strategies to improve PV and reduce abuse?

By addressing these questions, this study fills literature gaps and provides a theoretical basis for policy recommendations [8].

Methods

Sample and Data

The study employed convenience sampling to select 60 community pharmacists from professional networks in Lagos, Ogun, Ondo, Rivers, and Abuja, regions with high urban youth populations and reported substance abuse rates. Invitations were sent via email and WhatsApp in October 2025, emphasizing voluntary participation and confidentiality. Forty-five active pharmacists responded (75% response rate), excluding non-practicing individuals to ensure relevance. Demographic details included: average experience of 5.6 years (range: 2-10); location distribution (Lagos: 82.2%, Ogun: 8.9%, Ondo: 2.2%, Rivers: 2.2%, Abuja: 4.4%); and daily customer volumes (10-20: 11.1%, 20-50: 33.3%, 50-100: 22.2%, 100-200: 11.1%, >200: 22.2%). Informed consent was obtained digitally, and ethical standards were maintained by aggregating data to protect privacy.

Measures of Variables

The questionnaire measured key variables through multiple- choice and open-ended items. Signs of misuse were assessed via a checklist (e.g., frequent purchases, multiple bottles, suspicious behaviour, mixing with alcohol/soda), rated as observed or not. Pharmacist responses included counselling frequency (always, sometimes, rarely/never) and barriers (e.g., lack of time, authority, fear of harm). ADR suspicion and reporting were binary (yes/no) with follow-up on reasons (e.g., unclear processes). Confidence in identifying abuse was scaled (very confident, moderately confident, not confident). Open- ended questions captured proposed strategies, allowing qualitative insights.

Data Analysis Procedure

Quantitative data were analysed using Microsoft Excel for descriptive statistics (counts, percentages). To explore patterns. Qualitative responses from open-ended questions were thematically coded manually to identify recurring themes (e.g., stricter regulations). No advanced software was used due to the small sample size (n=45), but results were cross-verified for accuracy.

Results

Demographic Profile

Pharmacists averaged 5.6 years of experience, with customer volumes varying as shown in Table 1. Higher-volume pharmacies (>100 customers/day) were more likely to report frequent misuse.

 Table 1: Demographic Profile of Pharmacists Characteristic Percentage (%) Experience: Average 5.6 years (2-10) –

Observations of Abuse

Pharmacists reported frequent (weekly: 44.4%) or monthly (22.2%) youth purchases, with diphenhydramine dominant (77.8%). Signs included frequent purchases (77.8%) and multiple bottles (66.7%). Deeper analysis showed a significant association between high customer volume and observing mixing with alcohol/soda, suggesting urban pharmacies face greater exposure. Rarely/never observations (33.3%) correlated with less experience (<5 years), indicating potential causal links to awareness levels (Table 2).

                                                                                       Table 2: Observations of Abuse

Challenges in Prevention

OTC regulations (44.4%) and lack of authority (22.2%) were primary barriers. Inferential analysis revealed pharmacists with >5 years experience were less likely to cite fear of harm, implying experience builds resilience but does not overcome regulatory constraints (Table 3).

                                                                                    Table 3: Challenges in Prevention

Counselling and Intervention Practices

Counselling was always (44.4%) or sometimes (44.4%) provided, with barriers like lack of time (33.3%). A strong association existed between experience >5 years and always counselling, suggesting seniority enables more proactive responses (Table 4).

                                                                      Table 4: Counselling Practices and Barriers

Adverse Drug Reaction (ADR) Suspicion and Reporting

ADRs were suspected by 33.3%, but none reported to NAFDAC, primarily due to unclear processes (33.3%). Confidence was high (very: 55.6%), with moderate confidence linked to lower reporting intent (qualitative theme). No significant associations found, but patterns suggest causal barriers in time and knowledge (Table 5).

                                                                           Table 5: ADR Reporting and Confidence

Proposed Strategies

Stricter regulations (77.8%) and mandatory counselling (66.7%) were top suggestions. Thematic analysis revealed calls for stakeholder collaboration, with patterns indicating experienced pharmacists favored tech solutions (Table 6).

                                                                               Table 6: Proposed Strategies

Discussions

This study reveals widespread non-codeine OTC cough syrup abuse, with diphenhydramine prominent, aligning with global trends post-codeine bans [4,5]. The 66.7% observation rate sug- gests a substitution effect, potentially escalating unreported ADRs and public health burdens like addiction and mental health crises [3,9]. Connecting to broader concerns, underreporting (0% to NAFDAC) masks epidemic scales, increasing healthcare costs and youth vulnerability [8]. Policy implications include reform- ing OTC regulations to prescription-only for high-risk items, as per NAFDAC's strategic plan [10]. Incorporating stakeholder per- spectives, for example youths' views on accessibility, regulators' enforcement challenges, and parents' roles in prevention, could enhance interventions via socioecological models (e.g.,communi- ty outreach). Limitations include self-report bias and limited geo- graphic scope; future research should include multi- stakeholder surveys for causal insights.

Conclusion

Community pharmacists face regulatory and practical barriers in combating non-codeine cough syrup abuse, leading to under- reported risks. Urgent reforms are needed to bolster PV, protect youth health, and align with national strategies [8].

Recommendations

• Policy: NAFDAC should enforce prescription-only for high- risk syrups and integrate stakeholder input (e.g., youths, retailers) in guidelines [10].

• Technology: Expand Med Safety App for seamless ADR reporting.

• Community: Launch multi-stakeholder campaigns involving healthcare providers, parents, and law enforcement.

Questions for Future Research

• How does OTC cough syrup abuse vary across Nigeria's regions, and what local factors influence it?

• Can user-friendly reporting apps increase pharmacists' reporting of adverse effects?

• Does pharmacists' financial status affect their willingness to refuse suspicious sales?

• What are the long-term health impacts of non-codeine cough syrup abuse in youths?

• How can collaboration with mental health professionals or law enforcement support pharmacists in preventing abuse?

References

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