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We read with interest your reporting of the growth in the misuse and
trafficking of prescription drugs in BMJ 3 March 2007 Volume 334 and
wanted to highlight another often forgotten form of dependency, that of
over the counter (OTC) drugs. In the last 3 months we have seen 3 patients
with addictions to Nurofen plus ™. Nurofen plus ™ is a compound analgesic,
available without prescription, containing 200mg ibuprofen and 12.8mg
codeine per tablet. All 3 patients had begun using the product for its
approved indications, but their use had escalated as they became tolerant
to the codeine element.
Codeine phosphate is only available on prescription but has been available
over the counter in combination with aspirin or paracetamol, containing up
to 8mg codeine per tablet, for many years. Codeine is also available in
combination with ibuprofen with up to 12.8mg per tablet (such as in
Nurofen plus ™).
A Medline search found no research into addiction to ibuprofen/codeine
compounds and nothing reviewing OTC drug dependence in the UK. A Google
search, however, revealed numerous websites and media articles documenting
cases of addiction and offering support to those people trying to withdraw
from these drugs.
Websites such as over-count.org.uk and codeinefree.me.uk tell many
personal stories, often remarkably similar and usually starting with
appropriate use of analgesia for pain such as back injury or menstrual
cramps. Over-count does not provide figures for Nurofen plus™ use but
indicates that some users are taking up to 75 tablets a day over 4-5
years. Over-count also reports that 34% of people regularly taking high
doses of Nurofen plus ™ have suffered from pancreatitis, and that many
require additional medication, such as ranitidine, to treat dyspeptic
symptoms. Although postings on the over-count website illustrate that many
people have dependence on Nurofen plus ™, they report the most common
addiction to be to Solpadeine ™ (paracetamol and codeine) and suggest more
than 4,000 people registered on their website currently have this problem.
There are no official statistics documenting the extent of dependence on
legal non-prescription drugs but it has been estimated that it affects
more than 30,000 people in the UK. Although addiction to codeine combined
in OTC painkillers has been recognised for many years, anecdotal reports
suggest this problem is increasing and we need large scale research to
assess and monitor the extent of the problem.
In 2005, the Medicines and Healthcare products Regulatory Agency (MHRA)
and the Proprietary Association of Great Britain, the UK trade and
standards association for the manufactures of OTC drugs, investigated the
problem and found that although misuse was significantly under-reported,
it was exceedingly small compared to the amount of daily sales. This
information came from yellow-card reporting from doctors and pharmacists,
and likely shows the very small tip of a clinical iceberg.
The evidence cited by this news article gives a striking insight into
the medicalization of drug abuse and in more general terms mood itself.
The article does not mention the rise of certain lifestyle drugs such as
modafinil which improve alertness and mood, offering a competitive
advantage in situations such as medical school exams (1). I myself have
frequented several overseas pharmacy websites, the mouse cursor hovering
dangerously near to the 'add to cart' button. Indeed the Times newspaper
carried an article in 2006 suggesting that a government scientist had
advocated derestricting these lifestyle enhancers. Alternatively one might
consider the prescription use of drugs such as modafinil as part of an
under-reported subculture of drug abuse -with our open access to drugs and
competitive instincts we may lead the way in this respect.
1. N Engl J Med 2005; 353:1089-1091, Sep 15, 2005. Perspective
Getting an Edge — Use of Stimulants and Antidepressants in College
2. The Sunday TimesJune 04, 2006
No 10 scientist urges brain pills for all
Over-the-counter – a worrying and often forgotten form of dependency
We read with interest your reporting of the growth in the misuse and
trafficking of prescription drugs in BMJ 3 March 2007 Volume 334 and
wanted to highlight another often forgotten form of dependency, that of
over the counter (OTC) drugs. In the last 3 months we have seen 3 patients
with addictions to Nurofen plus ™. Nurofen plus ™ is a compound analgesic,
available without prescription, containing 200mg ibuprofen and 12.8mg
codeine per tablet. All 3 patients had begun using the product for its
approved indications, but their use had escalated as they became tolerant
to the codeine element.
Codeine phosphate is only available on prescription but has been available
over the counter in combination with aspirin or paracetamol, containing up
to 8mg codeine per tablet, for many years. Codeine is also available in
combination with ibuprofen with up to 12.8mg per tablet (such as in
Nurofen plus ™).
A Medline search found no research into addiction to ibuprofen/codeine
compounds and nothing reviewing OTC drug dependence in the UK. A Google
search, however, revealed numerous websites and media articles documenting
cases of addiction and offering support to those people trying to withdraw
from these drugs.
Websites such as over-count.org.uk and codeinefree.me.uk tell many
personal stories, often remarkably similar and usually starting with
appropriate use of analgesia for pain such as back injury or menstrual
cramps. Over-count does not provide figures for Nurofen plus™ use but
indicates that some users are taking up to 75 tablets a day over 4-5
years. Over-count also reports that 34% of people regularly taking high
doses of Nurofen plus ™ have suffered from pancreatitis, and that many
require additional medication, such as ranitidine, to treat dyspeptic
symptoms. Although postings on the over-count website illustrate that many
people have dependence on Nurofen plus ™, they report the most common
addiction to be to Solpadeine ™ (paracetamol and codeine) and suggest more
than 4,000 people registered on their website currently have this problem.
There are no official statistics documenting the extent of dependence on
legal non-prescription drugs but it has been estimated that it affects
more than 30,000 people in the UK. Although addiction to codeine combined
in OTC painkillers has been recognised for many years, anecdotal reports
suggest this problem is increasing and we need large scale research to
assess and monitor the extent of the problem.
In 2005, the Medicines and Healthcare products Regulatory Agency (MHRA)
and the Proprietary Association of Great Britain, the UK trade and
standards association for the manufactures of OTC drugs, investigated the
problem and found that although misuse was significantly under-reported,
it was exceedingly small compared to the amount of daily sales. This
information came from yellow-card reporting from doctors and pharmacists,
and likely shows the very small tip of a clinical iceberg.
Competing interests:
None declared
Competing interests: No competing interests