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.
- 1. Stannard C. Opioids in the UK: what’s the problem? BMJ 2013; 347: f5108.
- 2. Roxburgh A, Bruno R, Larance B, Burns L. Prescription of opioid analgesics and related harms in Australia. Med J Aust 2011; 195: 280-284. <MJA full text>
- 3. Roxburgh A, Burns L, Drummer OH, et al. Trends in fentanyl prescriptions and fentanyl-related mortality in Australia. Drug Alcohol Rev 2013; 32: 269-275.
- 4. Rintoul AC, Dobbin MD, Drummer OH, Ozanne-Smith J. Increasing deaths involving oxycodone, Victoria, Australia, 2000-09. Inj Prev 2011; 17: 254-259.
- 5. International Narcotics Control Board. Narcotic drugs: estimated world requirements for 2014; statistics for 2012. New York: United Nations, 2013. http://apps.who.int/medicinedocs/documents/s21513en/s21513en.pdf (accessed Aug 2015).
- 6. Tobin CL, Dobbin M, McAvoy B. Regulatory responses to over-the-counter codeine analgesic misuse in Australia, New Zealand and the United Kingdom. Aust N Z J Public Health 2013; 37: 483-488.
- 7. MacDonald N, MacLeod SM. Has the time come to phase out codeine? CMAJ 2010; 182: 1825.
- 8. Iedema J. Cautions with codeine. Aust Prescr 2011; 34: 133-135.
- 9. Sproule BA, Busto UE, Somer G, et al. Characteristics of dependent and nondependent regular users of codeine. J Clin Psychopharmacol 1999; 19: 367-372.
- 10. Nielsen S, Cameron J, Pahoki S. Over the counter codeine dependence. Melbourne: Turning Point Alcohol and Drug Centre, 2010. http://atdc.org.au/wp-content/uploads/2011/02/OTC_CODEINE_REPORT.pdf (accessed Aug 2015).
- 11. Carter B, Hawcutt DB, Arnott J. The restrictions to the use of codeine and dilemmas about safe alternatives. J Child Health Care 2013; 17: 335-337.
- 12. Karamatic R, Croese J, Roche E. Serious morbidity associated with misuse of over-the-counter codeine-ibuprofen analgesics. Med J Aust 2011; 195: 516. <MJA full text>
- 13. Evans C, Chalmers-Watson TA, Gearry RB. Combination NSAID-codeine preparations and gastrointestinal toxicity. N Z Med J 2010; 123: 92-93.
- 14. Frei MY, Neilsen 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. <MJA full text>
- 15. Clark R, Borirakchanyavat V, Davidson A, et al. Hepatic damage and death from overdose of paracetamol. Lancet 1973; 301: 66-70.
- 16. 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.
- 17. Bradford LD. CYP2D6 allele frequency in European Caucasians, Asians, Africans and their descendants. Pharmacogenomics. 2012; 3: 229-243.
- 18. Office for National Statistics. Deaths related to drug poisoning in England and Wales, 2012. London: ONS, 2013. http://www.ons.gov.uk/ons/dcp171778_320841.pdf (accessed Aug 2015).
- 19. Kelly LE, Rieder M, Van Den Anker J, et al. More codeine fatalities after tonsillectomy in North American children. Pediatrics 2012; 129: e1343-1346.
- 20. Pilgrim JL, Dobbin M, Drummer OH. Fatal misuse of codeine–ibuprofen analgesics in Victoria, Australia. Med J Aust 2013; 5: 329-331. <MJA full text>
- 21. Gerostamoulos J, Burke MP, Drummer OH. Involvement of codeine in drug-related deaths. Am J Forensic Med Pathol 1996; 17: 327-335.
- 22. New drugs. Aust Prescriber 2002; 25: 94-99.
- 23. Australian Register of Therapeutic Goods. Public summary: Panadeine extra tablet blister pack. 2013. https://www.ebs.tga.gov.au/servlet/xmlmillr6?dbid=ebs/PublicHTML/pdfStore.nsf&docid=101436&agid=%28PrintDetailsPublic%29&actionid=1 (accessed Aug 2015).
- 24. Mann JJ, Apter A, Bertolote J, et al. Suicide prevention strategies: a systematic review. JAMA 2005; 294: 2064-2074.
- 25. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med 2005; 6: 107-112.
- 26. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10: 113-130.
- 27. Department of Health and Human Services (USA). Addressing prescription drug abuse in the United States: current activities and future opportunities. Washington DC: Department of Health and Human Services, 2013. http://www.cdc.gov/drugoverdose/pdf/hhs_prescription_drug_abuse_report_09.2013.pdf (accessed Aug 2015).
- 28. Johnson EM, Porucznik CA, Anderson JW, Rolfs RT. State-level strategies for reducing prescription drug overdose deaths: Utah’s prescription safety program. Pain Med 2011; 12: S66-S72.
- 29. McCauley JL, Back SE, Brady KT. Pilot of a brief, web-based educational intervention targeting safe storage and disposal of prescription opioids. Addict Behav 2013; 38: 2230-2235.
- 30. National Coronial Information System. Data quality and limitations [website]. 2014. http://www.ncis.org.au/data-quality/data-limitations/ (accessed Apr 2015).
Publication of your online response is subject to the Medical Journal of Australia's editorial discretion. You will be notified by email within five working days should your response be accepted.