Morphine is a substrate of the organic cation transporter OCT1 and polymorphisms in OCT1 gene affect morphine pharmacokinetics after codeine administration

We investigated whether morphine and its pro-drug codeine are substrates of the highly genetically polymorphic organic cation transporter OCT1 and whether OCT1 polymorphisms may affect morphine and codeine pharmacokinetics in humans. Morphine showed low transporter-independent membrane permeability (0.5 × 10⁻⁶ cm/s). Morphine uptake was increased up to 4-fold in HEK293 cells overexpressing human OCT1. The increase was concentration-dependent and followed Michaelis-Menten kinetics (KM = 3.4 μM, VMAX = 27 pmol/min/mg protein). OCT1-mediated morphine uptake was abolished by common loss-of-function polymorphisms in the OCT1 gene and was strongly inhibited by drug-drug interactions with irinotecan, verapamil and ondansetron. Morphine uptake in primary human hepatocytes was strongly reduced by MPP⁺, an inhibitor of organic cation transporters, and morphine was not a substrate of OCT3, the other organic cation transporter expressed in human hepatocytes. In concordance with the in vitro data, morphine plasma concentrations in healthy volunteers were significantly dependent on OCT1 polymorphisms. After codeine administration, the mean AUC of morphine was 56% higher in carriers of loss-of-function OCT1 polymorphisms compared to non-carriers (P = 0.005). The difference remained significant after adjustment for CYP2D6 genotype (P = 0.03). Codeine itself had high transporter-independent membrane permeability (8.2 × 10⁻⁶ cm/s). Codeine uptake in HEK293 cells was not affected by OCT1 overexpression and OCT1 polymorphisms did not affect codeine AUCs. In conclusion, OCT1 plays an important role in the hepatocellular uptake of morphine. Carriers of loss-of-function OCT1 polymorphisms may be at higher risk of adverse effects after codeine administration, especially if they are also ultra-rapid CYP2D6 metabolizers.

A label-free electrochemical biosensor based on a DNA aptamer against codeine

In order to develop a sensor for opium alkaloid codeine detection, DNA aptamers against codeine were generated by SELEX (systematic evolution of ligands by exponential enrichment) technique. An aptamer HL7-14, which is a 37-mer sequence with Kd values of 0.91 μM, was optimized by the truncation-mutation assay. The specificity investigation shows that HL7-14 exhibits high specificity to codeine over morphine, and almost cannot bind to other small molecule. With this new selected aptamer, a novel electrochemical label-free codeine aptamer biosensor based on Au-mesoporous silica nanoparticles (Au-MSN) as immobilized substrate has been proposed using [Fe(CN)6](3-/4-) as electroactive redox probe. The linear range covered from 10 pM to 100 nM with correlation coefficient of 0.9979 and the detection limit was 3 pM. Our study demonstrates that the biosensor has good specificity, stability and well regeneration. It can be used to detect codeine.

Codeine-induced sperm DNA damage is mediated predominantly by oxidative stress rather than apoptosis

ABSTRACTBackground: Opioids have been implicated to induce infertility. Although codeine remains the most used opioid for recreational purpose, no study has documented its effect on sperm quality. Elucidating the effect of codeine on sperm cells and the associated mechanisms may provide an insight into preventing drug-induced sperm damage. Twenty-one New Zealand white rabbits were randomized into three groups; control and codeine-treated. The codeine-treated groups received either 4 or 10mg/kg b.w of codeine for six weeks.Results: Codeine treatment led to significant decrease in sperm count, motility, viability, normal morphology, and sperm membrane integrity. This was associated with significant rise in sperm DNA fragmentation, oxidative damage, and caspase 3 activity. The percentage of sperm DNA fragmentation correlates positively with 8-hydroxy-2'-deoxyguanosine, a biomarker of oxidative DNA damage, and caspase 3 activity, a biomarker of apoptosis. The observed correlation was stronger between sperm DNA fragmentation and oxidative DNA damage than sperm DNA fragmentation and caspase 3 activity.Conclusion: This study revealed that chronic codeine exposure causes sperm DNA fragmentation and poor sperm quality primarily via oxidative stress rather than activation of caspase 3-dependent apoptosis. Findings of the present study may explain drug-induced male factor infertility, particularly, those associated with opioid use.

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

BACKGROUND AND AIMS

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

DESIGN

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

SETTING

Australia.

PARTICIPANTS

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

MEASURES

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

FINDINGS

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

CONCLUSIONS

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

Changes in non-opioid substitution treatment episodes for pharmaceutical opioids and heroin from 2002 to 2011

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.

Angiotensin converting enzyme-2 as therapeutic target in COVID-19

The pandemic of coronavirus disease 2019 (COVID-19) is a global health emergency that poses a significant threat to world people's health. This outbreak causes major challenges to healthcare systems. Given the lack of effective treatments or vaccine for it, the identification of novel and safe drugs against COVID-19 infection is an urgent need. Angiotensin-converting enzyme 2 (ACE2) is not only an entry receptor of the SARS-CoV-2 virus, the virus that causes COVID-19, but also can protect from lung injury. In this view, we highlighted potential approaches to address ACE2-mediated SARS-CoV-2 virus, including 1) delivering an excessive soluble form of ACE2 (recombinant human ACE2: rhACE2) and 2) inhibition of the interaction between SARS-CoV-2 virus and ACE2 by some compounds with competitive effects (morphine and codeine). Further clinical trials in this regard can reveal a more definite conclusion against the COVID-19 disaster.

Morphine and codeine concentrations in human urine following controlled poppy seeds administration of known opiate content

Opiates are an important component for drug testing due to their high abuse potential. Proper urine opiate interpretation includes ruling out poppy seed ingestion; however, detailed elimination studies after controlled poppy seed administration with known morphine and codeine doses are not available. Therefore, we investigated urine opiate pharmacokinetics after controlled oral administration of uncooked poppy seeds with known morphine and codeine content. Participants were administered two 45 g oral poppy seed doses 8 h apart, each containing 15.7 mg morphine and 3mg codeine. Urine was collected ad libitum up to 32 h after the first dose. Specimens were analyzed with the Roche Opiates II immunoassay at 2000 and 300 μg/L cutoffs, and the ThermoFisher CEDIA(®) heroin metabolite (6-acetylmorphine, 6-AM) and Lin-Zhi 6-AM immunoassays with 10 μg/L cutoffs to determine if poppy seed ingestion could produce positive results in these heroin marker assays. In addition, all specimens were quantified for morphine and codeine by GC/MS. Participants (N=22) provided 391 urine specimens over 32 h following dosing; 26.6% and 83.4% were positive for morphine at 2000 and 300 μg/L GC/MS cutoffs, respectively. For the 19 subjects who completed the study, morphine concentrations ranged from <300 to 7522 μg/L with a median peak concentration of 5239 μg/L. The median first morphine-positive urine sample at 2000 μg/L cutoff concentration occurred at 6.6 h (1.2-12.1), with the last positive from 2.6 to 18 h after the second dose. No specimens were positive for codeine at a cutoff concentration of 2000 μg/L, but 20.2% exceeded 300 μg/L, with peak concentrations of 658 μg/L (284-1540). The Roche Opiates II immunoassay had efficiencies greater than 96% for the 2000 and 300 μg/L cutoffs. The CEDIA 6-AM immunoassay had a specificity of 91%, while the Lin-Zhi assay had no false positive results. These data provide valuable information for interpreting urine opiate results.

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.

Inside gel electromembrane extraction: A novel green methodology for the extraction of morphine and codeine from human biological fluids

In this work, a new mode of gel-electromembrane extraction (G-EME), called "inside" gel-EME (IG-EME) is proposed for the extraction of morphine and codeine as model basic drugs from complex biological samples. Here, an aqueous media that was captured inside the agarose gel membrane, acted as both gel membrane and the acceptor phase (AP) at the same time. In this regard, the membrane served as the separation filter (membrane) and supported liquid acceptor phase (SLAP) as well. With this new development, unwanted changes of the AP volume during the extraction, which is a common issue in the G-EME (due to electroendosmosis (EEO) phenomenon), was addressed properly. Briefly, the setup involved insertion of negative electrode inside the gel membrane and positive electrode into the donor phase (DP). Following that, the IG-EME was easily performed using optimal conditions (pH of the DP: 6.0; membrane composition (agarose concentration: 1% (w/v) in aqueous media with pH 3.0, and 15 mm thickness); voltage: 25 V; and extraction time: 30 min). After extraction, the agarose gel was withdrawn and centrifuged for 5 min with 12000 rpm, to disrupt its framework to release the "trapped aqueous AP" apart from the gel structure. The separated AP was finally injected into the HPLC-UV for the analysis. The limits of detection (LODs) and recoveries in this proposed method were obtained 1.5 ng mL^-1 and 67.7 %-73.8 %, respectively. The system feasibility was examined by the quantification of model drugs in the real plasma and urine samples.

Acupuncture instead of codeine for tonsillectomy pain in children

OBJECTIVES

Severe throat pain can result from tonsillectomy and last up to 10 days in children. Codeine elixir has long been used for pain relief, but has recently been banned by the Food and Drug Administration due to a recently recognized risk of death. We explored acupuncture as an alternative means of pain relief for children and adolescents after tonsillectomy.

METHODS

This was a retrospective review of children and adolescents who underwent tonsillectomy over a three-month period. No narcotics were prescribed after surgery. Patients who wanted help with pain relief were offered acupuncture. Perceived pain level was assessed before and after the acupuncture treatment. Following the 10-day recovery for tonsillectomy, patients or their parents were queried as to how long the pain relief from acupuncture intervention was perceived to last.

RESULTS

56 children and adolescents underwent tonsillectomy in the three-month window selected for the retrospective review. 31 of these patients (ranging from 2 to 17 years in age) received an acupuncture intervention for postoperative pain. The mean reported pain level before acupuncture was 5.52 (SD = 2.28) out of 10. This fell to 1.92 (SD = 2.43) after acupuncture. Statistical analysis supported the general conclusion that pain reports decline after acupuncture in the sampled population. However, the limitations of the methodology and the sample suggest that this generalization should be treated as preliminary. 17 patients or their parents provided a post-recovery report for how long they believed the acupuncture intervention lasted. The mean duration of perceived acupuncture benefit was 61.24 h, though the standard deviation was large (64.58 h) with about 30% of patients reporting less than three hours of benefit and about 30% reporting more than 60 h. No adverse effects were observed as a result of acupuncture treatments.

CONCLUSIONS

The data tentatively suggest that acupuncture decreases perceived pain in children and adolescents after tonsillectomy. These data - combined with the cost effectiveness, safety and ease of administering acupuncture - suggest that further studies exploring the effectiveness of acupuncture in juveniles after tonsillectomy are merited.

Prevalence and Health Characteristics of Prescription Opioid Use, Misuse, and Use Disorders Among U.S. Adolescents

PURPOSE

The prevalence of past-year prescription opioid use (POU), nonmedical POU (NMPOU), and POU disorder (POUD) and their correlates were examined in a national sample of American adolescents (N = 41,579).

METHODS

This study used data from the public-use files of the 2015, 2016, and 2017 National Surveys on Drug Use and Health, which captured substance use and mental health problems among noninstitutionalized individuals. Prevalence and specific types of prescription opioids and other substances used and misused in the past year were examined among adolescents. Logistic regression analyses were conducted to determine correlates (demographics, other substances used, past-year major depressive episode, school enrollment, two-parent household, number of lifetime medical conditions, and survey year) of POU, NMPOU, and POUD.

RESULTS

Multiple substance use was common within the past year. The most frequently used prescription opioids were hydrocodone, codeine, oxycodone, and other opioids among adolescents. Cannabis use disorder and alcohol use disorder were comparatively prevalent among opioid misusers. Several correlates (demographics, other substances used, lifetime medical conditions, major depressive episode, and survey year) of POU, NMPOU, and POUD were found.

CONCLUSIONS

In this national sample, multiple substance use was common among adolescents with past-year POU and NMPOU. Clinical screening for opioid use problems, assessment, and treatment expansion for POUD can focus on persons with substance use, mental health, and/or behavioral problems. Longitudinal studies are needed to better elucidate temporal associations between POU and NMPOU/POUD among adolescents, and more prevention and treatment research on rural residents and minority groups is needed.

Cognitive and socio-cognitive functioning of chronic non-medical prescription opioid users

RATIONALE

Non-medical prescription opioid use (NMPOU) has become a major public health issue in the USA and is also increasing in Europe. However, little is known about neuropsychological associations of NMPOU-specifically regarding social cognition, which is essential for social functioning and treatability of opioid dependence. Previous studies with heroin users and opioid-substituted patients reported deficits in various cognitive functions, but these results are likely confounded by comorbid physical and psychiatric diseases, overdose-associated hypoxia, and adulteration of street heroin. Therefore, the purpose of the present study was to investigate social and non-social cognition in a relatively pure NMPOU sample taking opioid analgesics or antitussives.

METHODS

We assessed 23 individuals with NMPOU objectively confirmed by hair analyses and 29 opioid-naïve, healthy controls, employing a comprehensive neuropsychological test battery.

RESULTS

Significant impairments were found between NMPOU individuals and controls regarding the cognitive domains of attention (p < .01, Hedge's g = .85), declarative memory (p < .05, g = .66), and global cognitive empathy (p < .01, g = 0.99)-the latter included problems with emotion recognition from faces, voices, and complex scenes. Opioid hair concentrations transformed to morphine equivalents were negatively correlated with global cognitive empathy (r = - 0.52, p < .01), suggesting dose-dependent deficits.

CONCLUSION

In contrast to stimulant users primarily displaying deficits in emotional empathy, opioid users showed relatively selective impairments in measures of cognitive empathy, with dose-dependent effects suggesting potential opioid-induced deficits and involvement of the opioid-system in processes of cognitive empathy. These results have important implications for future interventions of opioid dependence targeting social functioning and consequently enhancing therapy outcome and preventing relapse.

Is South Africa being spared the global opioid crisis? A review of trends in drug treatment demand for heroin, nyaope and codeine-related medicines in South Africa (2012-2017)

INTRODUCTION

South Africa has seen a sharp increase in treatment admission trends for opioids despite beliefs that rates of opioid use remain low and do not represent a major problem. To advocate for the extension of Opioid Use Disorder (OUD) treatment and harm minimisation services in South Africa, better estimates of the extent of opioid use is needed. This paper responds to this need by describing (i) trends in treatment utilization for opioid-related problems in South Africa and (ii) differences in the profile of patients accessing treatment for different classes of opioids - heroin, 'nyaope' and codeine use.

METHODS

Data were collected from 83 specialist treatment centres participating in the South African Community Epidemiology Network on Drug Use between 2012 and 2017. Descriptive analyses were conducted to describe the sociodemographic profile of patients and multiple logistic regression was used to explore socio-demographic and clinical factors associated with admission to treatment for opioid use disorders (OUD) .

RESULTS

From January 2012 to December 2017, data from 11 2032 treatment episodes were collated. Of these, 20 319 (18.1%) were from patients admitted for an OUD. Over time, the proportion of overall opioid-related admissions increased significantly from 16.1% of all admissions in 2012 to 20.0% in 2017 (p <0.001). Data also suggests a significant increase in the overall proportion of patients reporting injection drug use, from 1.6% in 2013 to 3.5% in 2017 (p <0.001). Clear differences in employment status, referral sources between classes of opioids were also noted.

CONCLUSION

Over the last 5 years, South Africa has seen an increase in the proportion of opioid related disorders (OUD) treatment admissions. Public health interventions, evidence-based harm reduction approaches and improving access to treatment are among the interventions urgently needed to reduce the harms associated with the increased use of opioids in South Africa.

Monitoring consumption of methadone and heroin in major Chinese cities by wastewater-based epidemiology

BACKGROUND

Methadone maintenance treatment (MMT) services have been used in China for treatment of heroin dependence. But no study has been conducted to assess the appropriateness of MMT distribution and the potential abuse of methadone in China. This study aims to do that through a nationwide estimation of methadone consumption in China via wastewater-based epidemiology and subsequently compare it with MMT data and level of heroin abuse.

METHODS

Wastewater samples were collected from 53 wastewater treatment plants in 27 major cities that cover all geographic regions of China. Methadone and pure heroin consumptions were estimated based on influent concentrations of methadone, 2-ethylidene-1,5-dimethyl-3,3-diphenylpyrrolidine (EDDP), morphine and codeine.

RESULTS

Drug residues were detected in most samples. The ratio of EDDP/methadone was around 2 in influents and methadone and EDDP loads were strongly correlated, indicating that they originated from human consumption. Both influent methadone and EDDP loads in Southwest and Northwest China were significantly higher than those in other regions. The highest estimated consumptions of methadone and heroin in China were 22.0 ± 2.1 mg/1000 in./d and 263.9 ± 115.9 mg/1000 in./d, respectively. There was a significant positive correlation between methadone and heroin consumptions.

CONCLUSIONS

Consumption of methadone in China was primarily from MMT services. The use of methadone and heroin displayed a clear geographical pattern: it is higher in the western inland regions than in the eastern regions. This study has shown that the distribution of MMT services is reflective of the level of heroin abuse in different regions of China.

Medical professionals' perspectives on prescribed and over-the-counter medicines containing codeine: a cross-sectional study

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.

Preconcentration of morphine and codeine using a magnetite/reduced graphene oxide/silver nano-composite and their determination by high-performance liquid chromatography

A novel magnetic solid-phase extraction technique based on a ternary nano-composite, magnetite/reduced graphene oxide/silver, as a nano-sorbent was developed for simultaneous extraction/preconcentration and measurement of morphine and codeine in biological samples by high-performance liquid chromatography. The magnetic ternary nano-composite was synthesized and its functional groups, morphological structure, and magnetic properties were characterized by field emission scanning electron microscopy, vibrating sample magnetometer, powder X-ray diffraction, energy dispersive X-ray spectroscopy and Fourier transform infrared spectroscopy. The optimizing of the significant variables affecting the extraction process was evaluated by a response surface methodology. In the optimized conditions, the constructed calibration curves for morphine and codeine are linear in the range of 0.01-10 μg L^-1 with correlation coefficients of 0.9983 and 0.9976, respectively. The detection limit and enrichment factor for morphine and codeine are 1.8 ng L^-1, 1000 and 2.1 ng L^-1, 1000, respectively. The presented technique was employed for the monitoring of morphine and codeine in numerous blood and urine samples with relative recoveries between 97.0 and 102.5%, and relative standard deviations of 1.02-5.10% for the spiked samples.

Codeine-induced hepatic injury is via oxido-inflammatory damage and caspase-3-mediated apoptosis

Codeine (3-methylmorphine) is a known analgesic, antitussive, and antidiarrheal drug that is often abused for recreational purposes. It is metabolized in the liver via the cytochrome P450 system and thus hypothesized to induce hepatic injury especially when misused. Thus, the present study aimed at investigating changes in liver function, hepatic enzyme biomarker, proton pumps, antioxidant status, free radicals and TNF-α levels, as well as caspase 3 activities and hepatic DNA fragmentation after 6 weeks of oral codeine administration. Twenty-one male rabbits were randomized into 3 groups (n = 7). The control group had 1 ml of normal saline, while the low-dose and high-dose codeine groups received 4 and 10 mg/kg b.w of codeine respectively daily. The codeine-treated animals had significantly lower levels of serum proteins, increased activities of hepatic enzyme biomarkers and caspase 3, raised hepatic concentrations of free radicals and TNF-α, as well as increased hepatic DNA fragmentation. Codeine treatment also led to a significant decline in hepatic weight, activities of hepatic enzymatic antioxidant, Na+-K+-ATPase and Ca2+-ATPase. These alterations were more pronounced in high-dose codeine treated animals than in the low-dose group. Histopathological study showed moderate fatty degeneration of hepatic parenchyma, infiltration of the portal tract by inflammatory cells with dense collagen fibre deposition in codeine-treated animals. The present study revealed that codeine induced liver injury and hepatic DNA damage via caspase 3-dependent signaling by suppressing hepatic antioxidant status and enhancing free radical and TNF-α generation.

Ultra-sensitive electrochemical sensing of acetaminophen and codeine in biological fluids using CuO/CuFe2O4 nanoparticles as a novel electrocatalyst

Copper ferrite–copper oxide (CuO-CuFe₂O₄) nanoparticles as a semiconductor composite with p–n junction were synthesized by co-precipitation reaction. Then, a novel CuO-CuFe₂O₄ carbon paste modified electrode was fabricated which displays an effectual electrocatalytic response to the oxidation of acetaminophen (AC) and codeine (CO). A linear range of 0.01–1.5 μmol L⁻¹ and 0.06–10.0 μmol L⁻¹ with the detection limits of 0.007 μmol L⁻¹ and 0.01 μmol L⁻¹ were achieved for AC and CO, respectively. The practical usage of the proposed sensor revealed reasonable results for quantification of AC and CO in biological fluids.

Simultaneous determination of ascorbic acid, acetaminophen and codeine based on multi-walled carbon nanotubes modified with magnetic nanoparticles paste electrode

Based on incorporating ZnCrFeO4 into multi-walled carbon nanotubes paste matrix (MWCNTs/ZnCrFeO4/CPE), a chemically modified electrode was prepared for the simultaneous determination of ascorbic acid (AA), acetaminophen (AC) and codeine (CO). The prepared electrode, MWCNTs/ZnCrFeO4/CPE, was characterized by scanning electron microscopy (SEM) and electrochemical impedance spectroscopy (EIS). The MWCNTs/ZnCrFeO4/CPE showed an efficient electrocatalytic activity for the oxidation of AA, AC, and CO. The separations of the oxidation peak potentials for AA-AC and AC-CO were about 250mV and 630mV, respectively. The calibration curves obtained for AA, AC, and CO were in the ranges of 0.4-730.0μmolL(-1), 0.1-368.0μmolL(-1), and 0.3-250.0μmolL(-1), respectively. The detection limits (S/N=3) were 0.03μmolL(-1), 0.009μmolL(-1), and 0.01μmolL(-1) for AA, AC, and CO, respectively. The method was also successfully employed as a selective, simple, and precise method to determinate AA, AC, and CO in pharmaceutical and biological samples.

Real-world effectiveness of onabotulinumtoxinA treatment for the prevention of headaches in adults with chronic migraine in Australia: a retrospective study

Background

OnabotulinumtoxinA (BOTOX®, Allergan plc, Dublin, Ireland) is approved for the preventive treatment of headaches in adult patients with chronic migraine (CM) in Australia by the country’s reimbursement mechanism for medicines, the Pharmaceutical Benefits Scheme (PBS). To our knowledge, this study represents the first focused report evaluating real-world evidence of onabotulinumtoxinA treatment via the PBS in Australian clinics.

Methods

This study reviewed the medical records of adults with inadequately controlled CM from 7 private neurology practices in Australia who, beginning in March 2014, received PBS-subsidized onabotulinumtoxinA per product labelling for the first time. The primary effectiveness measure was the percentage of patients achieving a response defined by 50% or greater reduction in headache days from baseline after 2 treatment cycles. Additional data were recorded in the case report form when available and included demographics, clinical characteristics, headache severity and frequency, Headache Impact Test (HIT-6) score, medication use, and days missed of work or study at baseline, after 2 treatment cycles, and at last follow-up. Differences in mean changes from baseline were evaluated with a 1-tailed t-test or Pearson’s chi-squared test (p < 0.05).

Results

The study population included 211 patients with a mean (SD) of 25.2 (5.3) monthly headache days at baseline. In the primary outcome analysis, 74% of patients achieved a response, with a mean (SD) of 10.6 (7.9) headache days after 2 treatment cycles (p < 0.001). Secondary effectiveness outcomes included mean (SD) reductions in HIT-6 score of − 11.7 (9.8) and − 11.8 (12.2) after 2 treatment cycles (p < 0.001) and final follow-up (p < 0.001), respectively, and mean (SD) decreases in days per month of acute pain medication use of − 11.5 (7.6) after 2 treatment cycles (p < 0.001) and − 12.7 (8.1) at final follow-up (p < 0.001).

Conclusion

This study provides additional clinical evidence for the consistent effectiveness of onabotulinumtoxinA for the treatment of CM in Australia. This effectiveness was made evident by reductions in migraine days, severe headache days, and HIT-6 scores from baseline.

How to replace codeine after tonsillectomy in children under 12 years of age? Guidelines of the French Oto-Rhino-Laryngology--Head and Neck Surgery Society (SFORL)

The authors present the guidelines of the French Oto-rhino-laryngology--Head and Neck Surgery Society (SFORL) regarding pain management in children and adults following tonsillectomy. A multidisciplinary work group was entrusted with a literature review. Guidelines were drawn up based on the articles retrieved and the group members' experience. They were read over by an editorial group independent of the work group. A coordination meeting drew up the final version. Guidelines were graded A, B or C or as professional agreement in decreasing order of level of evidence. At home, non-steroid anti-inflammatory drugs (NSAIDs) are recommended in association with paracetamol in elevated respiratory risk and especially obstructive sleep apnea syndrome; in elevated hemorrhagic risk (hemostasis disorder, surgical problems, etc.), tramadol is recommended. Two other treatment schedules (modified NSAIDs and corticosteroids) have not undergone dedicated study and should be assessed. Management of post-tonsillectomy pain in children is founded on individual risk/benefit analysis.

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.

Codeine should not be prescribed for breastfeeding mothers or children under the age of 12

Medical regulatory authorities, including the Food and Drug Administration and European Medicine Agency, have published restrictions regarding the use of codeine in paediatric patients and breastfeeding mothers. This review explored the various parameters that are involved in the metabolism and toxicology of codeine in these two populations.

CONCLUSION

The growing volume of data on potential serious adverse events and questionable efficacy indicates that codeine should not be prescribed for children under 12 years of age and breastfeeding mothers.

Cytochrome P450 2D6 based electrochemical sensor for the determination of codeine

Considering the enzymatic activity of the cytochrome P450 2D6 on substrates such as codeine, the current paper includes the development of an enzymatic biosensor for detection of this drug. Home-made screen-printed electrodes were used as electrochemical transducers of the biosensor, in which the enzyme was covalently attached to the carbon surface of the working electrode, this type of modification being the most suitable for the immobilization of the biological element. Chronoamperometric measurements were carried out under optimum conditions of pH and working potential, pH 7 and +200 mV vs. screen-printed Ag/AgCl electrode, giving a reduction signal related to the concentration of codeine in solution. Consecutive additions of a solution of codeine were performed to obtain calibration curves in order to validate the electrochemical method in terms of precision and calculate its capability of detection. These biosensors were used for the determination of codeine in urine and commercial pharmaceutical samples.

Pharmaceutical opioid poisonings in Victoria, Australia: Rates and characteristics of a decade of emergency department presentations among nine pharmaceutical opioids

BACKGROUND AND AIMS

Pharmaceutical opioids are a significant contributor to the global 'opioid crisis', yet few studies have comprehensively distinguished between opioid types. We measured whether a range of common pharmaceutical opioids varied in their contribution to the rates and characteristics of harm in a population-wide indicator of non-fatal overdose.

DESIGN

Retrospective observational study of emergency department (ED) patient care records in the Victorian Emergency Minimum Data set (VEMD), July 2009 to June 2019.

SETTING

Victoria, Australia.

CASES

ED presentations for non-fatal overdose related to pharmaceutical opioid use (n = 5403), where the specific pharmaceutical opioid was documented.

MEASUREMENTS

We compared harms across the nine individual pharmaceutical opioids most commonly sold, and considered where multiple opioids contributed to the overdose. We calculated supply-adjusted rates of ED presentations using Poisson regression and used multinomial logistic regression to compare demographic and clinical characteristics of presentations among nine distinct pharmaceutical opioids and a 10th category where multiple opioids were documented for the presentation.

FINDINGS

There were wide differences, up to 27-fold, between supply-adjusted rates of overdose. When considering presentations with sole opioids, the highest supply-adjusted overdose rates [per 100 000 oral morphine equivalents (OME); 95% confidence interval (CI)] were for codeine (OME = 0.078, 95% CI = 0.073-0.08) and oxycodone (OME =0.029, 95% CI = 0.027-0.030) and the lowest were for tapentadol (OME = 0.004, 95% CI = 0.003-0.006) and fentanyl (OME = 0.003, 95% CI = 0.002-0.004). These rates appeared related to availability rather than opioid potency. Most (62%) poisonings involved females. Codeine, oxycodone and tramadol were associated with younger presentations (respectively, 59.5%, 41.7% and 49.8% of presentations were 12-34 years old), and intentional self-harm (respectively 65.2%, 50.6%, and 52.8% of presentations). Relative to morphine, fentanyl [ 0.32 relative risk ratio (RRR)] and methadone ( 0.58 RRR) presentations were less likely to be coded as self-harm. Relative to morphine-buprenorphine, codeine, oxycodone and tramadol presentations were significantly more likely to be associated with the less urgent triage categories (respectively 2.18, 1.80, 1.52, 1.65 RRR).

CONCLUSIONS

In Victoria, Australia, rates and characteristics of emergency department presentations for pharmaceutical opioids show distinct variations by opioid type.