‘Respectable Addiction’ - A qualitative study of over the counter medicine abuse in the UK Richard Cooper July 2011 School of Health and Related Research (ScHARR) University of Sheffield Regent Court 30, Regent Street, Sheffield, S1 4DA, UK ACKNOWLEDGEMENTS I would like to thank all the participants in this study, including the stakeholders, the pharmacists and medicine counter assistants. In particular I would like to thank those participants who had experienced OTC medicine addiction personally, and who overcame often considerable concerns about their identity to speak about their experiences. I would also like to thank the Pharmacy Practice Research Trust for funding this study and for the particular support of Charlotte Coates and Beth Allen at various stages. Thanks must go also to Professor Christine Bond, who helped in part of the pharmacy recruiting stage of the study. Especial thanks are also due to David Greave and Mark Edwards for their assistance in this study. Finally, I would like to thank Sue Wilson for her considerable efforts in transcribing. Published by the Pharmacy Practice Research Trust 1 Lambeth High Street London SE1 7JN First Published 2011 © Pharmacy Practice Research Trust Printed in Great Britain by the Pharmacy Practice Research Trust ISBN: 978-09563323-7-0 All rights reserved. No part of this publication may be reproduced, stored on a retrieval system or transmitted in any form or by any means, without prior permission of the copyright holder. The publisher makes no representation, express or limited, with regard to the accuracy of the information stored in this book and cannot accept any legal responsibility or liability for any of the errors or omissions that may be made. ii iii Executive Summary Background and aims The sale of over the counter (OTC) medicines from pharmacies represents an opportunity for people to self-medicate and manage their own symptoms. However, some OTC medicines have the potential for being used incorrectly or abused, and there have been increasing concerns about risks associated with some medicines. The primary aim of this study was to describe and understand current issues relating to OTC medicine addiction by investigating the experiences of individuals affected by OTC medicine addiction in the United Kingdom (UK), pharmacists and medicines counter assistants (MCAs), and key UK stakeholders. Additional aims involved exploring the role of the internet, pharmacy involvement, and different types of medicine use. Method Qualitative, semi-structured interviews were undertaken with three purposively sampled groups. Firstly, 16 key stakeholders from organizations and employment related to OTC medicine addiction were interviewed including representatives from pharmacy organisations and businesses, industry representation, medical addiction interest groups, addiction and eating disorder charities, clinical perspectives from public, private and voluntary treatment services, and academia; secondly, 10 pharmacists and 7 MCAs were interviewed, representing different locations (England, Scotland and Wales) and pharmacy ownership types (multiple, independent, rural, city); thirdly, 25 individuals were recruited via two UK on-line medicine addiction support groups (Overcount and Codeine Free). Semi-structured qualitative interviews were undertaken by telephone and in-person and audio recorded, save for one participant who requested email/text-based communication. Interviews were conducted during 2009 and 2010 and all were audio recorded and transcribed verbatim. Analysis involved a process of constant comparison, with initial open and descriptive coding, and subsequent axial coding, with refinement of emergent themes. University of Sheffield ethics approval was obtained. Key findings Individuals who had experienced OTC medicine addiction – Three types of ‘respectable addict’ Individuals referred to themselves as ‘addicts’ or ‘addicted’ and all described the use of an opiate – usually codeine - containing medicine, but with occasional examples of pseudoephedrine and diphenhydramine containing products being reported. All but two participants had begun using OTC medicines for genuine medical reasons to treat symptoms that included headaches, migraine, period, joint or post-operative pain. For some this had occurred after medical treatment had ended but for others, varying relationships between past and on-going use of prescription medicines and OTC medicines were identified, including examples of topping-up, gap filling and variable consumption (fig. 1). Some had attempted to self-treat symptoms completely and only two participants had intended to exploit a medicine side effect for non-therapeutic reasons from the outset. Three distinct types of OTC medicine addiction were identified based upon the quantity of medicine taken: type I involved those who never exceeded the maximum dose; type II involved those who sometimes took slightly higher than recommended doses; and type III included those who took significantly higher doses than recommended (fig. 2). iv OTC use after prescribed supply ended The three types appeared discrete and there was no evidence of transitioning between them. All three types Prescribed medicine OTC medicine described withdrawal symptoms and using the product for different reasons than clinically indicated, often OTC use during prescribed supply: describing ‘a buzz’ or ‘calm’ from codeine. Recurrent OTC medicine patterns of drug-seeking behaviour were described, Topping-up Prescribed medicine including purchasing and use rituals such as brand specificity, deception and secretiveness, anxiety when Covering Prescribed OTC Prescribed supplies diminished, and intentionally varying the medicine medicine medicine prescribing gaps pharmacies they used. Two participants had used the internet to obtain supplies, and described obtaining Varying Prescribed multiple packets with relatively lax control and medicine between OTC OTC prescribed medicine medicine and OTC registration procedures. Most individuals raised safety Figure 1 Relationship between prescribed and OTC medicine concerns about internet-supplied medicines. All individuals had attempted to stop but some were still taking an OTC medicine; self-treatment, advice from on-line help forums, involvement of doctors and drug and alcohol treatment services and narcotics anonymous were variously described (fig. 2). None Genuine medical condition or symptoms (n=23) Initial intention to abuse a product sought pharmacy advice, and some without associated medical symptoms (n=2) explicitly rejected medical help or Previous medical Self‐management of Past use of illicit support from help forums due to Initial use prescribing/ symptoms substances (n=3) concerns about their addiction being treatment recorded, concerns about lack of GP On‐going medical Past alcohol prescribing/ dependency understanding, or a desire to hide treatment OTC medicine addiction (n=3) their addiction. Views of the role of pharmacists/ MCAs were mixed, but Never exceeded Slightlyexceeded Considerably exceeded maximum dose (n=10) maximum dose (n=7) maximum dose (n=8) Typology TYPE I TYPE II TYPE III mainly centred on the ease of of abuse obtaining supplies and the ineffectiveness of standard questions. Complex and potentially conflicting Self‐ Involvement On‐line Private NA Addiction service (n=5) Treatment identity claims were expressed (fig. 3), treatment of GP forum (n=25) clinic (n=1) (n=1) including explicit recognition of an ‘addict’ identity which was contrasted Use at time with those who were addicted to illicit On‐going OTC medicine addiction No OTC medicine addiction of study (n=9) (n=16) drugs or alcohol, which has negative Figure 2 Summary of different initial use, types of use, treatment and current use connotations. A respectable identity claim was clearly identified in descriptions of individual’s professional roles and self-perceived intelligence and frequent desire not to have addiction recorded; secrecy was often described along with shame for some. v Individuals were aware of risks associated with OTC PE RSONAL Addict Identity medicines and distinguished these from more potentially Dr ug seeking behaviour Withdrawal harmful or problematic substances, such as illicit drugs, Perceived Loss of co ntrol stereotypical Use for different effect medicines sold via the internet and some prescription addict identity All opiates Managing Alcohol? Lack of treatment medicines. In relation to policy and regulation, the Chaotic appearances options Illicit substance Hidden Family majority were in favour of continued availability of OTC Alcohol misuse Professional Treatment options Identity Appearance medicines that may cause addiction, and generally Intelligent Knowledgeable viewed addiction warnings on medicine packs and SOCIAL Resp ectable appearance Figure 3 Different identity claims leaflets as being ineffective for those already addicted but of some benefit to warn new users. Individuals blamed themselves more than pharmacists, regulation, manufacturers or doctors for their OTC medicine addiction. Stakeholders – ‘Raising awareness, improving treatment’ The wide range of stakeholder groups provided different insights and backgrounds but many common themes. Emergent themes included issues around products involved, the scale of the problem, treatment, internet supply, views on pharmacists, and policies. The medicine referred to most frequently, and for some the only medicine associated with OTC medicine abuse, was codeine. Like those with direct