A "respectable" addiction

Drug addiction has a hidden face. The stereotypical image of a down-and-out heroin addict desperate for another fix can obscure the less familiar figure of the 40-something mum who secretly pops painkillers, watching the clock until its time for her next dose.

“Respectable addiction” is not an emerging societal problem, as some might believe, it has been prevalent for many years. International research spanning well over a decade has suggested that a surprisingly high number of people are knowingly or otherwise abusing over the counter (OTC) medication, and there is a widespread awareness of this problem among both the general public and the professionals – doctors and pharmacists – alike.

Non-prescription analgesics containing codeine - a short acting opium based drug that belongs to the same family as heroin and morphine – are the most commonly identified OTC medicines being abuse in Ireland, but problems have also been linked to products containing dextromethorphan (cough suppressant), pseudoephedrine (decongestant), and laxatives.

Although the true extent of OTC misuse/abuse and addiction in Ireland is unclear, all indications are that it is relatively widespread and increasing. In a 2007 survey of over 100 pharmacists in Ireland, the vast majority (94%) believed that some customers, estimated at an average of four per day, who purchased products containing codeine, were addicted to codeine.

According to the National Drug Treatment Reporting System, maintained by the Health Research Board, the numbers entering treatment for codeine as a problem drug have increased considerably in recent years, from 40 in 1998 to 180 in 2009. In addition, between 1998 and 2007, codeine, either alone or in conjunction with another drug, was implicated in the cause of 90 fatal poisonings.

In an effort to reduce the risk of overuse and addiction, the Pharmaceutical Society of Ireland (PSI) published guidelines in May 2010 on the safe dispensing of non-prescription products containing codeine. The new rules have succeeded in removing these products off display and into the dispensary, so that they are not only sold under the direct personal supervision of the pharmacist but the pharmacist is required to counsel the consumer and where prudent, suggest an alternate method of analgesia.

However, a public health academic in the UK is now calling for further protective steps to be taken by the pharmacy profession, recommending that the OTC sales of opiates, including codeine-based painkillers, should be recorded and monitored as a way of tackling drug misuse by so-called "respectable addicts”.

Dr Richard Cooper, a lecturer in public health at the University of Sheffield, recently published research that revealed the frustration of community pharmacists that they are unable to track the supply of these opiates to customers from other pharmacies. The study also highlighted the concerns of pharmacists and other health professionals in relation to the current lack of treatment and support options for individuals affected by OTC medicine abuse.

These concerns are shared by many pharmacists across Ireland, including David Carroll, supervising pharmacist in Boots, Grafton Street, Dublin, who introduced tight restrictions on codeine sales two years ahead of the PSI guidelines, including direct consultation with customers warning them of the side-effects of codeine, its addiction potential and how it should be used for no more than three days.

He devised these protocols after becoming increasingly troubled that a high proportion of analgesic sales in his store were made up of products containing codeine.

“By far the biggest problem we have with regard to the abuse of OTC medicine in Ireland is with codeine-combination pain killers, such as Nurofen Plus and Solpadine,” he told Modern Medicine of Ireland.

“The bottom line is codeine medication is really only appropriate for short term use, for a couple of days. It’s ideal for a person who has had a wisdom tooth out, for example, and they are in bad physical pain; that’s fine, take it for a couple of days and be done with it.

“But the fact is many people who abuse codeine-based painkillers don’t even realise how addictive it is; they may not even realise that they are addicted. If they were shooting up heroin or doing lines of cocaine to get high then it would be quite clear in their heads that they have a problem, but if they’re just taking something to kill a bad headache, they think ‘what’s the harm?’”

David cited recent findings of a large survey of self-described codeine addicts where approximately 70% of them had never been told the medicine was addictive, and a similar proportion were taking more than the recommended dosage on a continuous basis.

“The paracetamol and codeine combination has only a slightly better analgesic effect but the codeine has that calming and euphoric effect that’s chilling them out and calming them down a little bit more, and they think it’s the only thing that can make them feel better. They can’t stop taking it because if they do they experience very unpleasant withdrawal symptoms and the pain comes back – it’s literally a withdrawal headache and they’ve been feeding a cycle,” he explained.

Like all opioids, continued use of codeine induces physical dependence and can be psychologically addictive. Some symptoms of OTC opiate withdrawal include anxiety, nausea and vomiting, flu like symptoms, tachycardia and hypertension, and dysphoria.

“When a person is withdrawing from the codeine and they need it, you can actually see it in their eyes. They come in looking for Solpadine or Nurofen Plus and nothing else, and they will use any excuse to get it,” David remarked. “You can offer them alternatives but nothing else will do because it’s the only thing they want and they can become very irrational and irate about it. And still, some of them may not realise that there is any kind of addiction there.”

He makes an important distinction between the types of people who misuse OTC medicines: a small number will conscientiously disobey the user instructions to get a ‘kick’, but there are also people who have inadvertently become addicted to these products and are aware of their dependence but cannot beat the addiction. Finally, there are some who are completely unaware that they are misusing these products – they keep within the recommended limits both frequently and regularly to treat drug-induced headache, for example.

“It can be difficult to spot a person who is misusing or abusing an OTC medicine but there are some red flags to watch for. Asking for a product by name, for example. The vast majority of people will say they want something for a dry cough or a tickly cough, but a telltale sign can be if someone asks specifically for a named product such as Benylin original, which contains a sedating antihistamine that can be abused if taken in large quantities. Or someone who asks for a 24 pack of Solpadeine Soluble, which gets you a hit more quickly and they want the bigger pack.

“Also, people who get incredibly irate when you start asking them questions. On the one hand they’ll say they only take it every six months, but there they are losing the head with you - if they only have this conversation twice a year, why is it annoying them so much? Are they having this conversation regularly in other pharmacies?”

With regard to laxative abuse, David said that the typical profile of a misuser is a person with eating disorders. Mental alarm bells should ring for the pharmacist if a very thin person requests the 60 or 100 pack of Senokot, for example.

The abuse of some OTC products has become a serious and fast-growing public health problem. A 2005 survey of members of the public in Northern Ireland found that almost one third of participants had personally encountered OTC abuse.

The seriousness of the problem in Ireland was underscored last year in a study at St Patrick’s University Hospital, Dublin, where 20 people were admitted during the course of a year for OTC opiate abuse treatment. The authors said that the patients’ self-reported codeine intake of 261 milligram per day – which they suggested was a deliberate under-estimation of usage - would mean a dangerously large amount of paracetamol or ibuprofen would be simultaneously ingested in combined compounds, putting the patient’s health at serious risk.

The authors pointed out that the availability of OTC opiates and the covert nature of this form of substance abuse means individuals can easily misuse OTC opiates by accident.

Since instigating safe sale of codeine practices in his pharmacy, David has spoken with people who admitted that they knew they had a problem but that since nobody had confronted them about it they were reluctant to deal with it. He has also encountered many people who never realised, until their consultation in the pharmacy, that they might have a codeine addiction problem.

In these situations the pharmacist can advise on how to deal with codeine withdrawal, usually through gradually reduce their codeine medication under the supervision of their GP or at a drug treatment centre.

“But it’s never as simple as saying ‘I’m going to stop that now’. I know of at least one person who had to go on methadone to help him come off codeine, and most people with problems may have to be referred to their doctors to help them come off it in a very controlled way,” he added.

At the end of the day, the community pharmacist has to rely on his or her own judgement as to when referral is necessary and to whom, often trusting the word of the individual that they will seek help for their addiction, as there is no formal referral pathway and refusal of supply may simply drive the client to another unsuspecting pharmacy.

There is also no system of quantative measurement available to track the level of abuse/misuse, either locally or nationally.

“Codeine is highly addictive and OTC medications containing codeine should be limited to very restricted use or eventually, if it continues being abused here, it will be made prescription-only. That would be unfair though as the vast majority of people are using these drugs safely and as directed. It would be unfair to punish the majority because of a small number who misuse them,” said David. “We need to create and sustain greater awareness about the safe use of these medications and it is important that pharmacists and doctors remain ever vigilant.”