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

Community pharmacists' role towards preventing abuse or misuse and dependence of codeine-containing analgesic medications in Saudi Arabia: a multicenter cross-sectional study

Introduction

The misuse or abuse and dependence of medications containing codeine continue to be a major global public health concern. This study aimed to investigate the role of community pharmacists in preventing the abuse or misuse and dependence of codeine-containing analgesic drugs in Saudi Arabia.

Methods

A cross-sectional study involving 226 community pharmacists from various community pharmacies across multiple cities of Saudi Arabia was conducted from 09 May 2023 to 09 October 2023. Study data were collected and managed using Research Electronic Data Capture tool. Fourteen trained data collectors visited randomly selected community pharmacies in different cities, provided pharmacists with an electronic questionnaire link, and collected their responses electronically. The dataset was downloaded in SPSS format, and analyzed for both descriptive and inferential purposes.

Results

The primary indicators that community pharmacists considered when suspecting cases of abuse or misuse and dependence included customers who requested a larger quantity of the medication (88.5%), frequently visited the pharmacy and sought the specific medicine (82.7%), and those who took advantage of the crowd (70.8%). Pharmacists have been instrumental in preventing abuse or misuse and dependence by ensuring that medicines with abuse potential are not easily accessible to consumers (87.6%), providing alternative options (81%), reducing the dose (65%), referring patients to physicians (62.4%), and refusing to sell or denying availability (54.9%). Additionally, pharmacists primarily focused on raising public awareness (85%) as a noteworthy proportion of customers (54.9%) became desperate to obtain the drug after missing a dose. It was also suggested that community pharmacists should receive specialized training in substance abuse or misuse, as 46.9% of them lacked such training.

Discussion

Community pharmacists, being frequently the initial point of contact easily reachable, possess the capability to greatly assist in identifying the patients and averting abuse or misuse and dependence during the dispensing of medication. Further, they can provide valuable guidance to those involved in efforts to reduce drug abuse or misuse and dependence.

Development and validation of a brief screening tool for over-the-counter codeine dependence

BACKGROUND

Low-dose codeine is sold without a prescription in countries like the UK, Ireland, and South Africa. Due to misuse concerns, exploring pharmacy screening tools to identify those at risk and needing additional support is vital.

OBJECTIVES

The study aims to develop and validate a brief screening tool that assesses the risk of codeine dependence with language appropriate for routine use in community pharmacies.

METHOD

Scale development and validation occurred over two studies. In Study 1, scale item generation was based on structured analyses of psychosocial and pharmacy variables from frequent over-the-counter codeine consumers (N = 795). CFA was used to assess the cohesiveness of the resultant four-item Codeine Dependence Scale (CDS). ROC analyses were used to assess the performance of the CDS against risk cases identified by the Severity of Dependence Scale; identifying an optimal cut-off value of ≥2 as representing individuals at risk of codeine dependence. In Study 2, this CDS threshold was assessed against positive DSM-5 Opioid Use Disorder (OUD) cases related to codeine use assessed using the AUDADIS-IV.

RESULTS

With a cut-off score of ≥2, the CDS has sensitivity and specificity of 76% and 48%, respectively, against a DSM-5 codeine-related OUD diagnosis using the AUDADIS-IV. For identification of any codeine-related OUD (as measured by the AUDADIS-IV) 15 months after baseline, the CDS achieved an overall correct classification rate of 52%; 72% for positive cases.

CONCLUSIONS

The CDS exhibits reasonable cross-sectional and longitudinal sensitivity but low specificity, partly due to its brevity. However, the inclusive nature of the CDS is not a negative for application as a screening tool in a pharmacy setting as individual CDS items represent critical conversation points with a pharmacist, regardless of the screening outcome. The non-confronting nature of CDS items make the scale a viable option for pharmacy-based SBI in countries where codeine remains OTC.

Self-Medication in Rural Northeastern Romania: Patients' Attitudes and Habits

In recent years, many healthcare systems, along with healthcare professionals, have provided services in a patient-centered manner, in which patients are key actors in the care process. Encouraging self-care creates responsible patients, but it must be practiced responsibly. This study aims to analyze the tendency towards self-medication for patients from a rural area in Northeastern Romania. Data were collected using a questionnaire, which consisted of 25 questions, that has been developed by the research team. Student's T test or one-way ANOVA was used, and the reliability of the questionnaire was calculated using Cronbach's alpha coefficient. Fifty-eight patients agreed to participate and were interviewed. The results of the study suggest that respondents practice self-medication, which they resort to when their condition cannot be treated with natural remedies or herbs and when it impairs their ability to do their daily activities. Self-medication could be explained by the lack of self-care services as well as the trust patients have in the specific treatment. Patients prefer asking the pharmacist for drugs instead of visiting a physician, which could be due to higher accessibility and time-efficiency, while also being prone to stock up on certain medications due to limited access to healthcare.

The association between the availability of over the counter codeine and the prevalence of non-medical use

PURPOSE

To investigate the prevalence of non-medical use (NMU) of codeine in Germany, Italy, Spain and the UK and whether availability of OTC codeine has any association with NMU of the drug.

METHODS

Data collected in the online Survey of Non-Medical Use of Prescription Drugs, in surveys launched in the second half of 2018 from (Germany (n = 14,969), Italy, (n = 9974), Spain (n = 9912) and the UK (n = 9819) were analysed. For each survey, the estimated prevalence and 95% confidence interval (CI) of respondents reporting NMU of prescription and/or OTC codeine within the last 12 months were calculated and compared.

RESULTS

The prevalence of last 12-month NMU in Spain was 12.6% (95% CI 11.7-13.6) for prescription codeine, 6.3% (5.6-7.0) for OTC codeine and 16.1% (15.1-17.3) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU in the UK was 5.4% (4.9-5.8) for prescription codeine, 4.5% (4.1-5.0) for OTC codeine and 8.3% (7.8-8.9) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU for prescription codeine was 2.1% (1.9-2.4) in Germany and 1.9% (1.7-2.2) in Italy.

CONCLUSION

The prevalence of last 12-month NMU of any codeine product is approximately eight times greater in Spain and four times greater in the UK compared to Germany and Italy where the drug is only available by prescription. While other factors may contribute, these findings suggest that availability of codeine OTC is associated with greater NMU.

Physician Perspectives on Codeine Accessibility, Patterns of Use, Misuse, and Dependence in Saudi Arabia

In Saudi Arabia, there are concerning rates of non-compliance with pharmaceutical regulations prohibiting the pharmacy dispensing of prescription-only medications without a physician prescription. This is the first study in the Middle East which examines physicians’ perceptions regarding misuse of codeine, listed as a narcotic, controlled, and prescription-only drug. The CODEMISUSED survey was adapted to the Saudi Arabian context and pilot tested, prior to cross-sectional administration to physicians in Riyadh, Jeddah, Abha, and Jazan (n = 105). Descriptive statistics (frequencies and percentage) present physician level of agreement, neutrality, and disagreement with statements regarding codeine prescribing, patient awareness and use, online and community pharmacy availability, and dependence. The study indicates concern by physicians regarding patient intentional use of codeine to enhance mood, misuse patterns, lack of awareness around habit-forming use and iatrogenic dependence, and sourcing via illegal dispensing. It underscores the imperatives to address pharmacy compliance with pharmaceutical regulatory controls, implement enhanced pharmacovigilance, and improve awareness around safe use.

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.

The Severity of Dependence Scale (SDS) for Codeine: Preliminary Investigation of the Psychometric Properties of the SDS in an Online Sample of Codeine Users From the UK

Objective: Investigate the psychometric properties of the Severity of Dependence Scale (SDS) for codeine and its association with aberrant codeine related behaviors. Design: A voluntary and uncompensated cross-sectional online survey. Setting: Online population (≥18 years). Respondents: Two hundred and eighty-six respondents (66% women) who had used codeine containing medicines in the last 3 months and were living in the UK. Results: Of the respondents (mean age = 35.4 years, SD = 12.5), more than half were employed. Only 3.5% respondents reported no income. The majority of respondents (45.1%) primarily obtained prescription-only codeine from a consultation with a health professional, whilst 40.9% mainly purchased "over-the-counter" codeine containing medicines in a pharmacy without a medical prescription. Principal component analysis indicated a single factor solution accounting for 75% of the variance. Factor loadings ranged from 0.83 to 0.89. Cronbach's Alpha was high (α = 0.92). Several behaviors relating to codeine use were found to significantly predict probable codeine dependence. These included: daily codeine use in the last 3 months (OR = 66.89, 95% CI = 15.8-283.18); tolerance to codeine (OR = 32.14, 95% CI = 13.82-74.75); problems with role responsibility due to intoxication (OR = 9.89, 95% CI = 4.95-19.78); having sought advice on the internet to manage codeine use (OR = 9.56, 95% CI = 4.5-20.31); history of alcohol or drug treatment (OR = 3.73, 95% CI = 1.88-7.43). Conclusions: The SDS was acceptable and feasible to use to assess probable psychological codeine dependence in an online sample of people using codeine containing medicines. SDS scores were associated with behaviors known to be indicators of codeine dependence. Studies are needed in well-defined populations of people who use codeine to test the different aspects of psychometry of the scale compared against "gold standard" criterion [a diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)].

Identification of factors influencing tampering of codeine-containing medicines in England: a qualitative study

Background

Tampering of psychoactive medicines presents challenges to regulation and public health. However, little is currently known about what influences the decisions to treat codeine-containing medicines (CCM) with cold water extraction (CWE) from the perspective of individuals employing these techniques. The article identifies factors influencing utilisation of CWE to separate codeine from compounded analgesics, such as paracetamol and ibuprofen, found in CCM.

Methods

Purposive sampling of 27 participants residing in England who took part in a qualitative interview. Of these, 14 individuals (11 males and 3 females) reported tampering of psychoactive medicines, and the relevant transcripts were included in the analyses for the study. Participants were recruited from one addiction treatment service and from an online survey. The mean age of the participants was 31.5 years (range = 18–42 years). Qualitative data analysis followed the processes of iterative categorization (IC). The codes ‘harm reduction’, ‘information sources’ and ‘changes on the drug markets’ were grouped and summarised. The coding of the data was done in a Microsoft® Word document.

Results

Two groups of participants were identified in the data analysis: (i) individuals who used CCM (n = 5), and (ii) individuals who used CCM and heroin (n = 9). Participants in both groups used CWE due to concerns of paracetamol overdose from the use of excessive dosages of CCM. For both of them, information obtained from the internet encouraged the use of CWE. Participants using CCM described how the many steps involved in conducting CWE, including sourcing codeine boxes from pharmacies (over the counter), presented a barrier against using CWE. Participants using CCM and heroin explained how reduced availability in the local heroin supply influenced utilisation of CWE techniques to maintain their use of opioids and avoid withdrawal. Withdrawal symptoms and cravings outweighed the concerns about the quality of the extracted codeine mixtures in this participant group, especially the ability of CWE to remove paracetamol and tablet fillers.

Conclusions

Utilisation of CWE of codeine was influenced by several factors including drug market supply, the availability of detailed information on the internet about CWE and restrictions on codeine sourcing in pharmacies. Risks identified with CWE include consumption of unknown doses of paracetamol if the CWE techniques are not used correctly. Attempts at extracting codeine from CCM should be considered in risk assessments of opioid medicines.

Pharmacological Aspects of Over-the-Counter Opioid Drugs Misuse

Several over-the-counter (OTC) drugs are known to be misused. Among them are opioids such as codeine, dihydrocodeine, and loperamide. This work elucidates their pharmacology, interactions, safety profiles, and how pharmacology is being manipulated to misuse these common medications, with the aim to expand on the subject outlined by the authors focusing on abuse prevention and prevalence rates. The reviewed literature was identified in several online databases through searches conducted with phrases created by combining the international non-proprietary names of the drugs with terms related to drug misuse. The results show that OTC opioids are misused as an alternative for illicit narcotics, or prescription-only opioids. The potency of codeine and loperamide is strongly dependent on the individual enzymatic activity of CYP2D6 and CYP3A4, as well as P-glycoprotein function. Codeine can also be utilized as a substrate for clandestine syntheses of more potent drugs of abuse, namely desomorphine (“Krokodil”), and morphine. The dangerous methods used to prepare these substances can result in poisoning from toxic chemicals and impurities originating from the synthesis procedure. OTC opioids are generally safe when consumed in accordance with medical guidelines. However, the intake of supratherapeutic amounts of these substances may reveal surprising traits of common medications.

Experiences of over-the-counter codeine misusers and accounts of recovery: A qualitative study in Tasmania, Australia

INTRODUCTION AND AIMS

There is international concern about misuse of over-the-counter (OTC) codeine, yet few studies have reported the perspectives of misusers themselves. This study explored the experience of OTC codeine misuse and recovery in Tasmania, Australia.

DESIGN AND METHODS

Semi-structured telephone interviews were conducted with 15 self-identified long-term users of OTC codeine. The interview guide prompted responses about reasons for codeine use, positive and negative impacts, recovery, identity and codeine accessibility. Transcripts were analysed abductively using qualitative content analysis. Categories that emerged from misuser accounts were aligned to three broad temporal phases: (i) transition to misuse; (ii) growing awareness; and (iii) towards recovery.

RESULTS

Salient features of the misuse experience included: initial use for the self-treatment of physical pain; ongoing use to self-medicate physical pain, stress or mental health conditions; a perception of safety of OTC codeine; an insidious transition from use to misuse; growing awareness of a problem over time; support provided by family, friends and the internet; recovery through self-change; and recognition that recovery is an ongoing process.

DISCUSSION AND CONCLUSIONS

Knowledge and understanding of the experience of OTC codeine misuse and recovery is critical to inform and tailor approaches to prevention and intervention. The findings suggest that strategies to improve the management of pain, stress and mental health, raise self-awareness of problematic use and potential for self-change, and increase social and web-based supports, should be considered when designing health policy initiatives that aim to reduce misuse.

Codeine use and harms in Australia: evaluating the effects of re-scheduling

BACKGROUND AND AIMS

Globally, codeine is the most-used opioid. In December 2016, Australia announced that low-strength codeine (≤ 15 mg) would be re-scheduled and no longer available for purchase over-the-counter; this was implemented in February 2018. We aimed to evaluate the effect of this scheduling change on codeine misuse and use and misuse of other opioids.

DESIGN AND SETTING

Interrupted time-series analysis of monthly opioid exposure calls to New South Wales Poisons Information Centre (NSWPIC, captures 50% of Australia's poisoning calls), January 2015- January 2019 and monthly national codeine sales, March 2015-March 2019. We incorporated a washout period (January 2017 - January 2018) between the announcement and implementation, when prescriber/consumer behaviour may have been influenced.

PARTICIPANTS

Intentional opioid overdoses resulting in a call to NSWPIC.

MEASUREMENTS

We used linear segmented regression to identify abrupt changes in level and slope of fitted lines. Codeine poisonings and sales were stratified into high strength (> 15 mg per dose unit) and low strength (≤ 15 mg). Only low-strength formulations were re-scheduled.

FINDINGS

We observed an abrupt -50.8 percentage [95% confidence interval (CI) = -79.0 to -22.6%] level change in monthly codeine-related poisonings and no change in slope in the 12 months after February 2018. There was no increase in calls to the NSWPIC for high-strength products, level change: -37.2% (95% CI = -82.3 to 8%) or non-codeine opioids, level change: -4.4% (95% CI = -33.3 to 24.4%). Overall, the re-scheduling resulted in a level change in opioid calls of -35.8% calls/month (95% CI = -51.2 to -20.4%). Low-strength codeine sales decreased by 87.3% (95% CI = -88.5 to -85.9%), with no increase in high-strength codeine sales in the 14 months following re-scheduling, -4.0% (95% CI = -19.6 to 14.6%).

CONCLUSIONS

Codeine re-scheduling in Australia appears to have reduced codeine misuse and sales.

Extent of misuse and dependence of codeine-containing products among medical and pharmacy students in a Nigerian University

BACKGROUND

Misuse and dependency of opioids especially codeine-containing products is of increasing global concern. Inappropriate use of opioids among healthcare students could affect quality of service and ethical conducts of these future professionals, thereby putting the society at risk. This study aimed to evaluate knowledge and perception of medical and pharmacy students in a Nigerian tertiary University on use of opioids with focus on codeine-containing products.

METHODS

A cross-sectional survey among 335-medical and 185-pharmacy students from University of Ibadan, Nigeria, between September and December 2018, using a self-administered semi-structured questionnaire.

RESULTS

A total of 178 (34.2%) in multiple responses had used opioid-containing products among the respondents, of this, 171 (96.1%) used codeine-containing formulation. Precisely, 146 (28.1%) of the students had used codeine-containing products before, of this, 16 (11.0%) used the products for non-medical or recreational purpose regarded as a misuse/abuse. In all, 201 (38.7%) had good knowledge of opioid use, with 51 (34.9%) among those who had used opioids and 150 (40.1%) among those who had not used opioids (X² = 1.186; p = 0.276). Majority (469; 90.2%) had good perception of risks associated with opioid use; comprising (130; 89.0%) among those who had taken opioids and (339; 90.6%) among those who had not taken opioids before (X² = 0.304; p = 0.508). Logistic-regression shows that students who experienced some side effects to be experienced again 22.1 [AOR = 22.1, 95% CI: (5.98-81.72)] as well as those pressured into using codeine-containing products 10.6 [AOR = 10.6, 95% CI: (1.36-82.39)] had more tendency of misuse.

CONCLUSION

There is a potential for misuse of codeine-containing products among medical and pharmacy students. Peer-influence and experience of some side effects are possible predictors of misuse among the students. Thus, healthcare students' curriculum should incorporate preventive programme, while public education and policy that favours peer-support programme on medication misuse is advocated for healthcare students.

Impaired consciousness, hypokalaemia and renal tubular acidosis in sustained Nurofen Plus abuse

Ibuprofen-induced renal tubular acidosis is a rare but important diagnosis which should be considered in patients presenting with hypokalaemia and metabolic acidosis. This case report details the case of a 33-year-old woman presenting with reduced conscious state, metabolic acidosis and profound hypokalaemia without an obvious cause. With correction of the patient’s electrolyte and acid-base disturbance, her conscious state improved allowing disclosure of her use of Nurofen Plus for its euphoric opiate effects. The diagnosis of renal tubular acidosis had been considered and subsequent disclosure of excessive chronic ingestion of ibuprofen suggested this to be the underlying cause. The striking feature of our patient was the insidious development of the problem and delayed accurate drug history. An important safety message arising from our case is the composite risk of dependence on the opiate component of over the counter analgesics, such as Nurofen Plus, and adverse events related to the ibuprofen component.

'For pain, no shame' and 'My secret solace': Accounts of over-the-counter codeine dependence using Q methodology

BACKGROUND

Dependence on over-the-counter (OTC) codeine is recognised internationally as a rising public health issue. The effectiveness of health intervention strategies may be influenced by the beliefs held by those who are dependent. Applying Q methodology, this study aimed to identify shared accounts of OTC codeine dependence.

METHODS

Twenty-six participants from Tasmania, Australia, met eligibility criteria for the study as long-term OTC codeine users with a Severity of Dependence Score of five or higher. Forty-six opinion statements about OTC codeine dependence were sourced from the literature and online discussion forums. These were rank-ordered by participants from least to most agree and explanatory comments for the most strongly positioned statements were provided. By-person factor analysis was used to group participants who had sorted the statements similarly.

RESULTS

Two distinct accounts of OTC codeine dependence were identified. Participants representing Factor One, 'For pain, no shame', were not ashamed of their OTC codeine use, believed access should not be restricted and regarded it as necessary for the relief of physical pain. In contrast, Factor Two, 'My secret solace', was characterized by feelings of guilt and shame. Participants in this group intentionally used codeine for its effects on mood; to help them relax and to relieve stress, rather than solely for pain relief. They did not consider regular use of codeine to be socially acceptable and hid their use from others.

CONCLUSION

The way in which OTC codeine use is viewed by those who are dependent is not uniform. Two distinct accounts were identified in this sample. Participants from each group varied in their beliefs about access, causality, reasons for use and feelings of legitimacy and shame. An understanding of these differences can be used to better target interventions and guide policy for the prevention and management of OTC codeine dependence.

From pain treatment to opioid dependence: a qualitative study of the environmental influence on codeine use in UK adults

OBJECTIVES

To investigate the views and experiences of people who use codeine in order to describe the 'risk environment' capable of producing and reducing harm.

DESIGN

This was a qualitative interview study. Psychological dependence on codeine was measured using the Severity of Dependence Scale. A cut-off score of 5 or higher indicates probable codeine dependence.

SETTING

Participants were recruited from an online survey and one residential rehabilitation service.

PARTICIPANTS

16 adults (13 women and 3 men) from the UK who had used codeine in the last 12 months other than as directed or as indicated. All participants began using codeine to treat physical pain. Mean age was 32.7 years (SD=10.1) and mean period of codeine use was 9.1 years (SD=7.6).

RESULTS

Participants' experiences indicated that they became dependent on codeine as a result of various environmental factors present in a risk environment. Supporting environments to reduce risk included: medicine review of repeat prescribing of codeine, well-managed dose tapering to reduce codeine consumption, support from social structures in form of friends and online and access to addiction treatment. Environments capable of producing harm included: unsupervised and long-term codeine prescribing, poor access to non-pharmacological pain treatments, barriers to provision of risk education of codeine related harm and breakdown in structures to reduce the use of over the counter codeine other than as indicated.

CONCLUSION

The study identified microenvironments and macroenvironments capable of producing dependence on codeine, including repeat prescribing and unsupervised use over a longer time period. The economic environment was important in its influence on the available resources for holistic pain therapy in primary care in order to offer alternative treatments to codeine. Overall, the goal is to create an environment that reduces risk of harm by promoting safe use of codeine for treatment of pain, while providing effective care for those developing withdrawal and dependence.

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.

The impact of codeine re-scheduling on misuse: a retrospective review of calls to Australia's largest poisons centre

BACKGROUND AND AIMS

Codeine is the most commonly used opioid in the world, and is available over the counter (OTC) in many countries, including Australia. Several countries are reconsidering codeine's OTC status due to concerns over addiction and misuse, with serious morbidity and mortality being reported. Australia's Therapeutic Goods Administration restricted codeine containing analgesics to 'Pharmacist Only' in 2010, and has recently been considering further up-scheduling to make codeine 'Prescription Only'. This paper estimated Australian trends of codeine misuse over the past 12 years, and examined whether trends changed following previous rescheduling efforts in 2010.

DESIGN

A retrospective review of calls regarding codeine misuse made to the New South Wales Poisons Information Centre (NSWPIC, Australia's largest poisons centre), 2004-15. Joinpoint software was used to quantify the average annual change in calls, and whether there was a significant change in trend at any time, including following rescheduling.

SETTING

Australia.

PARTICIPANTS

Four hundred patients about whom a call was made to the NSWPIC.

MEASURES

Calls per year, patient age, gender, tablets taken per day, formulation used, symptom disposition.

FINDINGS

The NSWPIC database contained 400 cases of codeine combination analgesic misuse from 2004 to 2015. Joinpoint analysis showed that the frequency of cases increased significantly from 2004 to 2015, with an average annual percentage change (AAPC) of 19.5% [95% confidence interval (CI) = 13.8-25.5% P < 0.0001] for paracetamol/codeine and 17.9% (95% CI = 7.9-28.9%, P < 0.01) for ibuprofen/codeine. No significant change in trend was seen at any time, including following 2010 rescheduling. The median age of patients was 34 and 27 years for paracetamol/codeine and ibuprofen/codeine cases, respectively. Gender distribution was approximately equal. Clinical features reported were consistent with codeine, paracetamol and ibuprofen toxicity.

CONCLUSIONS

Misuse of codeine combination products appears to be increasing in Australia. Limited rescheduling in 2010 failed to curb this increase.