Volume 194 - Issue 9
Misuse of codeine-containing combination analgesics
Author: Michael A McDonough
Med J Aust 2011; 194 (9): 486. || doi: 10.5694/j.1326-5377.2011.tb03069.x
Published online: 2 May 2011
Published online: 2 May 2011
To the Editor: Frei and colleagues recently drew our attention to combination analgesic misuse-related morbidity.1 The same phenomenon has also been reported in New Zealand.2 About 50 years ago, analgesic misuse was widespread in Australia and commonly involved chronic, excessive use of combination analgesics (including the aspirin–phenacetin–caffeine [APC] products, Bex and Vincent’s Powders). After many years, some people who used APC developed “analgesic nephropathy”, which made up 12%–15% of dialysis cases.3
I recently performed a retrospective chart review of patients who were referred to the Drug and Alcohol Services at the Western Hospital (Melbourne) for excessive compound analgesic use between September 2005 and September 2010. There were 32 patients (18% of all referrals; median age, 38 years; 23 were women). All had some form of chronic pain, had initiated compound analgesic use for acute pain (eg, headache) and all described progressive use of analgesics because of psychogenic effects (eg, “gave me energy”, “helped me forget”). All 32 patients were diagnosed with opioid dependence and had medical and psychiatric problems correlating with their compound analgesic misuse.
One patient, a 34-year-old man, reported taking more than 70 codeine–ibuprofen tablets daily and sustained recurrent gastric ulceration, which eventually required surgery. Despite this, he continued to misuse the analgesics until he undertook opioid replacement pharmacotherapy.
A 24-year-old man misusing the same analgesic, despite completing a detoxification program, also relapsed and died after bleeding from gastric ulceration.4 Overall, the patient profiles were remarkably similar to those described by Frei and colleagues.1
Combination analgesic misuse appears largely correlated with products containing drugs of dependence (eg, codeine) and the phenomenon of “rebound pain” (ie, pain that recurs after a short-acting analgesic effect wanes, or “medication overuse headache”). Most morbidity and mortality risks associated with combination analgesic misuse are a consequence of chronic overdose of the non-steroidal anti-inflammatory drug and/or paracetamol components. Paracetamol (mostly when in combination with an opioid analgesic) is reported as the commonest cause of acute liver failure in the United States and United Kingdom.5 Another long-term complication can be hearing loss.6 Two patients in my clinic group had hearing loss, and the ear, nose and throat specialist’s opinion was that it was related to analgesic misuse. Dextropropoxyphene–paracetamol combination products are still available in Australia but are no longer available in the UK. I question the need for opioids in combination analgesic products and, if used, they should be restricted to prescription.
References
- Frei MY, Nielson S, Dobbin MD, Tobin CL. Serious morbidity associated with misuse of over-the-counter codeine–ibuprofen analgesics: a series of 27 cases. Med J Aust 2010; 193: 294-296. 0_CBBGJCHD
- Robinson GM, Robinson S, McCarthy P, Cameron C. Misuse of over-the-counter codeine-containing analgesics: dependence and other adverse effects. N Z Med J 2010; 123: 59-64. 0_CBBGIBAE
- Kincaid-Smith P. Analgesic nephropathy. Kidney Int 1978; 13: 1-4. 0_i1095854
- Coroner’s case finding. Melbourne: Coroners Court of Victoria, November 2006. 0_i1095856
- Larson AM, Polson J, Fontana RJ, et al. Acetaminophen-induced acute liver failure: results of a United States multicenter, prospective study. Hepatology 2005; 42: 1364-1372. 0_i1095858
- Curhan SG, Eavey R, Shargorodsky J, Curhan GC. Analgesic use and the risk of hearing loss in men. Am J Med 2010; 123: 231-237. 0_i1095860