Sorptive tape-spray tandem mass spectrometry using aluminum foil coated with mixed-mode microparticles

Direct mass spectrometry (MS) is an exciting strategy in bioanalysis, enabling rapid decision-making in different scenarios. Its application is usually hindered by matrix effects and the typically low concentration of the target compounds in the biofluids. In this sense, combining a previous sample preparation step minimizes or removes these shortcomings. This article describes sorptive tape-spray tandem mass spectrometry (STS-MS/MS) based on mixed-mode particles as a strategy to combine sample preparation and MS analysis in a single device. The technique uses a sorptive tape (ST) consisting of mixed-mode polymeric microparticles (combining ionic exchange and hydrophobic interactions) coated over aluminum foil in a spatial controlled way. The tapes act as the sorptive phases to isolate the analytes from the sample matrix and substrates for STS-MS/MS. The performance of the technique has been evaluated by developing a method to determine codeine in saliva as proof of concept. The affordability of the STs elements allows the preparation of many individual phases at low cost so that several samples can be extracted simultaneously, thus increasing the sample throughput. The extraction variables were optimized following a multivariate approach. Working under the optimum conditions, the limit of detection was 0.3 μg L-1, while the intraday precision, calculated as relative standard deviation (RSD) at three concentration levels, was better than 9.4 %. The accuracy, expressed as relative recovery, was in the range of 78-98 %. The method was also applied to the analysis of real samples. Despite being a powerful strategy, the direct combination of microextraction to MS is not always affordable in all laboratories. For this reason, the STs were also combined with commercial liquid chromatography-MS working under the direct infusion mode to demonstrate the usefulness of the ST in classical extraction workflows.

Characterization of Codeine Treatment Responders Among Patients with Refractory or Unexplained Chronic Cough: A Prospective Real-World Cohort Study

PURPOSE

Codeine is a narcotic antitussive often considered for managing patients with refractory or unexplained chronic cough. This study aimed to evaluate the proportion and characteristics of patients who responded to codeine treatment in real-world practice.

METHODS

Data from the Korean Chronic Cough Registry, a multicenter prospective cohort study, were analyzed. Physicians assessed the response to codeine based on the timing and degree of improvement after treatment initiation. Follow-up assessments included the Leicester Cough Questionnaire and cough severity visual analog scale at six months. In a subset of subjects, objective cough frequency was evaluated following the initiation of codeine treatment.

RESULTS

Of 305 patients, 124 (40.7%) responded to treatments based on anatomic diagnostic protocols, while 181 (59.3%) remained unexplained or refractory to etiological treatments. Fifty-one subjects (16.7%) were classified as codeine treatment responders (those showing a rapid and clear response), 57 (18.7%) as partial responders, and 62 (20.3%) as non-responders. Codeine responders showed rapid improvement in objective cough frequency and severity scores within a week of the treatment. At 6 months, responders showed significantly improved scores in cough scores, compared to non-responders. Several baseline parameters were associated with a more favorable treatment response, including older age, non-productive cough, and the absence of heartburn.

CONCLUSIONS

Approximately 60% of chronic cough patients in specialist clinics may require antitussive drugs. While codeine benefits some, only a limited proportion (about 20%) of patients may experience rapid and significant improvement. This underscores the urgent need for new antitussive drugs to address these unmet clinical needs.

Development and validation of a brief screening tool for over-the-counter codeine dependence

BACKGROUND

Low-dose codeine is sold without a prescription in countries like the UK, Ireland, and South Africa. Due to misuse concerns, exploring pharmacy screening tools to identify those at risk and needing additional support is vital.

OBJECTIVES

The study aims to develop and validate a brief screening tool that assesses the risk of codeine dependence with language appropriate for routine use in community pharmacies.

METHOD

Scale development and validation occurred over two studies. In Study 1, scale item generation was based on structured analyses of psychosocial and pharmacy variables from frequent over-the-counter codeine consumers (N = 795). CFA was used to assess the cohesiveness of the resultant four-item Codeine Dependence Scale (CDS). ROC analyses were used to assess the performance of the CDS against risk cases identified by the Severity of Dependence Scale; identifying an optimal cut-off value of ≥2 as representing individuals at risk of codeine dependence. In Study 2, this CDS threshold was assessed against positive DSM-5 Opioid Use Disorder (OUD) cases related to codeine use assessed using the AUDADIS-IV.

RESULTS

With a cut-off score of ≥2, the CDS has sensitivity and specificity of 76% and 48%, respectively, against a DSM-5 codeine-related OUD diagnosis using the AUDADIS-IV. For identification of any codeine-related OUD (as measured by the AUDADIS-IV) 15 months after baseline, the CDS achieved an overall correct classification rate of 52%; 72% for positive cases.

CONCLUSIONS

The CDS exhibits reasonable cross-sectional and longitudinal sensitivity but low specificity, partly due to its brevity. However, the inclusive nature of the CDS is not a negative for application as a screening tool in a pharmacy setting as individual CDS items represent critical conversation points with a pharmacist, regardless of the screening outcome. The non-confronting nature of CDS items make the scale a viable option for pharmacy-based SBI in countries where codeine remains OTC.

Association of tramadol use with risk of hip fractures in patients with osteoarthritis: A systematic review and meta-analysis of observational studies

OBJECTIVE

Many studies have reported conflicting results for the use of tramadol with the risk of fractures, especially hip fractures. This systematic review and meta-analysis study aimed to evaluate the association of tramadol use versus codeine use with the risk of hip fracture for the first time.

METHODS

PubMed, Scopus, Google Scholar, and Web of Science databases were searched with specific keywords to find studies that examined the association of tramadol use with hip fracture risk in patients with osteoarthritis up to May 2023. The risk of hip fracture secondary to tramadol versus codeine use was estimated based on age and sex. This systematic review was conducted based on the PRISMA checklist. Heterogeneity between studies was evaluated using Cochran's Q and I2 tests. Egger's test was used to check publication bias. The Newcastle-Ottawa Checklist (NOS) was used to assess the quality of the studies.

FINDINGS

Ten studies with 1,939,293 participants were reviewed. The majority of participants were female. Based on the study evaluation checklist, most studies were of good quality. Tramadol use significantly increases the overall risk of hip fracture. (HR: 1.32, 95% CI: 1.14, 1.51, P: 0.001, I2:19.3%) Tramadol use significantly increases the risk of hip fracture in men (HR: 1.48, 95% CI: 1.24, 1.73, P: 0.001 I2:35%) and age ≤65 years (HR: 1.63, 95% CI: 1.45, 1.80, P: 0.001, I2:0%).

CONCLUSION

The use of tramadol significantly increases the risk of hip fracture. This increased risk of hip fracture was greater in males younger than 65 years.

Narcotic analgesics

There is documentation of the use of opium derived products in the ancient history of the Assyrians: the Egyptians; in the sixth century AD by the Roman Dioscorides; and by Avicenna (980-1037). Reference to opium like products is made by Paracelsus and by Shakespeare. Charles Louis Derosne and Fredrich Wilhelm Adam Serturner isolated morphine from raw opium in 1802 and 1806 respectively, and it was Sertürner who named the substance morphine, after Morpheus, the Greek God of dreams. By the middle 1800s, Opium and related opioid derived products were the source of a major addiction in USA, and to some extent in the United Kingdom. Opioid products are of major therapeutic value in the treatment of pain from injury, post surgery, intractable pain conditions, and some forms of terminal cancer.

Quantitative LC-MS/MS Analysis of Opiates and Opioids in Human Urine

We hereby present a direct, clinical LC-MS/MS assay for the simultaneous analysis of opiates and opioids in human urine. The assay is used as confirmations as well as a quantitative assay following immunoassay urine drug screens. Hence, the utility is extended to report opiate/opioid levels in the range 10-1000 ng/mL for each of the 13 analytes, which include morphine and metabolites; codeine and metabolites; as well as synthetics such as heroin metabolites, dihydrocodeine, oxycodone, and naloxone. The assay employs dilute and shoot, utilizing reversed-phase liquid chromatography for mixture separation and positive-mode electrospray-ionization multiple-reaction-monitoring for MS detection in the TSQ Endura triple-quadrupole (QqQ) instrument. Thereafter, quantitative analysis is based on the linear calibration using six reference standards, whereby the instrument response for each analyte at a given concentration is normalized against stable isotope labeled internal standard.

Modulatory effects of Cannabis sativa co-administration with tramadol and codeine on cognitive function in male rats

Most teenagers mix up various psychoactive cocktail substances in combinations to get intoxicated. The role of the mixture combination of codeine (CDE), tramadol (TMD), and Cannabis sativa (CNB) on brain cognition, purinergic, cholinergic, and antioxidant enzyme activities remains unknown. This study sought to assess the mechanism of action of combinations of CDE+ TMD+ CNB on the function and activities of the brain of male Wistar rats. Forty-eight male Wistar rats were divided into 8 groups, n = 6. Group 1 served as a control, groups 2, 3, and 4 were exposed to CDE (2 mg/kg bw), TMD (10 mg/kg bw), and CNB (200 mg/kg bw), while groups 5, 6, 7, and 8 were co-administered with CDE+TMD, CNB+ TMD, CNB+CDE, and CNB+TMD+CDE orally for 28 days. This study revealed the effect of prolonged administration of CNB, TMD, and CDE on the suppression of cognitive function, acetyl-cholinesterase (AChE), butyl-cholinesterase (BChE), monoamine oxidase (MAO) enzyme activities, and antioxidant enzyme activities in rats' brains when compared against control rats (P < 0.05). However, the activities of ectonucleosides (NTPdase), adenosine deaminase (ADA), and malondialdehyde levels produced in the brain of rats were significantly elevated (P < 0.05). This study reported the mechanism behind the neurotoxicity of CNB, TMD, and CDE on rats' cognitive, cholinergic, purinergic, and antioxidant enzymes as a consequence of the drastic reduction in cholinesterase enzyme activities leading to neurotransmitter poisoning.

Lean/Sizzurp Ingredients, Use, and Coping With Mental Health Symptoms

The substance combination of codeine and promethazine, commonly termed lean/sizzurp, has been identified as a method that some individuals use to cope with PTSD and other mental health symptomology. A sample of 1423 adults with self-reported past year lean use was recruited from substance-related Reddit pages to complete a survey about lean, including information about using lean to cope with emotions, thoughts, or feelings. To be included in the sample, persons needed to: (1) be ⩾18 years old, (2) report past year lean use, (3) complete lean use screeners, and (4) pass data quality checks (eg, bot detection). As Reddit is an online forum, no geographic restrictions were placed on study participation. Data on demographic characteristics, lean use, and mental health disorder symptomology were captured from participants. Logistic regression models included anxiety, depression, and trauma as independent variables along with covariates to examine using lean to cope with emotions, thoughts, or feelings in the past 30 days. Most participants were male (n = 1102; 77.4%), with an average age of 26.9 (SD = 5.2) years. Most participants used included codeine as an ingredient in lean (n = 1060; 74.5%); promethazine was added as an ingredient by 31.7% of the sample (n = 451), and the combination of codeine and promethazine was included as ingredients by 13.5% (n = 192) of the sample. Participants with anxiety, lifetime trauma exposure, and who were female had increased odds of using lean to cope with emotions, thoughts, or feelings in the past 30 days. Those with depression and unstable housing exhibited decreased odds of using lean to cope with emotions, thoughts, or feelings in the past 30 days. This study recruited persons via social media to learn more about lean use, especially lean use to cope with mental health symptoms; future population-level studies are needed.

The therapeutic potential of opioids in narcolepsy type 1: A systematic literature review and questionnaire study

OBJECTIVE

Narcolepsy type 1 is a primary sleep disorder caused by deficient hypocretin transmission leading to excessive daytime sleepiness and cataplexy. Opioids have been suggested to increase the number of hypocretin-producing neurons. We aimed to assess opioid use and its self-reported effect on narcolepsy type 1 symptom severity through a literature review and questionnaire study.

METHODS

We systematically reviewed literature on opioid use in narcolepsy. We also recruited 100 people with narcolepsy type 1 who completed an online questionnaire on opioid use in the previous three years. The main questionnaire topics were the indication for use, and the possible effects on narcolepsy symptom severity. Structured follow-up interviews were conducted when opioid use was reported.

RESULTS

The systematic literature review mainly showed improvements in narcolepsy symptom severity. Recent opioid use was reported by 16/100 questionnaire respondents, who had used 20 opioids (codeine: 7/20, tramadol: 6/20, oxycodone: 6/20, fentanyl: 1/20). Narcolepsy symptom changes were reported in 11/20. Positive effects on disturbed nocturnal sleep (9/20), excessive daytime sleepiness (4/20), hypnagogic hallucinations (3/17), cataplexy (2/18), and sleep paralysis (1/13) were most pronounced for oxycodone (4/6) and codeine (4/7).

CONCLUSIONS

Opioids were relatively frequently used compared to a similarly young general Dutch sample. Oxycodone and, to a lesser extent, codeine were associated with self-reported narcolepsy symptom severity improvements. Positive changes in disturbed nocturnal sleep and daytime sleepiness were most frequently reported, while cataplexy effects were less pronounced. Randomised controlled trials are now needed to verify the potential of opioids as therapeutic agents for narcolepsy.

Analgesic effect of oral paracetamol 1000 mg/ibuprofen 400 mg, paracetamol 1000 mg/codeine 60 mg, paracetamol 1000 mg/ibuprofen 400 mg/codeine 60 mg, or placebo on acute postoperative pain: a single-dose, randomized, and double-blind study

PURPOSE

Combining analgesics with different mechanisms of action may increase the analgesic efficacy. The multidimensional pharmacodynamic profiles of ibuprofen 400 mg/paracetamol 1000 mg, ibuprofen 400 mg/paracetamol 1000 mg/codeine 60 mg, and paracetamol 1000 mg/codeine 60 mg and placebo were compared.

METHODS

A randomized, double-blind, placebo-controlled, parallel-group, single-centre, outpatient, and single-dose study used 200 patients of both sexes and homogenous ethnicity after third molar surgery (mean age 24 years, range 19-30 years). Primary outcome was sum pain intensity over 6 h (SPI). Secondary outcomes were time to analgesic onset, duration of analgesia, time to rescue drug intake, number of patients taking rescue drug, sum pain intensity difference (SPID), maximum pain intensity difference, time to maximum pain intensity difference, number needed to treat, prevent remedication and harm values, adverse effects, and patient-reported outcome measure (PROM).

RESULTS

Analgesia following ibuprofen and paracetamol combination with or without codeine was comparable. Both were better than paracetamol combined with codeine. Secondary variables supported this finding. Post hoc analysis of SPI and SPID revealed a sex/drug interaction trend in the codeine-containing groups where females experienced less analgesia. PROM showed a significant sex/drug interaction in the paracetamol and codeine group, but not in the other codeine-containing group. Especially females reported known and mild side effects in the codeine-containing groups.

CONCLUSION

Codeine added to ibuprofen/paracetamol does not seem to add analgesia in a sex-mixed study population. Sex may be a confounding factor when testing weak opioid analgesics such as codeine. PROM seems to be more sensitive than traditional outcome measures.

TRIAL REGISTRATION

ClinicalTrials.gov June 2009 NCT00921700.

Knowledge, Attitude, and the Practice of Community Pharmacists to Dispense Opioid-Related and Opioid-Containing Medication in Eastern Province, Saudi Arabia

Objectives

This study was done to evaluate the knowledge of community pharmacists-working in Saudi Arabia-regarding over-the-counter opioid-related and opioid-containing medications.

Materials and Methods

A quantitative cross-sectional study was conducted using an online questionnaire that was distributed through social media and taken to the community pharmacists in person. A total of 101 responders were reached in a period of around 3 weeks.

Results

Most of the pharmacists working in community pharmacies in Saudi Arabia are non-Saudi (85.15%), males (88.12%), and the majority are holders of bachelor's degrees (85.15%). More than half of the participants spend a considerably sufficient time with the patient 6-10 minutes (60.4%). The availability of a private counseling room in community pharmacies is significantly low (21.78%). Only (69.41%) of participants always counsel the patient before dispensing opioid-related medications. Most of the participants (84.76%) believe that all over-the-counter opioid-related and opioid-containing medications should be restricted to avoid drug abuse.

Conclusion

A little neglect from pharmacists' side regarding dispensing such medications was observed; thus, there is a significant need to raise their awareness regarding over-the-counter opioid abuse.

Codeine prescription pattern and treatment responses in patients with chronic cough: a routinely collected institutional database analysis

Background

Codeine has been long used as an antitussive drug in several countries. However, a prescription pattern of codeine, such as dose or treatment duration, has not been reported in detail. Furthermore, there is few scientific evidence on the efficacy and safety. We aimed to examine codeine prescription pattern and explore treatment response in patients with chronic cough in real-world practice.

Methods

This was a retrospective cohort analysis of patients with chronic cough who were newly referred to tertiary allergy and asthma clinics between July 2017 and July 2018. Routinely collected electronic healthcare records (EHRs), including medical notes, prescriptions, and outpatient visits, were analyzed. Codeine prescription records were examined for duration, mean daily dose, and 1-year cumulative dose. Codeine responses were evaluated by manual EHR reviews.

Results

Among a total of 1,233 newly referred patients with chronic cough, 666 were prescribed codeine for a median [interquartile range (IQR)] of 27.5 days (IQR 14-60 days); the median daily dose was 30 mg/year (IQR 21.6-30 mg/year), and the 1-year cumulative dose was 720 mg/year (IQR 420-1,800 mg/year). About 14.0% of patients were prescribed codeine for >8 weeks; they were older and had a longer cough duration, throat abnormal sensation and less dyspnea than patients prescribed codeine for ≤8 weeks or who did not receive codeine. Codeine prescription and duration was positively associated with the number of other cough-related medications, diagnostic tests, or outpatient visits. Cough status change was noted in 61.3% of codeine-prescribed patients (as 'improved' in 40.1% and 'not improved' in 21.2%), but not documented in 38.7%. Side effects were described in 7.8%.

Conclusions

Codeine prescription may be frequent and chronic in real-world practice of patients with chronic cough, despite the lack of robust clinical evidence on the efficacy. High prescription rates suggest unmet clinical needs. Prospective studies are warranted to identify codeine treatment responses and safety, and to build up clinical evidence to guide appropriate use of narcotic antitussives.

Hospital admissions for paracetamol poisoning declined following codeine re-scheduling in Australia

BACKGROUND

Codeine was restricted to prescription only in Australia in 2018. This intervention aimed to reduce harms from codeine dependance and use, including toxicity from co-formulated paracetamol. We aimed to quantify the impact of this intervention on paracetamol poisoning hospital admissions in a national hospital admissions database.

METHODS

We analyzed the number of paracetamol overdoses resulting in hospital admissions from the Australian Institute of Health and Welfare National Hospital Morbidity Database, January 2011 to June 2020. We used interrupted time series analysis to quantify the effect of codeine re-scheduling on the monthly number of paracetamol poisoning-related hospital admissions in Australia. We compared paracetamol poisonings with no opioid combinations, and poisonings with probable paracetamol-codeine combinations.

RESULTS

There was an immediate and sustained decrease (level shift) in the number of paracetamol poisoning-related hospital admissions following codeine re-scheduling (RR=0.85; 95% CI 0.80-0.89). This reduction was due to the decrease in poisonings with likely paracetamol-codeine combinations (RR=0.62; 95% CI 0.57-0.67) while there was no change in other paracetamol poisonings (RR=0.91; 95% CI 0.96-1.01).

CONCLUSION

Codeine re-scheduling in Australia appears to have reduced paracetamol poisoning-related hospital admissions.

Understanding the Dynamics of More Restrictive Medicines Policy: A Case Study of Codeine Up-Scheduling in Australia

BACKGROUND

There has been increasing concern over opioid-related harms across the world. In Australia in 2018, codeine-containing products were up-scheduled from over-the-counter access at pharmacies, to requiring a prescription. The drug regulator's decision to up-schedule was contentious and widely debated, due to the potentially large impact on consumers and healthcare professionals. This study aimed to analyse influences on the codeine up-scheduling policy.

METHODS

This retrospective policy analysis used the Advocacy Coalition Framework (ACF) to understand how policy actors with shared beliefs formed adversarial coalitions to shape policy. Data were drawn from documents (regulator policy documents, public submissions, news reports, organisational media releases and position statements) and semi-structured interviews with 15 key policy actors. Codes were generated relating to policy processes and actor beliefs; broad themes included the role of health professionals, perceptions of opioids, impact on consumers, and the role of government in healthcare.

RESULTS

Two coalitions in this policy subsystem were identified: (1) supportive [with respect to the up-scheduling], and (2) opposing. The key evident beliefs of the supportive coalition were that the harms of codeine outweighed the benefits, and that government regulation was the best pathway for protecting consumers. The opposing coalition believed that the benefits of codeine accessible through pharmacists outweighed any harms, and consumers should manage their health without any more intervention than necessary. The policy decision reflected the influence of the supportive coalition, and this analysis highlighted the importance of their public health framing of the issue, the acceptability of their experts and supporting evidence, and the perceived legitimacy of the up-scheduling process.

CONCLUSION

Understanding these coalitions, their beliefs, and how they are translated through existing policy processes and institutions provides insight for those interested in influencing future health policy. Specific lessons include the importance of strategic frames and advocacy, and engagement with formal policy processes.

Pharmacokinetics and transplacental transfer of codeine and codeine metabolites from Papaver somniferum L

ETHNOPHARMACOLOGICAL RELEVANCE

Papaveris Pericarpium, which is the dried husk of Papaver somniferum L., has been used as a phytomedicine to relieve cough, diarrhea and pain. The alkaloid codeine contained therein via biotransformation converts to morphine and potentially produces addictive and toxic effects. Due to the healthy concern for a pregnant woman, our hypothesis is that codeine and its metabolites can penetrate the placental barrier to reach the foetus and amniotic fluid, and these processes may be modulated by the transporter.

AIM OF THE STUDY

Because codeine is also considered a prodrug of morphine, it has a good analgesic effect. It is often used by pregnant women but may expose the foetus to the risk of morphine harm. The aim of this study is to investigate the metabolic rate, distribution and transplacental transfer mechanism of codeine and its metabolites morphine and morphine-3-glucuronide (M3G) in pregnant rats and to assess the risk of medication for pregnant women.

MATERIALS AND METHODS

Ultrahigh-performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) combined with a microdialysis system was developed to monitor codeine, morphine and M3G in multiple sites of maternal blood, placenta, foetus and amniotic fluid after codeine administration. A compartmental model was used to calculate the pharmacokinetic parameters of codeine in blood after codeine administration (10 mg/kg, i.v.). The area under the concentration (AUC) ratio of AUC_metabolite/AUC_codeine and AUC_tissue/AUC_blood was used to represent the metabolic biotransformation ratio and the drug from blood-to-tissue transfer ratio, respectively.

RESULTS

The pharmacokinetic results demonstrated that codeine fit well with a two-compartment model and went through rapid metabolism to morphine and M3G in pregnant rats after codeine administration (10 mg/kg, i.v.). The biotransformation ratios of AUC_morphine/AUC_codeine, AUC_M3G/AUC_morphine and AUC_M3G/AUC_codeine were 0.12 ± 0.03, 54.45 ± 20.61 and 6.53 ± 2.47, respectively, after codeine administration (10 mg/kg, i.v.), which suggested that codeine was easily metabolized into M3G through morphine. The tissue distribution results demonstrated that all of the analytes penetrated into the foetus through the placenta; however, the blood-to-tissue transfer ratio (AUC_tissue/AUC_blood) of morphine and M3G was relatively lower than that of codeine after codeine administration (10 mg/kg, i.v.), which suggested that the blood-placenta barrier blocks the penetration of morphine and M3G into the foetus. Thus, the tissue transfer of morphine in the placenta and foetus was significantly enhanced by treatment with corticosterone, an inhibitor of organic cation transporter (OCT).

CONCLUSION

Based on microdialysis coupled to a validated UHPLC-MS/MS system, the pharmacokinetics and metabolic biotransformation of codeine and its metabolites were analyzed and clarified. The potential mechanism of morphine placental transfer was modulated by OCT transporters.

Non-medical use of pharmaceutical opioids with and without other illicit substance use: Trends from two repeated nationally representative Australian surveys

Background

Due to concerns over the public health impact of increasing opioid use, Australia up-scheduled codeine in 2018, requiring codeine-containing pharmaceuticals to be prescription-only. We examined pre-post changes in the prevalence and correlates of non-medical use of pharmaceutical opioids (NMUPO) and other illicit substance use (ISU).

Methods

We conducted a cross-sectional analysis of 45,463 participants aged 14 or above in the Australian National Drug Strategy Household Surveys (NDSHS) 2016 and 2019. Participants were categorized based on their past 12 months NMUPO and ISU patterns. Correlates examined included socio-demographic, psychological (Kessler 10), health and behavioral variables.

Results

The overall prevalence of any NMUPO decreased from 3.56% in 2016 to 2.65% in 2019, and the prevalence of codeine use from 2.98% to 1.49%. No significant changes were observed in the use of other types of painkillers (e.g. oxycodone and fentanyl) between 2016 and 2019. The overall decrease in NMUPO primarily occurred among people who used NMUPO only and did not use other illicit drugs. Older adults were more likely to report NMUPO only. Younger age, higher psychological distress, risky alcohol use, and daily smoking were associated with both NMUPO and illicit drug use.

Conclusions

A comparison of cross-sectional data from two time-points showed that the prevalence of NMUPO use among people who used NMUPO exclusively was lower post-up-scheduling of codeine in Australia. However, NMUPO use did not reduce among people who used both NMUPO and other illicit drugs. Public health interventions are needed to reduce opioid-related harm in those who also used other illicit drugs.

Utilization of magnetic pomelo peel-derived biochar for extraction and LC-MS determination of opioid drugs in wastewaters

In this study, magnetic pomelo peel-derived biochar composite was fabricated and applied as a low-cost adsorbent for simultaneous extraction of morphine-like opioids named morphine, codeine, and 6-monoacetylmorphine from wastewaters, prior to their determination via liquid chromatography-mass spectrometry. A total of four biochar products were synthesized under different pyrolytic temperatures 400, 500, 600 and 700°C, respectively, and the 400°C biochar was found to have the greatest extraction ability, with enrichment factors of 34, 58, 61 for the three drugs. The primary adsorption mechanism includes π-π interaction and H-bonding. Parameters affecting the extraction of opioids were optimized. Under optimum conditions (such as pH = 7; adsorbent amount = 15 mg; sample volume = 20 mL; eluent solvent, 200 μL of methanol), the method was proved to be linear in the range of 0.05-10.0 μg/L, with coefficients of determination greater than 0.99, and the limits of detection were 0.006-0.010 μg/L. In-batch and inter-batch precisions were 1.8-6.5% and 4.8-10.6%, respectively. The method was successfully applied for determination of the target opioids in the samples of influent and effluent wastewater. The developed method by using magnetic pomelo peel-derived biochar could potentially be applied for the effective estimation of illicit drug consumption. This article is protected by copyright. All rights reserved.

Effectiveness and Safety of Codeine and Levodropropizine in Patients With Chronic Cough

BACKGROUND

Recent progress in chronic cough management includes controlling cough triggers and hypersensitivity using antitussives. Therefore, we investigated the effects and safety outcomes of antitussives, codeine and levodropropizine, in patients with chronic cough.

METHODS

We conducted an open-label, randomized comparative trial with newly referred patients with chronic cough. Patients were orally administered codeine (60 mg/day) and levodropropizine (180 mg/day) for 2 weeks. Cough severity, including the visual analog scale (VAS), Cough Symptom Score (CSS), Leicester Cough Questionnaire (LCQ), and safety for each treatment were assessed. The primary outcome was VAS score changes before and after 2 weeks of treatment.

RESULTS

Among the 88 participants, 45 and 43 in the codeine and levodropropizine groups, respectively, were included in the analysis. Changes in the VAS score were higher in the codeine group than in the levodropropizine group (35.11 ± 20.74 vs. 19.77 ± 24.83, P = 0.002). Patients administered codeine also had improved CSS (2.96 ± 2.35 vs. 1.26 ± 1.89, P < 0.001) and LCQ (3.28 ± 3.36 vs. 1.61 ± 3.53, P = 0.025) than those administered levodropropizine. Treatment-related adverse events, including drowsiness, constipation, and headaches, were more frequent in the codeine group than in the levodropropizine group. However, no significant differences existed in the adverse events leading to discontinuation.

CONCLUSION

Codeine is an effective and generally well-tolerated antitussive for chronic cough. However, it may induce side effects in some patients. Individual responses and adverse events should be carefully monitored when codeine is used to treat chronic cough.

Pharmacokinetics, adverse effects and effects on thermal nociception following administration of three doses of codeine to horses

BACKGROUND

In humans, codeine is a commonly prescribed analgesic that produces its therapeutic effect largely through metabolism to morphine. In some species, analgesic effects of morphine have also been attributed to the morphine-6-glucuronide (M6G) metabolite. Although an effective analgesic, administration of morphine to horses produces dose-dependent neuroexcitation at therapeutic doses. Oral administration of codeine at a dose of 0.6 mg/kg has been shown to generate morphine and M6G concentrations comparable to that observed following administration of clinically effective doses of morphine, without the concomitant adverse effects observed with morphine administration. Based on these results, it was hypothesized that codeine administration would provide effective analgesia with decreased adverse excitatory effects compared to morphine. Seven horses received a single oral dose of saline or 0.3, 0.6 or 1.2 mg/kg codeine or 0.2 mg/kg morphine IV (positive control) in a randomized balanced 5-way cross-over design. Blood samples were collected up to 72 hours post administration, codeine, codeine 6-glucuronide, norcodeine morphine, morphine 3-glucuronide and M6G concentrations determined by liquid chromatography- mass spectrometry and pharmacokinetic analysis performed. Pre- and post-drug related behavior, locomotor activity, heart rate and gastrointestinal borborygmi were recorded. Response to noxious stimuli was evaluated by determining thermal threshold latency.

RESULTS

Morphine concentrations were highest in the morphine dose group at all times post administration, however, M6G concentrations were significantly higher in all the codeine dose groups compared to the morphine group starting at 1 hour post drug administration and up to 72-hours in the 1.2 mg/kg group. With the exception of one horse that exhibited signs of colic following administration of 0.3 and 0.6 mg/kg, codeine administration was well tolerated. Morphine administration, led to signs of agitation, tremors and excitation. There was not a significant effect on thermal nociception in any of the dose groups studied.

CONCLUSIONS

The current study describes the metabolic profile and pharmacokinetics of codeine in horses and provides information that can be utilized in the design of future studies to understand the anti-nociceptive and analgesic effects of opioids in this species with the goal of promoting judicious and safe use of this important class of drugs.

Accelerated wound healing and its promoting effects of topical codeine on the healing of full-thickness cutaneous wound, evidences for modulating cytokines involved in pain, inflammation and collagen biosynthesis

INTRODUCTION

The inflammation and pain occur in all the wounds. Opioids drugs decrease pain and may act as an anti-inflammation. The current study was conducted to investigate the efficiency of the topical uses of Codeine on full-thickness excision wound models by focusing on relationship between pain mediators, inflammation and wound healing rate.

METHODS

Following the induction of anesthesia, a skin wound with a size of 7-mm punch was induced on the dorsal surfaces of each mouse. The mice were divided into five categories: groups I-III were daily administered 2.5%, 5%, and 10% Codeine gel; those in group IV were administered phenytoin cream, and group V (controls) received base ointment. To assess the effects of Codeine gel on the wound healing process, the wound area, histological parameters, and the relative protein expression of CXCR1, CXCR2, IL-6, IL-6R, PDGF, PDGFR, and COL1A along with the plasma concentrations of IL-1β, IL-10, and TNF-α were investigated on days 3, 7, and 14.

RESULTS

On days 7 and 14, the wound area was significantly lower in the treated mice compared to the controls (P < 0.05). Angiogenesis, collagen deposition, and epithelium thickness were significantly higher in the treatment groups compared to the control group (P < 0.05). The relative protein expressions of CXCR1, CXCR2, IL-6, and IL-6R and the plasma concentrations of IL-1β and TNF-α were significantly lower in the treated groups. Meanwhile, the relative protein expressions of PDGF, PDGFR, and COL1A and the plasma concentration of IL-10 were significantly higher in the treated mice (P < 0.05).

CONCLUSION

Administration of Codeine gel accelerated wound healing through decreasing the pain mediators, inflammation and promoting proliferative phase.

A novel self-aggregated gold nanoparticles based on sensitive immunochromatographic assays for highly detection of opium poppy in herbal teas

Opium poppy abused in food has aroused public concerns due to its serious side effects. Effective monitoring is essential to fight the abuse crisis. Herein, we synthesized an easily prepared, affordable, accessible highly aggregated gold nanoparticles (AGNPs) performing in lateral flow immunoassay (LFIA) for detection opium poppy in herbal teas. Simultaneously, a LFIA based ontime-resolved fluorescent microspheres (TRFMs) was developed as contrastive method. In this study, morphine (MOR), codeine (COD) and thebaine (THE) were as the specific recognition markers of opium poppy. Results demonstrated the quantitative limits of detection were 0.0049/0.0053/0.084, 0.034/0.037/0.37 ng mL^-1 for AGNPs/TRFMs-LFIA, respectively. The recoveries were 95%-107.5%/91%-106.7% with coefficient of variation was 1.6%-6.6%/1.8%-7.2%, indicating excellent accuracy and precision. Parallel experiments among AGNPs/TRFMs-LFIA and LC-MS/MS analysis showed good correlation. Overall, AGNPs-LFIA executed quantitative analysis within 15 min on the basis of simple treatment while providing a rapid and sensitive analysis strategy for illegal drugs abused.

The association between the availability of over the counter codeine and the prevalence of non-medical use

PURPOSE

To investigate the prevalence of non-medical use (NMU) of codeine in Germany, Italy, Spain and the UK and whether availability of OTC codeine has any association with NMU of the drug.

METHODS

Data collected in the online Survey of Non-Medical Use of Prescription Drugs, in surveys launched in the second half of 2018 from (Germany (n = 14,969), Italy, (n = 9974), Spain (n = 9912) and the UK (n = 9819) were analysed. For each survey, the estimated prevalence and 95% confidence interval (CI) of respondents reporting NMU of prescription and/or OTC codeine within the last 12 months were calculated and compared.

RESULTS

The prevalence of last 12-month NMU in Spain was 12.6% (95% CI 11.7-13.6) for prescription codeine, 6.3% (5.6-7.0) for OTC codeine and 16.1% (15.1-17.3) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU in the UK was 5.4% (4.9-5.8) for prescription codeine, 4.5% (4.1-5.0) for OTC codeine and 8.3% (7.8-8.9) for any codeine (prescription and/or OTC). The prevalence of last 12-month NMU for prescription codeine was 2.1% (1.9-2.4) in Germany and 1.9% (1.7-2.2) in Italy.

CONCLUSION

The prevalence of last 12-month NMU of any codeine product is approximately eight times greater in Spain and four times greater in the UK compared to Germany and Italy where the drug is only available by prescription. While other factors may contribute, these findings suggest that availability of codeine OTC is associated with greater NMU.

Pharmaceutical opioid poisonings in Victoria, Australia: Rates and characteristics of a decade of emergency department presentations among nine pharmaceutical opioids

BACKGROUND AND AIMS

Pharmaceutical opioids are a significant contributor to the global 'opioid crisis', yet few studies have comprehensively distinguished between opioid types. We measured whether a range of common pharmaceutical opioids varied in their contribution to the rates and characteristics of harm in a population-wide indicator of non-fatal overdose.

DESIGN

Retrospective observational study of emergency department (ED) patient care records in the Victorian Emergency Minimum Data set (VEMD), July 2009 to June 2019.

SETTING

Victoria, Australia.

CASES

ED presentations for non-fatal overdose related to pharmaceutical opioid use (n = 5403), where the specific pharmaceutical opioid was documented.

MEASUREMENTS

We compared harms across the nine individual pharmaceutical opioids most commonly sold, and considered where multiple opioids contributed to the overdose. We calculated supply-adjusted rates of ED presentations using Poisson regression and used multinomial logistic regression to compare demographic and clinical characteristics of presentations among nine distinct pharmaceutical opioids and a 10th category where multiple opioids were documented for the presentation.

FINDINGS

There were wide differences, up to 27-fold, between supply-adjusted rates of overdose. When considering presentations with sole opioids, the highest supply-adjusted overdose rates [per 100 000 oral morphine equivalents (OME); 95% confidence interval (CI)] were for codeine (OME = 0.078, 95% CI = 0.073-0.08) and oxycodone (OME =0.029, 95% CI = 0.027-0.030) and the lowest were for tapentadol (OME = 0.004, 95% CI = 0.003-0.006) and fentanyl (OME = 0.003, 95% CI = 0.002-0.004). These rates appeared related to availability rather than opioid potency. Most (62%) poisonings involved females. Codeine, oxycodone and tramadol were associated with younger presentations (respectively, 59.5%, 41.7% and 49.8% of presentations were 12-34 years old), and intentional self-harm (respectively 65.2%, 50.6%, and 52.8% of presentations). Relative to morphine, fentanyl [ 0.32 relative risk ratio (RRR)] and methadone ( 0.58 RRR) presentations were less likely to be coded as self-harm. Relative to morphine-buprenorphine, codeine, oxycodone and tramadol presentations were significantly more likely to be associated with the less urgent triage categories (respectively 2.18, 1.80, 1.52, 1.65 RRR).

CONCLUSIONS

In Victoria, Australia, rates and characteristics of emergency department presentations for pharmaceutical opioids show distinct variations by opioid type.

A prospective cohort study evaluating the impact of upscheduling codeine in Australia among frequent users of codeine

AIM

To evaluate and document the impacts of re-scheduling codeine to a prescription-only medication in Australia in February 2018.

DESIGN

Prospective cohort study. Participants completed an on-line survey with a range of outcome measures at four time-points, once before codeine was re-scheduled (November 2017) and three times after the event: 1 month after (February 2018), 4 months after (June 2018) and 12 months after (February 2019).

SETTING

Australia.

PARTICIPANTS

Participants were 260 Australians aged 18 years and above who reported regular over-the-counter (OTC) codeine use and, at the time of the study, were not engaged in treatment for codeine dependence.

MEASUREMENTS

Survey measures included estimates of daily average codeine use (mg) and overall daily average opioid use [calculated using an oral morphine equivalent daily dose (OMEDD, mg)], opioid use disorder with regard to codeine use (using a modified Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV), pain and pain self-efficacy, anxiety and depression and health service use.

FINDINGS

A reduction in total daily codeine use (mg) from 64.3 mg [95% confidence interval (CI) = 46.7-81.9] in November 2017 (baseline) to 27.6 mg (95% CI = 19.2-36.0) in February 2019 (final time-point) was observed. A decline in the proportion of participants who met criteria for an opioid use disorder was also evident, with 51.2% (n = 133) at baseline relative to 33.3% (n = 58) at the 12-month follow-up. This study had an overall participant retention rate of 67% at the final time-point.

CONCLUSION

Re-scheduling codeine in Australia has been accompanied by significant reductions in codeine use and prevalence rates of opioid use disorder in a cohort of individuals who regularly use the medication, without apparent adverse impacts on pain or measures of anxiety and depression.

Analgesic effect of oral ibuprofen 400, 600, and 800 mg; paracetamol 500 and 1000 mg; and paracetamol 1000 mg plus 60 mg codeine in acute postoperative pain: a single-dose, randomized, placebo-controlled, and double-blind study

PURPOSE

Effect size estimates of analgesic drugs can be misleading. Ibuprofen (400 mg, 600 mg, 800 mg), paracetamol (1000 mg, 500 mg), paracetamol 1000 mg/codeine 60 mg, and placebo were investigated to establish the multidimensional pharmacodynamic profiles of each drug on acute pain with calculated effect size estimates.

METHODS

A randomized, double-blind, single-dose, placebo-controlled, parallel-group, single-centre, outpatient, and single-dose study used 350 patients (mean age 25 year, range 18 to 30 years) of homogenous ethnicity after third molar surgery. Primary outcome was sum pain intensity over 6 h. Secondary outcomes were time to analgesic onset, duration of analgesia, time to rescue drug intake, number of patients taking rescue drug, sum pain intensity difference, maximum pain intensity difference, time to maximum pain intensity difference, number needed to treat values, adverse effects, overall drug assessment as patient-reported outcome measure (PROM), and the effect size estimates NNT and NNTp.

RESULTS

Ibuprofen doses above 400 mg do not significantly increase analgesic effect. Paracetamol has a very flat analgesic dose-response profile. Paracetamol 1000/codeine 60 mg gives similar analgesia as ibuprofen from 400 mg, but has a shorter time to analgesic onset. Active drugs show no significant difference in maximal analgesic effect. Other secondary outcomes support these findings. The frequencies of adverse effects were low, mild to moderate in all active groups. NNT and NTTp values did not coincide well with PROMs.

CONCLUSION

Ibuprofen doses above 400 mg for acute pain offer limited analgesic gain. Paracetamol 1000 mg/codeine 60 mg is comparable to ibuprofen doses from 400 mg. Calculated effect size estimates and PROM in our study seem not to relate well as clinical analgesic efficacy estimators.

TRIAL REGISTRATION

NCT00699114.

Morphine alkaloids: History, biology, and synthesis

This chapter provides a short overview of the history of morphine since it's isolation by Sertürner in 1805. The biosynthesis of the title alkaloid as well as all total and formal syntheses of morphine and codeine published after 1996 are discussed in detail. The last section of this chapter provides a detailed overview of medicinally relevant derivatives of the title alkaloid.

The impact of codeine upscheduling on overdoses, Emergency Department presentations and mortality in Victoria, Australia

BACKGROUND AND AIMS

Prior to February 2018, codeine was available over-the-counter (OTC) in Australia as a pharmacist-only medicine (Schedule 3) in low-strength formulations when in combination with simple analgesics. In February 2018, The Advisory Committee on Medicines Scheduling (ACMS) upscheduled codeine-containing medicines (CCM) to Schedule 4 (prescription-only medicine). This study aimed to determine the impact of upscheduling on prescriptions, overdoses and deaths.

METHODS

This study used interrupted time series analysis, a quasi-experimental design, to retrospectively evaluate the impact of upscheduling on overdose poisoning calls to the Victorian Poisons Information Centre (VPIC), Emergency Department (ED) presentations to Austin Health, and deaths reported to the Victorian Coroner from 1 January 2013-31 December 2019.

RESULTS

There was a significant reduction in the trend of high-strength codeine poisoning calls by 0.36 (P = 0.03, 95 % CI = [-0.69, -0.04]). Low-strength codeine poisoning calls to the VPIC reduced by 13.31 (P <0.001, 95 % CI = [-16.80, 9.82]]) calls in February 2018, followed by continued reduction of 0.12 calls per month. High-strength codeine overdose ED presentations reduced in the first quarter of 2018 by 3.72 presentations (P = 0.004, 95 % CI = [-6.13, -1.31]). Low-strength codeine overdose ED presentations after the first quarter of 2018 by 0.33 (P = 0.03, 95 % CI = [-0.63, -0.03]) presentations per month. Codeine-related deaths reduced by 7.19 (P < 0.001, 95 % CI = [-9.44, -4.94]) deaths in February 2018.

CONCLUSIONS

Codeine upscheduling to prescription-only medicine has reduced codeine-related poisoning calls, overdoses and unnatural death in Victoria.

Medical prescription forms of opioid cough suppressants falsified by the patients before and after they switched from OTC to prescription-only in France

BACKGROUND

The French Ministry of Health scheduled opioid cough suppressants as prescription-only drugs on July 12^th , 2017. The present study assessed the impact of this regulation on the diversion modalities of the concerned drugs and the related drug pholcodine by analysing the national OSIAP (Ordonnances suspectes indicateur d'abus possible) database.

METHODS

Medical prescriptions with at least one mention of codeine, dextromethorphan, ethylmorphine, noscapine or pholcodine for cough suppression recorded in 2013-2019 were extracted from OSIAP. Annual mentioning rates were estimated by dividing numbers of mentions over those of prescriptions recorded the year considered. A descriptive analysis compared the characteristics of prescriptions before and after July 12^th , 2017.

RESULTS

Overall, 832 mentions of the requested drugs were retrieved on 827 prescription forms. Codeine was the most frequent (n=809, 8.7%) with 6 additional mentions of codeine/ethylmorphine combination, followed by dextromethorphan (n=11, 0.1%) and pholcodine (n=6, 0.1%). There was no mention of noscapine. Annual mentioning rates varied between 0 and 0.3% for all drugs except codeine. Codeine mentioning rates ranged between 0.3% (n=2) and 0.7% (n=9) before July 12^th , 2017 and increased to 10.1% (n= 61) thereafter in 2017, 16.1% (n=314) in 2018, and 19.8% (n=414) in 2019. The profile of subjects evolved accordingly with an arisen male/female ratio (10.0 versus 1.5 before), a younger age (23 years versus 40 before, p<0.001).

DISCUSSION

The sharp increase of recourse to falsified prescription forms indicates that codeine diversion continues despite a restricted access, whereas the other drugs studied do not seem to have been impacted.

Abnormal white matter within brain structural networks is associated with high-impulse behaviour in codeine-containing cough syrup dependent users

Codeine-containing cough syrup (CCS) is considered as one of the most popular drug of dependence among adolescents because of its inexpensiveness and easy availability. However, its relationship with neurobiological effects remains sparsely explored. Herein, we examined how high-impulse behaviours relate to changes in the brain structural networks. Forty codeine-containing cough syrup dependent (CCSD) users and age-, gender-, and number of cigarettes smoked per day -matched forty healthy control (HC) subjects underwent structural brain imaging via MRI. High-impulse behaviour was assessed using the 30-item self-rated Barratt Impulsiveness Scale (BIS-11), and structural networks were constructed using diffusion tensor imaging and AAL-90 template. Between-group topological metrics were compared using nonparametric permutations. Benjamin-Hochberg false discovery rate correction was used to correct for multiple comparisons (P < 0.05). The relationships between abnormal network metrics and clinical characteristics of CCS dependent (BIS-11 total score, CCS- dependent duration and mean dose) were examined by Spearman's correlation. Structural networks of the CCSD group demonstrated lower small-world properties than those of the HC group. Abnormal changes in nodal properties among CCSD users were located mainly in the frontal gyrus, inferior parietal lobe and olfactory cortex. NBS analysis further indicated disrupted structural connections between the frontal gyrus and multiple brain regions. There were significant correlations between abnormal nodal properties of the frontal gyrus and clinical characteristics (BIS-11 total score, CCS dependent duration and mean dose) in the CCSD group. These findings suggest that the high-impulse behavioural expression in CCS addiction is associated with widespread brain regions, particularly within those in the frontal cortex. Aberrant brain regions and disrupted connectivity of structural network may be the bases of neuropathology for underlying symptoms of high-impulse behaviours in CCSD users, which may provide a novel sight to better treat and prevent codeine dependency in adolescents.

Apoptotic inducement of neuronal cells by codeine: possible role of disrupted redox state and caspase 3 signaling

Background

Codeine, a common drug of abuse, has been reported to induce organ damage; however, there are scanty available data on the effects of codeine on the brain.

Objective

Thus, we tested the hypothesis that redox dysregulation and inflammation of the brain induced by codeine exposure is 8-OHdG and/or caspase 3-dependent.

Methods

New Zealand White rabbits (Oryctolagus cuniculus) received vehicle (control; n = 7), low-dose codeine (4 mg/kg/day p.o; n = 6), or high-dose codeine (10 mg/kg/day p.o; n = 6) for six weeks. Body weight was checked before and after the study.

Results

Findings showed that codeine exposure resulted in redox dysregulation (evident by elevated MDA and H₂O₂ accompanied by reduced enzymatic antioxidant activities), elevated MPO activity, and distorted cytoarchitecture of the brain tissue. The observed codeine-induced redox imbalance and brain inflammation was accompanied by depletion of neuronal and purkinje cells, reduced AchE activity, and elevated 8-OHdG levels and caspase 3 activity.

Conclusions

The current study demonstrates that chronic codeine use induces oxido-inflammatory response and apoptosis of the brain tissue that is associated with neuronal and purkinje cells injury, and impaired AchE activity through 8-OHdG and/or caspase 3-dependent pathway.

•

Codeine led to redox dysregulation and inflammation of the brain.

•

This was accompanied by distorted cytoarchitecture of the brain.

•

Codeine also caused depletion of neuronal and purkinje cells with reduced acetylcholinesterase activity.

•

Codeine-induced brain injury was mediated by upregulation of 8-OHdG/caspase 3 signaling.

Effects of opioids on reproduction in Japanese medaka, Oryzias latipes

To study the effects of exposure of fish to opioid drugs, we exposed Japanese medaka (Oryzias latipes) over a full life cycle to codeine spiked into river water at nominal concentrations of 100, 1,000 and 25,000 ng/L and to fentanyl spiked into river water at nominal concentrations of 5, 25 and 1,000 ng/L. The measured concentrations during medaka exposures were consistent with the nominal concentrations. Treatments with codeine at all test concentrations reduced the number of eggs produced by female medaka, as well as the number of mature oocytes observed histologically in the ovaries. Exposures to codeine also resulted in altered concentrations of hormones within the hypothalamic-pituitary-gonadal axis, including reduced levels of 17β-estradiol in female medaka. Fentanyl did not affect reproduction or the levels of hormones in medaka at the concentrations tested. Monitoring of surface waters in southern Ontario, Canada downstream of wastewater treatment plants showed that the test concentrations of fentanyl and codeine were environmentally relevant. The results of this work contribute to the literature on the impacts of opioids and other drugs of abuse released into surface waters.

Microscopic features of the rat adrenal gland associated with chronic codeine phosphate administration

Codeine is an opioid analgesic and antitussive that has been widely abused. Some adverse effects noted with its abuse include adrenocortical insufficiency and activation of the hypothalamic-pituitary-adrenal axis. The structural basis for these dysfunctions is not clearly understood. Twenty-five adult male rats were used for the study. They were divided into intervention and control groups that were administered 40 mg/kg of codeine phosphate and normal saline respectively by gavage daily for 50 days. Subsequently, both groups were given normal saline for a further fourteen days to note recovery changes. At day 0, 50 and 64, rats were randomly selected from both groups, euthanized and adrenal glands harvested for histological processing and analysis. At day 50 of codeine administration, the adrenal glands demonstrated an increase in zona fasciculata thickness but a decrease in zona reticularis thickness. Lower values were noted in the volume density of zona reticularis and cells count of the medulla in the experimental compared to the control groups (P-value<0.05). The experimental group also showed an increase in vascularization and connective tissue in the glands. After 14 days of recovery, most of the changes observed in experimental animals were reversed and the adrenal glands in both groups had similar features. A decrease in cell count of the adrenal medulla was however observed (P-value<0.05). In conclusion administration of codeine phosphate causes discernible changes in the microscopic structure of the adrenal gland, most of which appear to be reversed after two weeks recovery period.

β2-adrenergic receptor affinity chromatography with an interaction force analysis model: A method for analysis of active compounds targeting β2-adrenergic receptor

Asthma is one of the most prevalent diseases worldwide, and β₂-adrenergic receptor (β₂AR) agonists have been reported to be highly effective bronchodilators against this disease. In this study, we successfully constructed a novel CHO-β₂AR affinity chromatography (CHO-β₂AR/AC), which was evaluated by infrared spectroscopic and scanning electron microscope (SEM) analysis. In addition, CHO-β₂AR/AC model exhibited good selectivity and reliability with the relative standard deviation smaller than 5.6% after 30 days. Furthermore, an interaction force analysis model was developed based on CHO-β₂AR/AC. The results showed that the interaction force analysis model (Φ•E•pKa) exhibited a strong correlation with equilibrium dissociation constant (K_D) (r²=0.9284, p=0.002) and a good correlation with logarithm of half-maximum effective concentration (pEC₅₀) values (r²=0.7135, p=0.034). In addition, a pool of clinically approved drugs was screened by this CHO-β₂AR/AC model. Codeine wasfound to bind to and activate β₂AR with K_D value of 4.10 × 10^-7 M, leading to increased cyclic adenosine monophosphate (cAMP) production with EC₅₀ of 6.49 × 10^-7 M and reduction of intracellular Ca²⁺ concentration, which in turn relaxes bronchial contraction with EC₅₀ of 2.62 × 10^-6 M. Furthermore, the K_D value and pEC₅₀ of codeine were within the 95% prediction range of the interaction force analysis model. The results indicate that the CHO-β₂AR/AC with interaction force analysis model constructed in this study can be used to effectively and rapidly screen active compounds targeting β₂AR.

Codeine-induced sperm DNA damage is mediated predominantly by oxidative stress rather than apoptosis

ABSTRACTBackground: Opioids have been implicated to induce infertility. Although codeine remains the most used opioid for recreational purpose, no study has documented its effect on sperm quality. Elucidating the effect of codeine on sperm cells and the associated mechanisms may provide an insight into preventing drug-induced sperm damage. Twenty-one New Zealand white rabbits were randomized into three groups; control and codeine-treated. The codeine-treated groups received either 4 or 10mg/kg b.w of codeine for six weeks.Results: Codeine treatment led to significant decrease in sperm count, motility, viability, normal morphology, and sperm membrane integrity. This was associated with significant rise in sperm DNA fragmentation, oxidative damage, and caspase 3 activity. The percentage of sperm DNA fragmentation correlates positively with 8-hydroxy-2'-deoxyguanosine, a biomarker of oxidative DNA damage, and caspase 3 activity, a biomarker of apoptosis. The observed correlation was stronger between sperm DNA fragmentation and oxidative DNA damage than sperm DNA fragmentation and caspase 3 activity.Conclusion: This study revealed that chronic codeine exposure causes sperm DNA fragmentation and poor sperm quality primarily via oxidative stress rather than activation of caspase 3-dependent apoptosis. Findings of the present study may explain drug-induced male factor infertility, particularly, those associated with opioid use.

A Study in a Greek Cohort

OBJECTIVE

To assess CYP2D6 genotype prevalence in chronic pain patients treated with tramadol or codeine.

DESIGN

Prospective cohort study.

SETTING

General hospital, pain management unit.

SUBJECTS

Patients with chronic pain, treated with codeine or tramadol.

METHODS

Patients' pain was assessed at baseline (numeric rating scale [NRS]; 0-10). Prescription of codeine or tramadol was selected randomly. The assessment of patients' response to the drug in terms of pain relief and adverse effects was performed after 24 hours. Reduction of pain intensity of >50% or an NRS <4 was considered a positive response. Patients' blood samples were collected during the first visit. Genotyping for the common variants CYP2D6 *2, *3, *4, *5, *6, *9, *10, *14, and *17 was performed, and alleles not carrying any polymorphic allele were classified as CYP2D6*1 (wild-type [wt]).

RESULTS

Seventy-six consecutive patients were studied (20 males, 56 females), aged 21-85 years. Thirty-four received tramadol and 42 codeine. The main genotypes of CYP2D6 identified were the wt/wt (35.5%), the *4/wt (17.1%), and the *6/wt (10.5%). Adverse effects were common, especially in carriers of *9/*9, *5/*5, *5/*4, and *10/*10, as well as in variants including the 4 allele (*4/*1 [38.4%] and *4/*4 [42.8%]).

CONCLUSIONS

Genotyping can facilitate personalized pain management with opioids, as specific alleles are related to decreased efficacy and adverse effects.

The effect of codeine administration on oxidative stress biomarkers and the expression of the neuron-specific enolase in the brain of Wistar rats

The study aimed to assess the effects of codeine medication on some oxidative stress parameters and how it affects the expression of enolase in neuronal cells. The codeine medication used for the study was Archilin™ with codeine syrup and dihydrocodeine 30 mg. The study used 30 male Wistar rats which were grouped in five: A, B, C, D, and E (n = 6), while treatments were administered for 21 days. Based on the LD₅₀s of 6.09 ml/kg body weight (b.wt.) Archilin™ with codeine syrup and 3.145 mg/kg b.wt. dihydrocodeine, group A served as control and were given normal saline; groups B and C were treated with 1 mg/kg and 2 mg/kg b.wt. dihydrocodeine, respectively; while groups D and E were treated with 2 ml/kg and 4 ml/kg b.wt. Archilin™ with codeine syrup, respectively. After treatments, animals were sacrificed via cervical dislocation and the brains were harvested and prepared for determination of oxidative stress biomarkers as well as immunohistochemical studies of neuron-specific enolase (NSE) to assess for neuronal cell integrity. Significantly decreased mean values (p < 0.05) of superoxide dismutase (SOD) and catalase (CAT) activities were observed while malondialdehyde (MDA) is significantly increased (p < 0.05) among treated groups. The expression of enolase was downregulated in treatment groups when compared to control. Animals in group A which are control showed strong staining intensity of the prefrontal cortex compared to groups C, D, and E which showed mild staining. The scoring of group A for cerebellum showed strong staining intensity, groups B and C showed mild staining, while groups D and E showed weak staining intensity. From the findings of this study, prolonged codeine syrup administration causes oxidative stress and this affects the expression of enolase in neuronal cells resulting in glucose hypometabolism which eventually results in functional brain failure.

Codeine induces increased resistance at the esophagogastric junction but has no effect on motility and bolus flow in the pharynx and upper esophageal sphincter in healthy volunteers: A randomized, double-blind, placebo-controlled, cross-over trial

BACKGROUND

Chronic opioid use can induce esophageal dysfunction with symptoms resembling achalasia and a manometric pattern of esophagogastric junction-outflow obstruction (EGJ-OO). However, the effect of opioids in acute setting on pharyngeal function and esophageal body contractility has not been investigated.

METHODS

After positioning the high-resolution impedance manometry (HRiM) catheter, codeine (60 mg) or placebo (glucose syrup) was infused intragastrically. Forty-five minutes post-infusion, participants received liquid, semi-solid, and solid boluses to assess esophageal and pharyngeal function. HRiM analysis was performed adhering to the Chicago classification v3.0. (CC v3.0). Pressure flow analysis (PFA) for the esophageal body and the pharynx was performed using the SwallowGateway™ online platform.

KEY RESULTS

Nineteen healthy volunteers (HV) [5 male; age 38.3] were included. After codeine administration, higher integrated relaxation pressure 4 s values resulted in significantly reduced deglutitive EGJ relaxation and distal latency was significantly shorter. Distal contractility was similar in both conditions. Bolus flow resistance at the EGJ and distention pressures increased significantly after codeine infusion. Based on CC v3.0, acute infusion of codeine induced EGJ-OO in six HV (p = 0.0003 vs. placebo). Codeine administration induced no significant alterations in any of the pharyngeal PFA metrics.

CONCLUSIONS & INFERENCES

In HV, acute administration of codeine increased bolus resistance at the EGJ secondary to induced incomplete EGJ relaxation leading to major motility disorders in a subset of subjects including EGJ-OO. However, an acute single dose of codeine did not affect motility or bolus flow in pharynx and UES. ClinicalTrials.gov number, NCT03784105.

Alterations in the biochemical indices in Wistar rats exposed to an overdose of codeine and dextromethorphan

OBJECTIVE

This study investigates the impact of repeated oral exposure to two cough syrups containing codeine and dextromethorphan (DXM) on male Wistar rats.

METHODS

We divided 35 rats into seven groups of five rats each. Group A was given 0.5 mL of distilled water, Groups B, C, and D were given 0.1, 0.2 and 0.4 mL/kg body weight (b. w) of cough syrup containing codeine (CSC), respectively, and Groups E, F, and G were administered 0.1, 0.2 and 0.4 mL/kg b. w of cough syrup containing DXM, respectively. The treatment was continued for 28 days. The rats were euthanised under mild diethyl ether anaesthesia. The kidney, liver, and blood of the rats were examined for further analyses.

RESULTS

Significant (p < 0.05) alterations were observed in the liver function tests: ALT, AST, ALP, albumin, and total bilirubin. All doses of CSC and DXM significantly increased the ALT levels (p < 0.05). Furthermore, similar significant alterations were observed for the kidney function parameters such as creatinine, urea, and uric acid (p < 0.05). All doses of DXM caused significant elevations in the levels of urea (p < 0.05). The histopathological evaluations also showed slight changes in the architecture of the liver, kidney, and brain tissues.

CONCLUSION

The findings of this study suggest that overdose of these cough syrups may predispose the consumer to hepatic and renal injuries.

Zebrafish (Danio rerio) larvae show behavioral and embryonic development defects when exposed to opioids at embryo stage

Opioid abuse continues to plague society, and in recent years, there has been an epidemic, leading to increased addiction and death. It is poorly understood how prenatal opioid use affects the lives of children. The aim of this work was to evaluate the effect of early embryonic codeine or morphine exposure in zebrafish (Danio rerio), examining gastrulation progression (epiboly), teratogenic effects, mortality and locomotor behavior response to light/dark cycles. Zebrafish embryos were exposed to codeine or morphine (designated C or M) at 1, 5 or 10 mg/L (designated 01, 05 or 10, respectively) from 3 to 24 h postfertilization (hpf) or from 3 to 48 hpf (designated -24 or - 48 for 1 or 2 days of exposure, respectively). The C10-24, C01-48, C05-48 and C10-48 groups showed significantly smaller eyes than control larvae at 7 days postfertilization (dpf). Locomotor behavior of control larvae in light/dark cycles showed greater swimming time and distance in dark cycles. Two-day codeine exposure produced strong effects, showing no significant response due to light/dark cycles in distance moved. Morphine exposed groups showed similar effects as observed in 2-day codeine exposed groups, showing less large movement activity and also no significant difference between inactive duration in response to light/dark cycles. In conclusion, we observed low teratogenic effects and mortality effects. Animals exposed to high levels and higher exposure times of opioids were hypoactive, relative to controls, in the dark period. Future studies will be needed to understand the neural defects producing behavior changes.

Functional phenotyping of the CYP2D6 probe drug codeine in the horse

Background

In humans, the drug metabolizing enzyme CYP2D6 is highly polymorphic resulting in substantial differences in the metabolism of drugs including anti-arrhythmics, neuroleptics, and opioids. The objective of this study was to phenotype a population of 100 horses from five different breeds and assess differences in the metabolic activity of the equine CYP2D6 homolog using codeine as a probe drug. Administration of a probe drug is a common method used for patient phenotyping in human medicine, whereby the ratio of parent drug to metabolite (metabolic ratio, MR) can be used to compare relative enzyme function between individuals. A single oral dose of codeine (0.6 mg/kg) was administered and plasma concentrations of codeine and its metabolites were determined using liquid chromatography mass spectrometry. The MR of codeine O-demethylation [(codeine)/(morphine + morphine-3-glucuronide + morphine-6-glucuronide)] was determined using the area under the plasma concentration-time curve extrapolated from time zero to infinity (AUC_0-∞) for each analyte and used to group horses into predicted phenotypes (high-, moderate-, and low-MR).

Results

The MR of codeine O-demethylation ranged from 0.002 to 0.147 (median 0.018) among all horses. No significant difference in MR was observed between breeds, age, or sex. Of the 100 horses, 11 were classified as high-MR, 72 moderate-MR, and 17 low-MR. Codeine AUC_0-∞ and O-demethylation MR were significantly different (p < 0.05) between all three groups. The mean ± SD MR was 0.089 ± 0.027, 0.022 ± 0.011, and 0.0095 ± 0.001 for high-, moderate-, and low-MR groups, respectively. The AUC for the morphine metabolites morphine-3-glucuronide and morphine-6-glucuronide were significantly different between high-and low-MR groups (p < 0.004 and p < 0.006).

Conclusions

The MR calculated from plasma following codeine administration allowed for classification of horses into metabolic phenotypes within a large population. The range of codeine metabolism observed among horses suggests the presence of genetic polymorphisms in CYP2D82 of which codeine is a known substrate. Additional studies including CYP2D82 genotyping of high- and low-MR individuals are necessary to determine the presence of CYP2D polymorphisms and their functional implications with respect to the metabolism of therapeutics.

Determinants of prescription opioid use: population-based evidence from Finland

BACKGROUND AND AIMS

Previous studies have shown that prescription opioid use is more common in socio-economically disadvantaged communities in the United States. This study examined the area and individual-level determinants of prescription opioid use in Finland during the period 1995-2016.

DESIGN

Logistic regression analysis using nation-wide data on filled opioid-related prescriptions dispensed at Finnish pharmacies and covered by National Health Insurance. Opioid consumption was linked, using personal identification codes, to population-based data maintained by Statistics Finland, which records individual background and area-level characteristics.

SETTING AND PARTICIPANTS

Working-age population aged between 15 and 64 years in Finland during the periods 1995-2007 (n = 4 315 409) and 2009-16 (n = 4 116 992).

MEASUREMENTS

Annual prescription opioid use was measured using defined daily doses (DDD) and whether people used opioids during a year.

FINDINGS

Prescription opioid use increased in Finland from 1995 to 2016 (from less than 1 to 7%), but the increase was explained by the change in the treatment of codeine-based opioids in National Health Insurance. The area-level unemployment rate was positively correlated with the share of opioid users at the municipal level (r = 0.36; P < 0.001). In comparison with being employed, being outside the labour force was associated with increased opioid use in 1995-2007 [odds ratio (OR) = 2.22, 95% confidence interval (CI) = 2.10-2.36] and non-codeine opioid use in 2009-16 (OR = 2.16, 95% CI = 2.06-2.27), but not with codeine opioid use in 2009-16.

CONCLUSIONS

Prescription opioid use in Finland appears to be more common among low socio-economic status people, similar to the United States and the United Kingdom.

Codeine-induced hepatic injury is via oxido-inflammatory damage and caspase-3-mediated apoptosis

Codeine (3-methylmorphine) is a known analgesic, antitussive, and antidiarrheal drug that is often abused for recreational purposes. It is metabolized in the liver via the cytochrome P450 system and thus hypothesized to induce hepatic injury especially when misused. Thus, the present study aimed at investigating changes in liver function, hepatic enzyme biomarker, proton pumps, antioxidant status, free radicals and TNF-α levels, as well as caspase 3 activities and hepatic DNA fragmentation after 6 weeks of oral codeine administration. Twenty-one male rabbits were randomized into 3 groups (n = 7). The control group had 1 ml of normal saline, while the low-dose and high-dose codeine groups received 4 and 10 mg/kg b.w of codeine respectively daily. The codeine-treated animals had significantly lower levels of serum proteins, increased activities of hepatic enzyme biomarkers and caspase 3, raised hepatic concentrations of free radicals and TNF-α, as well as increased hepatic DNA fragmentation. Codeine treatment also led to a significant decline in hepatic weight, activities of hepatic enzymatic antioxidant, Na⁺-K⁺-ATPase and Ca²⁺-ATPase. These alterations were more pronounced in high-dose codeine treated animals than in the low-dose group. Histopathological study showed moderate fatty degeneration of hepatic parenchyma, infiltration of the portal tract by inflammatory cells with dense collagen fibre deposition in codeine-treated animals. The present study revealed that codeine induced liver injury and hepatic DNA damage via caspase 3-dependent signaling by suppressing hepatic antioxidant status and enhancing free radical and TNF-α generation.

Identification of factors influencing tampering of codeine-containing medicines in England: a qualitative study

Background

Tampering of psychoactive medicines presents challenges to regulation and public health. However, little is currently known about what influences the decisions to treat codeine-containing medicines (CCM) with cold water extraction (CWE) from the perspective of individuals employing these techniques. The article identifies factors influencing utilisation of CWE to separate codeine from compounded analgesics, such as paracetamol and ibuprofen, found in CCM.

Methods

Purposive sampling of 27 participants residing in England who took part in a qualitative interview. Of these, 14 individuals (11 males and 3 females) reported tampering of psychoactive medicines, and the relevant transcripts were included in the analyses for the study. Participants were recruited from one addiction treatment service and from an online survey. The mean age of the participants was 31.5 years (range = 18–42 years). Qualitative data analysis followed the processes of iterative categorization (IC). The codes ‘harm reduction’, ‘information sources’ and ‘changes on the drug markets’ were grouped and summarised. The coding of the data was done in a Microsoft® Word document.

Results

Two groups of participants were identified in the data analysis: (i) individuals who used CCM (n = 5), and (ii) individuals who used CCM and heroin (n = 9). Participants in both groups used CWE due to concerns of paracetamol overdose from the use of excessive dosages of CCM. For both of them, information obtained from the internet encouraged the use of CWE. Participants using CCM described how the many steps involved in conducting CWE, including sourcing codeine boxes from pharmacies (over the counter), presented a barrier against using CWE. Participants using CCM and heroin explained how reduced availability in the local heroin supply influenced utilisation of CWE techniques to maintain their use of opioids and avoid withdrawal. Withdrawal symptoms and cravings outweighed the concerns about the quality of the extracted codeine mixtures in this participant group, especially the ability of CWE to remove paracetamol and tablet fillers.

Conclusions

Utilisation of CWE of codeine was influenced by several factors including drug market supply, the availability of detailed information on the internet about CWE and restrictions on codeine sourcing in pharmacies. Risks identified with CWE include consumption of unknown doses of paracetamol if the CWE techniques are not used correctly. Attempts at extracting codeine from CCM should be considered in risk assessments of opioid medicines.

Is South Africa being spared the global opioid crisis? A review of trends in drug treatment demand for heroin, nyaope and codeine-related medicines in South Africa (2012-2017)

INTRODUCTION

South Africa has seen a sharp increase in treatment admission trends for opioids despite beliefs that rates of opioid use remain low and do not represent a major problem. To advocate for the extension of Opioid Use Disorder (OUD) treatment and harm minimisation services in South Africa, better estimates of the extent of opioid use is needed. This paper responds to this need by describing (i) trends in treatment utilization for opioid-related problems in South Africa and (ii) differences in the profile of patients accessing treatment for different classes of opioids - heroin, 'nyaope' and codeine use.

METHODS

Data were collected from 83 specialist treatment centres participating in the South African Community Epidemiology Network on Drug Use between 2012 and 2017. Descriptive analyses were conducted to describe the sociodemographic profile of patients and multiple logistic regression was used to explore socio-demographic and clinical factors associated with admission to treatment for opioid use disorders (OUD) .

RESULTS

From January 2012 to December 2017, data from 11 2032 treatment episodes were collated. Of these, 20 319 (18.1%) were from patients admitted for an OUD. Over time, the proportion of overall opioid-related admissions increased significantly from 16.1% of all admissions in 2012 to 20.0% in 2017 (p <0.001). Data also suggests a significant increase in the overall proportion of patients reporting injection drug use, from 1.6% in 2013 to 3.5% in 2017 (p <0.001). Clear differences in employment status, referral sources between classes of opioids were also noted.

CONCLUSION

Over the last 5 years, South Africa has seen an increase in the proportion of opioid related disorders (OUD) treatment admissions. Public health interventions, evidence-based harm reduction approaches and improving access to treatment are among the interventions urgently needed to reduce the harms associated with the increased use of opioids in South Africa.

Comparison between isolated and associated with codeine acetaminophen in pain control of acute apical abscess: a randomized clinical trial

OBJECTIVES

The study aimed to compare the acetaminophen administration efficacy or its combination with codeine for pain control in acute apical abscesses cases.

MATERIALS AND METHODS

Thirty-nine patients who sought emergency treatment in the Faculty of Dentistry of the Federal University of Rio Grande do Sul were included, all of them with acute apical abscess diagnosis. These patients were divided into two groups: acetaminophen group-prescription of acetaminophen (1000 mg) and acetaminophen-codeine group-prescription of acetaminophen (1000 mg) + codeine (30 mg), both with oral intake every 6 h for 3 days. The pain scores were recorded by the patients on their own at 6, 12, 24, 48, and 72 h after finishing clinical assistance, by filling a pain evolution journal, containing a visual analogue scale (VAS). Student t test was conducted to investigate different mean ages between groups 1 and 2. A comparison of weight and means of initial pain scores between groups was carried out using the Mann-Whitney U test. Chi-square test was performed to compare gender, affected tooth, education, initial swelling, and frequency of adverse effect between test and control groups. Mann-Whitney U test was applied to compare groups in the same period. Friedman's test was used to compare results from the same group over time.

RESULTS

Both groups showed score reduction over time (P < 0.05). Paracetamol-codeine group showed significant pain score reduction at 48 h registers when compared to baseline and at 6 h scores (P < 0.05). Further, pain scores at 72 h were significantly lower, when compared to the baseline, at 6 h, and at 12 h scores (P < 0.05). Acetaminophen group showed significant pain score reduction observed at 72 h, when compared to the baseline and at 6 h scores (P < 0.05). There were no significant differences in pain score reduction over time between groups (P > 0.05). There was no difference between the groups regarding the frequency of adverse reactions (P > 0.05).

CONCLUSION

Both medications were effective for pain control in acute apical abscess cases. The findings might have inferred in pain control of acute apical abscess associated pain in patients who used an antibiotic drug. External validity of the findings for acute apical abscess cases with no need for an antibiotic prescription is uncertain.

CLINICAL RELEVANCE

This paper suggests acetaminophen 1000 mg can be used for pain control in the treatment of acute apical abscess associated with systemic manifestation.

Angiotensin converting enzyme-2 as therapeutic target in COVID-19

The pandemic of coronavirus disease 2019 (COVID-19) is a global health emergency that poses a significant threat to world people's health. This outbreak causes major challenges to healthcare systems. Given the lack of effective treatments or vaccine for it, the identification of novel and safe drugs against COVID-19 infection is an urgent need. Angiotensin-converting enzyme 2 (ACE2) is not only an entry receptor of the SARS-CoV-2 virus, the virus that causes COVID-19, but also can protect from lung injury. In this view, we highlighted potential approaches to address ACE2-mediated SARS-CoV-2 virus, including 1) delivering an excessive soluble form of ACE2 (recombinant human ACE2: rhACE2) and 2) inhibition of the interaction between SARS-CoV-2 virus and ACE2 by some compounds with competitive effects (morphine and codeine). Further clinical trials in this regard can reveal a more definite conclusion against the COVID-19 disaster.

Exploring Australian pharmacists' perceptions and attitudes toward codeine up-scheduling from over-the-counter to prescription only

Objective:

Explore the perceptions, attitudes and experiences of pharmacists relating to the up-scheduling of low dose codeine containing analgesics and the impact on pharmacy practice.

Methods:

A mixed design method was used consisting of an anonymous online questionnaire survey to quantitatively capture broad pre-scheduling change perceptions paired with a series of in-depth post-scheduling semi-structured interviews to provide a qualitative picture of the impact of codeine up-scheduling on pharmacy practice in Australia.

Results:

A total of 191 pharmacists completed the quantitative survey and 10 participated in the in-depth interview. The majority of respondents supported the decision to up-schedule over-the-counter combination products containing codeine to some degree. Three main themes emerged from the data: pharmacists’ perceptions of the codeine up-scheduling decision, preparing for the up-schedule and impact of the up-schedule on pharmacy practice. Pharmacists were concerned about the impact of up-scheduling on the pharmacy business, patient access to pain relief and the diminishment of their professional role.

Conclusions:

There were diverse perceptions, preparedness and impact on practice regarding the up-scheduling of low dose codeine products. Further research should be conducted to gauge if and how these perceptions have changed over time and to identify whether pain is being managed more effectively post codeine up-scheduling.

Prevalence and Health Characteristics of Prescription Opioid Use, Misuse, and Use Disorders Among U.S. Adolescents

PURPOSE

The prevalence of past-year prescription opioid use (POU), nonmedical POU (NMPOU), and POU disorder (POUD) and their correlates were examined in a national sample of American adolescents (N = 41,579).

METHODS

This study used data from the public-use files of the 2015, 2016, and 2017 National Surveys on Drug Use and Health, which captured substance use and mental health problems among noninstitutionalized individuals. Prevalence and specific types of prescription opioids and other substances used and misused in the past year were examined among adolescents. Logistic regression analyses were conducted to determine correlates (demographics, other substances used, past-year major depressive episode, school enrollment, two-parent household, number of lifetime medical conditions, and survey year) of POU, NMPOU, and POUD.

RESULTS

Multiple substance use was common within the past year. The most frequently used prescription opioids were hydrocodone, codeine, oxycodone, and other opioids among adolescents. Cannabis use disorder and alcohol use disorder were comparatively prevalent among opioid misusers. Several correlates (demographics, other substances used, lifetime medical conditions, major depressive episode, and survey year) of POU, NMPOU, and POUD were found.

CONCLUSIONS

In this national sample, multiple substance use was common among adolescents with past-year POU and NMPOU. Clinical screening for opioid use problems, assessment, and treatment expansion for POUD can focus on persons with substance use, mental health, and/or behavioral problems. Longitudinal studies are needed to better elucidate temporal associations between POU and NMPOU/POUD among adolescents, and more prevention and treatment research on rural residents and minority groups is needed.

The views of Australian adults experiencing pain on the upscheduling of codeine-containing analgesics to 'prescription only'

Background Codeine is one of the most commonly used opioids worldwide and is available in different formulations, often combined with other simple analgesics. There is a growing concern of the potential harms associated with codeine misuse in the Australian community, and for this reason codeine containing analgesics have been upscheduled in Australia to 'prescription only medicines' from February 2018. There is currently limited knowledge on the views of Australian adults experiencing pain symptoms on this codeine restriction, and whether this change has impacted their ability to adequately manage their pain. Objective To investigate the views of adults experiencing pain on the 2018 codeine upscheduling in Australia. Setting Adults experiencing pain symptoms, predominantly recruited from Victoria, Australia. Method A descriptive cross-sectional study was conducted using a pre-tested customised anonymous self-administered questionnaire between January and March 2019. To capture a broad range of demographics, participants were recruited from ten Victorian community pharmacies across metropolitan Melbourne, Australia. Main outcome measure Opinions of Australian adults experiencing pain to targeted questions regarding the 2018 codeine upscheduling, including perceived advantages and disadvantages. Results A total of 120 participants completed the questionnaire. Sixty-two (52%) participants agreed/strongly agreed that codeine was helpful in alleviating pain symptoms before a prescription was required; while 43% of participants felt the codeine restriction has made it more difficult to manage their pain, with 33% unsure. Participants who were in favour of the codeine upscheduling believed that they are now more encouraged to consult healthcare professionals and make better use of the pain management services made available to them in the Australian community; however some now question the value of pharmacists in this context, given that there is now a reduced array of analgesic medicines available at pharmacies without a prescription. Conclusion This study showed there are mixed views, with some participants being unsure or not in favour of the codeine upscheduling, particularly based on qualitative responses. There is also opportunity in this space for healthcare providers to extend beyond standard practice and offer alternative pain management advice and support now that codeine is no longer available in Australian pharmacies without a prescription.