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Substance‐related disorders

Substance‐related disorders Letters 18 February 2019 Free

Unintended consequences of a cautious approach to e‐cigarette laws

To the Editor: The Australian Government's decision to uphold a restriction on Electronic Nicotine Delivery Systems (ENDS), or e‐cigarettes, is in keeping with its highly effective tobacco control framework. In its March 2017 ruling, the Therapeutic Goods Administration outlined the lack of long term safety data around ENDS and the emerging evidence suggesting that availability of these devices may be associated with an increase in cigarette smoking in young adults.1 While it remains illegal to sell ENDS products containing nicotine, an individual may import up to 3 months’ personal supply with a doctor's prescription.1 ENDS products are easily purchased online from overseas. Their attractive packaging and scent makes them appealing to children. As these products are not produced or licensed in Australia, there is no existing legislation around child‐safe packaging or labels warning of potential toxicity. The Centers for Disease Control and Prevention reported a rise in nicotine poisonings from one to 215 per month over a 5‐year period,2 the majority involving children aged under 5 years. Furthermore, a retrospective study of children aged under 6 years found that poisonings from liquid nicotine compared with traditional cigarettes were five times more likely to result in hospitalisation.3 Nicotine is both highly toxic and readily absorbable and, therefore, the potential for poisoning is high. Nicotine poisoning occurs through initial stimulation and ultimate blockade of the nicotinic acetylcholine receptor, resulting in hypotension, bradycardia and coma at high doses.4 The minimum potentially lethal dose of nicotine in humans is 60 mg.5 A review of e‐liquid products purchased online found the standard nicotine concentration to range between 0 and 36 mg/mL.6 Therefore, ingestion of even a small volume could cause serious harm or even death. We advocate for specific legislation to regulate the personal importation of these products. This legislation should include specific safety labelling highlighting the risks of poisoning in children and mandated supply in child‐proof packaging. Given the inherent difficulties in preventing and regulating the online trade of ENDS products, we strongly encourage the federal government to partner with organisations such as Quit Victoria to highlight the potential dangers of all imported nicotine products, whether they remain prohibited or not.

Christian Catalano · Noel E Cranswick · Jeff Robinson · Joanne Grindlay · Mick Creati · Margie H Danchin · Nicola Williams · Amanda Gwee

Letter to the Editor2
Environmental health Letters 21 May 2018 Free

Regulating e-cigarettes in Australia: implications for tobacco use by young people

To the Editor: I write to comment on the Perspective by Wolfenden and colleagues1 on e-cigarette use by young people. In the article, the authors make regulatory recommendations for e-cigarettes based on the assertion that vaping causes young people to take up smoking — the so-called gateway theory. However, while many studies have found that adolescents who try vaping are more likely to try smoking, there is no evidence of cause and effect. The longitudinal studies described only show an association and are unable to demonstrate causality.2 An alternative explanation is common liability; that is, that young people who are more attracted to experimentation are more likely to try both products. In fact, international reviews suggest that vaping is diverting adolescents away from smoking and reducing smoking rates.3 As vaping rates have been increasing in young people, smoking rates are rapidly declining — a finding inconsistent with a gateway effect. Real world studies show that most vaping by young people is experimental and short lived and only a minority use nicotine. Regular vaping among teens is almost exclusively confined to those who already smoke. A recent analysis of five national surveys in the United Kingdom of 60 000 adolescents found that regular vaping by never-smoking 11–16-year-olds was 0.1–0.5%.4 Perhaps most important of all, Wolfenden and colleagues1 dismiss the substantial public health benefit that could result from vaping. Population studies have indicated that millions of smokers have quit using e-cigarettes and modelling studies have found a substantial net public health benefit, even using pessimistic scenarios.5 Banning wider access to e-cigarettes on the basis of an unproven risk to adolescents would prevent access to a life-saving quitting aid for millions of smokers. A better solution is to employ strategies to minimise youth access and make vaping available for adult smokers who are otherwise unable to quit smoking with conventional therapies.

Colin P Mendelsohn

Environmental health Letters 21 May 2018 Free

Regulating e-cigarettes in Australia: implications for tobacco use by young people

To the Editor: Wolfenden and colleagues1 fail to justify the ban on the sale of nicotine-containing e-cigarettes in Australia and do not address the supporting arguments for allowing smokers to access these products.2,3 The concern that e-cigarettes may recruit young smokers justifies a regulatory response but not a ban on sales of nicotine-containing e-cigarettes to adults,3 who are thereby prevented from using these products. The authors cite a meta-analysis of studies that showed an association between the past 30-day use of e-cigarettes and combustible cigarettes;4 however, they ignore the weaknesses in the studies. First, most studies defined an adolescent e-cigarette user or cigarette smoker as one who had used either product in the past 30 days. These studies do not show that adolescents who used e-cigarettes were more likely to become daily smokers than their peers who did not use them. Second, the studies had substantial subject attrition (more than 30% in four out of nine studies) and they often poorly controlled for a shared liability to use drugs. The association was weakest in the largest and best controlled study.5 In addition, Wolfenden and colleagues make no mention of the steep decline in youth smoking rates that has occurred in both the United Kingdom and the United Sates while vaping has increased among young people.5,6 Nor do they mention that the UK’s smoking prevalence is now the same as Australia’s, in the absence of plain packaging or high tobacco tax.6 The authors’ claim that a relaxation of the ban on e-cigarette sales in Australia “has the potential for unintended harm” ignores the direct harms caused by the current ban; for example, the unregulated use of e-cigarettes, a black market, and the criminalisation of e-cigarettes users.6 Finally, even if the evidence for a gateway effect were accepted, it would, at most, justify a tighter regulation of e-cigarettes; it does not justify a prohibition on adult e-cigarette use. If it did, we would be morally obliged to prohibit the sale of cigarettes to smokers because on their argument this would be the most effective way of preventing adolescents from smoking cigarettes.

Wayne D Hall

Social determinants of health Editorial 5 March 2018 Free

Tobacco retail density: still the new frontier in tobacco control

Reducing the number of tobacco sellers would make it easier for smokers to quit After four decades of intense and innovative tobacco control policies and programs, Australian governments have achieved large reductions in population level smoking rates. The focus of this comprehensive approach has been to reduce consumer demand for tobacco products through high tobacco taxes, emotive mass media campaigns, graphic health warnings on packages, subsidised smoking cessation services and treatments, smoke-free public spaces, and bans on all forms of tobacco advertising.1 However, despite early calls for restrictions on the number and location of tobacco retail outlets,2 Australia is falling behind other jurisdictions in adopting polices that seek to limit the supply of tobacco products. In the United States, for example, both San Francisco and New York have adopted regulations that cap the number of tobacco retailers in each city district, responding to the high concentration of outlets in low income neighbourhoods. The disproportionate concentration of tobacco retailers in areas of greatest socio-economic disadvantage also exists in Australia, as highlighted in the report by Melody and her colleagues in this issue of the Journal.3 In Australia, however, no policies specifically aim to reduce the currently very high number of tobacco retailers. While no jurisdiction has yet to reduce outlet density sufficiently to assess the impact on smoking rates, there is strong evidence that having fewer retailers reduces the level of impulse purchasing of cigarettes. Canadian research found that one-third of smokers, especially younger smokers, would smoke less if they simply had to travel further to buy cigarettes.4 In an Australian study, the mere sight of tobacco retail outlets prompted impulse purchases, even in the absence of point-of-sale displays of tobacco products at the checkout counter.5 Continually resisting not only the urge to smoke but also to purchase cigarettes make it incredibly difficult for smokers to quit. Tobacco control policies that make it easier and also prevent relapse are critical for reducing the more than 18 000 deaths caused by smoking in Australia each year.6 Not only are tobacco retailers more numerous in low income neighbourhoods, tobacco retailers in disadvantaged areas are also less likely to comply with regulations regarding the retail display, sale, and promotion of tobacco in stores.7 Populations at greatest risk of taking up smoking, continuing to smoke, and suffering from the health effects of smoking are therefore not only exposed to more retailers, but are also afforded the least protection by tobacco control laws. Reducing the number of tobacco outlets could be achieved by several complementary policy options. The introduction of a substantive annual tobacco licensing fee in South Australia led to an almost 25% decrease in the number of retailers in that state.8 This is in sharp contrast to New South Wales, where very few tobacco retailers stopped selling after a no-fee tobacco retailer notification scheme was introduced.9 As would-be ex-smokers report frequent relapsing when they consume alcohol, banning tobacco sales in licensed premises would both reduce the number of tobacco outlets and support quitting smokers where they are most vulnerable.5 Such a move is unlikely to encounter substantial resistance, as tobacco sales appear to be of limited financial importance to bars and clubs.10 Other options include permanently banning retailers from selling tobacco if they have been convicted of selling to underage smokers, and offering incentives that encourage retailers to stop selling tobacco, such as a subsidised program to help them sell more fresh fruit and vegetables. In 2009, tobacco outlet density was described as the “new frontier for tobacco control.”11 Nearly 10 years later, Australia — in so many ways a leader in tobacco control — has yet to develop policies for reducing its high density of tobacco outlets. It is essential to challenge the existing retail sales environment, which sees tobacco sold ubiquitously alongside everyday household items. Framing tobacco retail policies as assisting former smokers to remain abstinent is entirely in line with the highly successful approaches Australia already employs to reduce the heath burden of tobacco use. Limiting the number of outlets that sell tobacco products, reducing the concentration of outlets, especially in disadvantaged areas, and limiting which outlets can legitimately sell tobacco products must be priority policy goals. It is time for Australia to break through the tobacco retail frontier and lead the way in regulating the supply of tobacco products.

Becky Freeman · Suzan Burton

17 01239
Substance‐related disorders Systematic review 12 February 2018 Free

Identifying and treating codeine dependence: a systematic review

Objectives: Codeine dependence is a significant public health problem, motivating the recent rescheduling of codeine in Australia (1 February 2018). To provide information for informing clinical responses, we undertook a systematic review of what is known about identifying and treating codeine dependence. Study design: Articles published in English that described people who were codeine-dependent or a clinical approach to treating people who were codeine-dependent, without restriction on year of publication, were reviewed. Articles not including empirical data were excluded. One researcher screened each abstract; two researchers independently reviewed full text articles. Study quality was assessed, and data were extracted with standardised tools. Data sources: MEDLINE and EMBASE were searched for relevant publications on 22 November 2016. The reference lists of eligible studies were searched to identify further relevant publications. 2150 articles were initially identified, of which 41 were eligible for inclusion in our analysis. Data synthesis: Studies consistently reported specific characteristics associated with codeine dependence, including mental health comorbidity and escalation of codeine use attributed to psychiatric problems. Case reports and series described codeine dependence masked by complications associated with overusing simple analgesics and delayed detection. Ten studies described the treatment of codeine dependence. Three reports identified a role for behavioural therapy; the efficacy of CYP inhibitors in a small open label trial was not confirmed in a randomised controlled trial; four case series/chart reviews described opioid agonist therapy and medicated inpatient withdrawal; two qualitative studies identified barriers related to perceptions of codeine-dependent people and treatment providers, and confirmed positive perceptions and treatment outcomes achieved with opioid agonist treatments. Conclusion: Strategies for identifying problematic codeine use are needed. Identifying codeine dependence in clinical settings is often delayed, contributing to serious morbidity. Commonly described approaches for managing codeine dependence include opioid taper, opioid agonist treatment, and psychological therapies. These approaches are consistent with published evidence for pharmaceutical opioid dependence treatment and with broader frameworks for treating opioid dependence. PROSPERO registration: CRD42016052129.

Suzanne Nielsen · Tim MacDonald · Jacinta L Johnson

17 00749
Substance‐related disorders Letters 15 January 2018 Free

Caution with the forthcoming rescheduling of over-the-counter codeine-containing analgesics

To the Editor: After extensive public consultation, the Therapeutic Goods Administration announced that all over-the-counter codeine preparations, including over-the-counter codeine-containing analgesics (OTC CCAs) will be rescheduled as prescription only in February 2018, citing the substantial risk of drug toxicity from deliberate misuse and the relative lack of efficacy compared with safer products. Codeine is a weak analgesic — even at doses of 60 mg — and the Australian Medicines Handbook notes that “there is no conclusive evidence that products containing 8–15 mg of codeine per tablet with paracetamol, aspirin or ibuprofen have any benefits over these non-opioids alone”.1 Misuse and harm are widespread, with people who are addicted to codeine taking 40 or more tablets a day. In 2016, more than 500 000 Australians aged 14 years or over used OTC CCAs non-medically. Despite more restrictive scheduling in 2010, a Poisons Information Centre described a 17.9% annual increase from 2004–2015 in calls concerning the misuse of ibuprofen–codeine analgesics.2 Moreover, drug clinics describe a 10-year four-fold increase in treatments where codeine was a drug of concern (Box). Prolonged high-dose ibuprofen exposure secondary to codeine addiction may cause bleeding or perforated gastric ulcers; non-steroidal anti-inflammatory drug-induced enteropathy, with diaphragm disease and bowel obstruction; anaemia; protein-losing enteropathy; hypoalbuminaemia; renal tubular acidosis and death. Medical practitioners should consider OTC CCA misuse in patients presenting with non-steroidal anti-inflammatory drug-related or paracetamol-related morbidity, as many patients do not disclose their misuse, therefore creating a failure to recognise the underlying cause of the presenting complaint.4 Apart from the human cost of serious injury and loss of life, there is also the cost of treatment for dependence; the cost of hundreds of hospital admissions, involving avoidable surgery, intensive care and serious morbidity;4,5 and the statistical cost of lives lost.6 Practitioners need to prepare for the forthcoming rescheduling to avoid substituting OTC CCAs with either prescription opioid analgesics or prescribing a codeine–paracetamol product, which may cause paracetamol hepatotoxicity. In addition, practitioners should treat codeine dependence by referral, opioid replacement therapy or medicated withdrawal with follow-up. The unfavourable risk–benefit profile for OTC CCAs means that the planned Australian rescheduling aligns with many other countries to minimise harm. Access to effective analgesics without a prescription is now provided by products with the non-addictive ibuprofen–paracetamol combination, which offer better analgesia than OTC CCAs.7 Box – Treatments provided for own drug use, by principal and additional drug of concern (codeine), from 2003–04 to 2013–143

Stephan A Schug · Malcolm DH Dobbin · Jennifer L Pilgrim

Letter to the Editor1
Anaesthetics Letters 17 July 2017 Free

Wastewater analysis shows a large decrease in oxycodone use in Adelaide

To the Editor: In Adelaide, which comprises 78% of the population of South Australia, municipal wastewater has been subject to bimonthly analysis since 2009 to measure trends in substance use. Beginning in October 2015, there was a precipitous decrease in the detection of oxycodone residues in wastewater samples (Box). This decrease was counter to the long term trend of increasing amounts of this opioid in previous samples. Prescribing data show a continuing increase in the use of prescription opioid analgesics (POAs), including oxycodone, nationally and in SA, during the period between 1992 and 2011.1 There is a strong relationship between the amount of POAs used in a community and the amount of harm from opioid dependence and overdose.1 The cause of this regional trend change in oxycodone use has not been established. On 1 July 2015, there were some significant changes in the regulation of work injuries in SA which led to a decrease in the number of complex long term claimants, and there was also a similar change in South Australian motor vehicle injury regulation in July 2013. Complex injury claims are strongly correlated with POA use;2 however, the role of these factors is highly speculative and there may be many other factors that contributed to the results. The methods used for the bimonthly wastewater analysis in Adelaide have been published before,3 and another group used this process to report changes in population methamphetamine use in Queensland.4 From October 2015, there was a change in the established temporal trend for oxycodone residues detected in Adelaide wastewater (Box). However, over the same period, there is no such trend change for national Pharmaceutical Benefits Scheme (PBS) and Repatriation PBS data for the number of oxycodone prescriptions dispensed (not total doses),5 or for Adelaide wastewater residues of methadone, which is predominantly dispensed for treatment of severe opioid use disorders via a specific program. A limitation of our investigations was that no regional oxycodone prescription or wastewater data from other jurisdictions were available for comparison. Nonetheless, our findings suggest that wastewater analysis could potentially be used to rapidly monitor changes in substance use on a regional basis. Box – Oxycodone and methadone residue in Adelaide wastewater compared with national data for the total number of oxycodone prescriptions supplied, December 2011 – February 20175 PBS = Pharmaceutical Benefits Scheme. RPBS = Repatriation Pharmaceutical Benefits Scheme.

Philip Crowley · Jason M White · Benjamin J Tscharke · Cobus Gerber

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