Respectable Addicts? Identity and Over-the-Counter Medicine Abuse

1
Respectable Addicts? Identity and
Over-the-Counter Medicine Abuse
Richard CooperLecturer in Public HealthScHARR,
University of Sheffield
2
Overview

• Brief background to OTC medicines
• Review of OTC abuse literature/evidence
• Describe a qualitative study involving those
  affected
• Describe findings
• Argue the respectable addict represents a tension
  in three rival areas
• Identify emergent issues/problems
• Conclusions

3
Background and evidence
4
OTC medicine background

• The availability of medicines to buy OTC offers
  customers ease of access to, and choice of,
  medicines.
• Offers opportunity for customers to self-medicate
  and be active participants in their own health.
• Wide range of medicines available.
• P category available from pharmacies only
• GSL category available from any retail outlet.
• Trend in increasing de-regulation of POMs has led
  to more choice.
• Internet availability also increasing (e-Pharmacy)

5
OTC Abuse Literature

• Typology based on agency/predicament apparent
  but confusion over terminology
  addiction/dependency rare
• Misuse (wrong dose or indication, unintentional)
• Abuse (deliberately exploiting side effects,
  experimentation)
• Substitution (to replace illicit drug use)1

6
OTC Abuse Literature

• Typology based on agency/predicament apparent
  but confusion over terminology
  addiction/dependency rare
• Misuse (wrong dose or indication, unintentional)
• Abuse (deliberately exploiting side effects,
  experimentation)
• Substitution (to replace illicit drug use)1
• Variation in OTC medicines implicated in abuse
  internationally by availability and customer
  preferences.

5 key groups of medicines implicated
Codeine containing compound analgesics Solpadeine, Nurofen Plus
Cough products (dextromethorphan)
Laxatives
Decongestants Sudafed
Antihistamines (sedative) Nytol, Actifed, Night Nurse, Phenergan,
7
OTC Abuse Literature

• Relatively little empirical research into OTC
  abuse.
• No evaluation of treatment.
• No clear patterns as to those affected.

Scale of Issue/Demographics
Two thirds of UK pharmacists have reported abuse/misuse.2,3,4
Third of NI general public reported encountering OTC abuse.5
4 of US teenagers abusing OTC products.
21.4 million packs of codeine-containing OTC meds sold 2008.
A problem associated with middle-aged females? 6
Just over 200 clients with OTC opiate problems in formal treatment (0.25 of all clients). Over half exit treatment drug-free. 6
15,000 web support users. 7
8
OTC Abuse Literature

• Addiction (codeine)
• Euphoria (dextromethorphan)
• Risk of other abuse (e.g. alcohol, illicit drugs)
• Electrolyte imbalance (laxatives)
• Convulsions/acidosis (chlorphenamine)

• Economic cost
• Accidents
• Adverse effect on jobs and relationships

Primary Medicine of abuse

• Gastro-intestinal irritation, haemorrhage , death
  (ibuprofen)
• Rebound headaches (paracetamol and ibuprofen)
• Hypokalaemia/acidosis (ibuprofen)

Additional Ingredient
SOCIAL OTHER
PHYSIOLOGICAL
9
OTC Abuse Responses

• Some evidence of attempts to manage/reduce
  abuse
• Pharmacy-based (hide products, refuse sales,
  record sales)
• Harm-reduction intervention pilot GP referral
• Proposed contract/reduction scheme in pharmacies?

10
OTC Abuse Responses

• Some evidence of attempts to manage/reduce
  abuse
• Pharmacy-based (hide products, refuse sales,
  record sales,)
• Harm-reduction intervention pilot GP referral
• Proposed contract/reduction scheme in pharmacies?

• Revised advice on OTC codeine sales 2009
• 100 packs of co-codamol soluble now POM
• Indications only for pain (not cold, flu)
• Front box warning Can cause addiction. For
  three days use only.
• Similar changes in Australia

11
OTC Abuse Responses

• Some evidence of attempts to manage/reduce
  abuse
• Pharmacy-based (hide products, refuse sales,
  record sales,)
• Harm-reduction intervention pilot GP referral
• Proposed contract/reduction scheme in pharmacies?

• Revised advice on OTC codeine sales 2009
• 100 packs of co-codamol soluble now POM
• Indications only for pain (not cold, flu)
• Front box warning Can cause addiction. For
  three days use only.
• Similar changes in Australia

• Year long APPDMG8 reported in 2009
• Training for doctors, nurses and AHPs
• Increased awareness of problem
• Recognition/support for on-line help
• Information for patients about risks

12
Qualitative Study
13
Methods
Semi-structured, qualitative telephone interviews
with 16 key stakeholders of organisations with
interests in OTC medicines
Stage 1
Semi-structured, qualitative face to face/phone
interviews with quota sample of 10 pharmacists
and 7 MCAs from community pharmacies in UK
Stage 2
Semi-structured, qualitative telephone interviews
with 25 individuals who have/had experience of
OTC medicine abuse/misuse. Recorded/transcribed,
1hr. Recruitment via postings on 2 internet
forums helping those with OTC medicine problems
CodeineFree and Overcount
Stage 3
14
Semi-structured, qualitative telephone interviews
with 25 individuals who have/had experience of
OTC medicine abuse/misuse. Recorded/transcribed,
1hr. Recruitment via postings on 2 internet
forums helping those with OTC medicine problems
CodeineFree and Overcount
Stage 3
15
age Employment status Medicine(s) involved Doses Current use? Treatment/support
M 40s Unemployed Paramol Sudafedalcohol Up to 36/day either 1616 or 121212 III No GP, DAT, (methadone), Overcount
M DND Professional Co-codamol, then Syndol Up to 8 per day I Yes GP, CFM
M 30s Professional Co-codamol 12-14/day III Yes CFM
M 30s Professional self-employed Nurofen Plus prev. non-opiate illicit Max of 60 tablets/ day III No GP, DAT (Buprenorphine) CFM
F Former health prfn Solpadeine Up to 8/day I No CFM
F Co-codamol sol Rx co-codamol Up to 16/day (max 4/dose) III No CFM
F Healthcare profnl Nurofen Plus 32/day (max 64/day) III No CFM buprenorphine
F 30s Uni student Feminax then Cuprofen Plus prev. alcohol 36/day III Yes CFM
F 40s professional Nurofen Plus 24/day III No CFM
F 20s Professional Co-codamol prescribed Up to 8/day I No CFM
F Professional Co-codamol prescribed up to 16/day occ. prescribed II Yes GP,
M 50s Retired Professional Nurofen Plus prescribed codeine 10/day Nurofen plus MDD codeine III No Overcount
M 60s Professional Solpadeine soluble Up to 10/day II No Private treatment
M Professional Phensedyl 90 bottles/week III No GP, DAT
M Professional Panadol Ultra then Nurofen Plus 15-20 of each III No GP
M Solpadeine 4/day I No Overcount
M Self-employed Nurofen Plus 10/day II Yes CFM, DAT, GP
F Solpadeine Up to 8/day I Yes Overcount
F Syndol Up to 8/day I Yes CFM, GP
M Former health care professional Codiene linctus, Gees linctus,stolen DHC Varied but much above max daily dose. III No CFM DAT (methadone)
M 60s Retired professional Phensedyl, Actifed, Codeine linc, diverted Rx codeine 200ml codeine linctus/day III no CFMGPDAT-methadone
F 30s Professional Syndol nytol Syndol 12/day II Yes Overcount
F 50s Professional Feminax, then Veganin 6-10/day. Max12/day II Yes Overcount GP Drug Action
16
(No Transcript)
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Initial use

• All but two described initially using a product
  for a medical condition (migraine, periods, ME,
  injury, gynae)
• Use continued to avoid withdrawal (headache,
  tremor, palpitations) or for other effect (buzz,
  calming, sedative).
• Medicines were all codeine/DHC (Nurofen Plus,
  Co-codamol, linctus) but some pseudoephedrine,
  and sedative antihistamines

Physical pain doesnt really bother me that much
unless it interferes with something I am doing.
So I was much more interested in the
psychological effects ... My ongoing anxiety.
Jack
There was a medical condition involved. I was
in hospital, came out of hospital and was given
co-codomol or something at the time for the pain.
That ended and the next thing I am downing
Nurofen Plus. Karen
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Link between Rx and OTC
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3 Types of Abuse

• Words addict or addiction specifically used
  by participants.
• Drug seeking behaviours loss of control over
  self/consumption, rituals of specific brands,
  planned pharmacy routes, covert ( hidden to work,
  but not some friends/family)
• Harms varied perceived withdrawal/anxiety at
  lower doses, GI problems dependency/withdrawal,
  criminal acts, job/relationship issues at higher

...Ive never taken more than six a day,
never gone over that Never escalated because
I think I was too scared of going beyond that
I dont think I realised there was codeine in it
at all Aylsa (Nurofen Plus)
the next thing I am downing Nurofen Plus.
It started off probably taking the normal doses
and the next thing ... I am taking twenty four
tablets a day. Karen
Well, I mean I suppose on a really bad day and
this hasnt happened recently, but on a really
bad day, I suppose I could take sixteen So I
would just knock back four at a time. Because
that would give me that, as I say, its not a
high. Literally, I zone out. Rachel
(co-codamol 8/500 tablets)
I would take eight in one day. But then of
course in increasing amounts. Till the point
came that I was taking thirty two a day. Even on
really bad days, I would take a second lot of
thirty two. Theresa
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Treatment and support

• Range of support identified with varying success
  and perceptions.
• Formal GP/DAAT help resisted by some for fear of
  recording problem.
• Pharmacy involvement neutral easy to bypass
  questions.
• On-line support offered confirmation/self-treatmen
  t but engagement low

I went to my doctors and I would either try my
best, you know, with the prescribed
dihydrocodeine but it er came to a point where it
was beyond, you know, it needed a specialist to
help. Malcolm
my own private GP he just laughed and
said, dont be so stupid, stop taking them. On
the other hand, what is he supposed to say?
Richard
As soon as I walked in there DAAT , you could
see the other people who come there have got
serious drug and alcohol problems and I stick out
like a sore thumb. Theresa
I have mentioned it to the doctor and he sort
of said, well its something you handle
yourself. At this sort of level, if you know
what I mean?Dwain
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Identity Claims
Personal
All opioids Alcohol?
Managing appearances
Hidden Family
Social
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Addict Identity

• Addict or addiction mentioned by all
  participants.
• Variety of drug seeking behaviours described
• Withdrawal experienced
• Loss of control over self/consumption
• Rituals of specific brands
• Elaborate and methodical routes to visit
  pharmacies to avoid detection
• Covert, hidden activity (work, public but
  some used friends, family).
• Shame identified by some in deceiving, hiding
  addiction.
• On-line forums used to confirm (validate?)
  addict status.

Yeah I am an addict, no doubt about it. As much
as a heroin addict, yeah. Shameful and it
makes you feel dirty and guilty, but I was an
addict, yeah. Yvette
I also never hoarded it. It was part of the
ritual for me to go out and have to find it every
day. Theresa
I do think we are all stupid quite honestly. I
think I am stupid. I cant believe that I have
done this to myself. You know I find it really
hard to understand. Karen
... my wife is, in fact in many ways, keeping
an eye on me in that sense. Shell say, ooh, you
having that again, are you? ... actually at
one point I started writing on when I bought the
packet. Graham
The web site gives me the ability to anonymise
myself. To experience and participate without it
actually being physically me. I think where I am
at right now is I need to own up who I am which
probably wouldnt mean Id take part online, but
it would I think part of my process. John
23
Not like other addicts but
If I went to any other pharmacies in town,
nobody would even bat an eyelid ... And I think
as well if I was to go in and look like their
stereotypical addict, they may go, Oh well, you
know and call the pharmacist over. But I
dont. I look like your normal middle aged
woman. Rachel

• Frequent attempts to distinguish themselves from
  other types of addicts, esp. those more
  chaotic/socially unacceptable.
• However, recognition that there were common
  features, either in the
• Pharmacology of substance e.g. codeine as
  opioid
• Dependency symptoms withdrawal, dose
• Some participants had co-dependencies and viewed
  OTC abuse in same way as previous/current alcohol
  use, illicit substance use.
• DAAT services re-enforced difference.

I think in society its a negative stereotype,
because you think of addicts and you think of
drink, drugs, heroin, cocaine, you know needles
and all those sorts of things But my
understanding of an addict is somebody who cannot
get through the day without what it is they are
addicted to. I cant get through the day
without taking codeine. Rachel
I could not function without codeine just
because you can buy it legally in the
chemists, does not mean that it is any
different from heroin. Thats just a social
concept isnt it, you know, no difference.
Yvette
As soon as I walked in there, you could see the
other people who come there have got serious drug
and alcohol problems and I stick out like a sore
thumb. Its painfully obvious people look at me
and think what on earth is somebody like her
doing in a place like this. Because I dont
have a can of Heineken in my hand or tram marks
up my arm or stand outside smoking Theresa
24
Professional identity
there are lots of people out there like me,
that are intelligent professionals ... I dont
know where we can go for support without putting
ourselves at risk. Theresa I am a nurse so
know what damage I was doing and still couldnt
stop and even when I got ill and had this huge
gastric bleed, I still cant believe that as an
intelligent woman.

• Frequent discourse of claims relating to
  occupational or social status.
• Used to distinguish them and their situation from
  other forms of addiction.
• Attempts to assert knowledge
• About pharmacology
• Medicine doses/active ingredients
• Addiction is atypical for some, as a loss of
  control set against dominant control over their
  (successful) lives.
• For some, NHS/GP involvement actively resisted to
  avoid addiction being recorded a career threat.
  

Oh my god, I hated it if I went away - and I go
to America quite a bit, you know. Well you are
not going to get them in America and thats when
you have got to go around thirteen pharmacies and
find twenty packets to take with you. Yvette
Addicts are people on the street who havent got
a job I am sat here in a suit in an office, my
own office with a very good career, senior
manager within a very large organisation I
cant be an addict. I am. John
You know, should something different arise later
that I need to get back to the doctor for but I
have this mark from previous on my record, it
affects what I need later on. Jack
25
Discussion
26
Discussion questions

• Is the respectable addict a viable category?
  Linked to Reiths9 claim that addiction
  originated as a middle class concern about
  control (cf productivity in working classes)?
• Or is there a danger, after Hacking10, of making
  up people and spreading even further the web of
  addictive types?
• A moral concern about legitimate use and deviant
  abuse?
• Is a lesser category of pseudoaddiction11 needed
  for some, to reflect inadequate pain relief?
• What influence do on-line support groups have?
  For some (McIntosh McKeganey)12, recovery
  narratives/identity are constructed by treatment.
• But...self-help group identity absent for many
  (passive).

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Conclusions

• OTC medicine abuse occurs, often with links to
  medical treatment and range of medicine use and
  associated harms.
• Emergence of Respectable addict identity
  reflects hidden nature of problem and with
  implications for treatment.
• Variable engagement with, and benefit from,
  formal services (GP, DAAT, pharmacy).
• Qualitative study limitations recruitment
  through websites, self-selecting participants,
  not able to capture.

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Funded by the Pharmacy Practice Research Trust
Richard CooperLecturer in Public HealthScHARR,
University of Sheffield Richard.cooper_at_sheffield.a
c.uk