Codeine Misuse Research Articles

The misuse of codeine containing medicines: Perceptions and behaviours of qualified pharmacy professionals.

Pharmacy professionals working in community pharmacies frequently provide pharmacist-initiated therapy, including codeine-containing medicines. Codeine is an opioid with great potential for misuse, adding to the global opioid epidemic burden. Professional pharmacy personnel are the first intervention point in relation to management of codeine use. This study highlights the importance of pharmacy professionals' perceptions and behaviours in combatting the opioid epidemic. A descriptive cross-sectional study was conducted. Simple random sampling included pharmacy professionals in the metropolitan city of Johannesburg. An electronic questionnaire was distributed via e-mail and data analysed descriptively. Findings indicate that pharmacy personnel routinely ask patients about codeine use (n= 48; 53.9%), avoid dispensing over-the-counter (OTC) codeine as an initial treatment (n= 61; 69%) and express confidence to identify and manage codeine misuse (n= 69; 77.5%). Despite this, increased patient demands for OTC codeine (n= 69; 77.5%) were concerning, highlighting the ease of availability from internet sources (n= 76; 85.4%) and multiple pharmacies (n= 84; 94.4%). Apprehension about the lack of patient awareness on adverse health consequences (n= 66; 74.2%) and the risk of codeine dependence (n= 79; 88.8%) was expressed. Growing concern regarding availability and accessibility of codeine-containing medicines within the community pharmacy sector is highlighted. Adverse health consequences of codeine misuse and dependence are not understood by customers and the ineffective information provided by pharmacy personnel was highlighted as a concern.Contribution:The results of this study give insight to the influence of dispensing personnel's attitude towards the growing challenges with respect to codeine containing medication abuse.

Combining Q methodology and interviews using mixed methods integration: an exemplar study exploring over-the-counter codeine misuse in Australia

ABSTRACT Q methodological studies often incorporate post-Q sort interviews to facilitate and enrich the interpretation of identified factors. This article describes a novel approach in which Q methodology and interviews comprise separate strands which are analyzed separately then converged for further analysis. The new approach is exemplified in a study exploring over-the-counter codeine misuse in Australia. The Q methodology and interview results are summarized, integrated and then discussed, including methodological challenges. This article contributes to scholarly literature by introducing and illustrating the applicability of using mixed methods integration to combine Q methodology and interviews; providing new insights into over-the-counter codeine misuse; and proposing ‘unique contribution’ as an alternative descriptor to the integration fit of ‘silence’.

Ameliorative Capacity of Rice Husk Extract on Codeine-induced Testicular Dysfunction in Male Wistar Albino Rats

Rice husks (RHs) is an agro waste generated from rice production with limited application. Codeine belongs to the numerous drugs of abuse worldwide and its impact on reproductive injury has been reported. This study was designed to establish the ameliorative potential of brown rice husk extract (RHE) against reproductive damage induced by codeine misuse. Experimental rats were grouped into six groups with six rats per group: Group I received only rat chow and clean water for 30 days. Group II received only codeine 10 mg/kg body weight (b.w) of rats. Group III received only RHE 500 mg/kg b.w of rats. The 4th, 5th and 6th groups received codeine 10 mg/kg/b.w alongside 250 mg, 500 mg and 1000 mg RHE, respectively. Treatments (RHE and codeine) were administered once during the early hours between 9-10 am daily for 30 days, the animals were sacrificed, and blood and tissue samples were harvested. Male reproductive hormones such as testosterone, Follicle stimulating hormone (FSH) and luteinizing hormone (LH), and sperm quality parameters were assayed. The testis tissues were excised and examined for histopathological changes. The result revealed that high dose codeine administration significantly decreased epidermal morphology, motility, and sperm count as well as testosterone, FSH, and LH concentrations, respectively. The histopathological examination revealed distinct abnormal changes in the codeine control group when compared with the other experimental groups. RHE administration significantly improved the altered assayed parameters.

Simultaneous determination of some opioid drugs using Cu-hemin MOF@MWCNTs as an electrochemical sensor.

Due to its toxicological and pharmacological activity, the misuse and overuse of morphine (MO), codeine (CO), and heroine have attracted attention in the medical and forensic toxicology fields. This study proposed a new electrochemical sensor with an acceptable detection limit, linear range, and selectivity for simultaneous determination of MO and CO. This sensor is based on Cu-Hemin metal-organic framework (CHM) and multiwall carbon nanotubes (MWCNTs). First, a facile chemical method was chosen to synthesize CHM and then composite it with MWCNTs. Afterward, the structure of CHM@MWCNTs was verified by XRD, FT-IR, Raman spectroscopy, UV-vis, ICP-OES, FE-SEM, EDX, and elemental mapping. In the next step, under optimal conditions, this electrochemical sensor can sensitive simultaneous determination of MO and CO, showing a dynamic concentration range from 0.09 to 30μM for both species and a low detection limit of 9.2nM and 11.2nM for MO and CO, respectively. Moreover, the applicability in real samples was confirmed by the simultaneous determination of MO and CO in human urine and MO injection. This work reveals a trustable sensor based on MOF and MWCNTs to simultaneously determine opioid drugs in clinical application.

Exploring Over the Counter and Prescription Only Medication misuse amongst adults accessing specialist treatment services: A survey during COVID-19

IntroductionAn improved understanding of Over the Counter (OTC) and Prescription Only Medication (POM) misuse by people who access substance misuse services (SMS) is essential so that appropriate treatment interventions can be provided. There is growing awareness and concerns about this issue, especially during COVID-19; however, there is a paucity of published data (1, 2).AimTo use a questionnaire to explore the misuse of OTC/POM by adults accessing SMS, including the types of medication involved, demographic characteristics, the use of other substances and changes during COVID-19.MethodsFollowing successful piloting, an anonymous (online/paper) self-administered survey was completed by English-speaking adults (18 years or over) currently accessing SMS with a purposive sampling approach. This was undertaken in community SMS across England, provided by one of the UK’s largest third sector organisations. Quantitative analysis was undertaken using SPSS and thematic analysis for qualitative data.ResultsIn 2021, 80 questionnaires were completed, and the 56 that met the inclusion criteria were analysed. All were caucasian (94.6% British), aged between 18 and 61 years and the majority identified as male (58.9%). Forty respondents (71.4%) were in receipt of prescribed interventions for their use of substances, with an adherence rate of 92.5% despite increased liberalisation of dispensing arrangements and additional challenges during COVID-19. In the preceding month 44.6% used alcohol (52% daily), 73.2% used tobacco/vaped and 58.9% used illicit substances concomitantly. Twenty-one (37.5%) reported misusing more than one OTC/POM, route of administration was predominantly oral and ease of their availability was conveyed. Relationships between categories were tested using chi-square/Fisher’s exact test and statistically significant relationships (p <0.05) were identified between the misuse of codeine and the prescribing of oral opioid substitute treatment, and changes during COVID-19 to OTC/POM and illicit misuse. Generally respondents were very complimentary about SMS, outlining the positive impact of accessing pharmacological and psychosocial interventions. However, the need for more training/education and psychologically informed approaches by GPs and pharmacies was highlighted: there was a theme of primary care restrictions on access to medicines leading to escalating OTC/POM misuse and increased use of unregulated illicit sources.ConclusionConducting research during a pandemic is exceptionally challenging. OTC/POM misuse is occurring amongst people accessing SMS and polypharmacy is concerning. A renewed approach to liberalisation, withdrawal management and training for primary care professionals must be considered. Improvements at a systems-level and changes to commissioning/national pathways may assist this and further research is required to explore the themes identified.References(1) Gittins R, Missen L, Maidment I. Misuse of medication in adult substance misuse services: a systematic review protocol. BMJ Open 2021;11:e047283. doi: 10.1136/bmjopen-2020-047283(2) Gittins R, Cole S. Buprenorphine for the management of kratom dependency during covid-19: A case report. Drug Science, Policy and Law. January 2021. doi:10.1177/20503245211021193

Physician Perspectives on Codeine Accessibility, Patterns of Use, Misuse, and Dependence in Saudi Arabia

In Saudi Arabia, there are concerning rates of non-compliance with pharmaceutical regulations prohibiting the pharmacy dispensing of prescription-only medications without a physician prescription. This is the first study in the Middle East which examines physicians’ perceptions regarding misuse of codeine, listed as a narcotic, controlled, and prescription-only drug. The CODEMISUSED survey was adapted to the Saudi Arabian context and pilot tested, prior to cross-sectional administration to physicians in Riyadh, Jeddah, Abha, and Jazan (n = 105). Descriptive statistics (frequencies and percentage) present physician level of agreement, neutrality, and disagreement with statements regarding codeine prescribing, patient awareness and use, online and community pharmacy availability, and dependence. The study indicates concern by physicians regarding patient intentional use of codeine to enhance mood, misuse patterns, lack of awareness around habit-forming use and iatrogenic dependence, and sourcing via illegal dispensing. It underscores the imperatives to address pharmacy compliance with pharmaceutical regulatory controls, implement enhanced pharmacovigilance, and improve awareness around safe use.

The impact of guidance on the supply of codeine-containing products on their use in intentional drug overdose.

BackgroundConcerns about the misuse of codeine led to the introduction of guidance restricting the supply of over-the-counter (OTC) codeine-containing products in Ireland in 2010. The aim of this study was to examine the impact of this guidance on the national rate of hospital-presenting self-harm involving codeine-related intentional drug overdose (IDO).MethodsPresentations involving IDO to Irish general hospitals between 1 January 2007 and 31 December 2013, as recorded by the National Self-Harm Registry Ireland, were analyzed. Event-based rates per 100 000 were calculated using national population data. Poisson regression models were used to assess rate changes between pre- and post-guidance periods and to calculate excess presentations.ResultsBetween January 2007 and December 2013, a total of 57 759 IDOs were recorded, with 4789 (8.3%) involving a codeine-containing product. The rate of codeine-related IDOs was 20% lower in the period following implementation of the guidance (incidence rate ratio: 0.80; 95% CI: 0.75 to 0.85), representing a total of 509 (95% CI: −624, −387) fewer codeine-related IDOs in that period. Reductions were observed across all ages and were more pronounced for females (0.76, 0.71 to 0.82) than males (0.87, 0.79 to 0.97). The rate of IDOs involving other drugs decreased by 3% in the same period (0.97, 0.95 to 0.98).ConclusionOur findings indicate that the rate of codeine-related IDOs was significantly lower in the period following the implementation of the guidance. There is a large body of evidence supporting the restriction of potentially harmful medication as an effective strategy in suicide prevention.

A Review of Analytical Methods for Codeine Determination.

Codeine is derived from morphine, an opioid analgesic, and has weaker analgesic and sedative effects than the parent molecule. This weak opioid is commonly used in combination with other drugs for over-the-counter cough relief medication. Due to the psychoactive properties of opioid drugs, the easily obtained codeine often becomes subject to misuse. Codeine misuse has emerged as a concerning public health issue due to its associated adverse effects such as headache, nausea, vomiting, and hemorrhage. Thus, it is very important to develop reliable analytical techniques to detect codeine for both quality control of pharmaceutical formulations and identifying drug misuse in the community. This review aims to provide critical outlooks on analytical methods applicable to the determination of codeine.

Tramadol non-medical use in Four European countries: A comparative analysis

BackgroundUnderstanding prescription medication misuse is challenging due to lack of consistent measures of misuse behaviors and prevalence between countries. Tramadol is an atypical opioid with a dual mechanism, and has low drug liking compared to conventional opioids. We evaluate tramadol misuse compared to conventional opioids utilizing a harmonized validated national survey across four countries: Germany, Italy, Spain, and the United Kingdom (UK). MethodsData from the Survey of Non-Medical Use of Prescription Drugs (NMURx) Program online cross-sectional general population national surveys are analyzed from 2018 from four countries, with 45,000 total responses. Misuse and abuse of tramadol, codeine, morphine, and oxycodone are compared, and national prevalence estimates calculated via calibration weighting. Rates are calculated per population and per drug availability. Supplemental data are included from patients entering treatment centres and poison centre exposures. ResultsIn 2018, distribution, misuse, and abuse of four prescription opioids show similar patterns across four countries. In all countries, codeine is misused by the largest number of adults (estimated 861,181 in Italy to 4,676,680 in Spain in past 12 months). When adjusted for availability, tramadol is misused uncommonly with lowest or second lowest rates in all countries. Most abuse occurs by the oral route for all opioids, including tramadol with only 7.27 (Germany) to 54.92 (UK) cases per 100,000 units sold. ConclusionsIn four countries, tramadol misuse and abuse are infrequent both in absolute number of cases and in comparison to conventional opioids. Even with availability of intravenous tramadol formulations, misuse by injection is rare.

‘It’s like making your own alcohol at home’: Factors influencing adolescent use of over-thecounter cough syrup

Background. Adolescents are increasingly experimenting with new ‘craze drugs’, including over-the-counter cough medicine (OTCCM). However, there is limited empirical evidence regarding South African (SA) adolescents’ use of codeine-containing medicines, especially OTCCMs. Objective. To describe SA adolescents’ views of OTCCM misuse, and the factors that may promote its use. Methods. The research adopted an exploratory qualitative design. Focus group discussions ( N =24) were conducted with 144 learners between 14 and 17 years old in two township communities in SA. Data were analysed thematically supported by Atlas.ti. Results. Three core themes emerged from the analysis, namely knowledge of OTCCM use; factors that influence OTCCM use; and effects of OTCCM use. Participants reported that young people use OTCCM recreationally. Four main factors were noted to influence OTCCM misuse in their communities, namely accessibility, affordability, social influences and the clandestine appeal of cough medicine. Adolescents also said that OTCCM had similar euphoric effects to alcohol or marijuana, but could not readily describe any negative impact. Conclusion. This exploratory study with adolescent participants provides contextualised empirical evidence about OTCCM. The findings call for the South African Health Products Regulatory Authority (SAHPRA) to promptly consider pending regulations on OTC codeinecontaining medication and demands increased awareness of codeine misuse in communities.

Designing Effective Warnings about Addiction on the Patient Information Leaflet of Over-the-Counter Codeine Sold in England to University Students.

(1) Background: The harm of misusing over-the-counter (OTC) codeine-containing medicines among university students in England is being increasingly recognized. Based on English university students, this paper aims to study the importance of information design on information communication, explore methods for effective warning design, and investigate university students’ perception of OTC codeine. (2) Methods: The effective warning design is addressed through case studies, answering correctness by the heat map generated from the eye-tracking experiment (ETE), and the total time spent on the tasks. User perceptions are made though online surveys. (3) Results: Information design significantly affects the way user processes information. Therefore, two emphasized warnings displayed in the headline, and the “possible side effect (PSE)” sections and warning signs of addiction presented under the PSE are suggested as effective ways to display warnings. For students’ perception of OTC codeine, 80% of university students are unfamiliar with the substance. After reading the patient information leaflets (PILs), 47% recommended tight regulation on codeine. (4) Conclusions: The misuse of OTC codeine could be a potential problem among English university students. The design of the PIL significantly influences the chance of unintentional medicine misuse. The display of warnings on the PILs of OTC codeine should be redesigned for better understanding.

Experiences of over-the-counter codeine misusers and accounts of recovery: A qualitative study in Tasmania, Australia.

There is international concern about misuse of over-the-counter (OTC) codeine, yet few studies have reported the perspectives of misusers themselves. This study explored the experience of OTC codeine misuse and recovery in Tasmania, Australia. Semi-structured telephone interviews were conducted with 15 self-identified long-term users of OTC codeine. The interview guide prompted responses about reasons for codeine use, positive and negative impacts, recovery, identity and codeine accessibility. Transcripts were analysed abductively using qualitative content analysis. Categories that emerged from misuser accounts were aligned to three broad temporal phases: (i) transition to misuse; (ii) growing awareness; and (iii) towards recovery. Salient features of the misuse experience included: initial use for the self-treatment of physical pain; ongoing use to self-medicate physical pain, stress or mental health conditions; a perception of safety of OTC codeine; an insidious transition from use to misuse; growing awareness of a problem over time; support provided by family, friends and the internet; recovery through self-change; and recognition that recovery is an ongoing process. Knowledge and understanding of the experience of OTC codeine misuse and recovery is critical to inform and tailor approaches to prevention and intervention. The findings suggest that strategies to improve the management of pain, stress and mental health, raise self-awareness of problematic use and potential for self-change, and increase social and web-based supports, should be considered when designing health policy initiatives that aim to reduce misuse.

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.

Commentary on Cairns et al. (2020): Codeine rescheduling-where to from here?

Commentary on Cairns et al. (2020): Codeine rescheduling-where to from here?

Codeine use and harms in Australia: evaluating the effects of re-scheduling.

Globally, codeine is the most-used opioid. In December 2016, Australia announced that low-strength codeine (≤15mg) would be re-scheduled and no longer available for purchase over-the-counter; this was implemented in February 2018. We aimed to evaluate the effect of this scheduling change on codeine misuse and use and misuse of other opioids. Interrupted time-series analysis of monthly opioid exposure calls to New South Wales Poisons Information Centre (NSWPIC, captures 50% of Australia's poisoning calls), January 2015- January 2019 and monthly national codeine sales, March 2015-March 2019. We incorporated a washout period (January 2017 - January 2018) between the announcement and implementation, when prescriber/consumer behaviour may have been influenced. Intentional opioid overdoses resulting in a call to NSWPIC. We used linear segmented regression to identify abrupt changes in level and slope of fitted lines. Codeine poisonings and sales were stratified into high strength (>15mg per dose unit) and low strength (≤15mg). Only low-strength formulations were re-scheduled. We observed an abrupt -50.8 percentage [95% confidence interval (CI)=-79.0 to -22.6%] level change in monthly codeine-related poisonings and no change in slope in the 12months after February 2018. There was no increase in calls to the NSWPIC for high-strength products, level change: -37.2% (95% CI=-82.3 to 8%) or non-codeine opioids, level change: -4.4% (95% CI=-33.3 to 24.4%). Overall, the re-scheduling resulted in a level change in opioid calls of -35.8% calls/month (95% CI=-51.2 to -20.4%). Low-strength codeine sales decreased by 87.3% (95% CI=-88.5 to -85.9%), with no increase in high-strength codeine sales in the 14months following re-scheduling, -4.0% (95% CI =-19.6 to 14.6%). Codeine re-scheduling in Australia appears to have reduced codeine misuse and sales.

A Narrative Review of Codeine and Preventive Measures in Mitigating against the Widespread of its Abuse and Misuse

Codeine is a phenanthrene extracted naturally from opium; it can also be produced artificially by the methylation of morphine. Among opiate drugs, codeine is the most frequently consumed around the world, broadly used for its pain relieving, antitussive properties, and its ability to prevent diarrhea. The abuse of codeine products is a major developing general health challenge in numerous nations around the globe, this is because such items are available in the range of over the counter medications (OTC) which are consistently, and easily gotten in the market even without prescription. This paper discuses Codeine and the Preventive measures in mitigating against its Abuse and Misuse. It is a review study in which the prevalence rate of codeine misuse, motives for misuse of codeine, Side effects of codeine abuse and Prevention of codeine abuse was discussed extensively under; Pharmacovigilance, drug education, monitoring and screening. It was concluded that the importance and uses of codeine are numerous, but the abuse of codeine and codeine products, for example the codeine cough syrup is a general health problem all over the world, and it remains necessary that codeine is regulated in each respective countries to reduce the prevalence rate of its misuse and abuse.

A comparative analysis of pharmacists\u2019 perspectives on codeine use and misuse \u2013 a three country survey

BackgroundThe misuse of codeine is of increasing concern in a number of countries, particularly as this relates to over -the-counter pain and cough relief medication, and is also supplied as a prescription medicine. The study aimed to obtain and analyse the opinions and experience of pharmacy staff with regard to codeine misuse.MethodsA cross-sectional web-based survey of pharmacy staff’s perspectives on this issue was administered through professional or regulatory bodies and completed by samples drawn in South Africa (n = 124), Ireland (n = 464) and the United Kingdom (n = 129).ResultsThe majority of participants reported combination codeine-containing products as most popular, but significantly more pharmacy staff in South Africa reported codeine-containing cough syrups as most commonly popular (X2 = 122.7(2), p < 0.001). Codeine use was also seen significantly more of a public health problem in South Africa than in the other two countries (X2 = 7.6(2), p = 0.02). There was no difference across countries in the level of codeine misuse reported by pharmacy staff. Further findings indicate that professional training and education is desired, with unequivocal findings for the need for greater codeine control (X2 = 12.0(2), p = 0.002).ConclusionIn conclusion, there were some inter-country differences, but overall the findings seem to suggest that pharmacists across all three countries view codeine misuse as a problem among their customers. Recommendations centre on risk management, surveillance and staff training.

Representations of Codeine Misuse on Instagram: Content Analysis.

BackgroundPrescription opioid misuse has doubled over the past 10 years and is now a public health epidemic. Analysis of social media data may provide additional insights into opioid misuse to supplement the traditional approaches of data collection (eg, self-report on surveys).ObjectiveThe aim of this study was to characterize representations of codeine misuse through analysis of public posts on Instagram to understand text phrases related to misuse.MethodsWe identified hashtags and searchable text phrases associated with codeine misuse by analyzing 1156 sequential Instagram posts over the course of 2 weeks from May 2016 to July 2016. Content analysis of posts associated with these hashtags identified the most common themes arising in images, as well as culture around misuse, including how misuse is happening and being perpetuated through social media.ResultsA majority of images (50/100; 50.0%) depicted codeine in its commonly misused form, combined with soda (lean). Codeine misuse was commonly represented with the ingestion of alcohol, cannabis, and benzodiazepines. Some images highlighted the previously noted affinity between codeine misuse and hip-hop culture or mainstream popular culture images.ConclusionsThe prevalence of codeine misuse images, glamorizing of ingestion with soda and alcohol, and their integration with mainstream, popular culture imagery holds the potential to normalize and increase codeine misuse and overdose. To reduce harm and prevent misuse, immediate public health efforts are needed to better understand the relationship between the potential normalization, ritualization, and commercialization of codeine misuse.

Misuse of pharmaceuticals by regular psychostimulant users is linked to mental health problems

Introduction. Misuse of pharmaceutical drugs, particularly by young people, is an issue of rising concern. Poly-substance use is common among regular psychostimulant users (RPU), and mental health problems are associated with pharmaceutical misuse, but RPU do not generally acknowledge their use as problematic. Objective. To examine links between mental health and misuse of non-prescription pharmaceuticals in a group of regular users of illicit psychostimulants. Method. Face to face structured interviews were conducted in April 2015 with 763 regular users of illicit psychostimulants as part of the Annual Ecstasy and Related Drugs Reporting System study in Australia. Results. At least half of the RPU in this study reported extra-medical or misuse of pharmaceuticals in the last six months in addition to regular use of illicit psychostimulants. Higher levels of psychological distress were recorded for RPU who also reported recent illicit use of opioids, antidepressants, benzodiazepines, or over-the-counter (OTC) codeine. Recent misuse of benzodiazepines or OTC codeine was associated with self-reported mental health problems and having attended a mental health professional. Those reporting recent misuse of opioids were at increased risk of mental health problems and more likely to record high levels of psychological distress, but less likely to have received prescription medications for their mental health problem. Discussion and conclusion. Regular users of illicit psychostimulants who also misuse pharmaceuticals are at increased risk of mental health problems, even after accounting for their use of illicit psychostimulants. Screening of this group for mental health problems is recommended.

Codeine misuse and dependence in South Africa: Perspectives of addiction treatment providers.

General practitioners are referring patients with codeine-related problems to specialist treatment facilities, but little is known about the addiction treatment providers, the kinds of treatment they provide, and whether training or other interventions are needed to strengthen this sector. To investigate the perspectives of addiction treatment providers regarding treatment for codeine misuse or dependence. Twenty addiction treatment providers linked to the South African Community Epidemiology Network on Drug Use and the South African Addiction Medicine Society were contacted telephonically and asked 20 questions. While many participants had received training in pharmacological management of individuals with opioid dependence, only two had received specific training on codeine management. Between half and two-thirds of the treatment settings they worked in provided detoxification, pharmacotherapy, psychosocial treatment and aftercare. Very few treatment settings offered long-term treatment for codeine misuse and dependence. Participants indicated that over half of their codeine patients entered treatment for intentional misuse for intoxication, and dependence resulting from excessive or long-term use. The main barriers to patients entering treatment were seen as denial of having a problem, not being ready for change, mental health problems, stigma, and affordability of treatment. Participants identified a need for further training in how to manage withdrawal and detoxification, treatment modalities including motivational interviewing, and relapse prevention. Gaps in training among treatment providers need to centre on how to manage withdrawal from codeine use and detoxification, motivational interviewing and relapse prevention. Interventions are needed to address barriers to entering treatment, including user denial.