Codeine and Ibuprofen... a cocktail poisoning society
Thursday, August 28, 2008
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.
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...
![](https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEidA8r6y4v2-RWWMYZcE6NGrUDRHDrDLjfGWVE8cVuouh7v2TSIGP3Zb6ODwR9rrp3JnOWTo1svCf78NkR2qSmiwROtiIW8-PYvoIKlXzBV1uPKLNnpiQhix67zGD6LzNhDM6R_ozRrulg/s320/Analgesic+Nephropathy.jpg)
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.
I have worked as both a renal nurse and UGI surgical nurse. I have nursed a few patients (mostly women) with DU perforations secondary to overuse of brufen products. I have also nursed many ESRF patients who are on dialysis because of analgesic nephropathy.
I get a little miffed with our "pop a pill" society. Most people go for the quick fix with no regard for other treatment options.
i admire your passion for this cause. you should also campaign against legal amphetamine use in children (Dexi's), or manipulation of the metabolic processes of the brain through SSRI's. Because investigation into any of these practices quickly leads to the realization that as long as the pharmaceutical companies keep making money, dangerous products and practices will continue to occur. The irony of conducting a 'war on drugs' when the biggest drug dealers in the world are allowed to run rampant at the expense of our health is disgusting at best.
Good post. (Wonder if the Homebake manufacturing process involved no 8 wire in any way). I was recently taking panadeine and nurofen quite regularly for back pain and there is STILL no way I was bending every which way. Nor was I asked anything apart from "savings or credit" despite getting the bulk packets (but then I was in about twice a week as opposed to daily). The adjunct therapies (tiger balm, physio prescribed exercises) were probably doing a fair amount too, as was the passage of time and my not yet being too old and decrepit.
a resident of the USA, I'm here from dragonflyinitiative via prnpenguin.
I agree that codeine isn't particularly effective. In my case it has the added odium of causing nausea, and/or vomiting.
I've been prescribed tylenol (acetaminophen) with codeine for pain from laparoscopic surgery. It didn't work very well, and made me feel like throwing up.
Some years later I was given the same after having my nasal septum straightened. My nose was packed. You do NOT want to throw up while your nose is packed.
I was offered the same after some oral surgery later and refused it. Said I'd get by without, thank you. The office got me a prescription for something that didn't make me throw up, and I was grateful.
Great Post.
It is mind boggling how easy it is to buy drugs containing codeine. Then the average liver coverts 10% of that into morphine; morphine being a pretty damn potent opioid.
Massive risk for abuse. Massive profits to be made.
Maybe the answer lies in education?
Well I take 12 nurofen plus everyday for years now. It was four a day up until a couple of years ago where it has become 12 a day. I had tooth ache so I thought I would go and get that fixed and spent three grand getting the teeth out. Yay I don't need codeine anymore......... Yes I do cause now I have restless leg syndrome so now I take 12 a day cause my legs hurt so badly. I now find out this symptom is actually a withdrawl symptom.
Anyway, I'm lying in bed at 5pm in absolute pain my stomach is a dull pain which has intensified the last couple of days and the noses coming from inside me are horrendous. My urine is dark dark and my stools are pale and I'm pretty sure this is serious. But I know once I ge out of bed I will Ned another twelve to twenty cause my legs are starting to hurt already.
I'm not going to a doctor because I'm embarassed. Not to talk to the doctor, but to be admitted to hospital and everyone to find out I'm a drug addict.
The best thing about this is that I don't even buy them, my partner does for me. She also works in a hospital. I love her but she knows if she doesn't get them I would and she just gets them on the way home to save the yelling.
Anyway guys, thanks Australia for letting me be like this. I imagine if I smoked weed or did some ice I would get arrested and locked up so I really appreciate that you let me sit here eating packets of nurofen plus a day and that I'm now thinking I am dying. Anyway, it's my choice right. I just am so glad for those discount pharmacies that sell these huge packs for only ten bucks each.
If anyone can help me please do. I need help. How do I make this go away? How do I make my body better. What happens at the hospital if I need surgery? What do they do? Is it reversable?
I am pretty sure I'm dying. You know what the funny thing about it is? I can beat cocaine and ice without even thinking about it twice but nurofen plus I am fully addicted too.
Thank you Australia for loving me and making sure the pharmacy can sell me these drugs for the pain in my legs. It goes away right when I have twelve nurofen plus.