Bad medicine: co-codamol

Codeine Addiction and Internet Forum Use and Support: Qualitative Netnographic Study

BACKGROUND

The use of codeine as an analgesic is well-recognized, but there are increasing concerns that for some individuals continued use may lead to misuse, dependence, and fatalities. Research suggests that those affected may represent a hard-to-reach group who do not engage with formal treatment services.

OBJECTIVE

This study sought to explore the experiences of people with self-reported addiction to codeine and, specifically, how a social media forum is used to communicate with others about this issue.

METHODS

Using a qualitative netnographic methodology, the social media forum Mumsnet was used, with permission, and searches were undertaken in 2016 of any posts that related to codeine and addiction. A total of 95 relevant posts were identified; a purposive sample of 25 posts was selected to undertake subsequent six-stage thematic analysis and development of emerging themes. These 25 posts were posted between 2003 and 2016 and comprised 757 individual posts.

RESULTS

Individuals created posts to actively request help in relation to usually their own, but occasionally their partner's or relative's, problems relating to codeine use and self-reported "addiction." Varying levels of detail were provided in narratives of problematic codeine use. There were both positive and negative descriptions of side effects emerging, problems experiencing withdrawal, and failed attempts to discontinue codeine use. Mainly positive and supportive responses to posts were identified from those with either self-reported health profession experience or lay respondents, who often drew on their own experiences of similar problems. Treatment advice emerged in two main ways, either as signposting to formal health services or to informal approaches and often anecdotal advice about how to taper or use cold turkey techniques. Some posts were more critical of the original poster, and arguments and challenges to advice were not uncommon. Shame and stigma were often associated with users' posts and, while there was a desire to receive support and treatment advice in this forum, users often wanted to keep their codeine use hidden in other aspects of their lives. Distinctly different views emerged as to whether responsibility lay with prescribers or patients. Some users expressed anger toward doctors and their prescribing practices.

CONCLUSIONS

This study provides a unique insight into how a public internet forum is used by individuals to confirm and seek support about problematic codeine use and of the ways others respond. The pseudonymous use of internet forums for such information and variation in treatment options suggested by often lay respondents suggest that increased formal support and awareness about codeine addiction are needed. There may be opportunities for providing further support directly on such online forums. Improvements in prescribing codeine and in the over-the-counter supply of codeine are required to prevent problematic use from occurring.

From pain treatment to opioid dependence: a qualitative study of the environmental influence on codeine use in UK adults

OBJECTIVES

To investigate the views and experiences of people who use codeine in order to describe the 'risk environment' capable of producing and reducing harm.

DESIGN

This was a qualitative interview study. Psychological dependence on codeine was measured using the Severity of Dependence Scale. A cut-off score of 5 or higher indicates probable codeine dependence.

SETTING

Participants were recruited from an online survey and one residential rehabilitation service.

PARTICIPANTS

16 adults (13 women and 3 men) from the UK who had used codeine in the last 12 months other than as directed or as indicated. All participants began using codeine to treat physical pain. Mean age was 32.7 years (SD=10.1) and mean period of codeine use was 9.1 years (SD=7.6).

RESULTS

Participants' experiences indicated that they became dependent on codeine as a result of various environmental factors present in a risk environment. Supporting environments to reduce risk included: medicine review of repeat prescribing of codeine, well-managed dose tapering to reduce codeine consumption, support from social structures in form of friends and online and access to addiction treatment. Environments capable of producing harm included: unsupervised and long-term codeine prescribing, poor access to non-pharmacological pain treatments, barriers to provision of risk education of codeine related harm and breakdown in structures to reduce the use of over the counter codeine other than as indicated.

CONCLUSION

The study identified microenvironments and macroenvironments capable of producing dependence on codeine, including repeat prescribing and unsupervised use over a longer time period. The economic environment was important in its influence on the available resources for holistic pain therapy in primary care in order to offer alternative treatments to codeine. Overall, the goal is to create an environment that reduces risk of harm by promoting safe use of codeine for treatment of pain, while providing effective care for those developing withdrawal and dependence.

Codeine use, dependence and help-seeking behaviour in the UK and Ireland: an online cross-sectional survey

BACKGROUND

Codeine misuse and dependence poses a clinical and public health challenge. However, little is known about dependence and treatment needs in the UK and Ireland.

AIM

To characterize codeine use, dependence and help-seeking behaviour.

DESIGN

An online cross-sectional survey advertised on Facebook, Twitter, health and drug websites and e-mail circulars.

METHODS

The survey collected data on demographics and codeine use amongst adults from the UK and Ireland. The Severity of Dependence Scale measured the level of codeine dependence.

RESULTS

The sample of 316 respondents had a mean age of 35.3 years (SD = 12.3) and 67% were women. Of the 316 respondents, 54 scored ≥5 on the Severity of Dependence Scale indicating codeine dependence (17.1%). Our study found that codeine dependence is a problem with both prescribed and 'over-the-counter' codeine. Codeine dependence was associated with daily use of codeine, faking or exaggerating symptoms to get a prescription for codeine and 'pharmacy shopping' ( P < 0.01). A higher number of respondents had sought advice on the Internet (12%) rather than from their general medical practitioner (GP) (5.4%). Less than 1% of respondents had sought advice from a pharmacist.

CONCLUSIONS

Codeine dependent users were more likely to seek help on the Internet to control their use of codeine than from a GP, which may indicate a potential for greater specialized addiction treatment demand through increased identification and referrals in primary care.

Prescribed opioids in primary care: cross-sectional and longitudinal analyses of influence of patient and practice characteristics

OBJECTIVES

To examine trends in opioid prescribing in primary care, identify patient and general practice characteristics associated with long-term and stronger opioid prescribing, and identify associations with changes in opioid prescribing.

DESIGN

Trend, cross-sectional and longitudinal analyses of routinely recorded patient data.

SETTING

111 primary care practices in Leeds and Bradford, UK.

PARTICIPANTS

We observed 471 828 patient-years in which all patients represented had at least 1 opioid prescription between April 2005 and March 2012. A cross-sectional analysis included 99 847 patients prescribed opioids between April 2011 and March 2012. A longitudinal analysis included 49 065 patient-years between April 2008 and March 2012. We excluded patients with cancer or treated for substance misuse.

MAIN OUTCOME MEASURES

Long-term opioid prescribing (4 or more prescriptions within 12 months), stronger opioid prescribing and stepping up to or down from stronger opioids.

RESULTS

Opioid prescribing in the adult population almost doubled for weaker opioids over 2005-2012 and rose over sixfold for stronger opioids. There was marked variation among general practices in the odds of patients stepping up to stronger opioids compared with those not stepping up (range 0.31-3.36), unexplained by practice-level variables. Stepping up to stronger opioids was most strongly associated with being underweight (adjusted OR 3.26, 1.49 to 7.17), increasing polypharmacy (4.15, 3.26 to 5.29 for 10 or more repeat prescriptions), increasing numbers of primary care appointments (3.04, 2.48 to 3.73 for over 12 appointments in the year) and referrals to specialist pain services (5.17, 4.37 to 6.12). Compared with women under 50 years, men under 50 were less likely to step down once prescribed stronger opioids (0.53, 0.37 to 0.75).

CONCLUSIONS

While clinicians should be alert to patients at risk of escalated opioid prescribing, much prescribing variation may be attributable to clinical behaviour. Effective strategies targeting clinicians and patients are needed to curb rising prescribing, especially of stronger opioids.