Volume 200 - Issue 3
Fatal misuse of codeine–ibuprofen analgesics in Victoria, Australia
Authors: Brian R McAvoy and Claire L Tobin
Med J Aust 2014; 200 (3): 150-151. || doi: 10.5694/mja13.11268
Published online: 17 February 2014
Published online: 17 February 2014
Those addicted to OTC codeine often do not fit stereotypes of illicit drug users and may present as well groomed professionals
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.
These reports provide limited insight into the prevalence of OTC codeine–ibuprofen misuse and harm. Descriptions of this problem rely on small case series. In many patients, the problem goes unrecognised, and patients present repeatedly with NSAID adverse effects before the underlying cause is identified.
Recent Australian and New Zealand changes to controls on these products have not sufficiently addressed this problem, as patients continue to present for treatment of dependence and high-dose NSAID toxicity resulting from their misuse. We support Pilgrim and colleagues’ recommendation that codeine not be included in these products, or that these products be prescription-only.
Competing interests
No relevant disclosures.
References
- Pilgrim JL, Dobbin M, Drummer OH. Fatal misuse of codeine-ibuprofen analgesics in Victoria, Australia. Med J Aust 2013; 199: 329-331. BABGDJBI
- 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. CBBDDHCE
- Evans C, Chalmers-Watson TA, Gearry RB. Medical image. Combination NSAID-codeine preparations and gastrointestinal toxicity. N Z Med J 2010; 123: 92-93.
- McAvoy BR, Dobbin MDH, Tobin CL. Over-the-counter codeine - misuse and harm in Australia and New Zealand. N Z Med J 2011; 124: 29-33. CBBGBBJG
- Dobbin M, Tobin C. Over the counter (OTC) ibuprofen/codeine analgesics: misuse and harm. Paper prepared for the National Drugs and Poisons Schedule Committee (Australia); 2008 May 22. CBBGGBBI