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Mathias R, Howes B, Cock V, Cock C. Reduced gastrointestinal-related hospitalisation costs following rescheduling of over-the-counter codeine-containing compound analgesics in Australia: results of a single hospital audit in South Australia. Intern Med J 2023; 53:2240-2246. [PMID: 37029690 DOI: 10.1111/imj.16080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 03/27/2023] [Indexed: 04/09/2023]
Abstract
BACKGROUND Codeine-containing compound analgesics (CCCAs) are associated with dependence and, when taken in excess, significant risks of harm. A previous audit showed significant costs related to admissions for gastrointestinal (GI) complications of CCCA. Based on this and other evidence of harm, the Australian Therapeutic Goods Administration changed CCCAs to prescription only in 2018. AIMS We aimed to identify the costs associated with codeine-related GI complications and whether the schedule change in 2018 led to a reduced clinical and financial strain on the health care system. METHODS We conducted an audit of GI admissions and associated costs of CCCAs at a tertiary teaching hospital in Adelaide between 2016 and 2020. Patients were grouped by 2-year time periods before (group 1) and following (group 2) schedule change. Costs for the index presentation were multiplied for subsequent presentations. Costs and outcomes were compared for groups (standard statistics; P value < 0.05 significant.) RESULTS: Three hundred forty patients (group 1, n = 164; group 2, n = 119) were identified, with the majority of these admitted due to nonsteroidal anti-inflammatory drugs (NSAIDs) only. For CCCAs (NSAID-containing), the same patients were admitted repeatedly with a reduction from 31 to eight admissions (P = 0.005), following rescheduling. The total cost of CCCA admissions was reduced from AU$ 561 691 for group 1 to AU$ 261 764 for group 2 (P < 0.001). CONCLUSIONS Australian rescheduling of CCCAs in 2018 resulted in a reduction in hospital admissions and costs related to GI complications. The cost savings, even in a single hospital department, were substantial.
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Affiliation(s)
- Ryan Mathias
- Department of Gastroenterology & Hepatology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Bejamin Howes
- Department of Gastroenterology & Hepatology, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Victoria Cock
- Drug and Alcohol Services South Australia (DASSA), Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, South Australia, Australia
| | - Charles Cock
- Department of Gastroenterology & Hepatology, Flinders Medical Centre, Adelaide, South Australia, Australia
- College of Medicine and Public Health, Flinders University of South Australia, Adelaide, South Australia, Australia
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2
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McCoy J, Nielsen S, Bruno R. A prospective cohort study evaluating the impact of upscheduling codeine in Australia among frequent users of codeine. Addiction 2022; 117:677-686. [PMID: 34490926 DOI: 10.1111/add.15683] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 08/18/2021] [Indexed: 12/11/2022]
Abstract
AIM To evaluate and document the impacts of re-scheduling codeine to a prescription-only medication in Australia in February 2018. DESIGN Prospective cohort study. Participants completed an on-line survey with a range of outcome measures at four time-points, once before codeine was re-scheduled (November 2017) and three times after the event: 1 month after (February 2018), 4 months after (June 2018) and 12 months after (February 2019). SETTING Australia. PARTICIPANTS Participants were 260 Australians aged 18 years and above who reported regular over-the-counter (OTC) codeine use and, at the time of the study, were not engaged in treatment for codeine dependence. MEASUREMENTS Survey measures included estimates of daily average codeine use (mg) and overall daily average opioid use [calculated using an oral morphine equivalent daily dose (OMEDD, mg)], opioid use disorder with regard to codeine use (using a modified Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV), pain and pain self-efficacy, anxiety and depression and health service use. FINDINGS A reduction in total daily codeine use (mg) from 64.3 mg [95% confidence interval (CI) = 46.7-81.9] in November 2017 (baseline) to 27.6 mg (95% CI = 19.2-36.0) in February 2019 (final time-point) was observed. A decline in the proportion of participants who met criteria for an opioid use disorder was also evident, with 51.2% (n = 133) at baseline relative to 33.3% (n = 58) at the 12-month follow-up. This study had an overall participant retention rate of 67% at the final time-point. CONCLUSION Re-scheduling codeine in Australia has been accompanied by significant reductions in codeine use and prevalence rates of opioid use disorder in a cohort of individuals who regularly use the medication, without apparent adverse impacts on pain or measures of anxiety and depression.
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Affiliation(s)
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Eastern Health Clinical School, Monash University, Frankston, Australia, 3199, Australia
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3
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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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4
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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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5
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Harnett JT, Dines AM, Wood DM, Archer JRH, Dargan PI. Cold water extraction of codeine/paracetamol combination products: a case series and literature review. Clin Toxicol (Phila) 2019; 58:107-111. [PMID: 31081395 DOI: 10.1080/15563650.2019.1612069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Introduction: Tampering with opioid containing medications for use other than their prescribed indication is well documented; however, the published literature has concentrated on stronger, prescription opioids. Less potent opioids, such as codeine, are available without prescription in many European countries in the form of combination analgesic products and these can also be altered, with reports in particular of "cold-water extraction" being a tampering method achievable using household kitchen equipment.Methods: We searched a database of patients attending two South London emergency departments for cases of self-reported ingestion of the products of cold-water extraction, with subsequent review of their case notes. We searched the scientific and grey literature to identify current knowledge of this technique.Results: We identified seven presentations in six patients, none of whom developed paracetamol toxicity or had concentrations suggesting ingestion of a significant dose of paracetamol. A review of the scientific literature on the method also demonstrated that the technique reduces recovered paracetamol in experimental laboratory settings. Additionally, the established literature characterizes the use of codeine in a recreational setting and reports one fatality associated with the method. Review of grey literature user-forums further describes recreational codeine use in relation to the method and frequent adverse events including hospital admission for paracetamol toxicity.Discussion: Whilst the method appears capable of providing a recreational dose of codeine with reduction in the recovered paracetamol, it cannot be considered safe. Pharmaceutical production methods have been successfully developed to prevent tampering through other means but none thus far have been directed at the cold water extraction technique.Conclusions: Clinicians should be aware of the potential toxicity from tampered nonprescription analgesics. There is also the need for public health education regarding the potential risks associated with these methods.
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Affiliation(s)
- James T Harnett
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Alison M Dines
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - David M Wood
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - John R H Archer
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Paul I Dargan
- Clinical Toxicology, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Faculty of Life Sciences and Medicine, King's College London, London, UK
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6
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Cock V, Edmonds C, Cock C. Complications related to chronic supratherapeutic use of codeine containing compound analgesics in a cohort of patients presenting for codeine withdrawal. Drug Alcohol Rev 2018; 37:731-737. [PMID: 29722073 DOI: 10.1111/dar.12809] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 03/21/2018] [Accepted: 04/05/2018] [Indexed: 12/27/2022]
Abstract
INTRODUCTION AND AIMS This study aimed to compare complications arising due to the supratherapeutic use of paracetamol/codeine or ibuprofen/codeine containing compound analgesics in primary codeine-dependent patients presenting to a drug and alcohol withdrawal service. Data was compared to determine if there was any difference in the number of complications observed between the two groups. DESIGN AND METHODS A retrospective case review of patients presenting for primary codeine dependence from 2009 to 2014. Sixty patients (42F, 36 ± 10 years) using ibuprofen/codeine and 46 (26F, 39 ± 10 years) using paracetamol/codeine containing compound analgesics were compared. A P value of <0.05 was considered significant. RESULTS Patients consumed similar daily doses of codeine (699 ± 45 vs. 636 ± 50 mg) with those consuming ibuprofen/codeine containing compound analgesics ingesting twice as many tablets daily (median 60 vs. 30 tablets; P < 0.0001). Complications related to supratherapeutic use of codeine containing compound analgesics occurred more commonly in patients taking ibuprofen/codeine (52/60; 87%) versus paracetamol/codeine compound analgesics (30/46; 65%) (P < 0.01). Patients taking ibuprofen/codeine containing compound analgesics were more likely to have gastrointestinal bleeding (P < 0.05), anaemia (P < 0.0001) and renal tubular acidosis (P < 0.05). There were two deaths in the group abusing ibuprofen/codeine compound analgesics. DISCUSSION AND CONCLUSIONS In patients with primary codeine dependence, there were more complications related to the supratherapeutic use of ibuprofen/codeine versus paracetamol/codeine containing compound analgesics. The patients in both groups ingested similar total daily codeine amounts. Increased daily tablet intake in the ibuprofen/codeine group could possibly have been linked to lower codeine content per tablet.
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Affiliation(s)
- Victoria Cock
- Drug and Alcohol Services South Australia, Adelaide, Australia
| | - Carolyn Edmonds
- Drug and Alcohol Services South Australia, Adelaide, Australia
| | - Charles Cock
- Department of Gastroenterology, Flinders University, Adelaide, Australia
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7
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Nielsen S, MacDonald T, Johnson JL. Identifying and treating codeine dependence: a systematic review. Med J Aust 2018; 208:451-461. [DOI: 10.5694/mja17.00749] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Accepted: 12/19/2017] [Indexed: 01/10/2023]
Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW
| | - Tim MacDonald
- Currumbin Clinic, Gold Coast, QLD
- Griffith University, Gold Coast, QLD
| | - Jacinta L Johnson
- University of South Australia, Adelaide, SA
- Southern Adelaide Local Health Network, Adelaide, SA
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8
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Mill D, Dawson J, Johnson JL. Managing acute pain in patients who report lactose intolerance: the safety of an old excipient re-examined. Ther Adv Drug Saf 2018; 9:227-235. [PMID: 29796247 DOI: 10.1177/2042098617751498] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 12/08/2017] [Indexed: 11/16/2022] Open
Abstract
Lactose intolerance is exceedingly common, reportedly affecting up to 70% of the world's population, leading to both abdominal and systemic symptoms. Current treatment focuses predominantly on restricting dietary consumption of lactose. Given lactose is one of the most commonly used excipients in the pharmaceutical industry, consideration must be given to the lactose content and therefore safety of pharmaceutical preparations prescribed for patients with lactose intolerance. This article summarizes the current literature examining the likelihood of inducing adverse effects through the administration of lactose-containing pharmaceutical preparations in patients reporting lactose intolerance, describes how to assess this risk on an individual patient basis and reviews suitable analgesic options for this population. A case study is presented detailing a patient reporting lactose intolerance who insists on treatment with the lactose-free product codeine/ibuprofen (Nurofen Plus) rather than other codeine-free analgesics. It is important to assess the likelihood of lactose as an excipient inducing symptoms in this scenario, as reluctance to cease codeine could suggest codeine dependence, an issue that is becoming increasingly common in countries such as Australia and Canada. Given codeine dependence is associated with serious sequelae including hospitalization and death, the patient must either be reassured the lactose component in their prescribed analgesics will not induce symptoms or an alternative treatment strategy must be confirmed. General recommendations applying theory from the literature to the management of acute pain in lactose-intolerant patients are discussed and specific treatment options are outlined. Although large inter-individual variability is reported, most lactose-intolerant patients can tolerate the small quantities of lactose found in pharmaceutical preparations. Cumulative lactose exposure can be assessed in patients taking multiple medications while also consuming lactose in the diet. In those sensitive to small quantities of lactose, lactase supplements can be trailed. Additionally, for the analgesic drug classes employed for the management of acute pain, lactose-free formulations, including most oral liquids and dispersible tablets and some oral tablets and capsules, are available.
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Affiliation(s)
- Deanna Mill
- University of South Australia, Adelaide, South Australia, Australia
| | - Jessica Dawson
- Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Jacinta Lee Johnson
- University of South Australia Division of Health Sciences, City East Campus, Corner Frome Rd and North Tce, Adelaide, South Australia, 5001, Australia
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9
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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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10
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Byrne GA, Wood PJ, Spark MJ. Non-prescription supply of combination analgesics containing codeine in community pharmacy: A simulated patient study. Res Social Adm Pharm 2017; 14:96-105. [PMID: 28283305 DOI: 10.1016/j.sapharm.2017.01.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 12/11/2016] [Accepted: 01/20/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND The inappropriate use of non-prescription combination analgesics containing codeine (NP-CACC) has become a significant health issue in Australia. OBJECTIVE To investigate the current management of NP-CACC direct product requests in community pharmacies located in Victoria, Australia. METHODS A covert simulated patient (SP) method was used to observe the responses of pharmacy staff during an NP-CACC request. Four SPs were trained to complete 1 of 2 scenarios. Each scenario involved a direct product request for Nurofen Plus (200 mg ibuprofen, 12.8 mg codeine) with identical reason for use, symptoms, and medical history but varied previous product use. Scenario One (Sc1) involved a first time NP-CACC user and in Scenario Two (Sc2) the SP had used NP-CACC regularly for the past month. Each visit was documented by the SP immediately after they left the pharmacy. A NP-CACC supply score, created from 4 outcomes (pharmacist involvement, establishment of therapeutic need, establishment of safety and provision of counselling), was given to each pharmacy visit (maximum of 8) during data analysis. RESULTS 145 pharmacy visits were completed. Both scenarios were performed in most of the 75 pharmacies visited (73 Sc1 and 72 Sc2). Treatment was provided in the majority of visits but refused in 37(24%) because the SP was unable to provide photo identification. A pharmacist was involved (directly or indirectly) in 77% of visits. Adequate questioning to establish therapeutic need occurred in 50% of pharmacy visits, safety was established in 17% of visits, and adequate counselling provided in 17% of visits. The SP scenario did not significantly affect the NP-CACC supply outcomes. NP-CACC supply scores ranged from 1 to 8, (Md = 5) with only 1 pharmacy visit achieving the maximum score of 8. CONCLUSIONS The majority of pharmacy visits did not achieve a full score relating to NP-CACC supply, illustrating the need for improved awareness of how to assess and manage patients requesting NP-CACC.
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Affiliation(s)
- Georgia A Byrne
- Department of Pharmacy and Applied Science, La Trobe Institute for Molecular Science, LaTrobe University Bendigo, Victoria 3550, Australia
| | - Penelope J Wood
- Department of Pharmacy and Applied Science, La Trobe Institute for Molecular Science, LaTrobe University Bendigo, Victoria 3550, Australia
| | - M Joy Spark
- Department of Pharmacy and Applied Science, La Trobe Institute for Molecular Science, LaTrobe University Bendigo, Victoria 3550, Australia.
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11
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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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12
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Medicines containing codeine: perspectives of medical professionals in the Republic of Ireland. Ir J Med Sci 2017; 186:555-563. [DOI: 10.1007/s11845-016-1546-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 12/25/2016] [Indexed: 01/31/2023]
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13
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Nielsen S, Van Hout MC. Over-the-Counter Codeine-from Therapeutic Use to Dependence, and the Grey Areas in Between. Curr Top Behav Neurosci 2017; 34:59-75. [PMID: 26768736 DOI: 10.1007/7854_2015_422] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
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.
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Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre, UNSW, 22-32 King Street, Randwick, NSW, 2031, Australia.
- South East Sydney Local Health District (SESLHD) Drug and Alcohol Services, 591-623 S Dowling Street, Surry Hills, NSW, 2010, Australia.
| | - Marie Claire Van Hout
- Department of Health, Sport and Exercise Science, School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland
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Cairns R, Brown JA, Buckley NA. The impact of codeine re-scheduling on misuse: a retrospective review of calls to Australia's largest poisons centre. Addiction 2016; 111:1848-53. [PMID: 27177599 DOI: 10.1111/add.13450] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 02/25/2016] [Accepted: 05/11/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND AIMS Codeine is the most commonly used opioid in the world, and is available over the counter (OTC) in many countries, including Australia. Several countries are reconsidering codeine's OTC status due to concerns over addiction and misuse, with serious morbidity and mortality being reported. Australia's Therapeutic Goods Administration restricted codeine containing analgesics to 'Pharmacist Only' in 2010, and has recently been considering further up-scheduling to make codeine 'Prescription Only'. This paper estimated Australian trends of codeine misuse over the past 12 years, and examined whether trends changed following previous rescheduling efforts in 2010. DESIGN A retrospective review of calls regarding codeine misuse made to the New South Wales Poisons Information Centre (NSWPIC, Australia's largest poisons centre), 2004-15. Joinpoint software was used to quantify the average annual change in calls, and whether there was a significant change in trend at any time, including following rescheduling. SETTING Australia. PARTICIPANTS Four hundred patients about whom a call was made to the NSWPIC. MEASURES Calls per year, patient age, gender, tablets taken per day, formulation used, symptom disposition. FINDINGS The NSWPIC database contained 400 cases of codeine combination analgesic misuse from 2004 to 2015. Joinpoint analysis showed that the frequency of cases increased significantly from 2004 to 2015, with an average annual percentage change (AAPC) of 19.5% [95% confidence interval (CI) = 13.8-25.5% P < 0.0001] for paracetamol/codeine and 17.9% (95% CI = 7.9-28.9%, P < 0.01) for ibuprofen/codeine. No significant change in trend was seen at any time, including following 2010 rescheduling. The median age of patients was 34 and 27 years for paracetamol/codeine and ibuprofen/codeine cases, respectively. Gender distribution was approximately equal. Clinical features reported were consistent with codeine, paracetamol and ibuprofen toxicity. CONCLUSIONS Misuse of codeine combination products appears to be increasing in Australia. Limited rescheduling in 2010 failed to curb this increase.
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Affiliation(s)
- Rose Cairns
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, NSW, Australia. .,Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, School of Medical Sciences, Sydney Medical School, The University of Sydney, NSW, Australia.
| | - Jared A Brown
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, NSW, Australia
| | - Nicholas A Buckley
- New South Wales Poisons Information Centre, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Clinical Pharmacology and Toxicology Research Group, Discipline of Pharmacology, School of Medical Sciences, Sydney Medical School, The University of Sydney, NSW, Australia
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15
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Foley M, Carney T, Rich E, Parry C, Van Hout MC, Deluca P. Medical professionals' perspectives on prescribed and over-the-counter medicines containing codeine: a cross-sectional study. BMJ Open 2016; 6:e011725. [PMID: 27417200 PMCID: PMC4947827 DOI: 10.1136/bmjopen-2016-011725] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To explore prescribing practitioners' perspectives on prescribed codeine use, their ability to identify dependence and their options for treatment in the UK. DESIGN Cross-sectional design using a questionnaire containing closed-ended and open-ended items. SETTING A nationally representative sample of prescribing professionals working in the UK. PARTICIPANTS 300 prescribing professionals working in primary care and pain settings. RESULTS Participants stated that they regularly reviewed patients prescribed codeine, understood the risks of dependence and recognised the potential for codeine to be used recreationally. Over half the participants felt patients were unaware of the adverse health consequences of high doses of combination codeine medicines. One-quarter of participants experienced patient resentment when asking about medicines containing codeine. Just under 40% of participants agreed that it was difficult to identify problematic use of codeine without being informed by the patient and did not feel confident in identification of codeine dependence. Less than 45% of all participants agreed that codeine dependence could be managed effectively in general practice. Slow or gradual withdrawal was the most popular suggested treatment in managing dependence. Education and counselling was also emphasised in managing codeine-dependent patients in primary care. CONCLUSIONS Communication with patients should involve assessment of patient understanding of their medication, including the risk of dependence. There is a need to develop extra supports for professionals including patient screening tools for identifying codeine dependence. The support structure for managing codeine-dependent patients in primary care requires further examination.
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Affiliation(s)
- Michelle Foley
- School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland
| | - Tara Carney
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Eileen Rich
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
| | - Charles Parry
- Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Paolo Deluca
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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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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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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18
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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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Dependence on Over the Counter (OTC) Codeine Containing Analgesics: Treatment and Recovery with Buprenorphine Naloxone. Int J Ment Health Addict 2015. [DOI: 10.1007/s11469-015-9618-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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21
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Nielsen S, Bruno R, Murnion B, Dunlop A, Degenhardt L, Demirkol A, Muhleisen P, Lintzeris N. Treating codeine dependence with buprenorphine: Dose requirements and induction outcomes from a retrospective case series in New South Wales, Australia. Drug Alcohol Rev 2015. [PMID: 26223631 DOI: 10.1111/dar.12315] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
INTRODUCTION AND AIMS Codeine dependence is an emerging public health concern, yet no studies have specifically examined the treatment of codeine dependence. Given the lower potency of codeine it cannot be assumed that buprenorphine dose requirements for heroin dependence will generalise to codeine. This is the first study to examine buprenorphine treatment for codeine dependence. DESIGN AND METHODS Retrospective case series of 19 codeine-dependent treatment entrants who received sublingual buprenorphine maintenance treatment through six specialist inpatient and outpatient treatment centres. Baseline codeine doses and buprenorphine dose at days 7 and 28 were collected, in addition to details on general demographics, pain and mental health, substance use and outcomes after 28 days of buprenorphine treatment. RESULTS A significant linear relationship was found between initial codeine dose and dose of buprenorphine given at days 7 and 28 for the codeine dose range of 50-960 mg day-1 (mean: 564 mg; 95% confidence interval 431-696 mg). Median buprenorphine dose was 12.0 mg (interquartile range 9.5 mg, range 4-32 mg) at day 7 and 16.0 mg (interquartile range 13.5 mg, range 4-32 mg) at day 28. Buprenorphine doses received were markedly higher than estimated codeine doses based on standard dose conversion tables. DISCUSSION AND CONCLUSIONS With increasing presentations relating to codeine dependence, these findings provide important guidance to clinicians. Buprenorphine doses were consistently higher than doses estimated based on the dose of codeine consumed, and were comparable with doses used in the treatment of dependence with heroin and more potent prescription opioids. [Nielsen S, Bruno R, Murnion B, Dunlop A, Degenhardt L, Demirkol A, Muhleisen P, Lintzeris N. Treating codeine dependence with buprenorphine: Dose requirements and induction outcomes from a retrospective case series in New South Wales, Australia. Drug Alcohol Rev 2015].
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Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Centre, University of New South Wales, Sydney, Australia.,Discipline of Addiction Medicine, University of Sydney, Sydney, Australia.,Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia
| | - Raimondo Bruno
- National Drug and Alcohol Centre, University of New South Wales, Sydney, Australia.,School of Medicine, University of Tasmania, Hobart, Australia
| | - Bridin Murnion
- Discipline of Addiction Medicine, University of Sydney, Sydney, Australia
| | - Adrian Dunlop
- District Drug and Alcohol Clinical Services, Hunter New England Local Health Services, Newcastle West, Australia.,School of Medicine and Public Health (Medicine), University of Newcastle, Newcastle, Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Centre, University of New South Wales, Sydney, Australia.,School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Murdoch Children's Research Institute, Royal Children's Hospital, Melbourne, Australia.,Department of Global Health, School of Public Health, University of Washington, Seattle, USA
| | - Apo Demirkol
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,School of Public Health and Community Medicine, University of New South Wales, Sydney, Australia
| | - Peter Muhleisen
- District Drug and Alcohol Clinical Services, Hunter New England Local Health Services, Newcastle West, Australia
| | - Nicholas Lintzeris
- Discipline of Addiction Medicine, University of Sydney, Sydney, Australia.,Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia
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22
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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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Nielsen S, Roxburgh A, Bruno R, Lintzeris N, Jefferson A, Degenhardt L. Changes in non-opioid substitution treatment episodes for pharmaceutical opioids and heroin from 2002 to 2011. Drug Alcohol Depend 2015; 149:212-9. [PMID: 25707708 DOI: 10.1016/j.drugalcdep.2015.02.004] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2014] [Revised: 01/27/2015] [Accepted: 02/03/2015] [Indexed: 01/28/2023]
Abstract
BACKGROUND There has been a well-documented increase in the non-medical use of pharmaceutical opioids (PO) worldwide. However, there has been little detailed examination of treatment demand, or the characteristics of those presenting for treatment, particularly for treatments other than opioid substitution. METHODS Data from closed drug and alcohol treatment episodes from the Alcohol and Other Drug Treatment Services National Minimum Data Set (AODTS-NMDS, representing non-opioid substitution treatment) in Australia for 2002-2003 to 2010-2011 were examined. In the four jurisdictions where detailed data were available, episodes where heroin was the principal drug of concern were compared to episodes for the four most frequently reported pharmaceutical opioids (morphine, codeine, fentanyl and oxycodone). RESULTS In 2002-2003, most (93%) opioid treatment was related to heroin with seven percent of all opioid treatment episodes reporting a PO as the principal drug of concern. In 2010-2011, 20% of all opioid treatment episodes were attributed to POs. Distinct changes over time were observed for different opioids. There was an increase in the average age at the start of treatment for heroin and oxycodone episodes, and a reduction in the proportion of females for codeine episodes, with 67% in 2002-2003 compared with 44% in 2010-2011. Codeine and oxycodone episodes had the lowest current or past injection rates. CONCLUSIONS Clear differences were observed over time and between different opioids. Monitoring these emerging patterns will be important to inform treatment needs, particularly in light of different patterns of poly drug use, different routes of administration and changing demographic characteristics.
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Affiliation(s)
- S Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia; Drug and Alcohol Services, South Eastern Sydney Local Health District, 591 South Dowling St, Surry Hills 2010, Australia.
| | - A Roxburgh
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia
| | - R Bruno
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia; School of Medicine, University of Tasmania, Level 1, Medical Science 1, 17 Liverpool Street, Hobart 7000, Australia
| | - N Lintzeris
- Drug and Alcohol Services, South Eastern Sydney Local Health District, 591 South Dowling St, Surry Hills 2010, Australia; University of Sydney, Department of Addiction Medicine, Missenden Road, Camperdown 2006, Australia
| | - A Jefferson
- Tobacco, Alcohol and Other Drugs Unit, Australian Institute of Health and Welfare, 1 Thynne Street, Fern Hill Park, Bruce 2617, Australia
| | - L Degenhardt
- National Drug and Alcohol Research Centre, University of New South Wales, Sydney, New South Wales 2052, Australia
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24
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Nod and wave: An Internet study of the codeine intoxication phenomenon. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:67-77. [DOI: 10.1016/j.drugpo.2014.06.016] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 06/18/2014] [Accepted: 06/23/2014] [Indexed: 11/21/2022]
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25
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Nielsen S, Murnion B, Dunlop A, Degenhardt L, Demirkol A, Muhleisen P, Lintzeris N. Comparing treatment-seeking codeine users and strong opioid users: Findings from a novel case series. Drug Alcohol Rev 2014; 34:304-11. [DOI: 10.1111/dar.12224] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 09/25/2014] [Indexed: 02/05/2023]
Affiliation(s)
- Suzanne Nielsen
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
- Royal Prince Alfred Hospital; University of Sydney; Sydney Australia
- Drug and Alcohol Services; South Eastern Sydney Local Health District; Sydney Australia
| | - Bridin Murnion
- Royal Prince Alfred Hospital; University of Sydney; Sydney Australia
| | - Adrian Dunlop
- Drug and Alcohol Services; Hunter New England Local Health District; Newcastle Australia
- School of Medicine and Public Health; Faculty of Health; University of Newcastle; Newcastle Australia
| | - Louisa Degenhardt
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
- School of Population and Global Health; University of Melbourne; Melbourne Australia
- Murdoch Children's Research Institute; Royal Children's Hospital; Melbourne Australia
- Department of Global Health; School of Public Health; University of Washington; Seattle USA
| | - Apo Demirkol
- Drug and Alcohol Services; South Eastern Sydney Local Health District; Sydney Australia
- School of Public Health and Community Medicine; University of New South Wales; Sydney Australia
| | - Peter Muhleisen
- Drug and Alcohol Services; Hunter New England Local Health District; Newcastle Australia
| | - Nicholas Lintzeris
- Royal Prince Alfred Hospital; University of Sydney; Sydney Australia
- Drug and Alcohol Services; South Eastern Sydney Local Health District; Sydney Australia
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26
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Claire Van Hout M. “Doctor shopping and pharmacy hopping”: practice innovations relating to codeine. DRUGS AND ALCOHOL TODAY 2014. [DOI: 10.1108/dat-03-2014-0014] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
– The misuse of pharmaceutical opioid analgesics is identified as a global public health concern. Codeine represents an interesting quandary in terms of its regulated status, with individuals varying in their metabolism of codeine, estimation of safe dosages, risk of adverse health consequences and abuse potential. Efforts to quantify and address hidden non-compliant medical codeine use, overuse and intentional misuse is compromised by availability to the public in prescribed and over the counter forms. The paper aims to discuss these issues.
Design/methodology/approach
– A review of literature on codeine use, misuse and dependence, and associated innovative medical and pharmacy interventions is presented, and was conducted as part of a larger scoping review on codeine.
Findings
– The review highlights the complexities associated with monitoring public health awareness of codeine's abuse potential, and customer/patients trends in non-compliant codeine use for therapeutic and recreational purposes. Aberrant codeine behaviours centre on visiting multiple doctors for prescriptions, repeated lost or stolen prescriptions, forging prescriptions and use of multiple pharmacies. Innovations to monitor misuse of codeine include national prescription databases and recent developments in real-time monitoring of dispensing activity.
Practical implications
– Further development of real-time monitoring processes with process evaluation is advised.
Originality/value
– This viewpoint is intended to demonstrate how efforts to quantify and address codeine use are compromised by its availability. It intends to encourage further policy and practitioner dialogue on how to monitor, support and intervene with consumers misusing codeine.
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27
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Hamer AM, Spark MJ, Wood PJ, Roberts E. The upscheduling of combination analgesics containing codeine: The impact on the practice of pharmacists. Res Social Adm Pharm 2014; 10:669-78. [DOI: 10.1016/j.sapharm.2013.08.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Revised: 08/17/2013] [Accepted: 08/18/2013] [Indexed: 11/26/2022]
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Abstract
The discovery of ibuprofen's anti-inflammatory activity by Dr (now Professor) Stewart Adams and colleagues (Boots Pure Chemical Company Ltd, Nottingham, UK) 50 years ago represented a milestone in the development of anti-inflammatory analgesics. Subsequent clinical studies were the basis for ibuprofen being widely accepted for treating painful conditions at high anti-rheumatic doses (≤ 2400 mg/d), with lower doses (≤ 1200 mg/d for ≤ 10 days) for mild-moderate acute pain (e.g. dental pain, headache, dysmenorrhoea, respiratory symptoms and acute injury). The early observations have since been verified in studies comparing ibuprofen with newer cyclo-oxygenase-2 selective inhibitors ('coxibs'), paracetamol and other non-steroidal anti-inflammatory drugs (NSAIDs). The use of the low-dose, non-prescription, over-the-counter (OTC) drug was based on marketing approval in 1983 (UK) and 1984 (USA); and it is now available in over 80 countries. The relative safety of OTC ibuprofen has been supported by large-scale controlled studies. It has the same low gastro-intestinal (GI) effects as paracetamol (acetaminophen) and fewer GI effects than aspirin. Ibuprofen is a racemate. Its physicochemical properties and the short plasma-elimination half-life of the R(-) isomer, together with its limited ability to inhibit cyclo-oxygenase-1 (COX-1) and thus prostaglandin (PG) synthesis, compared with that of S(+)-ibuprofen, are responsible for the relatively low GI toxicity. The R(-) isomer is then converted in the body to the S(+) isomer after absorption in the GI tract. Ex vivo inhibition of COX-1 (thromboxane A(2)) and COX-2 (PGE(2)) at the plasma concentrations of S(+)-ibuprofen corresponding to those found in the plasma following ingestion of 400 mg ibuprofen in dental and other inflammatory pain models provides evidence of the anti-inflammatory mechanism at OTC dosages. R(-)-ibuprofen has effects on leucocytes, suggesting that ibuprofen has anti-leucocyte effects, which underlie its anti-inflammatory actions. Future developments include novel gastro-tolerant forms for 'at risk' patients, and uses in the prevention of neuro-inflammatory states and cancers.
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Affiliation(s)
- K D Rainsford
- Biomedical Research Centre, Sheffield Hallam University, Sheffield, UK.
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29
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Tobin CL, Dobbin M, McAvoy B. Regulatory responses to over-the-counter codeine analgesic misuse in Australia, New Zealand and the United Kingdom. Aust N Z J Public Health 2013; 37:483-8. [DOI: 10.1111/1753-6405.12099] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
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Pilgrim JL, Dobbin M, Drummer OH. Fatal misuse of codeine–ibuprofen analgesics in Victoria, Australia. Med J Aust 2013; 199:329-31. [DOI: 10.5694/mja12.11843] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 06/11/2013] [Indexed: 11/17/2022]
Affiliation(s)
| | | | - Olaf H Drummer
- Department of Forensic Medicine, Monash University, Melbourne, VIC
- Forensic Scientific Services, Victorian Institute of Forensic Medicine, Melbourne, VIC
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Arora S, Roxburgh A, Bruno R, Nielsen S, Burns L. A cross-sectional analysis of over-the-counter codeine use among an Australian sample of people who regularly inject drugs. Drug Alcohol Rev 2013; 32:574-81. [DOI: 10.1111/dar.12059] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 05/19/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Sheena Arora
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
- Centre for Health Economics and Research Evaluation; University of Technology; Sydney Australia
| | - Amanda Roxburgh
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
| | - Raimondo Bruno
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
- School of Psychology; University of Tasmania; Hobart Australia
| | - Suzanne Nielsen
- Discipline of Addiction Medicine; Royal Prince Alfred Hospital; University of Sydney; Sydney Australia
| | - Lucy Burns
- National Drug and Alcohol Research Centre; University of New South Wales; Sydney Australia
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Abstract
BACKGROUND The sale of over-the-counter (OTC) medicines from pharmacies can help individuals self-manage symptoms. However, some OTC medicines may be abused, with addiction and harms being increasingly recognised. This review describes the current knowledge and understanding of OTC medicine abuse. APPROACH Comprehensive search of international empirical and review literature between 1990 and 2011. FINDINGS OTC MEDICINE ABUSE WAS IDENTIFIED IN MANY COUNTRIES AND ALTHOUGH IMPLICATED PRODUCTS VARIED, FIVE KEY GROUPS EMERGED: codeine-based (especially compound analgesic) medicines, cough products (particularly dextromethorphan), sedative antihistamines, decongestants and laxatives. No clear patterns relating to those affected or their experiences were identified and they may represent a hard-to-reach group, which coupled with heterogeneous data, makes estimating the scale of abuse problematic. Associated harms included direct physiological or psychological harm (e.g. opiate addiction), harm from another ingredient (e.g. ibuprofen-related gastric bleeding) and associated social and economic problems. Strategies and interventions included limiting supplies, raising public and professional awareness and using existing services and Internet support groups, although associated evaluations were lacking. Terminological variations were identified. CONCLUSIONS OTC medicine abuse is a recognised problem internationally but is currently incompletely understood. Research is needed to quantify scale of abuse, evaluate interventions and capture individual experiences, to inform policy, regulation and interventions.
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Affiliation(s)
- Richard J Cooper
- School of Health and Related Research (ScHARR), University of Sheffield , Sheffield , UK
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33
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Use of codeine-containing medicines by Irish psychiatric inpatients before and after regulatory limitations on their supply. Ir J Psychol Med 2013; 30:7-12. [DOI: 10.1017/ipm.2012.2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BackgroundIn recent years, concerns have been highlighted in several jurisdictions, including Ireland, regarding abuse of over-the-counter codeine-containing medicines. On the 1st of August 2010, national regulatory guidelines aimed at limiting the supply of these medicines in Ireland came into force.AimsTo study the effects of the new regulations on the use of non-prescribed codeine-containing medicines by psychiatric patients admitted to an Irish university teaching hospital before (n= 117) the regulations came into effect and 6 months afterwards (n= 126).MethodsParticipants completed a brief self-administered survey questionnaire about their use of over-the-counter codeine-containing medicines in the preceding 3 months.ResultsCompared with before the introduction of the new regulations, there was a large decline in the reported ‘often’ or ‘regular’ use of codeine-containing medicines in the 3 months before admission (33.3%v. 17.4%,χ2= 6.354,p= 0.01) and there was a reduction in the proportion of patients for whom others had expressed concerns about their frequency of use of such medications (15.5%v. 4.8%,χ2= 7.29,p= 0.03). There was also a decline in the proportion of patients who stated that they would use codeine-containing medicines for either a ‘feel-good’ effect or to curb cravings (15.9%v. 1.9%,p< 0.01, two-tailed Fisher's exact test).ConclusionWe conclude that tight regulations on the supply of non-prescription codeine-containing medicines have the potential to reduce the use and abuse of such medicines in patient populations availing of admission to psychiatry hospitals.
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Nielsen S, Cameron J, Pahoki S. Opportunities and challenges: over-the-counter codeine supply from the codeine consumer's perspective. INTERNATIONAL JOURNAL OF PHARMACY PRACTICE 2012; 21:161-8. [PMID: 23419000 DOI: 10.1111/j.2042-7174.2012.00247.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2011] [Accepted: 08/21/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES This study aimed to gain a better understanding on perspectives of over-the-counter (OTC) codeine users and issues relating to codeine dependence in the community pharmacy setting. Examining OTC codeine users' experiences aimed to promote better understanding of OTC codeine dependence, and inform pharmacy practices. METHODS Utilising a qualitative research methodology we conducted interviews with 20 participants who were OTC codeine users and met DSM IV criteria for codeine dependence. KEY FINDINGS Key themes identified included experience of participants acquiring OTC codeine and participants' interactions with pharmacists. The OTC codeine-dependent participants found it generally easy to access OTC codeine, describing 'standard' questioning, minimal intervention from pharmacists and only occasional refusal to supply. A better appearance and presentation was generally linked to easy codeine supply. CONCLUSIONS The experiences of participants suggest a number of barriers exist to effective intervention for OTC codeine dependence in the community pharmacy setting. Identification of these barriers will provide an opportunity to more effectively target interventions to reduce harm related to OTC codeine products. Increased involvement of pharmacists in OTC codeine sales was associated with help-seeking by codeine users.
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Affiliation(s)
- Suzanne Nielsen
- Eastern Health, Turning Point Alcohol and Drug Centre, Melbourne, Victoria, Australia.
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36
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NIELSEN SUZANNE, BRUNO RAIMONDO. Pharmaceutical drugs: The delicate balance between reducing pain and reducing harm. Drug Alcohol Rev 2011; 30:233-5. [DOI: 10.1111/j.1465-3362.2011.00326.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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37
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Frei MY, Nielsen S, Dobbin MDH, Tobin CL. Serious morbidity associated with misuse of over‐the‐counter codeine–ibuprofen analgesics: a series of 27 cases. Med J Aust 2010; 193:294-6. [DOI: 10.5694/j.1326-5377.2010.tb03911.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Accepted: 03/16/2010] [Indexed: 02/05/2023]
Affiliation(s)
- Matthew Y Frei
- Turning Point Alcohol and Drug Centre, Eastern Health, Melbourne, VIC
- South East Alcohol and Drug Service, Southern Health, Melbourne, VIC
- School of Psychology and Psychiatry, Monash University, Melbourne, VIC
| | - Suzanne Nielsen
- Turning Point Alcohol and Drug Centre, Eastern Health, Melbourne, VIC
- Eastern Health Clinical School, Monash University, Melbourne, VIC
| | - Malcolm D H Dobbin
- Mental Health, Drugs and Regions Division, Victorian Department of Health, Melbourne, VIC
| | - Claire L Tobin
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
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