Use of codeine-containing medicines by Irish psychiatric inpatients before and after regulatory limitations on their supply

Bioactive Secondary Metabolites from Plant Sources: Types, Synthesis, and Their Therapeutic Uses

Plants are the source of various photochemicals; metabolites are used in medicinal and environmental sectors as well as being widely used in commercial and pharmaceutical products. Although they produce a number of medicinal products, either already on the market or under trial, the amounts obtained from plant sources are very minute or difficult to synthesize at an industrial level due to the complex chemical composition and chirality exhibited by these compounds. However, plant cell cultures offer a good alternative for the consistent production of desired secondary metabolites under the influence of precursors and elicitors. In this review, we discuss the various aspects of secondary metabolites, production synthesis, and sources of medical products from plant sources.

A mixed-methods systematic review of the prevalence, reasons, associated harms and risk-reduction interventions of over-the-counter (OTC) medicines misuse, abuse and dependence in adults

Background

Over-the-counter (OTC) medicines are typically safe. However, there is evidence that OTC medicines can sometimes cause harm as a result of their misuse, abuse and dependence.

Aim of the review

To review the literature on OTC medicines misuse, abuse and dependence in adults and identify the implicated medicines, contributing factors, associated harms and risk-mitigating interventions.

Methods

Following PRISMA guidelines, electronic databases including Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, MEDLINE, PsycINFO Web of Science and Google Scholar were searched for peer-reviewed journal articles published in English between January 2011 and March 2019. Quantitative, qualitative and mixed-methods studies assessing aspects of misuse, abuse and dependence of OTC medicines in individuals aged 18 years or more were included. Studies that solely focused on adolescents only, doping in sports or abuse of OTC medicines in people who are substance abusers were excluded. The random effect meta-analysis model was used to pool the prevalence among the population-based studies.

Results

Of 2355 peer-reviewed studies initially identified, 53 were included in this review. According to the study design, the prevalence varied, but the overall pooled prevalence in the population-based studies was: 16.2% for misuse, 2.0% for abuse, and 7.2% for dependence. The common OTC medicines groups involved in the problematic use were analgesics (with or without codeine), sedative antihistamines, cough mixtures containing dextromethorphan. Physical, psychological, social and financial harms were associated with problematic use of OTC medicines in addition to hospitalisation and death. Interventions for the affected individuals were provided mainly through the community pharmacies, general practices and specialised addiction centres.

Conclusion

The problematic use of OTC medicines is quite prevalent in adults, necessitating raising public awareness about their safe use. In addition, innovative harm minimisation models need to be developed, evaluated and implemented across health care settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40545-021-00350-7.

Trends in strong opioid prescribing in Ireland: A repeated cross-sectional analysis of a national pharmacy claims database between 2010 and 2019

PURPOSE

Significant increases in opioid utilisation have been reported in many countries in recent decades. This study investigated strong opioid prescribing in Irish General Medical Services (GMS) patients over a 10-year period.

METHODS

A retrospective repeated cross-sectional analysis of a national pharmacy claims database between January 2010 and December 2019 was conducted. Strong opioid prescribing in GMS patients was evaluated, including by route of administration, age (16-64 years and ≥65 years) and gender. Measures of consumption included prescribing prevalence and defined daily dose (DDD)/1000 population/day. Prevalence ratios (PRs) with 95% confidence intervals (CIs), and percentage and absolute changes were determined.

RESULTS

Strong opioid prescribing prevalence increased from 14.43% in 2010 to 16.28% in 2019, with the greatest increase in the ≥65 years age group. Tramadol was the most frequently prescribed product, constituting 63.9% of total strong opioid prescribing. The prescribing prevalence of oxycodone increased from 0.95% in 2010 to 2.68% in 2019 (PR 2.81, 95% CI 2.76, 2.87), with steep increases in oxycodone-naloxone since it became available (PR 5.23, 95% CI 4.98, 5.50). The prescribing prevalence of tapentadol increased from 0.18% to 1.58% between 2012 (first complete year available for reimbursement) and 2019 (PR 8.79, 95% CI 8.43, 9.16). Strong opioid prescribing was highest in females aged ≥65 years.

CONCLUSIONS

This study found an overall increase in strong opioid prescribing in Ireland between 2010 and 2019, particularly in older adults. Tramadol was the most frequently prescribed product, with oxycodone and tapentadol prescribing increasing markedly over the study period.

Experiences of Codeine Use, Misuse and Dependence: Application of Liese and Franz's Cognitive Developmental Model of Substance Abuse

BACKGROUND

Misuse of codeine-containing medicines is an emerging public health issue.

AIMS

We present the application of Liese and Franz's (1996) cognitive developmental model of substance abuse to the trajectory from legitimate codeine use for pain, towards that of therapeutic and other forms of misuse, and physical and psychological dependence. It illustrates a cognitive behavioural analysis of the experiences of codeine misusers - which 'surfaces' the specific beliefs, thoughts, emotions and behaviours of this group of hidden codeine dependent individuals, who are distinct and unique from other opioid-dependent cohorts.

METHOD

In-depth one-to-one interviews with codeine misusers and dependent individuals in Ireland (n = 21) and South Africa (n = 25) are analysed and applied to Liese and Franz's (1996) cognitive developmental model of substance abuse.

RESULTS

Misuse and dependence pathways are maintained by the interplay between physiological determinants relating to pain, withdrawal and tolerance, and psychological influences such as therapeutic need, pre-empting of anticipated physical pain, pleasure from the dreamy sedative opiate effect of codeine and relief of emotional distress. Progression towards habitual use and misuse for therapeutic and intoxication purposes appears to be mediated by external environmental triggers pertaining to availability, internal meta-cognitions around physical pain and emotional distress, and increasing importance of codeine in the life of the user.

CONCLUSION

The concept mapping of codeine misuse and dependence presented here could provide psychological therapists working with individuals experiencing problems with codeine, misusing codeine and those with iatrogenic dependence, with an enhanced understanding of the key concepts involved in misuse and recovery pathways.

Over-the-Counter Codeine-from Therapeutic Use to Dependence, and the Grey Areas in Between

Codeine is a widely used analgesic, that is available for sale in pharmacies over the counter (OTC) in a number of countries including the UK, South Africa, Ireland, France and Australia. In these countries with OTC codeine sales there has been emerging concerns about misuse of and dependence on codeine containing combination analgesics, with increasing numbers of people presenting for help with codeine dependence at primary care and addiction treatment services. This has led to many countries reviewing availability of codeine in OTC available preparations, and considering possible measures to reduce harms from misuse of OTC codeine containing combination analgesics.

Managing inappropriate use of non-prescription combination analgesics containing codeine: A modified Delphi study

BACKGROUND

Misuse and/or dependence upon non-prescription combination analgesics containing codeine (NP-CACC) can result in serious physiological and psychological harms.

OBJECTIVE

To explore pharmacists' and other health care professionals' ideas and views on strategies for managing NP-CACC misuse and/or dependence in a community pharmacy setting.

METHODS

A 3-iteration modified Delphi study was conducted to gain the consensus view of panelists. Forty experts within the fields of pharmacy and drug misuse and/or dependence agreed to be on the panel. Questionnaires explored opinions on issues and possible strategies that could be used to manage NP-CACC misuse and/or dependence. Responses from the first-round questionnaire were summarized and reported back to panelists through the second-round questionnaire for further reflection and evaluation using a 6-point, Likert-type scale. Strategies included in the third-round questionnaire had agreement by more than 80% of panelists. Panelists provided feedback on effectiveness using a 6-point, Likert-type scale for impact.

RESULTS

The response rates for the 3 rounds were 65%, 67.5% and 55%, respectively. Panelists provided 54 strategies in round 1. In round 2 there was consensus agreement with 31 of these strategies. In round 3 there was consensus that 21 strategies were expected to be effective (>80% of panelists expected the strategy to be effective, median above Somewhat Effective (4), IQD ≤1). Of these, 8 were expected to have the most impact if implemented into clinical practice (chosen by 5 or more panelists in their Top 5 for impact). The strategies identified as effective and likely to have the most impact on NP-CACC misuse/dependence in a community pharmacy setting were: utilization of a national real-time database to monitor product sales to aid identification of at-risk people (100% effectiveness, rank 1 for impact); development of a referral pathway for management of people whom pharmacists have identified as at-risk (95.2% effectiveness, rank 2 for impact), and training to improve pharmacist communication with people (95% effectiveness, rank 2 for impact).

CONCLUSIONS

The high level of consensus achieved indicates that the strategies generated represent useful approaches which could be utilized to manage NP-CACC misuse and/or dependence within community pharmacy in the future.

Cough, codeine and confusion

Codeine is widely prescribed in clinical practice with over the counter (OTC) preparations of codeine freely available for consumption typically as a component of remedies for the common cold/cough. We describe the first reported case of acute confusional state in a previously healthy 14-year-old girl ultimately attributed to inappropriate codeine use. The usage of codeine in the paediatric setting has been highlighted in recent years with many reported deaths--mostly due to respiratory depression. The risks associated with codeine usage may be particularly unnecessary with OTC cough suppressants as evidence of efficacy is absent. Finally, codeine dependence is a common problem among adults and has been reported locally and internationally among adolescents. The combination of lack of efficacy, risk of acute intoxication and dependence, suggests that the use of OTC codeine preparations may be unwarranted.

‘Codeine is my companion’: misuse and dependence on codeine containing medicines in Ireland

Objectives

Global concern around over the counter availability of codeine containing products and risk of misuse, dependence and related harms are evident. A phenomenological study of lived experiences of codeine misuse and dependence was undertaken in Ireland, following the Pharmaceutical Society of Ireland’s 2010 guidelines for restricted supply of non-prescription codeine containing products.

Methods

In-depth interviews were conducted with a purposive sample of adult codeine misusers and dependents (n=21), both actively using, in treatment and in recovery. The narratives were analysed using the Empirical Phenomenological Psychological five-step method (Karlsson, 1995). A total of 10 themes with 82 categories were identified. Two concepts at a higher level of abstraction above the theme-level emerged during the final stage of analysis. The concepts identified were ‘emotional pain and user self-legitimization of use’ and ‘entrapment into habit-forming and invisible dependent use’. These concepts were reported in different ways by a majority of participants.

Results

Findings are presented under the following themes: (1) profile and product preferences; (2) awareness of habit forming use and harm; (3) negotiating pharmacy sales; (4) alternative sourcing routes; (5) the codeine feeling; (6) the daily routine; (7) acute and chronic side effects; (8) social isolation; (9) withdrawal and dependence and (10) help-seeking and treatment experiences.

Conclusions

There is a public health and regulatory imperative to develop proactive responses tackling public availability of codeine containing medicines, risk minimisation in consumer self-treatment for pain, enhanced patient awareness of potential for habit forming use and its consequences and continued health professional pharmacovigilence.

“Doctor shopping and pharmacy hopping”: practice innovations relating to codeine

Purpose

– The misuse of pharmaceutical opioid analgesics is identified as a global public health concern. Codeine represents an interesting quandary in terms of its regulated status, with individuals varying in their metabolism of codeine, estimation of safe dosages, risk of adverse health consequences and abuse potential. Efforts to quantify and address hidden non-compliant medical codeine use, overuse and intentional misuse is compromised by availability to the public in prescribed and over the counter forms. The paper aims to discuss these issues.

Design/methodology/approach

– A review of literature on codeine use, misuse and dependence, and associated innovative medical and pharmacy interventions is presented, and was conducted as part of a larger scoping review on codeine.

Findings

– The review highlights the complexities associated with monitoring public health awareness of codeine's abuse potential, and customer/patients trends in non-compliant codeine use for therapeutic and recreational purposes. Aberrant codeine behaviours centre on visiting multiple doctors for prescriptions, repeated lost or stolen prescriptions, forging prescriptions and use of multiple pharmacies. Innovations to monitor misuse of codeine include national prescription databases and recent developments in real-time monitoring of dispensing activity.

Practical implications

– Further development of real-time monitoring processes with process evaluation is advised.

Originality/value

– This viewpoint is intended to demonstrate how efforts to quantify and address codeine use are compromised by its availability. It intends to encourage further policy and practitioner dialogue on how to monitor, support and intervene with consumers misusing codeine.