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Respectable Addicts? Identity and Over- the-Counter Medicine Abuse Richard Cooper Lecturer in Public Health ScHARR, University of Sheffield.

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Presentation on theme: "Respectable Addicts? Identity and Over- the-Counter Medicine Abuse Richard Cooper Lecturer in Public Health ScHARR, University of Sheffield."— Presentation transcript:

1 Respectable Addicts? Identity and Over- the-Counter Medicine Abuse Richard Cooper Lecturer in Public Health ScHARR, University of Sheffield

2 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 Overview

3 Background and evidence

4 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)

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

6 Typology based on agency/predicament apparent but confusion over terminology – addiction/dependency rare: Misuse (wrong dose or indication, unintentional) Misuse (wrong dose or indication, unintentional) Abuse (deliberately exploiting side effects, experimentation) Abuse (deliberately exploiting side effects, experimentation) Substitution (to replace illicit drug use) 1 Substitution (to replace illicit drug use) 1 Variation in OTC medicines implicated in abuse internationally by availability and customer preferences. Variation in OTC medicines implicated in abuse internationally by availability and customer preferences. OTC Abuse Literature 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,

7 Relatively little empirical research into OTC abuse. Relatively little empirical research into OTC abuse. No evaluation of treatment. No evaluation of treatment. No clear patterns as to those affected. No clear patterns as to those affected. OTC Abuse Literature 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 million packs of codeine-containing OTC meds sold 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

8 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) Economic cost Accidents Adverse effect on jobs and relationships PHYSIOLOGICAL SOCIAL OTHER

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

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

11 OTC Abuse Responses Year long APPDMG 8 reported in 2009: Training for doctors, nurses and AHPs Training for doctors, nurses and AHPs Increased awareness of problem Increased awareness of problem Recognition/support for on-line help Recognition/support for on-line help Information for patients about risks Information for patients about risks 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 Some evidence of attempts to manage/reduce abuse: Pharmacy-based (hide products, refuse sales, record sales,) Pharmacy-based (hide products, refuse sales, record sales,) Harm-reduction intervention pilot – GP referral Harm-reduction intervention pilot – GP referral Proposed contract/reduction scheme in pharmacies? Proposed contract/reduction scheme in pharmacies?

12 Qualitative Study

13 Methods Semi-structured, qualitative telephone interviews with 16 key stakeholders of organisations with interests in OTC medicines 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 abuse/misuse. Recorded/transcribed, ~1hr. Recruitment via postings on 2 internet forums helping those with OTC medicine problems – CodeineFree and Overcount Stage 1 Stage 2 Stage 3

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

15 ageEmployment statusMedicine(s) involvedDoses Current use? Treatment/support M40sUnemployed Paramol +Sudafed+alcohol Up to 36/day either or III No GP, DAT, (methadone), Overcount MDNDProfessionalCo-codamol, then SyndolUp to 8 per day I YesGP, CFM M30sProfessionalCo-codamol12-14/day III YesCFM M30s Professional self- employed Nurofen Plus + prev. non-opiate illicit Max of 60 tablets/ day III No GP, DAT (Buprenorphine) CFM FFormer health prfnSolpadeineUp to 8/day I NoCFM FCo-codamol sol +Rx co-codamolUp to 16/day (max 4/dose) III NoCFM FHealthcare profnlNurofen Plus32/day (max 64/day) III NoCFM + buprenorphine F30sUni student Feminax then Cuprofen Plus prev. alcohol 36/day III YesCFM F40sprofessionalNurofen Plus24/day III NoCFM F20sProfessionalCo-codamol + prescribedUp to 8/day I NoCFM FProfessionalCo-codamol + prescribedup to 16/day occ. prescribed II YesGP, M50sRetired ProfessionalNurofen Plus + prescribed codeine 10/day Nurofen plus + MDD codeine III NoOvercount M60sProfessionalSolpadeine solubleUp to 10/day II NoPrivate treatment MProfessionalPhensedyl90 bottles/week III NoGP, DAT MProfessionalPanadol Ultra then Nurofen Plus15-20 of each IIINoGP MSolpadeine4/day I NoOvercount MSelf-employedNurofen Plus10/day IIYesCFM, DAT, GP FSolpadeineUp to 8/day I YesOvercount FSyndolUp to 8/day I YesCFM, GP M Former health care professional Codiene linctus, Gees linctus,stolen DHC Varied but much above max daily dose. III NoCFM + DAT (methadone) M60sRetired professional Phensedyl, Actifed, Codeine linc, d iverted Rx codeine 200ml codeine linctus/day III noCFM+GP+DAT-methadone F30sProfessionalSyndol + nytolSyndol: 12/day II YesOvercount F50sProfessionalFeminax, then Veganin6-10/day. Max=12/day II YesOvercount + GP + Drug Action

16

17 Initial use All but two described initially using a product for a medical condition (migraine, periods, ME, injury, gynae) 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). 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 Medicines were all codeine/DHC (Nurofen Plus, Co-codamol, linctus) but some pseudoephedrine, and sedative antihistamines Physical pain doesnt 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 There was a medical condition involved. I was in hospital, came out of hospital and was given co- codomol or something at the time for the pain. That ended and the next thing I am downing Nurofen Plus. Karen

18 Link between Rx and OTC

19 3 Types of Abuse Words addict or addiction specifically used by participants. 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) 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 Harms varied: perceived withdrawal/anxiety at lower doses, GI problems dependency/withdrawal, criminal acts, job/relationship issues at higher [...] Ive 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 dont think I realised there was codeine in it at all Aylsa (Nurofen Plus) […] 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 Well, I mean I suppose on a really bad day and this hasnt 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, its not a high. Literally, I zone out. Rachel (co- codamol 8/500 tablets) 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

20 Treatment and support Range of support identified with varying success and perceptions. Range of support identified with varying success and perceptions. Formal GP/DAAT help resisted by some for fear of recording problem. Formal GP/DAAT help resisted by some for fear of recording problem. Pharmacy involvement neutral – easy to bypass questions. Pharmacy involvement neutral – easy to bypass questions. On-line support offered confirmation/self-treatment but engagement low On-line support offered confirmation/self-treatment but engagement low 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 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 […] I have mentioned it to the doctor and he sort of said, well its something you handle yourself. At this sort of level, if you know what I mean?Dwain […] my own private GP […] he just laughed and said, dont be so stupid, stop taking them. On the other hand, what is he supposed to say? Richard

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

22 Addict Identity Addict or addiction mentioned by all participants. Addict or addiction mentioned by all participants. Variety of drug seeking behaviours described: Variety of drug seeking behaviours described: Withdrawal experienced Withdrawal experienced Loss of control over self/consumption Loss of control over self/consumption Rituals of specific brands Rituals of specific brands Elaborate and methodical routes to visit pharmacies to avoid detection Elaborate and methodical routes to visit pharmacies to avoid detection Covert, hidden activity – (work, public but some used friends, family). Covert, hidden activity – (work, public but some used friends, family). Shame identified by some – in deceiving, hiding addiction. Shame identified by some – in deceiving, hiding addiction. On-line forums used to confirm (validate?) addict status. 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 [...] my wife is, in fact in many ways, keeping an eye on me in that sense. Shell 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 wouldnt mean Id take part online, but it would I think part of my process. John 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 cant believe that I have done this to myself. You know I find it really hard to understand. Karen

23 Not like other addicts but… Frequent attempts to distinguish themselves from other types of addicts, esp. those more chaotic/socially unacceptable. 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: However, recognition that there were common features, either in the: Pharmacology of substance – e.g. codeine as opioid Pharmacology of substance – e.g. codeine as opioid Dependency symptoms – withdrawal, dose Dependency symptoms – withdrawal, dose Some participants had co- dependencies and viewed OTC abuse in same way as previous/current alcohol use, illicit substance use. Some participants had co- dependencies and viewed OTC abuse in same way as previous/current alcohol use, illicit substance use. DAAT services re-enforced difference. DAAT services re-enforced difference. I think in society its 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 cant 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. Thats just a social concept isnt 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. Its painfully obvious people look at me and think what on earth is somebody like her doing in a place like this. Because I dont have a can of Heineken in my hand or tram marks up my arm or stand outside smoking Theresa 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 dont. I look like your normal middle aged woman. Rachel

24 Professional identity Frequent discourse of claims relating to occupational or social status. Frequent discourse of claims relating to occupational or social status. Used to distinguish them and their situation from other forms of addiction. Used to distinguish them and their situation from other forms of addiction. Attempts to assert knowledge: Attempts to assert knowledge: About pharmacology About pharmacology Medicine doses/active ingredients Medicine doses/active ingredients Addiction is atypical for some, as a loss of control set against dominant control over their (successful) lives. 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. For some, NHS/GP involvement actively resisted to avoid addiction being recorded & a career threat. 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 […]there are lots of people out there like me, that are intelligent professionals [...] I dont 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 couldnt stop and even when I got ill and had this huge gastric bleed, I still cant 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 thats 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 havent 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 cant be an addict. I am. John

25 Discussion

26 Discussion questions Is the respectable addict a viable category? Linked to Reiths 9 claim that addiction originated as a middle class concern about control (cf productivity in working classes)? Is the respectable addict a viable category? Linked to Reiths 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? 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? A moral concern about legitimate use and deviant abuse? Is a lesser category of pseudoaddiction 11 needed for some, to reflect inadequate pain relief? 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 (McIntosh & McKeganey) 12, recovery narratives/identity are constructed by treatment. What influence do on-line support groups have? For some (McIntosh & McKeganey) 12, recovery narratives/identity are constructed by treatment. But...self-help group identity absent for many (passive). But...self-help group identity absent for many (passive).

27 Conclusions OTC medicine abuse occurs, often with links to medical treatment and range of medicine use and associated harms. 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. 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). Variable engagement with, and benefit from, formal services (GP, DAAT, pharmacy). Qualitative study limitations – recruitment through websites, self-selecting participants, not able to capture. Qualitative study limitations – recruitment through websites, self-selecting participants, not able to capture.

28 References 1. 1.Temple DJ Misuse of over the counter medicines in the UK In: Sheridan J & Strang J (eds) Drug Misuse & Community Pharmacy London: Taylor and Francis Paxton R and Chapple P. Misuse of over-the-counter medicines: a survey in one English county. Pharmaceutical Journal 1996;256: Matheson C, Bond C & Pitcairn J. Misuse of OTC medicines from community pharmacies: a population survey of Scottish pharmacies.Pharmaceutical Journal 2002;269: Pates R, McBride A, Li S & Ramadan R. Misuse of OTC medicines: a survey of community pharmacies in the South Wales health authority. Pharmaceutical Journal 2002;268: Wazaify M, Shields E, Hughes CM and McElnay JC. Societal perspectives on over-the -counter (OTC) medicines Family Practice 2005;22: National Treatment Agency. Addiction to medicine: an investigation into the configuration and commissioning of treatment services to support those who develop problems with prescription- only or over-the-counter medicine. London Ford C and Good B. Over the Counter drugs can be highly addictive. British Medical Journal 2007;334;917 8.Reay, G. (2009). All-Party Parliamentary Drugs Misuse Group. An Inquiry into Physical Dependence and Addiction to Prescription and Over-the-Counter Medication. London Reith G. Consumption & its discontents: addiction, identity & the problem of freedom. The British Journal of Sociology 2004;55(2); Hacking I Making up people. In Heller M et al Reconstructing Individualism Stanford Uni Press Bell K & Salmon A. Pain, physical dependence and pseudoaddiction: redefining addiction for nice people. Int Journal of Drug Policy 2009;20: McIntosh J & McKeganey N. Addicts narratives of recovery from drug use: constructing a non- addict identity. Social Science and Medicine 2000;50:

29 Funded by the Pharmacy Practice Research Trust Richard Cooper Lecturer in Public Health ScHARR, University of Sheffield


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