Australia has an addiction problem. I'm not talking about alcohol, amphetamines or sports (although they are important issues). I noticed the addiction as a pre-reg, but in the last two months it has once again reared its head. In Pathology, the tutor talked about this same problem, as did my PBL tutor a few months ago.

I'm talking about 'over the counter' (OTC) analgesics. In particular, those that contain codeine. I see it in every pharmacy. I read about it in the news. I've even seen the results on the wards. But there's no move to stop it. No prevention. Frankly, no-one seems to give a crap.

OTC analgesics are the cornerstone of self-medication. Paracetamol and ibuprofen are easily the two most used analgesic +/- antiinflammatory medications sold in Australia. For many patients, however, the analgesia obtained from these drugs is inadequate. To mollify this, many combination products are sold. They are called "Plus" or "Extra", and any product with this moniker contains codeine.

So, why am I so anti-codeine, you ask?

Firstly, codeine is an opioid. Whilst it is not as potent or fast-acting, it maintains all the addictive properties of the big H. Heroin, morphine and codeine have extremely similar molecular structures, and hence maintain many similar properties.

My second point on this matter, I will approach from a more historical context; In 1980s New Zealand there was a heroin shortage. Industrious and creative as Kiwis are, they decided to refine their injectable opioids from another source. This source needed to be readily available and easily convertible to heroin/morphine. Combination OTC analgesics had the codeine, and 'Homebake' was invented. Codeine extraction is a major issue in OTC analgesic abuse; just last year the pharmacy dept. at a major Brisbane teaching hospital mailed information leaflets to every pharmacy within 50km about the practice and how to watch for it. Certain brands are preferred; patients get shirty if you try and give them generics that may take longer to extract.

Whilst I was researching this post (and doing some study for the week), I typed "Nurofen(R)" and "plus" into Google. Google's default suggestions included Nurofen Plus(R) addiction, straight off the bat. My third point here is that these drugs are extremely addictive. Some forum posts report consumption of six to 12-fold overdoes every day.

Finally, codeine is not a very good drug in the first place. I suspect that it doesn't work very well at all. Several studies have shown codeine to provide no added benefit for migraine, and only a minimal therapeutic benefit vs paracetamol post-operatively. Don't get me wrong, I appreciate that sometimes codeine might be needed, but I'm pretty sure that I'm not seeing 100+ post-op patients a shift.

I mentioned the lack of prevention earlier. In fact, there's active promotion of these products for their "extra" strength. The two dominant products in Oz are Nurofen Plus(R) and Panafen Plus (R) . Both have highly public advertising campaigns; one evokes an Entrapment-esque jewel thief bending everywhichway thanks to her Nurofen Plus(R). I appreciate that advertising isn't always about reality, but I'm pretty sure that Reckitt Benckiser and their marketing team aren't going to take the time to mention that their jewel thief should perhaps consider taking the tablets with some food, or asking if she's pregnant. Reckitt couldn't care less; they just want you to go and buy some. Besides, it says on the box not to take too much or use it too frequently. As far as they're concerned, you don't even have to take any; once you've paid for the drugs, what happens is your problem now.

Unfortunately, I get the feeling that most pharmacists don't ask nearly enough questions about this. What I think happens is that the pharmacist satisfies themselves that the patient won't drop dead before finishing the box, and if the patient looks healthy and doesn't appear pregnant, it's an easy sale, an eight-dollar no-brainer. If you're an owner, more so. Remember, packets under 48 tablets don't get recorded, so hey, if they kill themselves it's hard to trace.

Gastric ulcers are one main serious event related to chronic NSAID abuse. That's if you keep chowing 'em down without gastro-protection. You might even tolerate the dyspepsia and reflux, if you're really stoic. By the time you get maleena or even a GI perforation, your pain ain't going anywhere. This is how people die quickly from NSAID abuse.

Dying slowly from NSAID abuse appears much more common. This is called Analgesic Nephrotoxicity. This is when your kidneys, through hypoperfusion and repeated chemical insult, decide to pack up and die. To get nephrotoxicity we're talking about 2-3kg of ibuprofen, or equivalent, over a period of years. For those of you playing at home, that's about 10000 tablets, or around 420 packets of 24. Earlier I mentioned a six-times daily overdose; chances are that young chap will have no kidneys within the next two years. Slowly, his renal function will falter and fail. He may get a big scare when his urine turns blood-red, but it's not common in this disease. Chances are, he'll show up at the ED with metabolic acidosis and all the other signs of renal failure. His kidneys might even look like these ones...


Each time I work up the coast, a girl who's not older than I am comes in for her box of Nurofen Plus(R). She's in each morning before eleven, and frequently returns in the evening for another box. "This one's for my boyfriend", she'll tell the shop assistant. Sometimes she just bites the bullet and buys a 72-pack. She provides a different name each time, and I honestly forget her name. I have refused sale several times. I have regularly refused to sell her even a 24-pack - especially the days when she looks green. I almost never work two shifts in a row. I'm certain she goes to other pharmacies during the week. If I tell her not to come back, I consider this morally abandoning the patient. She refuses to see a doctor. The last time I saw her, she was looking healthy but in a particularly bolshie mood. Comparatively, I was feeling a bit flabbergasted at the world. It made for an interesting counsel. This is exactly how it went;

Pt: "I want some Nurofen Plus(R). Just the twenty-four."
Me: "You take these regularly, don't you?"
Pt: "Yeah; I've had them before. I get migraines. I just need a box."
Me: "Okay, you take them with food?"
Pt: (Hands me $10 note) "Yeah, they don't give me any trouble."
Me: (slowly keying the register) "You know that if you keep taking these at more than the recommended dose that you're gonna die? Your kidneys will pack up and just not work."
Pt: "Hmph. I get pain."
Me: (handing over change) "Yep. I know. You should definitely see your doctor about it."
Pt: (walks off)
Me: "Hope I see you next time."

I meant it, too. I hope she miraculously overcomes her NSAID/Codeine addiction and escapes the horrendous morbidity associated with it. I hope I don't see her up at the hospital on death's door. I hope she asks for help.

So, what can we do about all this? Some commentators have suggested requiring a 'script for all codeine products; I think that's a good idea. Except that it will add hours onto the already choked public health system. Others have suggested up-scheduling all codeine-containing preparations to 'pharmacist prescribed' medications. I think this option will ease but not fully ameliorate the problem. I think that advertising OTC opioid-containing products needs to be made illegal. Public education needs to be increased, and the drug companies held accountable for what the say and do.

I've managed to talk about relatively simple cases above; overdoses in uncomplicated patients. The next step is to consider the heavily medicated patient who just has an ache. Patients perched precariously on the precipice of renal failure, with only a few viable nephrons; "I've just go a bit of a headache, love." You don't want her to suffer, do you?

My suggestions are three-fold; Doctors need to counsel their patients about appropriate pain management. They should urge their patients not to take combination products, and to establish clear and comprehensive pain-management plans which include appropriate follow-up. Patients should question why they need certain ingredients. Do you think the risks outweigh the benefits? Can this pain be treated without medicines, using a cold-pack or having a glass of water? Pharmacists should question, question, question. Have some balls and refuse the sale if it doesn't feel right. Do not recommend larger packs; instruct your staff to offer only the lowest size. Do not up-sell codeine as a stronger alternative.

I never want to hear one of my assistants say either:

"Yes, we have plain ibuprofen, but this Panafen Plus(R) has got the extra codeine in it. That's good for backpain/toothache/headaches/opioid addiction."

or:

"Oh, yes we do the twelve pack Nurofen Plus(R), but you can get 48 or seventy-two if you'd like."

Seriously. Give a crap. Don't feed the addiction.