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Abnormal white matter within brain structural networks is associated with high-impulse behaviour in codeine-containing cough syrup dependent users. Eur Arch Psychiatry Clin Neurosci 2021; 271:823-833. [PMID: 32124022 DOI: 10.1007/s00406-020-01111-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Accepted: 02/08/2020] [Indexed: 10/24/2022]
Abstract
Codeine-containing cough syrup (CCS) is considered as one of the most popular drug of dependence among adolescents because of its inexpensiveness and easy availability. However, its relationship with neurobiological effects remains sparsely explored. Herein, we examined how high-impulse behaviours relate to changes in the brain structural networks. Forty codeine-containing cough syrup dependent (CCSD) users and age-, gender-, and number of cigarettes smoked per day -matched forty healthy control (HC) subjects underwent structural brain imaging via MRI. High-impulse behaviour was assessed using the 30-item self-rated Barratt Impulsiveness Scale (BIS-11), and structural networks were constructed using diffusion tensor imaging and AAL-90 template. Between-group topological metrics were compared using nonparametric permutations. Benjamin-Hochberg false discovery rate correction was used to correct for multiple comparisons (P < 0.05). The relationships between abnormal network metrics and clinical characteristics of CCS dependent (BIS-11 total score, CCS- dependent duration and mean dose) were examined by Spearman's correlation. Structural networks of the CCSD group demonstrated lower small-world properties than those of the HC group. Abnormal changes in nodal properties among CCSD users were located mainly in the frontal gyrus, inferior parietal lobe and olfactory cortex. NBS analysis further indicated disrupted structural connections between the frontal gyrus and multiple brain regions. There were significant correlations between abnormal nodal properties of the frontal gyrus and clinical characteristics (BIS-11 total score, CCS dependent duration and mean dose) in the CCSD group. These findings suggest that the high-impulse behavioural expression in CCS addiction is associated with widespread brain regions, particularly within those in the frontal cortex. Aberrant brain regions and disrupted connectivity of structural network may be the bases of neuropathology for underlying symptoms of high-impulse behaviours in CCSD users, which may provide a novel sight to better treat and prevent codeine dependency in adolescents.
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Functional connectome-based biomarkers predict chronic codeine-containing cough syrup dependent. J Psychiatr Res 2020; 130:333-341. [PMID: 32889355 DOI: 10.1016/j.jpsychires.2020.08.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/26/2020] [Accepted: 08/03/2020] [Indexed: 12/30/2022]
Abstract
PURPOSE Codeine-containing cough syrup (CCS) is considered among the most popular drugs of abuse in adolescents worldwide. Accurate prediction and identification of CCS dependent (CCSD) users are crucial. This study aimed to identify a brain-connectome-based predictor of CCSD using a machine learning model based on a ten-fold cross-validation logistic regression (LR) classifier. METHODS 40 CCSD users and 40 healthy control (HC) subjects underwent functional magnetic resonance imaging to construct weight functional networks. Partial correlation analysis was used to analyze relations between abnormal network metrics and clinical characteristics (BIS total scores, CCS abuse duration, and mean CCS dose) in CCSD. A ten-fold cross-validation LR classifier was used to classify CCSD users and HC subjects. RESULTS The CCSD group showed significantly abnormal nodes and connections in the right posterior cingulate, right middle insula, bilateral prefrontal cortex, parietal lobe, temporal lobe, occipital lobe, and cerebellum. Furthermore, higher characteristic path length and lower clustering coefficient (Cp), global efficiency, and local efficiency (Eloc) were observed in the global topologies in CCSD. The abnormal global properties (Cp and Eloc) and node properties of the prefrontal cortex were significantly correlated with clinical characteristics (BIS-11 scores, CCS abuse duration) in CCSD. The LR classifier models demonstrated accuracy, sensitivity, specificity, precision, and AUC of 82.5%, 82.5%, 82.5%, 76.8%, and 82.5%. CONCLUSIONS These data demonstrate that abnormal functional connectome may be closely linked to clinical characteristics in CCSD. Functional connectome-based biomarkers can be a powerful tool for personalized diagnosis of CCSD in the future.
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Pharmacological Aspects of Over-the-Counter Opioid Drugs Misuse. Molecules 2020; 25:molecules25173905. [PMID: 32867117 PMCID: PMC7504308 DOI: 10.3390/molecules25173905] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/22/2020] [Accepted: 08/24/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Kirschbaum M, Barnett T, Cross M. Experiences of over-the-counter codeine misusers and accounts of recovery: A qualitative study in Tasmania, Australia. Drug Alcohol Rev 2020; 39:879-887. [PMID: 32367599 DOI: 10.1111/dar.13081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 04/02/2020] [Accepted: 04/06/2020] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
| | - Tony Barnett
- Centre for Rural Health, University of Tasmania, Launceston, Australia
| | - Merylin Cross
- Centre for Rural Health, University of Tasmania, Launceston, Australia
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'For pain, no shame' and 'My secret solace': Accounts of over-the-counter codeine dependence using Q methodology. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 73:121-128. [PMID: 31654934 DOI: 10.1016/j.drugpo.2019.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 09/30/2019] [Accepted: 10/03/2019] [Indexed: 11/22/2022]
Abstract
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.
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Ladha KS, Neuman MD, Broms G, Bethell J, Bateman BT, Wijeysundera DN, Bell M, Hallqvist L, Svensson T, Newcomb CW, Brensinger CM, Gaskins LJ, Wunsch H. Opioid Prescribing After Surgery in the United States, Canada, and Sweden. JAMA Netw Open 2019; 2:e1910734. [PMID: 31483475 PMCID: PMC6727684 DOI: 10.1001/jamanetworkopen.2019.10734] [Citation(s) in RCA: 143] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Small studies and anecdotal evidence suggest marked differences in the use of opioids after surgery internationally; however, this has not been evaluated systematically across populations receiving similar procedures in different countries. OBJECTIVE To determine whether there are differences in the frequency, amount, and type of opioids dispensed after surgery among the United States, Canada, and Sweden. DESIGN, SETTING, AND PARTICIPANTS This cohort study included patients without previous opioid prescriptions aged 16 to 64 years who underwent 4 low-risk surgical procedures (ie, laparoscopic cholecystectomy, laparoscopic appendectomy, arthroscopic knee meniscectomy, and breast excision) between January 2013 and December 2015 in the United States, between July 2013 and March 2016 in Canada, and between January 2013 and December 2014 in Sweden. Data analysis was conducted in all 3 countries from July 2018 to October 2018. MAIN OUTCOMES AND MEASURES The main outcome was postoperative opioid prescriptions filled within 7 days after discharge; the percentage of patients who filled a prescription, the total morphine milligram equivalent (MME) dose, and type of opioid dispensed were compared. RESULTS The study sample consisted of 129 379 patients in the United States, 84 653 in Canada, and 9802 in Sweden. Overall, 52 427 patients (40.5%) in the United States were men, with a mean (SD) age of 45.1 (12.7) years; in Canada, 25 074 patients (29.6%) were men, with a mean (SD) age of 43.5 (13.0) years; and in Sweden, 3314 (33.8%) were men, with a mean (SD) age of 42.5 (13.0). The proportion of patients in Sweden who filled an opioid prescription within the first 7 days after discharge for any procedure was lower than patients treated in the United States and Canada (Sweden, 1086 [11.1%]; United States, 98 594 [76.2%]; Canada, 66 544 [78.6%]; P < .001). For patients who filled a prescription, the mean (SD) MME dispensed within 7 days of discharge was highest in United States (247 [145] MME vs 169 [93] MME in Canada and 197 [191] MME in Sweden). Codeine and tramadol were more commonly dispensed in Canada (codeine, 26 136 patients [39.3%]; tramadol, 12 285 patients [18.5%]) and Sweden (codeine, 170 patients [15.7%]; tramadol, 315 patients [29.0%]) than in the United States (codeine, 3210 patients [3.3%]; tramadol, 3425 patients [3.5%]). CONCLUSIONS AND RELEVANCE The findings indicate that the United States and Canada have a 7-fold higher rate of opioid prescriptions filled in the immediate postoperative period compared with Sweden. Of the 3 countries examined, the mean dose of opioids for most surgical procedures was highest in the United States.
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Affiliation(s)
- Karim S. Ladha
- Department of Anesthesia, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Mark D. Neuman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Penn Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Gabriella Broms
- Division of Epidemiology and Centre for Pharmacoepidemiology, Karolinska Institutet, Solna, Sweden
- Department of Internal Medicine, Danderyd University Hospital, Danderyd, Sweden
| | - Jennifer Bethell
- ICES Central, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
| | - Brian T. Bateman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Duminda N. Wijeysundera
- Department of Anesthesia, St. Michael’s Hospital, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
- ICES Central, Toronto, Ontario, Canada
| | - Max Bell
- Section for Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Linn Hallqvist
- Section for Anaesthesiology and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
- Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Tobias Svensson
- Clinical Epidemiology Division, Karolinska Institutet, Solna, Sweden
| | - Craig W. Newcomb
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Colleen M. Brensinger
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Lakisha J. Gaskins
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Penn Center for Perioperative Outcomes Research and Transformation (CPORT), University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Hannah Wunsch
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- ICES Central, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Center, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
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