Complications related to chronic supratherapeutic use of codeine containing compound analgesics in a cohort of patients presenting for codeine withdrawal

Cock, Victoria; Edmonds, Carolyn; Cock, Charles

doi:10.1111/dar.12809

Cited by 8 publications

(13 citation statements)

References 18 publications

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“…In recent years, procedures for tampering with CCM, known as 'cold water extraction' (CWE), have emerged on the internet [2,13,14]. CWE usually involves crushing and dissolving tablets in water and then using home utensils such as coffee filters in order to separate the codeine from the accompanying paracetamol or ibuprofen (which both have potential for toxicity in doses exceeding the daily recommendations [15][16][17]). This can be done at home following relatively simple steps and enables people to ingest large quantities of codeine without the risk of paracetamol or ibuprofen overdose [14].…”

Section: Introductionmentioning

confidence: 99%

Identification of factors influencing tampering of codeine-containing medicines in England: a qualitative study

Kimergård¹,

Parkin²,

Jennings³

et al. 2020

Harm Reduct J

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Background Tampering of psychoactive medicines presents challenges to regulation and public health. However, little is currently known about what influences the decisions to treat codeine-containing medicines (CCM) with cold water extraction (CWE) from the perspective of individuals employing these techniques. The article identifies factors influencing utilisation of CWE to separate codeine from compounded analgesics, such as paracetamol and ibuprofen, found in CCM. Methods Purposive sampling of 27 participants residing in England who took part in a qualitative interview. Of these, 14 individuals (11 males and 3 females) reported tampering of psychoactive medicines, and the relevant transcripts were included in the analyses for the study. Participants were recruited from one addiction treatment service and from an online survey. The mean age of the participants was 31.5 years (range = 18–42 years). Qualitative data analysis followed the processes of iterative categorization (IC). The codes ‘harm reduction’, ‘information sources’ and ‘changes on the drug markets’ were grouped and summarised. The coding of the data was done in a Microsoft® Word document. Results Two groups of participants were identified in the data analysis: (i) individuals who used CCM (n = 5), and (ii) individuals who used CCM and heroin (n = 9). Participants in both groups used CWE due to concerns of paracetamol overdose from the use of excessive dosages of CCM. For both of them, information obtained from the internet encouraged the use of CWE. Participants using CCM described how the many steps involved in conducting CWE, including sourcing codeine boxes from pharmacies (over the counter), presented a barrier against using CWE. Participants using CCM and heroin explained how reduced availability in the local heroin supply influenced utilisation of CWE techniques to maintain their use of opioids and avoid withdrawal. Withdrawal symptoms and cravings outweighed the concerns about the quality of the extracted codeine mixtures in this participant group, especially the ability of CWE to remove paracetamol and tablet fillers. Conclusions Utilisation of CWE of codeine was influenced by several factors including drug market supply, the availability of detailed information on the internet about CWE and restrictions on codeine sourcing in pharmacies. Risks identified with CWE include consumption of unknown doses of paracetamol if the CWE techniques are not used correctly. Attempts at extracting codeine from CCM should be considered in risk assessments of opioid medicines.

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Section: Introductionmentioning

confidence: 99%

Identification of factors influencing tampering of codeine-containing medicines in England: a qualitative study

Kimergård¹,

Parkin²,

Jennings³

et al. 2020

Harm Reduct J

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“…There have been increasing reports of OTC codeine-related misuse and resultant harms, including dependence [5][6][7], gastric and renal morbidities [8][9][10] and even death [8,11,12]. Consequently, many countries have reviewed their policies regarding OTC codeine availability and made them more stringent, for example, by reducing pack sizes, implementing mandatory addiction warning labels on packaging, and recording and monitoring sales [13][14][15].…”

Section: Introductionmentioning

confidence: 99%

Experiences of over‐the‐counter codeine misusers and accounts of recovery: A qualitative study in Tasmania, Australia

Kirschbaum

Barnett

Cross

2020

Drug and Alcohol Review

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Introduction and Aims. There is international concern about misuse of over-the-counter (OTC) codeine, yet few studies have reported the perspectives of misusers themselves. This study explored the experience of OTC codeine misuse and recovery in Tasmania, Australia. Design and Methods. Semi-structured telephone interviews were conducted with 15 self-identified long-term users of OTC codeine. The interview guide prompted responses about reasons for codeine use, positive and negative impacts, recovery, identity and codeine accessibility. Transcripts were analysed abductively using qualitative content analysis. Categories that emerged from misuser accounts were aligned to three broad temporal phases: (i) transition to misuse; (ii) growing awareness; and (iii) towards recovery. Results. Salient features of the misuse experience included: initial use for the self-treatment of physical pain; ongoing use to self-medicate physical pain, stress or mental health conditions; a perception of safety of OTC codeine; an insidious transition from use to misuse; growing awareness of a problem over time; support provided by family, friends and the internet; recovery through self-change; and recognition that recovery is an ongoing process. Discussion and Conclusions. Knowledge and understanding of the experience of OTC codeine misuse and recovery is critical to inform and tailor approaches to prevention and intervention. The findings suggest that strategies to improve the management of pain, stress and mental health, raise self-awareness of problematic use and potential for self-change, and increase social and web-based supports, should be considered when designing health policy initiatives that aim to reduce misuse. [Kirschbaum M, Barnett T, Cross M. Experiences of over-the-counter codeine misusers and accounts of recovery: A qualitative study in Tasmania, Australia.

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“…Newer OTC codeine/ibuprofen analgesics provide more codeine phosphate (12.8 mg) than the leading OTC codeine/paracetamol product (8 mg). Misuse first became evident in 2005; several reports have since described increasing morbidity and numbers of deaths linked with supratherapeutic doses of ibuprofen secondary to codeine addiction …”

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confidence: 99%

“…At supratherapeutic doses, serious harm can be caused by the otherwise relatively safe analgesics paracetamol and ibuprofen. Several studies have found that most codeine‐addicted patients commenced taking OTC codeine combination analgesics for minor medical conditions, but some progress to consuming 30–60 or even more tablets a day.…”

mentioning

confidence: 99%

“…Small or large bowel diaphragm disease, the result of mucosal ulceration and contraction of rings of scar tissue, causes circumferential web‐like strictures and stenosis. Presenting as endoscopic capsule retention, with non‐specific symptoms making it difficult to diagnose, or as acute or subacute small bowel obstruction, it is pathognomonic of NSAID enteropathy …”

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confidence: 99%

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From over‐the‐counter to prescription only: early results of the rescheduling of codeine combination analgesics

Dobbin

2020

Medical Journal of Australia

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2 Schaffer AL, Cairns R, Brown J, et al. Changes in pharmaceutical sales to pharmacies after codeine was rescheduled a prescription only medicine. Med J Aust 2020; 212: 321-327. 3 Harris K, Jiang A, Knoeckel R, Isoardi KZ. Rescheduling codeine-containing analgesics reduced codeine-related hospital presentations. Med J Aust 2020; 212: 328. 4 Degenhardt L, Gisev N, Cama M, et al. The extent and correlates of community-based pharmaceutical opioid utilisation in Australia. Pharmacoepidemiol Drug Saf 2016; 25: 521-538. 5 Annabel B, Scrymgeour M. Fork handles. Australas J Pharm 2017; 98: 74-75. 6 McAllister WB. The global political economy of scheduling: the international-historical context of the Controlled Substances Act. Drug Alcohol Depend 2014; 76: 3-8. 7 Derry S, Karlin SM, Moore RA. Single dose oral ibuprofen plus codeine for acute postoperative pain in adults. Cochrane Database Syst Rev 2015; CD010107. 8 Daniels SE, Goulder MA, Aspley S, Reader S. A randomised, five-parallelgroup, placebo-controlled trial comparing the efficacy and tolerability of analgesic combinations including a novel single-tablet combination of ibuprofen/paracetamol for postoperative dental pain. Pain 2011; 152: 632-642. 9 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. 10 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: 294-296. https://www.mja.com.au/journ al/2010/193/5/serio us-morbi dity-assoc iated-misuse-over-count er-codei neibupr ofen-analg esics 11 Mill D, Johnson JL, Cock V, et al. 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 2018; 37: 247-256.

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Complications related to chronic supratherapeutic use of codeine containing compound analgesics in a cohort of patients presenting for codeine withdrawal

Cited by 8 publications

References 18 publications

Identification of factors influencing tampering of codeine-containing medicines in England: a qualitative study

Identification of factors influencing tampering of codeine-containing medicines in England: a qualitative study

Experiences of over‐the‐counter codeine misusers and accounts of recovery: A qualitative study in Tasmania, Australia

From over‐the‐counter to prescription only: early results of the rescheduling of codeine combination analgesics

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