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  • Hidden epidemic in Irish society

    Posted on March 18th, 2011 TimB No comments

    Dr Colin O’Gara outlines the symptoms and most effective treatments for codeine addiction and examines how availability controls can affect the incidence of dependency problems in the patient population.
    Addiction services within the Irish psychiatric system have traditionally been dominated by presentations of illicit substance abuse. An increasing number of newspaper articles in Ireland, however, have highlighted the rising problem of codeine abuse and addiction.

    In our specialist addiction services for illicit and over-the-counter (OTC) medication abuse at Saint John of God Hospital, we have certainly witnessed a substantial increase in presentations for codeine addiction. Yet the problem is a global one. In 2007, the International Narcotics Board (INB) noted that: “The abuse and trafficking of prescription drugs is set to exceed illicit drug abuse.”

    The INB also reported that over-the-counter preparations or prescription drugs were a drug of choice for many individuals and not abused as a substitute. In the US, prescription medicines are ranked as the second most misused class of drug after cannabis.

    The full extent of codeine addiction in Ireland is unknown, but 2010 pharmacy statistics indicate that codeine-containing products were the bestsellers nationally. Codeine is available in Ireland over the counter and by prescription. Doses of codeine vary according to the preparation — e.g. OTC Solpadeine contains 8mg of codeine, whereas Solpadol (prescription) contains 30mg of codeine per tablet.

    Presentations
    The vast majority of people will take codeine OTC, or as prescribed, for a limited period. Current recommendations in Ireland and the UK suggest that the drug should not be taken for more than three days. A minority, however, will take codeine in increasing amounts and, as tolerance develops, become addicted. Addicted patients use repeat prescriptions or the internet to feed an addiction of up to 1,000mg of codeine per day.

    Another group of patients take codeine purely for the purposes of ‘recreation’ — ingesting hundreds of milligrams of codeine in a binge. Consistent with other drug abuse, it is probably only 10 per cent of this group that go on to exhibit features of dependence, with the other 90 per cent moving on from the behaviour.

    Codeine addicts, like most addicts, are secretive and will aim to keep the habit hidden for as long as possible. Although codeine is considered a weak opioid, when taken in huge amounts its intoxicating effect is far from benign. We are referred professionals who have been ataxic, confused and unco-ordinated in the workplace or end up in emergency departments following overdose.

    Similarly, codeine addiction has a major impact on the family — the emotional and financial pain of the spouse and children affected by codeine addiction is no less than that of alcohol, heroin or any other addiction. The features of codeine addiction according to DSM IV are as follows:

    • A strong desire or sense of compulsion to take codeine-containing products;
    • Difficulties in controlling codeine-taking behaviour in terms of its onset, termination or levels of use;
    • A physiological withdrawal state when codeine use is stopped or reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms;
    • Evidence of tolerance, such that increased doses of codeine are required in order to achieve effects originally produced by lower doses;
    • Progressive neglect of alternative pleasures or interests because of codeine use, increased amount of time necessary to obtain or take codeine or to recover from its effects;
    • Persisting with codeine use despite clear evidence of overtly harmful consequences, such as harm to the liver, depressive mood states or impairment of cognitive functioning.

    So, what are the symptoms to be aware of when patients present at primary care level?

    • Repeated inappropriate requests for codeine-based analgesia;
    • Epigastric pain from gastric erosion;
    • Renal or hepatic damage;
    • Constipation;
    • Nausea;
    • Small pupils, blurred vision, poor night vision;
    • Bradycardia, hypotension;
    • Depression; and
    • Sexual problems.

    Common symptoms of codeine withdrawal include: runny nose; sweating; muscle twitching and muscle pain; headache; arrythmias; nausea, vomiting; stomach cramps; hypertension; insomnia; dehydration; weakness; and yawning.

    Treatment options

    • Detoxification

    Specialist inpatient detoxification programmes usually offer a choice of options, as patients’ requests will vary considerably around detoxification. The options are as follows:

    1)    No intervention — Some patients will request no intervention at all. Often, these patients are under time constraints and view ‘cold turkey’ as the most time-efficient option;
    2)    Sedatives — benzodiazepines and sedative anti-psychotic medication have long been used for detoxification from opioids. Both alleviate glutamate and adrenaline-mediated overactivity of the central and peripheral nervous systems;
    3)    Lofexidine (Britoflex) — is an alpha adrenergic agonist, which alleviates the noradrenergic surge associated with withdrawal;
    4)    Buprenorphine (Subutex) — A partial mu-opioid agonist, has proven benefit in withdrawal, alleviating the acute symptoms. Not widely available yet in Ireland and cost within Ireland is potentially a problem. We commence patients who choose this option on 4mg per day, increasing to up to 16mg a day, then reducing over five days.

    • Rehabilitation

    Most inpatient rehabilitation treatment programmes for codeine addiction last between one and three months and provide intensive therapy in groups and with individual therapists. When patients present to our service, they will often have little previous input from counsellors and need to learn the basics of interacting in therapeutic groups or with individual counsellors.

    Cognitive behavioural therapy provided on a one-to-one basis with the patient or in a small group aims to challenge the negative, self-defeating thoughts that maintain the addiction. In the case of codeine addiction, such thoughts might be, ‘I cannot cope with this pain without Nurofen’.
    Therapists would help patients to replace this thought with more helpful ones, for example: ‘I will cope with this pain by becoming more active and managing my stress better.’

    • Maintenance treatment

    For patients continuously failing to maintain abstinence, substitution with an alternative opioid is, from a harm-minimisation perspective, a sensible option. The other components of OTC codeine products, par-acetamol or NSAIDs in large doses, are dangerously toxic to the liver and small bowel. Methadone or buprenorphine are accepted options and there is some evidence that dihydrocodeine substitution can also be useful.

    Availability
    Within the small world of addiction medicine, it makes perfect sense to make all codeine-containing products prescription only. Some of my patients would never have been patients were it not for the OTC availability of codeine-containing products.

    For the majority of people who take codeine without any problem, however, having to attend a GP for Nurofen Plus or Solpadeine would surely be irritating. In my view, what we need is accurate information on the extent of the problem in Ireland, with a mature reflection on the impact of the current pharmacy restrictions.

    Perhaps on balance, the current measures are enough.

    • Dr Colin O’Gara is a Consultant Psychiatrist at the Saint John of God Hospital, Stillorgan, Co Dublin.

    Irish Medical Times 18/3/2011

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