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Dependence on Over the Counter (OTC) Codeine Containing Analgesics: Treatment and Recovery with Buprenorphine Naloxone

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Abstract

Misuse and dependence on prescribed and over the counter (OTC) codeine-combination analgesics is an emerging public health concern. We present a clinical case series of four adult patients dependent on OTC codeine combination analgesics in Ireland. Cases (two males/two females, aged 44–57 years) were consuming between 12 and 72 codeine-containing tablets/day. In three cases, consumption was linked to pain, with on-going misuse reflecting dependence on codeine. Cases were initiated on buprenorphine-naloxone (Suboxone®), stabilised on doses of between 4 mg/1 mg and 14 mg/3.5 mg per day and remain on treatment without additional opioid use, as verified by drug screening reports. Although anecdotal, these cases show the potential of effective opioid assisted treatment (OAT) using buprenorphine-naloxone (Suboxone®) to successfully treat this distinct form of opioid dependence disorder. Optimal service provision should recognise unique patient profiles and needs for this form of opioid dependence and incorporate psycho-social supports.

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References

  • Amato, L., Davolia, M., Peruccia, C. A., Ferria, M., Faggiano, F., & Mattick, R. P. (2005). An overview of systematic reviews of the effectiveness of opiate maintenance therapies: available evidence to inform clinical practice and research. Journal of Substance Abuse Treatment, 28(4), 321–329. doi:10.1016/j.jsat.2005.02.007.

  • Amato, L., Minozzi, S., Davoli, M., & Vecchi, S. (2011). Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Cochrane Database of Systematic Reviews, 10, CD004147. doi:10.1002/14651858.CD004147.pub4.

    PubMed  Google Scholar 

  • Bao, Y., Liu, Z., Epstein, D. H., Du, C., Shi, J., & Lu, L. (2009). A meta-analysis of retention in methadone maintenance by dose and dosing strategy. The American Journal of Drug and Alcohol Abuse, 35(1), 28–33. doi:10.1080/00952990802342899.

    Article  PubMed  PubMed Central  Google Scholar 

  • Connock M, Juarez Garcia A, Jowett S, Frew E, Liu Z, Taylor RJ, Fry-Smith A, Day E, Lintzeris N, Roberts T, Burls A, & Taylor RS. (2007). Methadone and buprenorphine for the management of opioid dependence: a systematic review and economic evaluation. Health Technology Assessment, 11(9):1–171, iii-iv. doi:10.3310/hta11090.

  • Conroy, S., & Hill, D. (2014). Failure to identify or effectively manage prescription opioid dependence acted as a gateway to heroin use—buprenorphine/naloxone treatment and recovery in a surgical patient. BMJ Case Reports. doi:10.1136/bcr-2014-207458.

    PubMed  Google Scholar 

  • Cooper, R. (2011). Respectable addiction - a qualitative study of over the counter medicine abuse in the UK. School of Health and Related Research (ScHARR): University of Sheffield.

    Google Scholar 

  • Cooper, R. J. (2013). I can’t be an addict. I am.’ Over-the-counter medicine abuse: a qualitative study. British Medical Journal Open, 3(6). doi:10.1136/bmjopen-2013-002913.

  • Department of Health (England) and the devolved administrations. (2007). Drug misuse and dependence: UK Guidelines on Clinical Management. London. Department of Health (England), the Scottish Government, Welsh Assembly and Northern Ireland Executive.

  • Dole, V. P., & Nywsander, M. (1965). A medical treatment for diacetylmorphine (heroin) addiction. A clinical trial with methadone hydrochloride. The Journal of the American Medical Association, 193(8), 646–650. doi:10.1001/jama.1965.03090080008002.

    Article  CAS  PubMed  Google Scholar 

  • Doran, C. M., Holmes, J., Ladewig, D., & Ling, W. (2005). Buprenorphine induction and stabilisation in the treatment of opiate dependence. Heroin Addiction and Related Clinical Problems, 7(1), 7–18. doi:10.1016/j.jsat.2011.12.009.

    Google Scholar 

  • Dutch, M. J. (2008). Nurofen Plus misuse: an emerging cause of perforated gastric ulcer. The Medical Journal of Australia, 188(1), 56–57.

    PubMed  Google Scholar 

  • Ernest, D., Chia, M., & Corallo, C. E. (2010). Profound hypokalaemia due to Nurofen Plus and Red Bull misuse. Critical care and resuscitation, 12(2), 109–110.

    PubMed  Google Scholar 

  • Evans, C., Chalmers-Watson, T. A., & Gearry, R. B. (2010). Medical Image. Combination NSAID-codeine preparations and gastrointestinal toxicity. New Zealand Medical Journal, 123(1324), 92–93.

    PubMed  Google Scholar 

  • Fareed, A., Vayalapalli, S., Casarella, J., & Drexler, K. (2012). Effect of Burprenorphine Dose on Treatment Outcome. Journal of Addictive Diseases, 31(1), 8–18. doi:10.1080/10550887.2011.642758.

    Article  PubMed  Google Scholar 

  • Fiellin, D. A., Schottenfeld, R. S., Cutter, C. J., Moore, B. A., Barry, D. T., & O’Connor, P. G. (2014). Primary care-based buprenorphine taper vs maintenance therapy for prescription opioid dependence: a randomized clinical trial. JAMA Internal Medicine, 174(12), 1947–1954. doi:10.1001/jamainternmed.2014.5302.

    Article  PubMed  Google Scholar 

  • Fine, P. G., Portenoy, R. K., & Ad Hoc Expert Panel on Evidence Review and Guidelines for Opioid Rotation (2009). Establishing ‘Best Practices’ for opioid rotation: conclusions of an expert panel. Journal of Pain and Symptom Management, 38(3), 418–425. doi:10.1016/j.jpainsymman.2009.06.002.

    Article  PubMed  PubMed Central  Google Scholar 

  • Frei, M. Y., Nielsen, S., Dobbin, M., & Tobin, C. L. (2010). Serious morbidity associated with misuse of over-the-counter codeine-ibuprofen analgesics: a series of 27 cases. The Medical Journal of Australia, 193(5), 294–296.

    PubMed  Google Scholar 

  • Gouveia, M., Sousa, R., Costa, J., & Borges, M. (2015). Economic evaluation of Suboxone® for substitution treatment of opioid drug dependence in Portugal. Heroin Addiction and Related Clinical Problems, 17(1), 43–50.

    Google Scholar 

  • Gowing, L., Ali, R., & White, J. M. (2009). Buprenorphine for the management of opioid withdrawal. Cochrane Database of Systematic Reviews, 3, CD002025. doi:10.1002/14651858.CD002025.pub4.

    PubMed  Google Scholar 

  • Gowing, L., Farrell, M. F., Bornemann, R., Sullivan, L. E., & Ali, R. (2011). Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database of Systematic Reviews, 8, CD004145. doi:10.1002/14651858.CD004145.pub4.

    PubMed  Google Scholar 

  • Gowing, L., Ali, R., Dunlop, A., Farrell, M., & Lintzeris, N. (2014). National Guidelines for Medication-Assisted Treatment of Opioid Dependence. Canberra: National Drug Strategy.

    Google Scholar 

  • Handley, S. A., & Flanagan, R. J. (2014). Drugs and other chemicals involved in fatal poisoning in England and Wales during 2000–2011. Clinical Toxicology, 52(1), 1–12. doi:10.3109/15563650.2013.872791.

    Article  CAS  PubMed  Google Scholar 

  • Hard, B. (2014). Management of opioid painkiller dependence in primary care: ongoing recovery with buprenorphine/naloxone. British Medical Journal Case Reports. doi:10.1136/bcr-2014-207308.

  • Hser, Y., Saxon, A. J., Huang, D., Hasson, A., Thomas, C., Hillhouse, M., et al. (2014). Treatment retention among patients randomized to buprenorphine/naloxone compared to methadone in a multi-site trial. Addiction, 109(1), 79–87. doi:10.1111/add.12333.

  • Kean, J (2015). Illicit and over-the-counter codeine dependence after acute back pain-successful treatment and ongoing recovery after buprenorphine/naloxone taper. Heroin Addiction And Related Clinical Problems.

  • Lambert, A. P., & Close, C. (2005). Life-threatening hypokalaemia from abuse of nurofen plus. Journal of the Royal Society of Medicine, 98(1), 21. doi:10.1258/jrsm.98.1.21.

    Article  PubMed  PubMed Central  Google Scholar 

  • Maas, J., Barton, G., Maskrey, V., Pinto, H., & Holland, R. (2013). Economic evaluation: a comparison of methadone versus buprenorphine for opiate substitution treatment. Drug and Alcohol Dependence, 133(2), 494–501. doi:10.1016/j.drugalcdep.2013.07.018.

    Article  PubMed  Google Scholar 

  • Marr, E., & Hill, D. (2015). Optimising service provision for prescribed opioid analgesic dependence. Heroin Addiction and Related Clinical Problems, 17(5), 13–18.

    Google Scholar 

  • Mathers BM, Degenhardt L, Ali H, Wiessing L, Hickman M, Mattick RP, Myers B, Ambekar A, & Strathdee SA; (2010). HIV prevention, treatment, and care services for people who inject drugs: a systematic review of global, regional, and national coverage. Lancet, 375(9719):1014–1028. doi:10.1016/S0140-6736(10)60232–2.

  • Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2009). Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database of Systematic Reviews, 3, CD002209. doi:10.1002/14651858.CD002209.pub2.

    PubMed  Google Scholar 

  • Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, 2, CD002207. doi:10.1002/14651858.CD002207.pub4.

    PubMed  Google Scholar 

  • McDonough, M. A. (2011). Misuse of codeine-containing combination analgesics. The Medical Journal of Australia, 194(9), 486.

    PubMed  Google Scholar 

  • Ministry of Health (2014). New Zealand practice guidelines for opioid SubstitutionTreatment. Wellington: Ministry of Health.

    Google Scholar 

  • Mutlu, E., & Bilici, R. (2015). Outcomes of buprenorphine-naloxone maintenance therapy: one-year follow up study from Turkey. Heroin Addiction and Related Clinical Problems, 17(1), 79–90.

    Google Scholar 

  • Myers, B., Siegfried, N., & Parry, C. D. (2003). Over-the-counter and prescription medicine misuse in cape town -findings from specialist treatment centres. South African Medical Journal, 93(5), 367–370.

    PubMed  Google Scholar 

  • National Institute for Health and Clinical Excellence (NICE) (2007). Drug misuse in over 16 s. Opioid detoxification. In Clinical guideline 52. London: NICE.

    Google Scholar 

  • Ng, J. L., Morgan, D. J., Loh, N. K., Gan, S. K., ColemanPL, O. G. S., & Prentice, D. (2011). Life-threatening hypokalaemia associated with ibuprofen-induced renal tubular acidosis. The Medical Journal of Australia, 194(6), 313–316.

    PubMed  Google Scholar 

  • Nielsen, S., Cameron, & Pahoki, S. (2010). Over-the-counter codeine dependence. Melbourne, Australia: The Turning Point Alcohol and Drugs Centre.

    Google Scholar 

  • Nielsen, S., Cameron, J., & Lee, N. (2011). Characteristics of a nontreatment-seeking sample of over-the-counter codeine users: implications for intervention and prevention. Journal of Opioid Management, 7(5), 363–370.

    PubMed  Google Scholar 

  • Nielsen, S., Hillhouse, M., Mooney, L., Fahey, J., & Ling, W. (2012). Comparing buprenorphine induction experience with heroin and prescription opioid users. Journal of Substance Abuse Treatment, 43(3), 285–290. doi:10.1016/j.jsat.2011.12.009.

    Article  PubMed  PubMed Central  Google Scholar 

  • Nielsen, S., Cameron, J., & Pahoki, S. (2013). Opportunities and challenges: over-the-counter codeine supply from the codeine consumer’s perspective. The International Journal of Pharmacy Practice, 21(3), 161–168. doi:10.1111/j.2042-7174.2012.00247.x.

    Article  PubMed  Google Scholar 

  • Nielsen, S., Roxburgh, A., Bruno, R., Lintzeris, N., Jefferson, A., & Degenhardt, L. (2015a). Changes in non-opioid substitution treatment episodes for pharmaceutical opioids and heroin from 2002 to 2011. Drug and Alcohol Dependence, 149, 212–219. doi:10.1016/j.drugalcdep.2015.02.004.

    Article  CAS  PubMed  Google Scholar 

  • Nielsen S, Bruno R, Murnion B, Dunlop A, Degenhardt L, Demirkol A, Muhleisen P, Lintzeris N. (2015b). Treating codeine dependence with buprenorphine: Dose requirements and induction outcomes from a retrospective case series in New South Wales, Australia. Drug and Alcohol Review. Early Online. doi:10.1111/dar.12315.

  • Nielsen, S., Murnion, B., Dunlop, A., Degenhardt, L., Demirkol, A., Muhleisen, P., et al. (2015c). Comparing treatment-seeking codeine users and strong opioid users: findings from a novel case series. Drug and Alcohol Review, 34(3), 304–311. doi:10.1111/dar.12315.

  • Pilgrim, J. L., Dobbin, M., & Drummer, O. H. (2013). Fatal misuse of codeine-ibuprofen analgesics in Victoria, Australia. The Medical Journal of Australia, 199(5), 329–331. doi:10.5694/mja12.11843.

    Article  PubMed  Google Scholar 

  • Reed K, Bond A, Witton J, Cornish R, Hickman M, & Strang J. (2011). The changing use of prescribed benzodiazepines and z-drugs and of over-the-counter codeine-containing products in England: a structured review of published English and international evidence and available data to inform consideration of the extent of dependence and harm. London. National Addiction Centre.

  • Riksheim, M., Gossop, M., & Clausen, T. (2014). From methadone to buprenorphine: changes during a 10 year period within a national opioid maintenance treatment programme. Journal of Substance Abuse Treatment, 46(3), 291–294. doi:10.1016/j.jsat.2013.10.006.

    Article  PubMed  Google Scholar 

  • Sigmon, S. C., Dunn, K. E., Badger, G. J., Heil, S. H., & Higgins, S. T. (2009). Brief buprenorphine detoxification for the treatment of prescription opioid dependence: a pilot study. Addictive Behaviours, 34(3), 304–311. doi:10.1016/j.addbeh.2008.11.017.

    Article  Google Scholar 

  • Soyka, M. (2015). New developments in the management of opioid dependence: focus on sublingual buprenorphine-naloxone. Substance Abuse and Rehabilitation, 6, 1–14. doi:10.2147/SAR.S45585.

    Article  PubMed  PubMed Central  Google Scholar 

  • Stannard, C. (2013). Opioids in the UK: what’s the problem? BMJ, 347, f5108. doi:10.1136/bmj.f5108.

    Article  PubMed  Google Scholar 

  • Strike C, Millson M, Hopkins S, Smith C (2013). What is low threshold methadone maintenance treatment? International Journal of Drug Policy 24(6), 51–56.

  • The Royal College of General Practitioners (2014). Prescription and over-the-counter medicines misuse and dependence. 1--4. http://www.rcgp.org.uk/learning.

  • Van Hout, M. C. (2015). Nod and wave: an internet study of the codeine intoxication phenomenon. International Journal of Drug Policy, 26(1), 67–77. doi:10.1016/j.drugpo.2014.06.016.

    Article  PubMed  Google Scholar 

  • Van Hout, M. C., & Norman, I. (2015). Misuse of non-prescription codeine containing products: recommendations for detection and reduction of risk in community pharmacies. In International journal of drug policy. Early: Online. doi:10.1016/j.drugpo.2015.09.007.

    Google Scholar 

  • Van Hout MC, Bergin M, Foley M, Rich E, Rapca AI, Harris R, & Norman I. (2014). A Scoping Review of Codeine Use, Misuse and Dependence, final report. CODEMISUSED Project European Commission 7th Framework Programme, EU. Brussels.

  • Van Hout MC, Horan A, Santlal K, Rich E, Bergin M. (2015a). ‘Codeine is my Companion’: Misuse and dependence on codeine containing medicines in Ireland. Irish Journal of Psychological Medicine. Early Online.

  • Van Hout MC, Rich E, Dada S, Bergin M. (2015b). Codeine is my Helper: A qualitative study of pharmacy access and codeine misuse in South Africa. Qualitative Health Research. Early Online. doi:10.1177/1049732315613764

  • Weiss, R. D., Potter, J. S., Fiellin, D., Byrne, M., Connery, H. S., Dickinson, W., et al. (2011). Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for presciption opioid dependence: a 2-phase randomized controlled trial. Archives of General Psychiatry, 68(12), 1238–1246. doi:10.1001/archgenpsychiatry.2011.121.

  • Wright, N. M. J., Sheard, L., Tompkins, C. N. E., Adams, C. E., Allgar, V. L., & Oldham, N. S. (2007). Buprenorphine versus dihydrocodeine for opiate detoxification in primary care: a randomised controlled trial. BMC Family Practice, 8, 3. doi:10.1186/1471-2296-8-3.g.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgments

Aidan McManus from Edge Medical Communications provided editorial assistance, funded by Indivior.

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Authors and Affiliations

  1. School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland

    Marie Claire Van Hout

  2. GP, Blackrock Family Practice, Blackrock, Co Dublin, Ireland

    Ide Delargy

  3. Substance Misuse Programme, Irish College of General Practitioners, Dublin, Ireland

    Ide Delargy

  4. Tolka River Project, Dublin, Ireland

    Gerry Ryan

  5. South Eastern Trust, Downshire Hospital, Downpatrick, Co Down, UK

    Siobhan Flanagan

  6. Addiction Services, Dublin North City, County Dublin, Ireland

    Hugh Gallagher

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  1. Marie Claire Van Hout
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  2. Ide Delargy
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  4. Siobhan Flanagan
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Correspondence to Marie Claire Van Hout.

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Authors declare they have no conflict of interest.

Financial Support

The research leading to these results has received funding from the European Community’s Seventh Framework Programme FP7/2007–2013 under grant agreement no 611,736.

Informed Consent

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study.

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Van Hout, M.C., Delargy, I., Ryan, G. et al. Dependence on Over the Counter (OTC) Codeine Containing Analgesics: Treatment and Recovery with Buprenorphine Naloxone. Int J Ment Health Addiction 14, 873–883 (2016). https://doi.org/10.1007/s11469-015-9618-2

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