'Some patients take 90 tablets of codeine-ibuprofen per day'

Dr Jacinta Johnson (PhD), a clinical pharmacist at Flinders Medical Centre, SA, explains her research findings on the misuse of OTC analgesics.

Australian Doctor: How common is hospitalisation due to side effects of OTC analgesic combination products?

Dr Johnson: We found at least 100 admissions over a five-year period just to our one hospital. But we expect that to be an underestimate.

AD: What kind of products were causing these problems?

Dr Johnson: Overwhelmingly most of the issues were in patients using ibuprofen-containing combinations — lots of perforated ulcers. A typical patient was using an average of 28 tablets of the codeine-ibuprofen products.

Related News:

We had some who were using a lot more than that — up to three packs a day, so 90 tablets a day. Some were using less but ran into trouble because they were using them over an extended period of time.

AD: What kind of problems were codeine products associated with?

Dr Johnson: For a lot of patients, the diagnosis was abdominal pain and it wasn’t picked up until later that this was related to the ibuprofen-codeine combination. 

Lots of the time it was just documented as anaemia, which was later found to be a gastrointestinal bleed. 

We had a few patients who were having ongoing hypokalaemia and acidosis. 

They were seen by the renal team who couldn’t work out what was going on with this patient until it turned out it was the NSAID they were on.

AD: What was the extent of OTC codeine misuse?

Dr Johnson: The average duration of use for any codeine product was just over 600 days, so about 20 months — much longer than recommended.

Related News:

These were all people who were using codeine products they had bought over the counter. Panadeine Forte misuse was not included.

Some of them did start with prescription medications; about 10% were patients who started using analgesics postoperatively, and when their Panadeine Forte or Endone ran out and the doctor didn’t want to give them any more, they went to whatever else they could get their hands on.

AD: What’s the takeaway message from your research?

Dr Johnson: That this is a bigger problem than we realised and education is critical. The patients had been using codeine for a long time and they had not sought help, but waited until they had to be admitted to hospital. 

And even if they do recognise it’s a problem, they feel like it’s their only choice. 

So we need to educate that there are other options around chronic pain. 

Also, it often took medical teams a long time to pick up on it because the patients weren’t forthcoming about how much codeine they were using. 

So the message is to watch out for it if you have a patient with low potassium and anaemia, and they tell you that they use some Nurofen Plus. Maybe they’re using a lot more than they are letting on.