A cross-sectional analysis of over-the-counter codeine use among an Australian sample of people who regularly inject drugs

The impact of proposed regulatory changes and rescheduling on low-dose codeine purchasing in Canada: a time-series analysis

BACKGROUND

Low-dose codeine products can be purchased without a prescription in most of Canada. We explored trends in the purchasing of these products across the Canadian provinces from 2014 to 2019, evaluating the impact of Health Canada's 2016 announcement of a proposed regulatory change and the 2017 opening of a 60-day public comment period, as well as the impact of Manitoba's 2016 policy change requiring a prescription for the purchase of all codeine products in that province.

METHODS

We evaluated population-adjusted monthly purchasing of codeine products from January 2014 to October 2019 using the IQVIA Canadian Drug Store and Hospital Purchases Audit database, stratified by province and over-the-counter (OTC) status. The primary outcomes were change in the monthly volume of low-dose codeine purchased after the 2016 federal regulatory proposal and the 2017 period of public comment across the provinces. Our secondary analysis was the impact of Manitoba's policy change in February 2016 requiring a prescription for low-dose codeine. We conducted a time-series analysis using interventional autoregressive integrated moving average models.

RESULTS

Over the study period, 24 120 kg of codeine (3.025 billion units) and 937 867 kg of acetaminophen were sold as OTC, low-dose codeine products across the Canadian provinces. Health Canada's 2016 announcement did not significantly affect OTC codeine purchasing (p = 0.57). The initiation of a 60-day public comment period was associated with a roughly 44% decrease in OTC codeine purchasing (p = 0.03). In Manitoba, purchasing of the same codeine formulations decreased after rescheduling in February 2016 (p < 0.001). We observed no significant change in the rate of purchasing of higher dose codeine formulations in response to scheduling changes in Manitoba (p = 0.22).

INTERPRETATION

Although Health Canada's 2016 announcement of a proposed regulatory change did not appear to have an effect on OTC codeine purchasing nationally, the 60-day comment period was associated with a decrease in purchasing. Further, Manitoba's 2016 policy change was associated with a significant and sustained decrease in the overall volume of codeine purchased. Given the potential risks of codeine dependence and acetaminophen toxicity with these products, a national rescheduling strategy should be considered.

The challenge of complex drug use: Associated use of codeine-containing medicines and new psychoactive substances in a European cross-sectional online population

OBJECTIVE

Misuse of codeine-containing medicines in combination with new psychoactive substances (NPS) is inadequately described. This study characterises codeine consumption amongst NPS users and non-NPS users to provide warning of health issues.

METHODS

Online survey conducted between July 2015 and March 2016.

RESULTS

Out of 340 respondents, residing in a country in Europe and using codeine recently, 63.8% were female. Mean age: 34.9 years (SD = 12.4). Substance use included NPS (18.5%) and illicit controlled drugs (55.9%). Factors relating to codeine use found to significantly predict NPS use were consuming codeine extracted from combination tablets (OR = 16.79, 95% CI [8.67, 32.51]), obtaining codeine from friends, family, and acquaintances (OR = 3.98, 95% CI [1.82, 8.7]), use of illicit controlled drugs (OR = 34.99, 95% CI [8.39, 145.94]) and use of codeine to experience euphoria (OR = 6.41, 95% CI [3.42, 12.04]).

CONCLUSIONS

Amongst NPS users, codeine is less likely to be used daily but more likely to be used for recreational purposes. Smaller populations engaging in high-risk use exist who take multiple drugs in high doses. Combinations of misused codeine and NPS highlight the need for policy to respond to a more complex drug situation.

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

An ecological study of the extent and factors associated with the use of prescription and over-the-counter codeine in Australia

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.

Patterns and correlates of non-fatal heroin overdose at 11-year follow-up: findings from the Australian Treatment Outcome Study

BACKGROUND

Overdose is a major cause of morbidity and mortality amongst opioid users. This paper reported recent non-fatal overdose amongst the Australian Treatment Outcome Study (ATOS) cohort at 11-year follow-up, and characteristics that predict recent overdose.

METHODS

Longitudinal cohort, with 431 (70.1%) of the original 615 participants interviewed. Participants were administered the ATOS structured interview, addressing demographics, treatment history, drug use, heroin overdose, criminality, health and psychopathology.

FINDINGS

Mean time since heroin initiation was 20.4 years. By 11-year follow-up, the proportion who had overdosed was 67.5%, and 24.4% had experienced five or more overdoses. In the 12 months preceding 11-year follow-up, 4.9% had overdosed (11.8% of those who had used heroin in that period). Of the 21 participants who had recently overdosed, 20 (95.2%) had overdosed previously, and 19 (90.5%) were not enrolled in a treatment programme at the time. Those who had recently overdosed reported higher levels of use of opiates other than heroin (57.1% vs 24.9%), benzodiazepines (61.9% vs 30.5%,), methamphetamine (38.1% vs 16.8%) and cocaine (19.0% vs 3.7%). They also had exhibited higher levels of heroin use and other drug use at baseline, 12 and 24 month follow-ups.

CONCLUSIONS

While the prevalence had declined, overdoses still occurred. A history of overdose and polydrug use patterns continued to provide strong markers for those at continued risk.

The practice of prescribing: discovering differences in what we tell patients about prescription medications

OBJECTIVE

This study explored patient recall of clinician presentation of information about prescription medication, looking specifically for communication patterns and differences by patient individual characteristics and by medication availability type.

METHODS

A cross sectional survey collected information about 216 patients' perceptions of clinician presentations of medication information.

RESULTS

Demographically, males recalled receiving more information about reasons, risks, and regimen in medication discussions. By medication type, patients reported receiving more medication information when the clinician presented a prescription-only medication as opposed to a medication that was also available over the counter.

CONCLUSION

Given the broad and unmonitored use of over-the-counter products, coupled with the increasing awareness of risks associated with many of these medications, it is concerning that patients report receiving less information about these products.

PRACTICE IMPLICATIONS

The emphasis on appropriate medication counseling should not be limited to medications available only by prescription. Prescribers should be mindful of these potential tendencies when discussing medications.