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Physician Perspectives on Codeine Accessibility, Patterns of Use, Misuse, and Dependence in Saudi Arabia. Int J Ment Health Addict 2021. [DOI: 10.1007/s11469-021-00670-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
AbstractIn 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.
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Bishop M, Schumann JL, Gerostamoulos D, Wong A. The impact of codeine upscheduling on overdoses, Emergency Department presentations and mortality in Victoria, Australia. Drug Alcohol Depend 2021; 226:108837. [PMID: 34216868 DOI: 10.1016/j.drugalcdep.2021.108837] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 05/01/2021] [Accepted: 05/05/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIMS Prior to February 2018, codeine was available over-the-counter (OTC) in Australia as a pharmacist-only medicine (Schedule 3) in low-strength formulations when in combination with simple analgesics. In February 2018, The Advisory Committee on Medicines Scheduling (ACMS) upscheduled codeine-containing medicines (CCM) to Schedule 4 (prescription-only medicine). This study aimed to determine the impact of upscheduling on prescriptions, overdoses and deaths. METHODS This study used interrupted time series analysis, a quasi-experimental design, to retrospectively evaluate the impact of upscheduling on overdose poisoning calls to the Victorian Poisons Information Centre (VPIC), Emergency Department (ED) presentations to Austin Health, and deaths reported to the Victorian Coroner from 1 January 2013-31 December 2019. RESULTS There was a significant reduction in the trend of high-strength codeine poisoning calls by 0.36 (P = 0.03, 95 % CI = [-0.69, -0.04]). Low-strength codeine poisoning calls to the VPIC reduced by 13.31 (P <0.001, 95 % CI = [-16.80, 9.82]]) calls in February 2018, followed by continued reduction of 0.12 calls per month. High-strength codeine overdose ED presentations reduced in the first quarter of 2018 by 3.72 presentations (P = 0.004, 95 % CI = [-6.13, -1.31]). Low-strength codeine overdose ED presentations after the first quarter of 2018 by 0.33 (P = 0.03, 95 % CI = [-0.63, -0.03]) presentations per month. Codeine-related deaths reduced by 7.19 (P < 0.001, 95 % CI = [-9.44, -4.94]) deaths in February 2018. CONCLUSIONS Codeine upscheduling to prescription-only medicine has reduced codeine-related poisoning calls, overdoses and unnatural death in Victoria.
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Affiliation(s)
- Milly Bishop
- The Royal Melbourne Hospital, 300 Grattan Street, Parkville, 3050, Australia.
| | - Jennifer L Schumann
- Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, VIC, 3006, Australia; Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, VIC, 3006, Australia
| | - Dimitri Gerostamoulos
- Department of Forensic Medicine, Monash University, 65 Kavanagh Street, Southbank, VIC, 3006, Australia; Victorian Institute of Forensic Medicine, 65 Kavanagh Street, Southbank, VIC, 3006, Australia
| | - Anselm Wong
- Victorian Poisons Information Centre and Emergency Department, Austin Health, Victoria, Australia; Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Victoria, Australia; Centre for Integrated Critical Care, The University of Melbourne, Victoria, Australia
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Chiappini S, Schifano F, Corkery JM, Guirguis A. Beyond the 'purple drank': Study of promethazine abuse according to the European Medicines Agency adverse drug reaction reports. J Psychopharmacol 2021; 35:681-692. [PMID: 33427017 PMCID: PMC8278560 DOI: 10.1177/0269881120959615] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Promethazine is a medicinal product, available on its own or in combination with other ingredients including dextromethorphan, paracetamol and/or expectorants. Anecdotal reports have however indicated that promethazine may have a misuse potential, especially in adolescents. OBJECTIVE We here aimed at studying how this phenomenon has been reported to the European Monitoring Agency Adverse Drug Reactions database. METHODS After a formal request to the European Monitoring Agency, the promethazine-specific dataset has been studied, performing a descriptive analysis of misuse/abuse/dependence-related adverse drug reaction reports. The study was approved by the University of Hertfordshire (LMS/PGR/UH/03234). RESULTS The analysis of promethazine data showed increasing levels of misuse/abuse/ dependence issues over time (2003-2019). Out of a total number of 1543 cases of adverse drug reactions, the abuse/misuse/dependence-related cases reported were 557, with 'drug abuse' (300/557: 53.8%) and 'intentional product misuse' (117/557: 21.0%). being the most represented adverse drug reactions. A high number of fatalities were described (310/557: 55.6%), mostly recorded as 'drug toxicity/drug abuse' cases, with opiates/opioids having been the most commonly reported concomitant drugs used. CONCLUSION Anecdotal promethazine misuse/abuse reports have been confirmed by European Monitoring Agency data. Promethazine misuse/abuse appears to be an alarming issue, being associated with drug-related fatalities. Thus, healthcare professionals should be warned about a possible misuse of promethazine and be vigilant, as in some countries medicinal products containing promethazine can be purchased over the counter. Since promethazine is often available in association with opioids, its abuse may be considered a public health issue, with huge implications for clinical practice.
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Affiliation(s)
- Stefania Chiappini
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield, UK
| | - Fabrizio Schifano
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield, UK,Fabrizio Schifano, Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, School of Life and Medical Sciences, University of Hertfordshire, College Lane Campus, Hatfield, Hertfordshire AL10 9AB, UK.
| | - John Martin Corkery
- Psychopharmacology, Drug Misuse and Novel Psychoactive Substances Research Unit, University of Hertfordshire, Hatfield, UK
| | - Amira Guirguis
- Swansea University Medical School, Institute of Life Sciences 2, Swansea University, Swansea, UK
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Elphinston RA, Connor JP, de Andrade D, Hipper L, Freeman C, Chan G, Sterling M. Impact of a policy change restricting access to codeine on prescription opioid-related emergency department presentations: an interrupted time series analysis. Pain 2021; 162:1095-1103. [PMID: 33086287 DOI: 10.1097/j.pain.0000000000002115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/12/2020] [Indexed: 12/22/2022]
Abstract
ABSTRACT Codeine is one of the most commonly used opioid analgesics. Significant codeine-related morbidity and mortality prompted regulatory responses, with the up-scheduling of codeine combination analgesics to prescription-only medicines implemented in Australia in February 2018. This study investigated the impact of codeine up-scheduling on the number of codeine and other (noncodeine) prescription opioid-related emergency department (ED) presentations in a large metropolitan tertiary hospital. Clinical features of these presentations were also examined. Interrupted time series analyses assessed monthly changes in ED presentations from June 2016 to November 2019. In the month immediately after up-scheduling, there was a significant reduction of 3.97 codeine-related presentations (B = -3.97, P = 0.022), indicating a 29.66% level change, followed by a significant change in trend to fewer monthly codeine-related presentations (B = -0.38, P = 0.005). Noncodeine prescription opioid-related (B = -1.90, P = 0.446) and ED presentations overall (B = -118.04, P = 0.140) remained unchanged immediately post-up-scheduling, with a significant change in trend from upward to downward for noncodeine (B = -0.76; P = 0.002) and ED presentations overall (B = -19.34, P = 0.022). A significant reduction of 4.58 (B = -4.58, P = 0.009) in codeine presentations involving subsequent hospital admission immediately post-up-scheduling was found; but no immediate reduction in codeine-related suicide-related overdoses, length of inpatient stay, or re-presentations (P > 0.0125; adjusted for multiple comparisons). Restricting supply of codeine to prescription-only may have resulted in less harmful codeine-related use in the community, without a corresponding immediate decrease in other opioid-related harms.
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Affiliation(s)
- Rachel A Elphinston
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Australia
- School of Psychology, The University of Queensland, Brisbane, Australia
- Addiction and Mental Health Service, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
- National Health and Medical Research Council Centre for Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Australia
| | - Jason P Connor
- Discipline of Psychiatry, The University of Queensland, Brisbane, Australia
- National Centre for Youth Substance Abuse Research, The University of Queensland, Brisbane, Australia
| | - Dominique de Andrade
- School of Psychology, The University of Queensland, Brisbane, Australia
- School of Psychology, Deakin University, Geelong, Melbourne, Australia
| | - Linda Hipper
- Addiction and Mental Health Service, Metro South Hospital and Health Service, Brisbane, Queensland, Australia
| | - Chris Freeman
- School of Pharmacy, The University of Queensland, Brisbane, Australia
| | - Gary Chan
- National Centre for Youth Substance Abuse Research, The University of Queensland, Brisbane, Australia
| | - Michele Sterling
- RECOVER Injury Research Centre, The University of Queensland, Brisbane, Australia
- National Health and Medical Research Council Centre for Research Excellence in Road Traffic Injury Recovery, The University of Queensland, Brisbane, Australia
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Deluca P, Foley M, Dunne J, Kimergård A. 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. Front Psychiatry 2021; 12:595706. [PMID: 33868038 PMCID: PMC8047057 DOI: 10.3389/fpsyt.2021.595706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 03/11/2021] [Indexed: 12/03/2022] Open
Abstract
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)].
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Affiliation(s)
- Paolo Deluca
- National Addiction Centre, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - Michelle Foley
- School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland
| | - Jacklyn Dunne
- National Addiction Centre, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
| | - Andreas Kimergård
- National Addiction Centre, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, United Kingdom
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Designing Effective Warnings about Addiction on the Patient Information Leaflet of Over-the-Counter Codeine Sold in England to University Students. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17155490. [PMID: 32751393 PMCID: PMC7432560 DOI: 10.3390/ijerph17155490] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 07/20/2020] [Accepted: 07/24/2020] [Indexed: 12/25/2022]
Abstract
(1) Background: The harm of misusing over-the-counter (OTC) codeine-containing medicines among university students in England is being increasingly recognized. Based on English university students, this paper aims to study the importance of information design on information communication, explore methods for effective warning design, and investigate university students’ perception of OTC codeine. (2) Methods: The effective warning design is addressed through case studies, answering correctness by the heat map generated from the eye-tracking experiment (ETE), and the total time spent on the tasks. User perceptions are made though online surveys. (3) Results: Information design significantly affects the way user processes information. Therefore, two emphasized warnings displayed in the headline, and the “possible side effect (PSE)” sections and warning signs of addiction presented under the PSE are suggested as effective ways to display warnings. For students’ perception of OTC codeine, 80% of university students are unfamiliar with the substance. After reading the patient information leaflets (PILs), 47% recommended tight regulation on codeine. (4) Conclusions: The misuse of OTC codeine could be a potential problem among English university students. The design of the PIL significantly influences the chance of unintentional medicine misuse. The display of warnings on the PILs of OTC codeine should be redesigned for better understanding.
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Mckenzie M, Johnson JL, Anderson K, Summers R, Wood P. Exploring Australian pharmacists' perceptions and attitudes toward codeine up-scheduling from over-the-counter to prescription only. Pharm Pract (Granada) 2020; 18:1904. [PMID: 32566049 PMCID: PMC7290177 DOI: 10.18549/pharmpract.2020.2.1904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 05/31/2020] [Indexed: 12/28/2022] Open
Abstract
Objective: Explore the perceptions, attitudes and experiences of pharmacists relating to the up-scheduling of low dose codeine containing analgesics and the impact on pharmacy practice. Methods: A mixed design method was used consisting of an anonymous online questionnaire survey to quantitatively capture broad pre-scheduling change perceptions paired with a series of in-depth post-scheduling semi-structured interviews to provide a qualitative picture of the impact of codeine up-scheduling on pharmacy practice in Australia. Results: A total of 191 pharmacists completed the quantitative survey and 10 participated in the in-depth interview. The majority of respondents supported the decision to up-schedule over-the-counter combination products containing codeine to some degree. Three main themes emerged from the data: pharmacists’ perceptions of the codeine up-scheduling decision, preparing for the up-schedule and impact of the up-schedule on pharmacy practice. Pharmacists were concerned about the impact of up-scheduling on the pharmacy business, patient access to pain relief and the diminishment of their professional role. Conclusions: There were diverse perceptions, preparedness and impact on practice regarding the up-scheduling of low dose codeine products. Further research should be conducted to gauge if and how these perceptions have changed over time and to identify whether pain is being managed more effectively post codeine up-scheduling.
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Affiliation(s)
- Melanie Mckenzie
- Department of Pharmacy and Biomedical Science, College of Science, Health & Engineering, La Trobe University. Bendigo, VIC (Australia).
| | - Jacinta L Johnson
- School of Pharmacy and Medical Sciences, University of South Australia. Adelaide, SA (Australia).
| | - Karen Anderson
- Rural Department of Community Health, La Trobe Rural Health School. Bendigo, VIC (Australia).
| | - Richard Summers
- Department of Pharmacy and Biomedical Science, College of Science, Health & Engineering, La Trobe University. Bendigo, Vic (Australia).
| | - Pene Wood
- Department of Pharmacy and Biomedical Science, College of Science, Health & Engineering, La Trobe University. Bendigo, Vic (Australia).
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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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Hu X, Gallagher M, Loveday W, Dev A, Connor JP. Network Analysis and Visualisation of Opioid Prescribing Data. IEEE J Biomed Health Inform 2020; 24:1447-1455. [DOI: 10.1109/jbhi.2019.2939028] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Mishriky J, Stupans I, Chan V. The views of Australian adults experiencing pain on the upscheduling of codeine-containing analgesics to 'prescription only'. Int J Clin Pharm 2020; 43:386-393. [PMID: 32301065 DOI: 10.1007/s11096-020-01026-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 04/03/2020] [Indexed: 11/29/2022]
Abstract
Background Codeine is one of the most commonly used opioids worldwide and is available in different formulations, often combined with other simple analgesics. There is a growing concern of the potential harms associated with codeine misuse in the Australian community, and for this reason codeine containing analgesics have been upscheduled in Australia to 'prescription only medicines' from February 2018. There is currently limited knowledge on the views of Australian adults experiencing pain symptoms on this codeine restriction, and whether this change has impacted their ability to adequately manage their pain. Objective To investigate the views of adults experiencing pain on the 2018 codeine upscheduling in Australia. Setting Adults experiencing pain symptoms, predominantly recruited from Victoria, Australia. Method A descriptive cross-sectional study was conducted using a pre-tested customised anonymous self-administered questionnaire between January and March 2019. To capture a broad range of demographics, participants were recruited from ten Victorian community pharmacies across metropolitan Melbourne, Australia. Main outcome measure Opinions of Australian adults experiencing pain to targeted questions regarding the 2018 codeine upscheduling, including perceived advantages and disadvantages. Results A total of 120 participants completed the questionnaire. Sixty-two (52%) participants agreed/strongly agreed that codeine was helpful in alleviating pain symptoms before a prescription was required; while 43% of participants felt the codeine restriction has made it more difficult to manage their pain, with 33% unsure. Participants who were in favour of the codeine upscheduling believed that they are now more encouraged to consult healthcare professionals and make better use of the pain management services made available to them in the Australian community; however some now question the value of pharmacists in this context, given that there is now a reduced array of analgesic medicines available at pharmacies without a prescription. Conclusion This study showed there are mixed views, with some participants being unsure or not in favour of the codeine upscheduling, particularly based on qualitative responses. There is also opportunity in this space for healthcare providers to extend beyond standard practice and offer alternative pain management advice and support now that codeine is no longer available in Australian pharmacies without a prescription.
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Affiliation(s)
- John Mishriky
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, 3083, Australia
| | - Ieva Stupans
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, 3083, Australia
| | - Vincent Chan
- Pharmacy, School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, 3083, Australia.
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The Promotion of Policy Changes Restricting Access to Codeine Medicines on Twitter: What do National Pain Organizations Say? THE JOURNAL OF PAIN 2019; 21:881-891. [PMID: 31857206 DOI: 10.1016/j.jpain.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 11/17/2019] [Accepted: 12/09/2019] [Indexed: 11/23/2022]
Abstract
Codeine is one of the most common opioid medicines for treating pain. Australia introduced policy changes in February 2018 to up-schedule codeine to prescription-only medicine due to concerns of adverse effects, opioid dependency, and overdose-related mortality. This study investigated the frequency and content of messages promoted on Twitter by 4 Australian peak pain organizations, pre- and postpolicy implementation. A time series analysis examined frequency of Twitter posts over a 48-week period. Text analysis via Leximancer examined message content. Results showed that promotion and education of the pending policy change dominated the Twitter feed prior to up-scheduling. However, immediately following policy change, there was a shift in content towards promoting conferences and research, and a significant decrease in the frequency of codeine-related posts, compared to opioid-related non-codeine posts. The findings suggest that pain organizations can provide timely and educational policy dissemination in the online environment. They have implications for individuals with chronic pain who use the Internet for health information and the degree to which they can trust these sources, as well as health professionals. Further research is required to determine if public health campaigns can be targeted to prevent opioid-related harm and improve pain care via this increasingly used medium. PERSPECTIVE: This study presents a first look at what information is being communicated by influential pain organizations that have an online Twitter presence and how messages were delivered during a major policy change restricting access to codeine medicines. Insights could drive targeted future online health campaigns for improved pain management.
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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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Weier M, Farrugia A. 'Potential issues of morbidity, toxicity and dependence': Problematizing the up-scheduling of over-the-counter codeine in Australia. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 80:102538. [PMID: 31362859 DOI: 10.1016/j.drugpo.2019.07.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 07/15/2019] [Accepted: 07/19/2019] [Indexed: 12/18/2022]
Abstract
Until February of 2018, Australians were able to purchase low-dose codeine products (LDCPs) over-the-counter from pharmacies. In 2017, following review and public consultation, Australia's therapeutic drug regulator rescheduled LDCPs to prescription-only, in line with other higher-dose codeine and opioid products. In this article, we draw on Bacchi's 'what's the problem represented to be' approach to 'work backwards', analysing this 'solution' and the particular 'problematisation' of codeine it produces and relies on. We analyse the 'final decision and reasons for decisions' document, which outlines the consultation and decision-making process leading to the rescheduling of LDCPs. We contend that abuse and dependence of codeine by people with chronic pain is the 'problem' constituted by the decision to reschedule LDCP. We consider the ethical and political implications of this problematisation. First, we argue that this problematisation limits the ways the LDCP consumption, particularly by people with chronic pain, can be understood. This problematisation effaces the multiple reasons people with chronic pain may consume LDCPs long term and works to naturalise notions of 'misuse'. We next argue that notions of the 'legitimate patient' and the 'illegitimate consumer' or 'abuser' are in different ways positioned as primarily responsible for managing their health. From here we argue that the problematisation of LDCPs in Australia produces codeine as the sole agent of harm in ways that background wider harm-producing social arrangements. Our analysis also suggests that the 'problem' of LDCPs unreflexively reinforces medical authoring and expertise as the primary solution. Finally, we suggest that the use of LDCPs in Australia could instead be re-problematised as an issue of 'chronic health mismanagement'. Responses to this problematisation would require a reorientation away from attempts to reduce accessibility such as up-scheduling to significantly more focus on long-term healthcare engagement for people consuming LDCPs to manage chronic health issues.
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Affiliation(s)
- Megan Weier
- Centre for Social Impact, School of Business, University of New South Wales, Sydney, NSW, Australia.
| | - Adrian Farrugia
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Vic, Australia
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Efficacy and Safety of Low-dose Codeine-containing Combination Analgesics for Pain: Systematic Review and Meta-Analysis. Clin J Pain 2019; 35:836-843. [PMID: 31318725 DOI: 10.1097/ajp.0000000000000746] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
OBJECTIVE To investigate the efficacy and safety of combination analgesic products containing low-dose codeine (up to 30 mg/dose) for pain. METHODS Electronic databases were used to identify eligible placebo-controlled, randomized controlled trials (RCTs). Two authors extracted data and assessed the risk of bias. Data were pooled using a random-effects model with the strength of evidence assessed using Grading of Recommendations Assessment, Development and Evaluation. The primary outcome was immediate pain relief (3 hours post administration) on a 0 to 100 pain scale. RESULTS Ten RCTs were eligible. There is low-quality evidence (4 RCTs, n=211 participants) that a single dose of a combination analgesic product (with an nonsteroidal anti-inflammatory) containing low-dose codeine (15 to 30 mg) provides small pain relief for acute dental pain (mean difference [MD], -12.7; 95% confidence interval [CI], -18.5 to -6.9) and moderate-quality evidence (1 RCT, n=93) of small pain relief for post-episiotomy pain and orthopedic surgery pain (MD,, -10.0; 95% CI, -19.0 to -1.0 and MD, -11.0; 95% CI, -20.7 to -1.3), respectively. There is low-quality evidence (1 RCT, n=80) that a multiple-dose regimen provides small pain relief for acute pain following photorefractive keratectomy (MD, -16.0; 95% CI, -24.5 to -7.5) and moderate-quality evidence of moderate pain relief for certain chronic pain conditions: for hip osteoarthritis (MD, -19.0; 95% CI, -31.2 to -6.8) and for temporomandibular joint pain (MD, -26.0; 95% CI, -44.5 to -7.5). Two studies reported a higher incidence of drowsiness in the treatment group compared with the placebo group (relative risk, 8.50; 95% CI, 1.96, 36.8 and 19.3; 95% CI, 1.2-306.5, respectively). DISCUSSION There is low to moderate level evidence that combination analgesic products containing low-dose codeine provide small to moderate pain relief for acute and chronic pain conditions in the immediate short term with limited trial data on use beyond 24 hours. Further research examining regular use of these medicines is needed with more emphasis on measuring potential harmful effects.
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Lee E, Cooper RJ. Codeine Addiction and Internet Forum Use and Support: Qualitative Netnographic Study. JMIR Ment Health 2019; 6:e12354. [PMID: 31021328 PMCID: PMC6658256 DOI: 10.2196/12354] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 01/31/2019] [Accepted: 03/13/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The use of codeine as an analgesic is well-recognized, but there are increasing concerns that for some individuals continued use may lead to misuse, dependence, and fatalities. Research suggests that those affected may represent a hard-to-reach group who do not engage with formal treatment services. OBJECTIVE This study sought to explore the experiences of people with self-reported addiction to codeine and, specifically, how a social media forum is used to communicate with others about this issue. METHODS Using a qualitative netnographic methodology, the social media forum Mumsnet was used, with permission, and searches were undertaken in 2016 of any posts that related to codeine and addiction. A total of 95 relevant posts were identified; a purposive sample of 25 posts was selected to undertake subsequent six-stage thematic analysis and development of emerging themes. These 25 posts were posted between 2003 and 2016 and comprised 757 individual posts. RESULTS Individuals created posts to actively request help in relation to usually their own, but occasionally their partner's or relative's, problems relating to codeine use and self-reported "addiction." Varying levels of detail were provided in narratives of problematic codeine use. There were both positive and negative descriptions of side effects emerging, problems experiencing withdrawal, and failed attempts to discontinue codeine use. Mainly positive and supportive responses to posts were identified from those with either self-reported health profession experience or lay respondents, who often drew on their own experiences of similar problems. Treatment advice emerged in two main ways, either as signposting to formal health services or to informal approaches and often anecdotal advice about how to taper or use cold turkey techniques. Some posts were more critical of the original poster, and arguments and challenges to advice were not uncommon. Shame and stigma were often associated with users' posts and, while there was a desire to receive support and treatment advice in this forum, users often wanted to keep their codeine use hidden in other aspects of their lives. Distinctly different views emerged as to whether responsibility lay with prescribers or patients. Some users expressed anger toward doctors and their prescribing practices. CONCLUSIONS This study provides a unique insight into how a public internet forum is used by individuals to confirm and seek support about problematic codeine use and of the ways others respond. The pseudonymous use of internet forums for such information and variation in treatment options suggested by often lay respondents suggest that increased formal support and awareness about codeine addiction are needed. There may be opportunities for providing further support directly on such online forums. Improvements in prescribing codeine and in the over-the-counter supply of codeine are required to prevent problematic use from occurring.
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Affiliation(s)
- Eleanor Lee
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
| | - Richard J Cooper
- School of Health and Related Research, University of Sheffield, Sheffield, United Kingdom
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Kinnaird E, Kimergård A, Jennings S, Drummond C, Deluca P. From pain treatment to opioid dependence: a qualitative study of the environmental influence on codeine use in UK adults. BMJ Open 2019; 9:e025331. [PMID: 30948580 PMCID: PMC6500317 DOI: 10.1136/bmjopen-2018-025331] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Emma Kinnaird
- Department of Eating Disorders, Psychological Medicine, King’s College London, London, UK
| | | | | | - Colin Drummond
- Addictions Department, King’s College London, London, UK
| | - Paolo Deluca
- Addictions Department, King’s College London, London, UK
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Kennedy C, Duggan E, Bennett K, Williams DJ. Rates of reported codeine-related poisonings and codeine prescribing following new national guidance in Ireland. Pharmacoepidemiol Drug Saf 2019; 28:106-111. [DOI: 10.1002/pds.4725] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/15/2018] [Accepted: 12/05/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Cormac Kennedy
- Department of Geriatrics and Stroke Medicine; Royal College of Surgeons in Ireland; Dublin Ireland
| | - Edel Duggan
- National Poisons Information Centre; Beaumont Hospital; Dublin Ireland
| | - Kathleen Bennett
- Division of Population Health Sciences; Royal College of Surgeons in Ireland; Dublin 2 Ireland
| | - David J. Williams
- Department of Geriatrics and Stroke Medicine; Royal College of Surgeons in Ireland; Dublin Ireland
- Department of Geriatrics and Stroke Medicine; Beaumont Hospital; Dublin 9 Ireland
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Tay EMY, Roberts DM. A spotlight on the role, use, and availability of codeine and the implications faced. Expert Rev Clin Pharmacol 2018; 11:1057-1059. [PMID: 30336710 DOI: 10.1080/17512433.2018.1537122] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Emma M Y Tay
- a Drug Health Services , Liverpool Hospital , Sydney , NSW , Australia.,b South Western Sydney Clinical School , University of New South Wales , Sydney , NSW , Australia
| | - Darren M Roberts
- c Alcohol and Drug Service and Department of Clinical Pharmacology and Toxicology , St Vincent's Hospital , Darlinghurst , NSW , Australia.,d St Vincent's Clinical School , University of New South Wales , Darlinghurst , NSW , Australia
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Advertising of Over-the-Counter Codeine-Containing Medicines in the EU: Differences in the Regulation of Advertising Between Member States. Pharmaceut Med 2018. [DOI: 10.1007/s40290-018-0245-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Foley M, Carney T, Rich E, Dada S, Mburu C, Parry C. A study of medical professionals' perspectives on medicines containing codeine in South Africa. S Afr J Psychiatr 2018; 24:1162. [PMID: 30263221 PMCID: PMC6138080 DOI: 10.4102/sajpsychiatry.v24.i0.1162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 05/08/2018] [Indexed: 11/01/2022] Open
Abstract
Background Misuse of codeine available on prescription and over-the-counter (OTC) has been highlighted as a potential problem in South Africa. Objective To examine the perceptions of medical professionals regarding codeine use (prescribed and OTC), misuse, dependence and treatment options in South Africa. Method Data for the study were obtained using a sample of medical professionals obtained through random and convenience sampling. A quantitative methodology was employed using a structured self-administered questionnaire with closed and open-ended items. Data analysis was conducted using SPSS version 21; 238 medical professionals involved in the prescribing of codeine completed the questionnaire. Results Two-thirds of participants stated that they routinely reviewed patients prescribed codeine, and high levels of concern were expressed about the availability of OTC medicine containing codeine in pharmacies (84.9%) and on the internet (71.3%). There was agreement that medicines containing codeine should be regulated to a prescription-only medicine (85.3%). Only 22% of participants agreed that they had suitable screening methods to help with detection of codeine dependence. Eighty per cent indicated that they would welcome the opportunity for greater instruction on prescribing potentially addictive medicines. Conclusion There appears to be a need to improve education on consumption and risks associated with codeine use. In addition, screening tools are needed to detect those with codeine dependence. Greater data sources are now needed to examine the sale of and consumption of codeine medicines in the interest of public health.
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Affiliation(s)
- Michelle Foley
- School of Health Sciences, Waterford Institute of Technology, Ireland
| | - Tara Carney
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, South Africa
| | - Eileen Rich
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, South Africa
| | - Siphokazi Dada
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, South Africa
| | | | - Charles Parry
- South African Medical Research Council, South Africa
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Foley M, Carney T, Rich E, Dada S, Mburu C, Parry C. A study of medical professionals’ perspectives on medicines containing codeine in South Africa. S Afr J Psychiatr 2018. [DOI: 10.4102/sajpsychiatry.v24i0.1162] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Inacio MCS, Cashman K, Pratt NL, Gillam MH, Caughey G, Graves SE, Roughead EE. Prevalence and changes in analgesic medication utilisation 1 year prior to total joint replacement in an older cohort of patients. Osteoarthritis Cartilage 2018; 26:356-362. [PMID: 29258881 DOI: 10.1016/j.joca.2017.11.016] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 10/24/2017] [Accepted: 11/01/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To evaluate the prevalence and change in analgesic medications use prior to joint replacement in older patients between 2001 and 2012. METHODS A population based epidemiological study was conducted. Opioids, non-steroidal anti-inflammatories (NSAIDs), paracetamol, corticosteroid injections, medications for neuropathic pain, hypnotics, and muscle relaxants supplied 1 year prior to total knee replacement (TKR, n = 15,517) and hip replacement (THR, n = 10,018) were assessed. Patient characteristics and surgical indication adjusted prevalence ratios (PRs) and 95% confidence intervals (CI) are provided. RESULTS From 2001 to 2012, in the TKR cohort (median age 78.9) the prevalence of opioid use prior to surgery increased from 37% to 49% (PR = 1.01, 95% CI 1.00-1.01, P = 0.01), while in the THR cohort (median age 81.1) it increased from 44% to 54% (PR = 1.01, 95% CI 1.01-1.02, P < 0.001). Paracetamol use increased from 52% to 61% (PR = 1.0, 95% CI 1.0-1.0, P = 0.913) in the TKR cohort and from 55% to 67% (PR = 1.01, 95% CI 1.00-1.01, P = 0.005) in the THR cohort. Neuropathic pain medication use increased from 5% to 11% in the TKR cohort (PR = 1.04, 95% CI 1.02-1.06, P < 0.0001) and from 6% to 12% in the THR cohort (PR = 1.06, 95% CI 1.04-1.09, P < 0.0001). NSAID use decreased from 76% to 50% in the TKR cohort (PR = 0.96, 95% CI 0.95-0.96, P < 0.0001), and from 81% to 47% in THR cohort (PR = 0.95, 95% CI 0.94-0.95, P < 0.0001). Corticosteroid injections prevalence also decreased (TKR: 21-18%, PR = 0.97, 95% CI 0.96-0.97, P < 0.001, THR: 18-17%, PR = 0.97, 95% CI 0.96-0.98, P < 0.001). CONCLUSION Pain medication utilization prior to joint replacement surgery changed significantly in this national older cohort of patients during the 2000s.
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Affiliation(s)
- M C S Inacio
- Medicine and Device Surveillance Centre of Research Excellence, Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - K Cashman
- Medicine and Device Surveillance Centre of Research Excellence, Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - N L Pratt
- Medicine and Device Surveillance Centre of Research Excellence, Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - M H Gillam
- Medicine and Device Surveillance Centre of Research Excellence, Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - G Caughey
- Medicine and Device Surveillance Centre of Research Excellence, Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia.
| | - S E Graves
- Australian Orthopaedic Association, National Total Joint Replacement Registry, Adelaide, Australia
| | - E E Roughead
- Medicine and Device Surveillance Centre of Research Excellence, Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
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24
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Pharmacists' perceptions and communication of risk for alertness impairing medications. Res Social Adm Pharm 2018; 14:31-45. [DOI: 10.1016/j.sapharm.2016.12.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 11/19/2016] [Accepted: 12/16/2016] [Indexed: 01/08/2023]
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Mill D, Johnson JL, Cock V, Monaghan E, Hotham ED. Counting the cost of over-the-counter codeine containing analgesic misuse: A retrospective review of hospital admissions over a 5 year period. Drug Alcohol Rev 2017; 37:247-256. [DOI: 10.1111/dar.12595] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 07/17/2017] [Accepted: 07/19/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Deanna Mill
- SA Pharmacy, SA Health; Government of South Australia; Adelaide Australia
| | - Jacinta L. Johnson
- SA Pharmacy, SA Health; Government of South Australia; Adelaide Australia
- School of Pharmacy and Medical Sciences; University of South Australia; Adelaide Australia
| | - Victoria Cock
- Drug and Alcohol Services of South Australia, SA Health, Government of South Australia; Adelaide Australia
| | - Emily Monaghan
- Drug and Alcohol Services of South Australia, SA Health, Government of South Australia; Adelaide Australia
| | - Elizabeth D. Hotham
- School of Pharmacy and Medical Sciences; University of South Australia; Adelaide Australia
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Experiences of Codeine Use, Misuse and Dependence: Application of Liese and Franz's Cognitive Developmental Model of Substance Abuse. Behav Cogn Psychother 2017; 45:238-252. [PMID: 28183374 DOI: 10.1017/s1352465817000030] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Buprenorphine-Naloxone in the Treatment of Codeine Dependence: a Scoping Review of Clinical Case Presentations. Int J Ment Health Addict 2017. [DOI: 10.1007/s11469-016-9655-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Codeine Shopping Behavior in a Retrospective Cohort of Chronic Noncancer Pain Patients: Incidence and Risk Factors. THE JOURNAL OF PAIN 2016; 17:1291-1301. [DOI: 10.1016/j.jpain.2016.08.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Revised: 08/23/2016] [Accepted: 08/24/2016] [Indexed: 02/02/2023]
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Thai PK, Lai FY, Bruno R, van Dyken E, Hall W, O'Brien J, Prichard J, Mueller JF. Refining the excretion factors of methadone and codeine for wastewater analysis - Combining data from pharmacokinetic and wastewater studies. ENVIRONMENT INTERNATIONAL 2016; 94:307-314. [PMID: 27295047 DOI: 10.1016/j.envint.2016.05.033] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/09/2016] [Accepted: 05/31/2016] [Indexed: 06/06/2023]
Abstract
Analysing drug residues in wastewater (wastewater analysis) to monitor the consumption of those drugs in the population has become a complementary method to epidemiological surveys. In this method, the excretion factor of a drug (or the percentage of drug metabolites excreted through urine) is a critical parameter for the back-estimation of the consumption of a drug. However, this parameter is usually derived from a small database of human pharmacokinetic studies. This is true for methadone and codeine, the two most commonly used opioids and also common substances of abuse. Therefore, we aimed to refine the current excretion factors used for estimating methadone and codeine by analysing published data from the literature on the excretion of methadone, its main metabolite, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), and codeine. Our review included both human drug pharmacokinetic studies and wastewater analysis studies. We found that while the commonly used excretion factor of methadone (~27.5%) was relatively accurate, the excretion factor of EDDP, a better biomarker for methadone consumption in sewer epidemiology, should be twice that of methadone (i.e. 55%) instead of the current equal or half values. For codeine, the excretion factor should be ~30% instead of 63.5% or 10% as previously used in wastewater analysis studies. Data from wastewater analysis studies could be used in this way to refine the excretion factors of the drugs of interest.
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Affiliation(s)
- Phong K Thai
- Queensland University of Technology, International Laboratory for Air Quality & Health, Brisbane, Queensland, Australia; University of Queensland, National Research Centre for Environmental Toxicology (Entox), Brisbane, Queensland, Australia.
| | - Foon Yin Lai
- University of Queensland, National Research Centre for Environmental Toxicology (Entox), Brisbane, Queensland, Australia
| | - Raimondo Bruno
- University of Tasmania, School of Psychology, Hobart, Tasmania, Australia
| | - Emma van Dyken
- University of Tasmania, Law Faculty, Hobart, Tasmania, Australia
| | - Wayne Hall
- University of Queensland, Centre for Youth Substance Abuse Research, Brisbane, Queensland, Australia
| | - Jake O'Brien
- University of Queensland, National Research Centre for Environmental Toxicology (Entox), Brisbane, Queensland, Australia
| | - Jeremy Prichard
- University of Tasmania, Law Faculty, Hobart, Tasmania, Australia
| | - Jochen F Mueller
- University of Queensland, National Research Centre for Environmental Toxicology (Entox), Brisbane, Queensland, Australia
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MacKinnon JIJ. Tighter regulations needed for over-the-counter codeine in Canada. Can Pharm J (Ott) 2016; 149:322-324. [PMID: 27829853 DOI: 10.1177/1715163516660572] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kimergård A, Deluca P, Hindersson P, Breindahl T. How Resistant to Tampering are Codeine Containing Analgesics on the Market? Assessing the Potential for Opioid Extraction. Pain Ther 2016; 5:187-201. [PMID: 27295264 PMCID: PMC5130903 DOI: 10.1007/s40122-016-0053-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2016] [Indexed: 01/08/2023] Open
Abstract
Introduction Misuse of opioid analgesics, in combination with diversion, dependence, and fatal overdoses, presents a serious problem for public health, which affects many countries worldwide. Within this context, tampering with opioids has been associated with serious harm. The aim of the present study was to assess the tampering potential of codeine combination analgesics on the market (containing codeine/non-opioid analgesics) by the extraction of codeine. Methods Codeine was extracted from three combination formulations sold lawfully from licensed pharmacies without a medical prescription in Denmark and the UK. Extraction of codeine followed tampering procedures available on the Internet. The amounts of codeine and accompanying non-opioid analgesics in tampering products were analysed with liquid chromatography and tandem mass spectrometry (LC–MS/MS). Results LC–MS/MS showed recoveries of the total amounts of codeine in tampering products of 81–84% from Product 1 (codeine/acetylsalicylic acid); 61–67% from Product 2 (codeine/ibuprofen); and 42–71% from Product 3 (codeine/paracetamol). Recoveries of non-opioid analgesics ranged between: 57–73% acetylsalicylic acid; 5.5–8.5% ibuprofen, and 5.0–9.2% paracetamol. Conclusion With the tampering procedures used, high amounts of codeine were separated from the accompanying analgesics in some, but not in all of the codeine containing formulations. Evidence-based medicine regulation, treatment for opioid dependence, and information to minimise risks to the public are essential components of an effective public health strategy to address the harms of tampering and misuse. Funding Marie Pedersen and Jensine Heiberg Foundation.
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Affiliation(s)
- Andreas Kimergård
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Addiction Sciences Building, 4 Windsor Walk, London, SE5 8BB, UK.
| | - Paolo Deluca
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Addiction Sciences Building, 4 Windsor Walk, London, SE5 8BB, UK
| | - Peter Hindersson
- Department of Clinical Biochemistry, North Denmark Regional Hospital (Aalborg University), Hjørring, Denmark
| | - Torben Breindahl
- Department of Clinical Biochemistry, North Denmark Regional Hospital (Aalborg University), Hjørring, Denmark
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Karanges EA, Blanch B, Buckley NA, Pearson SA. Twenty-five years of prescription opioid use in Australia: a whole-of-population analysis using pharmaceutical claims. Br J Clin Pharmacol 2016; 82:255-67. [PMID: 26991673 DOI: 10.1111/bcp.12937] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 03/10/2016] [Accepted: 03/13/2016] [Indexed: 12/22/2022] Open
Abstract
AIM The aim of this paper is to investigate 25-year trends in community use of prescribed opioid analgesics in Australia, and to map these trends against major changes to opioid registration and subsidy. METHODS We obtained dispensing data from 1990 to 2014 from two sources: dispensing claims processed under Australia's national drug subsidy programme, the Pharmaceutical Benefits Scheme, including under co-payment records from 2012; and estimates of non-subsidized medicine use from a survey of Australian pharmacies (until 2011). Utilization was expressed in defined daily doses (DDD)/1000 population/day. RESULTS Opioid dispensing increased almost four-fold between 1990 and 2014, from 4.6 to 17.4 DDD/1000 pop/day. In 1990, weak, short-acting or orally administered opioids accounted for over 90% of utilization. Use of long-acting opioids increased over 17-fold between 1990 and 2000, due primarily to the subsidy of long-acting morphine and increased use of methadone for pain management. Between 2000 and 2011, oxycodone, fentanyl, buprenorphine, tramadol and hydromorphone use increased markedly. Use of strong opioids, long-acting and transdermal preparations also increased, largely following the subsidy of various opioids for noncancer pain. In 2011, the most dispensed opioids were codeine (41.1% of total opioid use), oxycodone (19.7%) and tramadol (16.1%); long-acting formulations comprised approximately half, and strong opioids 40%, of opioid dispensing. CONCLUSIONS Opioid utilization in Australia is increasing, although these figures remain below levels reported in the US and Canada. The increased use of opioids was largely driven by the subsidy of long-acting formulations and opioids for the treatment of noncancer pain.
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Affiliation(s)
- Emily A Karanges
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Australia, 2052
| | - Bianca Blanch
- Faculty of Pharmacy, University of Sydney, Australia, 2006
| | - Nicholas A Buckley
- Discipline of Pharmacology, School of Medical Sciences, University of Sydney, Australia, 2006
| | - Sallie-Anne Pearson
- Medicines Policy Research Unit, Centre for Big Data Research in Health, University of New South Wales, Australia, 2052.,Faculty of Pharmacy, University of Sydney, Australia, 2006
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A Comparative Exploration of Community Pharmacists’ Views on the Nature and Management of Over-the-Counter (OTC) and Prescription Codeine Misuse in Three Regulatory Regimes: Ireland, South Africa and the United Kingdom. Int J Ment Health Addict 2016. [DOI: 10.1007/s11469-016-9640-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Van Hout MC, Norman I. Misuse of non-prescription codeine containing products: Recommendations for detection and reduction of risk in community pharmacies. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 27:17-22. [DOI: 10.1016/j.drugpo.2015.09.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Revised: 08/26/2015] [Accepted: 09/19/2015] [Indexed: 10/23/2022]
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An ecological study of the extent and factors associated with the use of prescription and over-the-counter codeine in Australia. Eur J Clin Pharmacol 2015; 72:469-94. [PMID: 26690771 DOI: 10.1007/s00228-015-1995-8] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 12/01/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE The extent and factors associated with codeine use in the community remain poorly understood despite the widespread global use of codeine. The aim of this study was to examine the use of prescription and over-the-counter (OTC) codeine in Australia and identify the geographic and socio-demographic characteristics associated with prescription and OTC codeine use. METHODS National sales data for prescription and OTC codeine (supplied by IMS Health) were used to estimate codeine utilisation (in pack sales and milligrammes) in Australia during 2013, mapped to Australian Bureau of Statistics (ABS) Statistical Local Areas (SLAs) and Remoteness Areas. Socio-demographic characteristics and total population estimates of SLAs were obtained from the ABS. SLA-level data on sex, age distribution, income, occupations involving physical labour and number of pharmacies were included in linear regression analyses to examine their association with total, prescription and OTC codeine use. RESULTS In total, 27,780,234 packs of codeine were sold in Australia during 2013, equating to 12,376 kg. OTC codeine preparations accounted for 15,490,207 packs (55.8 %) or 4967.30 kg (40.1 %). Nationally, an estimated 1.24 packs (or 554.10 mg) of codeine were sold per person; utilisation was higher in more remote areas. SLAs with a higher percentage of low-income earning households had the highest rates of prescription codeine use (β 0.16, p < 0.001), whereas SLAs with a higher percentage of males had the highest rates of OTC codeine use (β 0.22, p < 0.001). CONCLUSIONS Codeine use is common in Australia, with clear distinctions in the geographic and socio-demographic characteristics associated with prescription and OTC codeine use.
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‘Codeine is my companion’: misuse and dependence on codeine containing medicines in Ireland. Ir J Psychol Med 2015; 35:275-288. [DOI: 10.1017/ipm.2015.60] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
ObjectivesGlobal 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.MethodsIn-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.ResultsFindings 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.ConclusionsThere 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.
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Misuse of 'over-the-counter' codeine analgesics: does formulation play a role? Public Health 2015; 130:95-6. [PMID: 26612458 DOI: 10.1016/j.puhe.2015.10.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Accepted: 10/15/2015] [Indexed: 11/23/2022]
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Roxburgh A, Hall WD, Burns L, Pilgrim J, Saar E, Nielsen S, Degenhardt L. Trends and characteristics of accidental and intentional codeine overdose deaths in Australia. Med J Aust 2015; 203:299. [DOI: 10.5694/mja15.00183] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 07/31/2015] [Indexed: 01/27/2023]
Affiliation(s)
| | - Wayne D Hall
- University of New South Wales, Sydney, NSW
- University of Queensland, Brisbane, QLD
| | | | | | - Eva Saar
- Monash University, Melbourne, VIC
- National Coronial Information System, Melbourne, VIC
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39
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Foley M, Harris R, Rich E, Rapca A, Bergin M, Norman I, Van Hout MC. The availability of over-the-counter codeine medicines across the European Union. Public Health 2015. [PMID: 26215740 DOI: 10.1016/j.puhe.2015.06.014] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- M Foley
- School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland.
| | - R Harris
- H.I. Weldricks Ltd, Doncaster, United Kingdom
| | - E Rich
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Pretoria, South Africa
| | - A Rapca
- H.I. Weldricks Ltd, Doncaster, United Kingdom
| | - M Bergin
- School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland
| | - I Norman
- Kings College London, Florence Nightingale School of Nursing & Midwifery, London, United Kingdom
| | - M C Van Hout
- School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland
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40
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Agley J, McIntire R, DeSalle M, Tidd D, Wolf J, Gassman R. Connecting patients to services: Screening, brief intervention and referral to treatment in primary health care. DRUGS-EDUCATION PREVENTION AND POLICY 2014. [DOI: 10.3109/09687637.2014.899992] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Schatman ME, Darnall BD. A practical and ethical solution to the opioid scheduling conundrum. J Pain Res 2013; 7:1-3. [PMID: 24353439 PMCID: PMC3862644 DOI: 10.2147/jpr.s58148] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Beth D Darnall
- Stanford University School of Medicine, Division of Pain Medicine, Palo Alto, CA, USA
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