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Trends and characteristics of accidental and intentional codeine overdose deaths in Australia

Amanda Roxburgh, Wayne D Hall, Lucinda Burns, Jennifer Pilgrim, Eva Saar, Suzanne Nielsen and Louisa Degenhardt
Med J Aust 2015; 203 (7): 299. || doi: 10.5694/mja15.00183

Summary

Objectives: To examine trends in codeine-related mortality rates in Australia, and the clinical and toxicological characteristics of codeine-related deaths.

Design and setting: Analysis of prospectively collected data from the National Coronial Information System on deaths where codeine toxicity was determined to be an underlying or contributory cause of death. The study period was 2000–2013.

Main outcome measures: Population-adjusted numbers (per million persons) of (1) codeine-related deaths, classified by intent (accidental or intentional); and (2) heroin- and Schedule 8 opioid-related deaths (as a comparator).

Results: The overall rate of codeine-related deaths increased from 3.5 per million in 2000 to 8.7 per million in 2009. Deaths attributed to accidental overdoses were more common (48.8%) than intentional deaths (34.7%), and their proportion increased during the study period. High rates of prior comorbid mental health (53.6%), substance use (36.1%) and chronic pain (35.8%) problems were recorded for these deaths. For every two Schedule 8 opioid-related deaths in 2009, there was one codeine-related death. Most codeine-related deaths (83.7%) were the result of multiple drug toxicity.

Conclusions: Codeine-related deaths (with and without other drug toxicity) are increasing as the consumption of codeine-based products increases. Educational messages are needed to better inform the public about the potential harms of chronic codeine use, especially in the context of polypharmacy.

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  • Amanda Roxburgh1
  • Wayne D Hall1
  • Lucinda Burns1
  • Jennifer Pilgrim3
  • Eva Saar3
  • Suzanne Nielsen1
  • Louisa Degenhardt1

  • 1 University of New South Wales, Sydney, NSW
  • 2 University of Queensland, Brisbane, QLD
  • 3 Monash University, Melbourne, VIC
  • 4 National Coronial Information System, Melbourne, VIC

Correspondence: a.roxburgh@unsw.edu.au

Acknowledgements: 

This article is a product of the National Illicit Drug Indicators Project, which is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvement Grants Fund. The funders had no role in the research described in this paper.

Competing interests:

Louisa Degenhardt has received untied educational grants from Reckitt Benckiser for the postmarketing surveillance of opioid substitution therapy medications in Australia, and the development of an opioid-related behaviour scale. She has also received untied educational grants from Mundipharma to conduct postmarketing surveillance of the use of oxycodone formulations in Australia. Suzanne Nielsen has been an investigator on untied education grants from Reckitt Benckiser. These funders had no role in the research described in this article.

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access_time 07:38, 9 October 2015
Mi Strom

Simple question: If the data sources were 2000 to 2013, why are the results for 2000 to 2009 used as indicators for a "growth trend"?
Not having access to the source data it's difficult to understand why the subsequent 4 years worth of data were omitted.
How can the reader determine that the growth from 2000 to 2009 weren't the statistical anomaly & that from 2010 onwards the rates returned to their previous levels.
Of the 100% of data, only 70% of the data was used to draw your conclusion. And yet there's a remaining 30% which isn't disclosed in your findings.

Competing Interests: No relevant disclosures

Mr Mi Strom
N/A

access_time 11:42, 15 October 2015
Laurence Mather

In this report, attribution of the deaths as codeine ‘overdose’ or ‘related’ is problematic. The pharmacologically pertinent effects of codeine are ventilatory depression, cough suppression, and emesis. Certainly, these effects can lead to fatalities, particularly at doses also producing depression of consciousness. However, no information is given as how these deaths were (or might have been) attributable to ‘codeine overdoses’. The ingestion of codeine and the occurrence of death in someone are not pharmacologically synonymous with death by ‘codeine overdose’ or even being ‘codeine-related’. The majority of deaths (83.7%) were reported as ‘mixed drug toxicity’, with only 7.8% as ‘codeine toxicity’, as characterized by the morphinoids-drug screen algorithms. In the presence of polypharmacy and/or comorbidities, with unknown codeine dosing forms and doses, and with unknown codeine biofluid concentrations, even in those deaths where other medications or substances were not detected (and there is no information as to what may have been detectible and/or dismissed), it is really not possible to ascribe the deaths to codeine other than by suggestion. Hence, conclusions regarding codeine ‘overdose’ or codeine ‘related’ deaths do seem a pharmacological over-stretch.

Competing Interests: No relevant disclosures

Prof Laurence Mather
Sydney Medical School

access_time 12:21, 15 October 2015
Laurence Mather

I am becoming concerned about the burgeoning literature of drug harms and abuse that neglects the benefits of pharmacotherapy. If all one sees are drug problems, it is easy to see the problems as the norm.

Pain, a subjective sensation, needs individual treatment, sometimes requiring flexible dosing regimens of (whatever) analgesic agent(s). Despite commonly-perceived problems of over-use and abuse of codeine specifically [1,2] and opioids generally [3], there remains the significant problem of many people receiving unsatisfactory pain management.[4,5] Most pain is self-limiting and amenable to self-medication with non-prescription analgesic agents, some containing codeine in NSAID or paracetamol combinations. This is the pharmacologically-sound principle of ‘multimodal analgesia’. Ignoring pharmacogenetic complexities about codeine metabolism in relation to analgesia, it is suffice to concur that the efficacy of low-dose codeine combinations is often equivocal in randomised trials. Nevertheless, many individuals claim greater benefit from the codeine combination than the other agent alone – and they would be the ones to know.

No drug therapy is absolutely without risks. Nonetheless, I am less pharmacologically concerned about the risk of codeine toxicity, particularly from the non-prescription analgesic combinations, than I am about gastrointestinal and/or renal toxicity in those people who will inevitably use greater doses of other analgesics such as NSAIDs or paracetamol as non-codeine replacements for pain relief. It seems increasingly likely that codeine combinations will be made prescription only, and this will be assisted by reports such as this being uncritically added to the ‘analgesic problem’ literature.


1. Scheduling proposals referred to the August 2015 meeting of the Advisory Committee on Medicines Scheduling (ACMS #15)]. Available at https://www.tga.gov.au/interim-decisions-matters-referred-expert-advisory-committee-11#codeine
2. Wiseman H. Codeine deaths need action. MJA InSight Monday, 5 October, 2015
3. Roxburgh A, Bruno R, Larance B, Burns L. Prescription of opioid analgesics and related harms in Australia. Med J Aust 2011; 195: 280-284
4. Cousins MJ. Unrelieved pain: a major health care priority. Med J Aust 2012; 196: 373-374
5. Notcutt, W., & Gibbs, G. Inadequate pain management: myth, stigma and professional fear. Postgrad Med J 2010; 86 (1018): 453-458


Competing Interests: No relevant disclosures

Prof Laurence Mather
Sydney Medical School

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