In many countries around the world, codeine is available only on prescription. It’s a weak opioid, but can still cause addiction. Low dose codeine is also available in the UK, over-the-counter (OTC) in pharmacies. It’s sold in combination with paracetamol (co-codamol, e.g. Solpadol), in combination with ibuprofen (e.g. Nurofen Plus), and in combination with dihydrocodeine (co-dydramol, e.g. Paramol). Other OTC drugs have the capacity to be addictive and one issue is that all of these drugs have a veneer of ‘safety’ because they are so freely available. Fatalities, mostly from the non-codeine components, led to labelling changes in the UK a few years back.
Most folk use these combination painkillers in the short term with few problems (though there is pretty weak evidence for the analgesic effect of codeine at such low doses). Some folk become dependent on codeine and, because of tolerance, need to escalate the dose to get the same effect. Problems arise when you start to multiply the dose of the non-codeine component of the drug. Ibuprofen in higher doses is bad news for kidneys and tummies, paracetamol for livers.
Over the counter drug addiction is not a benign problem. Bleeding from the stomach can occur, as can kidney failure, liver failure and indeed if things are bad enough, multi-organ failure and death. The nature of addiction is that some folk suffer these consequences, go through a hospital admission, get well and then relapse on discharge.
Studying OTC addiction
The demographic of those who get addicted to OTC analgesics is often different from ‘typical’ clients seen in addiction services. Richard Cooper published a nice study in the British Medical Journal in 2013 and made the point that those who get addicted to OTC drugs are ‘hard to reach’.
Using internet discussion forums as a recruiting ground, he interviewed 25 adults to get a feel for their experiences and views.
Enrolling this small number of people took 18 months, which tells us something about how ‘hidden’ this group might be.
Three themes emerged:
- Initial use of the medicine, often linked to a genuine problem
- Gradual awareness of problems emerging
- Attempts to seek treatment and help
But there was more:
However, spanning these themes was also a dominant concern relating to the hidden nature of OTC medicine addiction and of participant’s presentation of themselves as being normal and distinct from those with other, illicit addictions.
All had a problem with an opiate (mostly codeine), but there were also problems with pseudoephedrine and sedative antihistamines.
- It was unproblematic to source the supply of OTC drugs
- Many did a tour of different pharmacies and held lists of them
- Some pharmacists confronted patients which could result in anger or sometimes in a ‘wakeup call’
- Mechanisms to prevent abuse ‘could be easily circumvented’
- Many accepted they were addicted or called themselves ‘addicts’
- People expressed disbelief that addiction ‘could have happened to them’ and thought that professional or educational background meant they ‘should have known better’.
- OTC dependent people want to keep their addiction hidden from family and colleagues.
There were some interesting rationalisations in the group. They didn’t want to identify with other ‘addicts’ who they ‘viewed more negatively in both a behavioural and visual sense’. This hierarchy of addiction is interesting and of course a way of people staying stuck. I think we generally call this stereotyping and stigma, which of course can also be seen in traditional treatment settings.
GPs were viewed as both helpful and unhelpful. Participants were concerned about anonymity and information being recorded in their notes. All of the participants were recruited from internet support groups, so this forum was seen as helpful in all cases. Interestingly mainstream treatment services were seen as not appropriate. OTC addicts did not want to sit with ‘other addicts’ and felt staff were inexperienced or viewed their problems as lesser. Pharmacists were not mentioned as a source of support. Self-treatment was also not found to be particularly effective. Overall I got a feeling of having to keep the whole thing secret, as if it was a terribly shameful thing; the addiction that cannot speak its name.
The fact that those having problems with OTC medication felt that they couldn’t get what they needed from mainstream addiction services is disappointing and services will want to reflect on what they need to do differently to offer help. I did wonder a few times when reading this paper if such forums might cause collusion over stigma, a sense of ‘otherness’ and keep people a bit stuck. If we have different ‘classes’ of addicts, we risk further marginalising the most vulnerable. One of the great things about mutual aid groups is the level playing field. On the other hand, getting mutual support in an online forum is clearly a good thing.
The idea that intelligence is a defence against addiction is an interesting one. It’s not confined to this group of course, but it does tend to buy into the idea that you’ve only got yourself to blame – you’re just not smart enough.
Three ‘tensions’ were identified:
On over-identification of addiction:
A…tension arises in the influence of the internet support groups; while being viewed positively overall and offering important support and treatment advice, this study suggests that they may contribute to a perception in some individuals that they are addicted, even at low doses. This potential widening of the types of addiction in society is an increasing concern and one which may also threaten the previous aim of raising awareness among doctors, since this may suggest a wider range of affected patients than might actually require identification and referral for treatment.
On feeling different:
A tension also arises in participants’ perception that they are different from those with other addictions and that treatments are not appropriate, and trying to reconcile this with participants’ insight that they have a problem and that existing treatments appear to be effective in some cases.
Between the devil and…
A final tension centres on making OTC medicines of potential abuse available to the public—which almost all participants supported—while recognising the potential harms for some individuals. This confirms the importance of choice and recognition moreover of a person who ‘wants autonomy and freedom to choose such medicines’.
So it’s difficult for pharmaceutical companies and legislators to get the balance right here. Most folk will use these drugs without problems, but vulnerable people may come unstuck.
And what about recovery?
Once again in an otherwise illuminating and helpful paper (this time about OTC addiction), recovery is missing. It’s not mentioned. Not as a word or a concept, never mind a solution. Folk with OTC drug dependence can have serious consequences. Families can be torn apart by this sort of dependency. Surely they deserve connections to recovery resources and to know that recovery is possible. To be fair, this was a qualitative study focussing on what the participant’s views were, so it possibly wasn’t on the radar. It would have been nice to know if they knew anything about it though.
Cooper, R. (2013). ‘I can’t be an addict. I am.’ Over-the-counter medicine abuse: a qualitative study BMJ Open, 3 (6) DOI: 10.1136/bmjopen-2013-002913