Fatal misuse of codeine–ibuprofen analgesics in Victoria, Australia

To the Editor: Pilgrim and colleagues describe one of the most serious outcomes associated with misuse of over-the-counter (OTC) codeine–ibuprofen analgesics, namely death due to high-dose non-steroidal anti-inflammatory drug (NSAID) toxicity resulting from addiction to codeine.1 Three recent published reports describe harm arising from misuse of these products in New Zealand.2-4 Common factors were high prevalence of mental health disorder, history of alcoholism and other substance misuse. These conditions are prevalent in Australia and New Zealand, where OTC opioid availability exposes vulnerable individuals to a risk of dependence, dose escalation, and consequent high-dose NSAID toxicity. The high average number of tablets consumed (49–65 tablets per day) and the prolonged duration of misuse in the New Zealand cases4 and in an Australian cohort of 77 described cases5 indicates the addictive nature of these products, and the inability of pharmacists to identify drug-seeking and prevent prolonged high-dose NSAID misuse and harm.