Increasing rates of addiction to OTC painkillers and microbial resistance to common antibiotics are causing concern among the medical community, James Fogarty reports.
The last century saw a giant step forward in medicine. The development of antibiotics meant that previously deadly bacteria could be treated. Medication has become a regular fixture in people’s homes.
Nowadays names like penicillin, paracetamol and ibuprofen are familiar house-hold words, but familiarity can breed contempt. While these resources are common, even available over the counter, are we using them properly? Or have their very availability meant they are being misused and abused? The evidence suggests they are.
According to figures from the National Drug Treatment Reporting System, which is maintained by the Health Research Board (HRB), the numbers entering treatment for codeine addiction have “increased considerably”. The numbers have increased from 40 in 1998 to 180 in 2009. Elsewhere, Dr Margaret Chan, Director General of the World Health Organisation warned that antibiotic resistant bacteria could spell the end of modern medicine; a resistance borne in no small way from the inappropriate use of the drugs.
Over the counter
The new consultant deal and the recent civil war at Hawkins House between Minster Reilly and Minister Shortall has overshadowed a number of interesting stories regarding OTC drugs. The revelation that gangs in Limerick are using such medicines to produce crystal meth is alarming to say the least and may lead to yet more drug-related death and misery. Another story from the UK highlighted the fact that improper use of OTC drugs can lead to rebound headaches.
Concern over misuse of OTC and prescription drugs is nothing new and there have been various attempts to try to tackle the problem. In 2010, the law changed allowing pharmacists to question people wishing to buy products containing codeine. Earlier this year, the Irish Medicines Board (IMB) introduced new guidelines on liquid paracetamol doses for children. However, it added that the development was not linked to safety issues but were introduced “as a proactive measure” to optimise effectiveness.However, despite these changes, the level of misuse is still relatively unknown, a knowledge gap which some believe may be having serious consequences.Dr Garrett McGovern is a GP specialising in addiction and he believes that current attempts to tackle illicit use are falling short. Codeine addiction, he said, is a big problem.“As it happens, I’m seeing a lot of this in my private clinic in Dundrum, in my addiction treatment programme. Of the patients I’m treating at the moment, probably more than one-third have that addiction, which is quite high I have to say,” he told the Medical Independent (MI).
Dr McGovern said that while there is no hard data regarding the number of people abusing OTC drugs, he estimates that as many as 10 per cent of all regular users of codeine products could be addicted. However, while codeine is physically addictive, he added that it is “relatively harmless” and a “low-end addiction”. The real problem is the other drugs which accompany the codeine, he said. “The real issue is that in order to get the low dose of codeine phosphate, they have to take these other drugs too, these very physically damaging drugs. For instance, the people I would see in general practice are at the end point of this addiction, and that is a burst ulcer from the anti-inflammatories or liver failure from copious amounts of paracetamol,” he said. Recently he saw one patient who had lost seven units of blood from a perforated ulcer as a result of paracetamol misuse. More worrying is that much of this addiction is accidental, he said. “It doesn’t really happen that people take these drugs to get a buzz from them and get physically addicted to them in that way. They are usually taken for legitimate reasons, for pain relief,” he said.
The pain is not particularly well managed, resulting in increased tolerance, and an increased habit. “The problem is that they really don’t understand. They think they’re treating their pain, but more likely they’re treating their physical dependency. In other words, if they don’t take the medication, they are going to see withdrawal symptoms,” he said.
This lack of knowledge is not just among patients. Other GPs might not see these cases very often and may be reluctant to engage in addiction training, he said. The HSE, for its part, is also not taking the problem seriously, he added. “We don’t have good empirical data. That just goes to show you that we don’t take this as seriously as we should. There isn’t a lot of goodwill to do a lot of research around this,” he said.
Furthermore, unlike heroin, codeine addiction, and the attendant drugs, can be found across the socio-economic spectrum, he said. He remarked that most people dependent on codeine would be reluctant to attend a HSE addiction clinic.However, not everyone agrees that misuse is a major problem. Ms Kathy Maher, Vice President of the Irish Pharmacy Union (IPU), said that legislation has reduced the prevalence of deliberate misuse, but lack of awareness continues to be a problem.
“Has it gone down? I think so,” she told MI. “Both products [paracetamol and ibuprofen] are very effective painkillers, but certainly I think their use has been rationalised. People are not necessarily abusing them, but sometimes misusing them, not realising that their headaches could be as a result of taking them for more than three days and they are having a rebound headache.”
One problem she identified is that of people deliberately misusing OTC drugs, visiting pharmacies where they are not well known. “They know the answers to the questions that we need to ask them, so those people are a little bit more difficult to trace,” she said. Dr Ray Walley, a North Dublin GP and Chair of the IMO GP Committee, agreed that the legislation has reduced misuse. “The legislation has been changed and personally I think that has made a big difference in regards to the abuse that was occurring with that. Anecdotally, there are people who are abusing cough bottles. In my patient population I haven’t come across a lot of it. But certainly prior to the legislation change, I was more aware of difficulties with codeine use,” he said. Whatever the reason for this misuse, the damage from these medications is significant. “Paracetamol is one of the safest drugs when used properly, but the damage can happen very, very quickly and the effects are devastating,” Maher said. “Especially with paracetamol, because it takes a small dose to cause irreversible damage.”
Source: James Fogarty, medicalindependent.ie, 04/10/12
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