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dicts? le Ad pectab Res Overity and Ident unter he-Co t Abuse dicine Me dicts? le Ad pectab Res Overity and Ident unter he-Co t Abuse dicine Me Richard Cooper Lecturer in Public Health Sc. HARR, University of Sheffield

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

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

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

OTC Abuse Literature Typology based on agency/predicament apparent but confusion over terminology – addiction/dependency OTC Abuse Literature Typology based on agency/predicament apparent but confusion over terminology – addiction/dependency rare: § § Misuse (wrong dose or indication, unintentional) Abuse (deliberately exploiting side effects, experimentation) Substitution (to replace illicit drug use)1 Variation in OTC medicines implicated in abuse internationally by availability and customer preferences. 5 key groups of medicines implicated: Codeine containing compound analgesics – Solpadeine, Nurofen Plus Cough products (dextromethorphan) Laxatives Decongestants – Sudafed Antihistamines (sedative)– Nytol, Actifed, Night Nurse, Phenergan,

OTC Abuse Literature § § § Relatively little empirical research into OTC abuse. No OTC Abuse Literature § § § Relatively little empirical research into OTC abuse. No evaluation of treatment. No clear patterns as to those affected. Scale of Issue/Demographics Two thirds of UK pharmacists have reported abuse/misuse. 2, 3, 4 Third of NI general public reported encountering OTC abuse. 5 4% of US teenagers abusing OTC products. 21. 4 million packs of codeine-containing OTC meds sold 2008. A problem associated with middle-aged females? 6 Just over 200 clients with OTC opiate problems in formal treatment (~0. 25% of all clients). Over half exit treatment drug-free. 6 15, 000 web support users. 7

OTC Abuse Literature Primary Medicine of abuse Additional Ingredient • Addiction (codeine) • Euphoria OTC Abuse Literature Primary Medicine of abuse Additional Ingredient • Addiction (codeine) • Euphoria (dextromethorphan) • Risk of other abuse (e. g. alcohol, illicit drugs) • Electrolyte imbalance (laxatives) • Convulsions/acidosis (chlorphenamine) • Gastro-intestinal irritation, haemorrhage , death (ibuprofen) • Rebound headaches (paracetamol and ibuprofen) • Hypokalaemia/acidosis (ibuprofen) PHYSIOLOGICAL • Economic cost • Accidents • Adverse effect on jobs and relationships SOCIAL OTHER

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

OTC Abuse Responses Some evidence of attempts to manage/reduce abuse: § § § Pharmacy-based OTC Abuse Responses Some evidence of attempts to manage/reduce abuse: § § § Pharmacy-based (hide products, refuse sales, record sales, ) Harm-reduction intervention pilot – GP referral Proposed contract/reduction scheme in pharmacies? Revised advice on OTC codeine sales 2009: § § § 100 packs of co-codamol soluble now POM Indications only for pain (not cold, flu) Front box warning: ‘Can cause addiction. For three days use only. ’ Similar changes in Australia

OTC Abuse Responses Some evidence of attempts to manage/reduce abuse: § § § Pharmacy-based OTC Abuse Responses Some evidence of attempts to manage/reduce abuse: § § § Pharmacy-based (hide products, refuse sales, record sales, ) Harm-reduction intervention pilot – GP referral Proposed contract/reduction scheme in pharmacies? Revised advice on OTC codeine sales 2009: § § § 100 packs of co-codamol soluble now POM Indications only for pain (not cold, flu) Front box warning: ‘Can cause addiction. For three days use only. ’ Similar changes in Australia Year long APPDMG 8 reported in 2009: § § Training for doctors, nurses and AHPs Increased awareness of problem Recognition/support for on-line help Information for patients about risks

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Methods Semi-structured, qualitative telephone interviews with 16 key Stage 1 stakeholders of organisations with Methods Semi-structured, qualitative telephone interviews with 16 key Stage 1 stakeholders of organisations with interests in OTC medicines Stage 2 Semi-structured, qualitative face to face/phone interviews with quota sample of 10 pharmacists and 7 MCAs from community pharmacies in UK Semi-structured, qualitative telephone interviews with 25 individuals who have/had experience of OTC medicine Stage 3 abuse/misuse. Recorded/transcribed, ~1 hr. Recruitment via postings on 2 internet forums helping those with OTC medicine problems – Codeine. Free and Overcount

Semi-structured, qualitative telephone interviews with 25 individuals who have/had experience of OTC medicine Stage Semi-structured, qualitative telephone interviews with 25 individuals who have/had experience of OTC medicine Stage 3 abuse/misuse. Recorded/transcribed, ~1 hr. Recruitment via postings on 2 internet forums helping those with OTC medicine problems – Codeine. Free and Overcount

age Employment status Medicine(s) involved M 40 s Unemployed Paramol +Sudafed+alcohol M DN Professional age Employment status Medicine(s) involved M 40 s Unemployed Paramol +Sudafed+alcohol M DN Professional D M 30 s Professional employed Co-codamol, then Syndol F F 30 s F 40 s F 20 s F M 50 s M 60 s M M F F M Doses Current Treatment/support use? Up to 36/day either 16+16 No GP, DAT, or 12+12+12 III (methadone), Overcount Up to 8 per day I Yes GP, CFM 12 -14/day III Co-codamol self- Nurofen Plus + prev. non- Max of 60 tablets/ day opiate illicit III Up to 8/day I Former health prfn Solpadeine Co-codamol sol +Rx co- Up to 16/day (max 4/dose) III codamol 32/day (max 64/day) III Healthcare profnl Nurofen Plus Uni student Feminax then Cuprofen Plus 36/day III prev. alcohol 24/day III professional Nurofen Plus Up to 8/day I Professional Co-codamol + prescribed up to 16/day occ. prescribed II Retired Nurofen Plus + prescribed 10/day Nurofen plus + MDD codeine III Professional codeine Up to 10/day II Professional Solpadeine soluble 90 bottles/week III Professional Phensedyl Professional Panadol Ultra then Nurofen 15 -20 of each III Plus 4/day I Solpadeine Self-employed Nurofen Plus 10/day II Up to 8/day I Solpadeine Up to 8/day I Syndol Former health care Codiene linctus, Gees Varied but much above Yes No No No CFM GP, DAT (Buprenorphine) CFM CFM No Yes CFM + buprenorphine CFM No No Yes CFM GP, No Overcount No No No Private treatment GP, DAT GP No Yes Yes No Overcount CFM, DAT, GP Overcount CFM, GP CFM + DAT

Initial use § § § All but two described initially using a product for Initial use § § § All but two described initially using a product for a medical condition (migraine, periods, ME, injury, gynae’) Use continued to avoid ‘withdrawal’ (headache, tremor, palpitations) or for other effect (buzz, calming, sedative). Medicines were all codeine/DHC (Nurofen Plus, Co-codamol, linctus) but some pseudoephedrine, and sedative antihistamines “There was a medical condition involved. I was in hospital, came out of hospital and was given cocodomol or something at the time for the pain. That ended and the next thing I am downing Nurofen Plus. ” Karen “Physical pain doesn’t really bother me that much unless it interferes with something I am doing. So I was much more interested in the psychological effects [. . . ] My ongoing anxiety. ” Jack

Link between Rx and OTC Link between Rx and OTC

3 Types of Abuse § § Words ‘addict’ or ‘addiction’ specifically used by participants. 3 Types of Abuse § § Words ‘addict’ or ‘addiction’ specifically used by participants. Drug seeking behaviours: loss of control over self/consumption, ‘rituals’ of specific brands, planned pharmacy routes, covert ( hidden to work, but not some friends/family) § Harms varied: perceived withdrawal/anxiety at lower doses, GI problems dependency/withdrawal, criminal acts, job/relationship issues at higher “[. . . ]I’ve never taken more than six a day, never gone over that […] Never escalated because I think I was too scared of going beyond that […] I don’t think I realised there was codeine in it at all” Aylsa (Nurofen Plus) “Well, I mean I suppose on a really bad day and this hasn’t happened recently, but on a really bad day, I suppose I could take sixteen […] So I would just knock back four at a time. Because that would give me that, as I say, it’s not a high. Literally, I zone out”. Rachel (cocodamol 8/500 tablets) ‘[…] the next thing I am downing Nurofen Plus. It started off probably taking the normal doses and the next thing [. . . ] I am taking twenty four tablets a day. ” Karen I would take eight in one day. But then of course in increasing amounts. Till the point came that I was taking thirty two a day. Even on really bad days, I would take a second lot of thirty two. ” Theresa

Treatment and support § § Range of support identified with varying success and perceptions. Treatment and support § § Range of support identified with varying success and perceptions. Formal GP/DAAT help resisted by some for fear of recording problem. Pharmacy involvement neutral – easy to bypass questions. On-line support offered confirmation/self-treatment but engagement low “[…] my own private GP […] he just laughed and said, ‘don’t be so stupid, stop taking them’. On the other hand, what is he supposed to say? ” Richard […] I have mentioned it to the doctor and he sort of said, ‘well it’s something you handle yourself’. At this sort of level, if you know what I mean? ”Dwain “I went to my doctors and I would either try my best, you know, with the prescribed dihydrocodeinebut it er came to a point where it was beyond, you know, it needed a specialist to help. ” Malcolm “As soon as I walked in there [DAAT] , you could see the other people who come there have got serious drug and alcohol problems and I stick out like a sore thumb. ” Theresa

Identity Claims Addict Identity Personal Drug seeking behaviour Withdrawal Perceived stereotypical addict identity Chaotic Identity Claims Addict Identity Personal Drug seeking behaviour Withdrawal Perceived stereotypical addict identity Chaotic Illicit substance Alcohol misuse Treatment options Appearance All opioids Loss of control Use for different effect Lack of treatment options Alcohol? Managing appearances Hidden Family Professional Identity Social Intelligent Knowledgeable Respectable appearance

Addict Identity § ‘Addict’ or ‘addiction’ mentioned by all participants. § Variety of drug Addict Identity § ‘Addict’ or ‘addiction’ mentioned by all participants. § Variety of drug seeking behaviours described: § § Withdrawal experienced Loss of control over self/consumption ‘Rituals’ of specific brands Elaborate and methodical routes to visit pharmacies to avoid detection § Covert, hidden activity – (work, public but some used friends, family). § Shame identified by some – in deceiving, hiding addiction. § On-line forums used to confirm (validate? ) addict status. “Yeah I am an addict, no doubt about it. As much as a heroin addict, yeah. Shameful and it makes you feel dirty and guilty, but I was an addict, yeah. ” Yvette “I also never hoarded it. It was part of the ritual for me to go out and have to find it every day. ” Theresa I do think we are all stupid quite honestly. I think I am stupid. I can’t believe that I have done this to myself. You know I find it really hard to understand. ” Karen “[. . . ] my wife is, in fact in many ways, keeping an eye on me in that sense. She’ll say, ‘ooh, you having that again, are you? ’ [. . . ] actually at one point I started writing on when I bought the packet. ” Graham “[The web site] gives me the ability to anonymise myself. To experience and participate without it actually being physically me. I think where I am at right now is I need to own up who I am which probably wouldn’t mean I’d take part online, but it would I think part of my process. ” John

Not like other addicts but… § Frequent attempts to distinguish themselves from other types Not like other addicts but… § Frequent attempts to distinguish themselves from other types of ‘addicts’, esp. those more chaotic/socially unacceptable. § However, recognition that there were common features, either in the: § Pharmacology of substance – e. g. codeine as opioid § Dependency symptoms – withdrawal, dose § Some participants had codependencies and viewed OTC abuse in same way as previous/current alcohol use, illicit substance use. § DAAT services re-enforced difference. “If I went to any other pharmacies in town, nobody would even bat an eyelid [. . . ] And I think as well if I was to go in and look like their stereotypical addict, they may go, ‘Oh well, you know’ and call the pharmacist over. But I don’t. I look like your normal middle aged woman. ” Rachel “I think in society it’s a negative stereotype, because you think of addicts and you think of drink, drugs, heroin, cocaine, you know needles and all those sorts of things […] But my understanding of an addict is somebody who cannot get through the day without what it is they are addicted to. I can’t get through the day without taking codeine. ” Rachel “I could not function without codeine & just because you can buy it legally in the chemists, does not mean that it is any different from heroin. That’s just a social concept isn’t it, you know, no difference. ” Yvette “As soon as I walked in there, you could see the other people who come there have got serious drug and alcohol problems and I stick out like a sore thumb. It’s painfully obvious people look at me and think ‘what on earth is somebody like her doing in a place like this’. Because I don’t have a can of Heineken in my hand or tram marks up my arm or stand outside smoking” Theresa

Professional identity § Frequent discourse of claims relating to occupational or social status. § Professional identity § Frequent discourse of claims relating to occupational or social status. § Used to distinguish them and their situation from other forms of addiction. § Attempts to assert knowledge: § About pharmacology § Medicine doses/active ingredients § Addiction is atypical for some, as a loss of control set against dominant control over their (successful) lives. § For some, NHS/GP involvement actively resisted to avoid addiction being recorded & a career threat. “[…]there are lots of people out there like me, that are intelligent professionals [. . . ] I don’t know where we can go for support without putting ourselves at risk. ” Theresa “I am a nurse so know what damage I was doing and still couldn’t stop and even when I got ill and had this huge gastric bleed, I still can’t believe that as an intelligent woman. ” “Oh my god, I hated it if I went away - and I go to America quite a bit, you know. Well you are not going to get them in America and that’s when you have got to go around thirteen pharmacies and find twenty packets to take with you. ” Yvette “Addicts are people on the street who haven’t got a job & I am sat here in a suit in an office, my own office with a very good career, senior manager within a very large organisation & I can’t be an addict. I am. ” John “You know, should something different arise later that I need to get back to the doctor for but I have this mark from previous on my record, it affects what I need later on. ” Jack

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Discussion questions § Is the ‘respectable addict’ a viable category? Linked to Reith’s 9 Discussion questions § Is the ‘respectable addict’ a viable category? Linked to Reith’s 9 claim that addiction originated as a ‘middle class’ concern about control (cf productivity in working classes)? § Or is there a danger, after Hacking 10, of ‘making up people’ and spreading even further the web of addictive types? § A moral concern about legitimate use and deviant abuse? § Is a lesser category of pseudoaddiction 11 needed for some, to reflect inadequate pain relief? § What influence do on-line support groups have? For some (Mc. Intosh & Mc. Keganey)12, recovery narratives/identity are constructed by treatment. § But. . . self-help group identity absent for many (passive).

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

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y the ded b Fun rmacy Pha ctice Pra rust arch T Rese Richard y the ded b Fun rmacy Pha ctice Pra rust arch T Rese Richard Cooper Lecturer in Public Health Sc. HARR, University of Sheffield Richard. [email protected] ac. uk