Codeine addiction a growing problem as Aussies abuse over-the-counter pain medication OUR OTHER DRUG CRISIS: Addiction to common headache pills is a gathering scourge. THE cause of Maxwell's stomach cramps baffled a bevy of doctors so the 20-something took matters into his own hands. A friend at work had some Nurofen Plus tablets. Maxwell* took some. The pain went away and he felt good. He took some more. It was all so simple, really. He'd just walk into a pharmacy, tell them about his gut ache - if they asked - get his pills and life felt better. He'd never dream of doing anything illegal, but taking a couple more pills than the recommended daily intake couldn't hurt. Not only did it ease his pain, it gave him a nice little buzz. So he took a few extra, soon building up a tolerance to the pills. Not to worry. It was not like he was a junkie or anything. Common pills may carry addiction warning Except, within a couple of years, he was. A codeine junkie. Clean-cut, well-spoken, full-time employed in the energy business ... but a junkie nonetheless. Every day, he'd gobble 50 tablets of the codeine/ibuprofen cocktail. He'd heard you could get addicted to codeine but he thought that was for weaker beings. When he wanted to stop, he would. "How hard could it be?" he reasoned. As it turned out, damn hard. Doctors compare it with getting off heroin ... codeine's chemical cousin. "It's like the worst fever and stomach bug you've ever had," Maxwell says. You think you're hot but you're cold or you just can't tell. You're anxious, sleep's gone, you're constantly getting these goosebumps and these feelings just run over you all the time. He tried "countless times" to kick his habit on his own but only ever lasted three days. His fiancee left him. He stagnated at work. His facade came crumbling down when he was admitted to hospital in agony, bleeding internally. He'd burned a hole in his stomach lining. It's the middle-class addiction to which no-one wants to admit, contributing to sales of 16 million packs of over-the-counter (OTC) codeine worth $145 million annually. All three of the men who spoke about their dependence to Qweekend did so only on the basis of anonymity. A female nurse in her thirties pulled out of an interview, so fearful was she of her former secret life being revealed. Says Maxwell, who was finally diagnosed with the irritable bowel disorder, Crohn's disease, after ending up in hospital: "I was always worried someone would find out; there was a lot of anxiety, guilt and shame." In case, like Maxwell, you think it can't be that hard to get off tablets sold over the counter without a prescription, consider this: he now takes Suboxone, the modern-day heroin replacement drug. Others are put on methadone. WHEN pain strikes, out first port of call is often a pharmacy. We know the pill that has worked before to subdue the migraine, the period pain, the backache. We're busy, and while regular physiotherapy would help the back, or getting more sleep might keep that pulsating headache at bay, we also know that the wonders of chemistry are awaiting us at the dispensary. For most of us, that's okay in the short term. We take the pill, the pain lessens and we stop taking the medication. But for those with underlying problems of depression and anxiety, or an addictive nature, pills containing codeine - a weak opioid analgesic - can lead to the slippery slope of dependence. Dr Christian Rowan has been watching the slide. The new president of doctors' lobby group the Australian Medical Association Queensland is also an addiction medicine specialist and says that in the past five years, the number of patients with addiction to OTC codeine has grown enough to alarm him. His private clinic at the Wesley Hospital in Brisbane's inner west sees mostly middle-class patients, 25 per cent of whom are addicted to OTC codeine. That's higher than those who come to him hooked on opioid and benzodiazepine prescription drugs that have been under the media spotlight, such as OxyContin, MS-Contin and Xanax (about 15 per cent), while illicit drug addiction makes up about 40 per cent and alcohol the rest. Rowan is deeply concerned about society's obsession with medical quick fixes. "It's the McDonaldisation of society," he says. Australia generally has had a great love for the pill, a simple solution, the quick fix. Take a pill and it resolves everything, but that's not the case. He is aware of a community perception that some in the medical fraternity are culpable of creating this quick fix attitude by prescribing pills to get patients out the door. We need a collaborative effort between doctors, pharmacists, the industry around education and training about the appropriate use of these products, both prescription and over-the-counter drugs. More funding for pain management services offering non-drug therapy - which requires more effort from patients than swallowing a pill but gives them the tools to deal with physical, and mental, pain in the long term - is needed. We had a lesson in the folly of being seduced by the quick fix in the '80s when Bex and Vincent's powders were taken off the market after a couple of decades of being swilled down for everything from headaches to calming nerves. A mix of aspirin, caffeine and phenacetin (which targets the nervous system), Bex was withdrawn from sale after its addictive nature became clear and kidney disease spiked among users. The withdrawal came long after the powder's advertising slogan, "Have a cup of tea, a Bex and a good lie down," became a part of our national lexicon. Rowan compares the "normalisation" of codeine-mixed drugs such as Nurofen Plus (codeine and ibuprofen), Panadeine Extra (codeine and paracetamol) and Mersyndol (codeine, paracetamol and doxylamine succinate) with what happened with Bex. "It's the normality, or domesticity of the tablet," he says. The tendency for people to say, 'I've had a stressful day, I'll take some tablets', is greater than it was in the Bex era. Whether it's taking some over-the-counter codeine or popping a few Valium or Xanax, it's creeping in. In Rowan's clinic, it is "socially stable" women under 45 who represent the biggest slab of patients addicted to OTC codeine. He puts some of the responsibility for the reliance on a pill on the shoulders of the manufacturers that launch aggressive marketing campaigns. While the codeine-based products that often come with a "plus" or "extra" in their name cannot be advertised, their purely ibuprofen or paracetamol relatives can. With advertising - and results - that show a drug works on babies, some consumers develop the attitude that a product range is harmless. ADDICTIVE PROPERTIES: The codeine found in common headache tablets can be a trap. "If you get comfortable with using a product for a particular age group and it stays with the journey throughout your life, that is a clever marketing ploy," Rowan says. Some of the marketing is that everything is safe and easy and effective, so there's a corporate responsibility for pharmaceutical companies. [We need] to get back to thinking that medications are serious things, [and] they need to be taken in an appropriate way under proper guidance. True enough, says pharmacist Professor Lisa Nissen, but she adds that doctors fuel the problem by prescribing pain medication as a matter of course. "You have a procedure on your knee in any day unit around this city, you'll get discharged on a box of Panadeine Forte [a prescription medicine with double the codeine of the OTC Panadeine Extra] and you'll take that for a week," says Nissen, president of the Queensland branch of the Pharmaceutical Society of Australia. That's enough for someone to become physically dependent on the opioid. So, not surprisingly, that stops, they feel shitty, any pain they have left over from their procedure feels worse because they're tired, stressed, anxious, so they think, I'd better go to the pharmacy and get some pain meds. That's how it started for Samuel*, one of Rowan's patients. As a bright young university student, he battled crippling anxiety before exams. A doctor prescribed Diazepam, or Valium, and it "was magic, it took all the stresses away." His results improved, but he was seduced by the release drugs offered and became addicted to the prescription drugs, which led to him injecting methamphetamine, or speed. That may sound hardcore, but the man sitting opposite me is testament to the fact that drug users come in all guises. Conservatively dressed in woollen vest and slacks, he is a middle-aged man working in the finance industry, earning more than $120,000 a year. He'd weaned himself off his illicit drug habit by his early thirties. But five years later, minor surgery saw him prescribed OxyContin. And it was, 'Oh, I'd forgotten about these'. Just that small therapeutic dose reminded me of what I used to get up to and reignited the problem. He was fearful of getting hooked on prescription drugs again. In my mind, fresh start, I won't touch any medicine through the doctor, but that led me to Panadeine Extra just over-the-counter. The pills helped his anxiety as well as his physical pain, and gave him a euphoric buzz. He started taking more than the recommended daily dose, and soon developed stomach cramps. He'd heard you could extract codeine from OTC tablets and looked up the process on the internet. There he found a host of sites detailing how to leach the paracetamol from the tablets, leaving mostly codeine. This is how codeine addicts enter the realm of astounding intake, up to 200 tablets a day. Too much codeine is not good; symptoms include nausea, constipation, memory problems, sedation and, in large amounts, cardiac and respiratory arrest. You can die, but it's rare. However, the human body suffers much more quickly from too much paracetamol or ibuprofen, with symptoms ranging from burst peptic ulcers to liver, pancreas and kidney damage. In his drug-addicted mind, Samuel reasoned he was being healthier by extracting the codeine. "I read how the paracetamol could be quite toxic, so I thought the logical thing to do was decrease the amount of paracetamol," he says. I don't know why I didn't think it was particularly problematic. I guess because it's so readily available and over-the-counter at the pharmacist. Maxwell, too, knew about codeine extraction but considered that "a step too far." At the peak of Samuel's addiction, through which he was "fully functioning" at work, he was using 120 tablets a day. Instead of doctor shopping, he was pharmacy shopping, spending up to $400 a week on OTC codeine. He had a list of pharmacies on rotation, always careful to leave a few days between visits. Dressed in a suit and well-mannered, he was never refused the pills. Sometimes they'd say, 'Perhaps you should see your doctor again, you don't seem to be getting enough relief out of these', but they'd [still] sell them. When Samuel found he couldn't wait to get home to take extracted codeine, instead "taking fistfuls of tablets" during his commute, he knew he had to act. He saw Rowan. He is now on Suboxone - "I don't think I would have reacted well to the idea of methadone, it's got that stereotype" - and receiving cognitive behaviour therapy and other non-drug treatments to deal with his anxiety and depression, the root of his problems. "There's a lot more to me than past indiscretions," he says. This can happen to anyone and it can remain hidden. There don't have to be dealers knocking on someone's door. GATEWAY DRUGS: Professor Lisa Nissen says addiction can start innocently enough. A COLOSTOMY bag fitted to a young man is a dreadful result of codeine addiction and one that public health physician Dr Jeremy Hayllar has seen and will see again. Unlike Rowan in private practice, the clinical director of the Alcohol and Drug Service for Metro North Health doesn't treat a lot of middle-class women in public clinics such as Biala, on Roma Street in Brisbane city, but he is seeing a small but growing number of Generation Y men addicted to the pills and suffering debilitating illnesses. "I can think of one young man who burst his colon, so he had to have a [colostomy] bag," Hayllar says. He has a loss of muscle integrity; his bowel leaks out under his skin so he's very incapacitated with that, and more surgery will be required to fix it up. So his pristine abdomen from two years ago is now a mess. Another of his patients is Maxwell, who is sitting in Hayllar's office, explaining the appeal of OTC drugs. I wouldn't dream of buying heroin off the street and why would you need to? You can go into a chemist," he says. Each tablet is a certain amount, so you know what you're getting, not the guessing game it would be with injectable drugs. Hayllar interrupts. "That's a very Gen Y comment," he says. They prefer prescriptions and prepared stuff because it's clean, from a known source and you know the dose. Some people, he says, metabolise codeine into morphine more quickly than others "and they're the ones probably who get into trouble." Hayllar presents a graph indicating the addictions that force patients to seek help through the Queensland Opioid Treatment Program. Most patients have a heroin problem but the percentage is falling as addiction to prescription morphine and oxycodone (trading as OxyContin) climbs. "And here," he says, pointing to a small sliver at the bottom of the bar graph, "we have codeine, and that first appears about five years ago and it's growing slowly." Hayllar's public health colleague, Dr Mark Daglish, director of addiction psychiatry at the Royal Brisbane and Women's Hospital, agrees codeine addiction has risen over the past five years. Colostomy bag cases are not new to him and he adds a shocking development: not only are some people extracting codeine from tablets, they are injecting it in liquid form. Daglish says statewide and national figures about codeine abuse are rubbery because services like his own generally record admissions under the catch-all category of "opiate." Professor Paul Haber, president of the Australasian Chapter of Addiction Medicine at the Royal Australasian College of Physicians, adds that private patients are not counted in the figures. People [with codeine addiction] tend not to go to the public sector D&A [drug and alcohol] services, so we just don't get data about them. In the UK, an all-party parliamentary inquiry in 2007-08 estimated 32,000 Britons were addicted to OTC drugs and warned that was the tip of the iceberg. One of those addicts was the late comedian Mel Smith, who in 2000 revealed his dependency on Nurofen Plus - sparked by a battle with gout - after ending up in hospital with two burst stomach ulcers. The US is stricter, with only low-dose codeine products sold over the counter. Australia has taken steps to limit access: in 2010, the pack sizes were reduced from 96 tablets to 30 and they now can only be sold from behind the pharmacist's counter. But Rowan says more should be done, arguing a federal government plan in the pipeline to monitor prescription narcotics (Schedule 8 drugs) via an electronic "real time" recording system be extended to OTC codeine. ACTIVE INGREDIENT: Paracetamol toxicity can be a danger in the codeine-addicted. The system will link all pharmacy sales of Schedule 8 drugs via computer so that pharmacists can check the frequency of a customer's purchase of the products. A federal Health Department spokeswoman says ongoing funding of the system is still being nutted out between the federal and state governments and that "go live" times are a matter for each state. It would be similar to the Queensland-initiated, Pharmacy Guild of Australia-funded Project STOP, which was set up to combat bulk buying of cold-and-flu tablets containing pseudoephedrine, which can be used to make speed. Driver's licence details are logged in a pharmacy-linked computer system and, if too many purchases have been made in a predetermined short time, pharmacists can refuse to sell the product. Says Rowan: "As a physician, we see harm from both OTC as well as prescription drugs, so my recommendation would be that we really need both [on the register]." He says he will push for discussions between the national AMA and the Pharmacy Guild (PGA) to see if a united position on the issue can be reached. However, Queensland-based Kos Sclavos, national president of the PGA, which represents owners of community pharmacies, is reticent. Sclavos, widely considered one of the country's most powerful lobbyists, says misuse and problems from prescription drugs far outweigh those of OTC codeine, which pharmacists already have the right to refuse to sell if they are concerned. "Is the risk or prevalence high enough that we are going to inconvenience people and add to the cost?" asks Sclavos. Because the administration costs of these sales would have an added burden. To be honest, here's another thing I'd say. Talk is cheap. A lot of health professionals say, 'Here's the problem'; I guess what I'm saying is, 'What is your solution?' A solution costs money and I'm not hearing that the AMA is offering to pay for this. Rowan says the AMA could not afford to fund a monitoring system. On the question of extending the planned system to include OTC codeine, the federal Health spokeswoman said it was up to states and territories to decide which drugs to monitor, while according to Queensland's chief health officer, Dr Jeannette Young, the federal government's proposed database was not designed to manage OTC transactions. At the front line of this argy bargy are the pharmacists themselves. Nissen, who represents dispensers in Queensland, says "we would be cautiously interested in opportunities to allow us to better manage the OTC codeine situation." Cautious, because the profession is loath to be seen as an arm of the police. If we're seen as police officers, that's not going to help us in being seen as someone that people can come and talk to ... If we ask questions, it's because we care. Nissen admits pharmacists need more training to broach the subject of overuse of OTC codeine. People feel like they're being interrogated, it's very adversarial at times. If you're in a position where you're just going to get angst if you intervene, over time, you just don't. That's a lost opportunity, and we realise that and are trying to work on ways to improve it. Support on that front may be on the way from the manufacturers of the drugs themselves. Dr Deon Schoombie, executive director of the Australian Self-Medication Industry, the lobby group for companies that manufacture and distribute OTC healthcare products, says it has been talking with Australia's drug regulator, the Therapeutic Goods Administration, about following Britain's lead and changing the labelling on boxes. "In the UK, they have on the front of the pack a warning to the effect of: 'Don't use for more than three days, can cause addiction'," Schoombie says. That's the sort of thing we can look at. He suggests such labelling would enable the pharmacist to point to the wording and discuss the drug's potentially addictive nature with the customer. It's inoffensive, it's neutral. Pressed on whether changing the labelling was something the group would "look at" or implement, Schoombie says: "We would fully support it." However, on the matter of including OTC codeine in the real-time monitoring proposal, Schoombie is more circumspect. "Definitely interested in looking at the merits of it," he says. TALK IS CHEAP: Pharmacy Guild of Australia president Kos Sclavos. FOR two days Paul just slept, under sedation in a psychiatric ward of a Brisbane hospital. Suicidal and exhausted, the aged care nurse had finally admitted to himself that his codeine addiction was out of control. "I'd just reached the end of life, basically," he says in a consultation room at Rowan's clinic. Every day, he'd been taking codeine extracted from 200 tablets. I was the equivalent of a heroin addict. His story, like others of dependency, is not simple. An epileptic, he had his first serious bout of depression as a young adult and was on a range of drugs for both conditions. A foot injury in his mid-twenties led to being prescribed Panadeine Forte, to which he became addicted. After three years of doctor-shopping it was harder to find a compliant GP and, desperate, he began extracting codeine from OTC products. "Addiction is about mental health," Paul says. Your defences are down, you look for anything to support your mental health. You feel depressed, lonely, misunderstood. It's the inner monologue of really being negative about yourself, and more than anything it is to try to calm that. And even though I was nursing, I was reluctant to seek help for mental health. His unwillingness to get help was compounded by a lack of trust in the medical system because of what he considered bad advice over the years. So instead, street map by his side, he would drive "across Brisbane" to different pharmacies to fuel his growing tolerance to codeine. He'd make up names if asked, drop a pharmacy off his rounds if staff became too inquisitive. I hated every minute of it. I felt trapped between a health system that I felt had let me down and my addiction. Now, almost five years on from his time in the psychiatric ward and in his late thirties, he is rebuilding his life with Rowan's guidance. He is on methadone, his "wonderful" wife is supporting him and he plans to return to university to finish a science degree next year. "My reasonableness came back," he says. My ultimate goal is to get off the methadone. I won't be satisfied until I'm off it, but I'll take appropriate steps and do it safely. As for putting OTC codeine on a nationally linked, real-time monitoring register, Paul is emphatic. "Absolutely," he says. I know how cunning I was and I'm sure there are more cunning people out there. And it's only going to get worse. Names have been changed. For help and support, contact the Alcohol and Drug Information Service (ph 1800 177 833)