Respectable Addicts? Identity and Over-the-Counter Medicine Abuse

1. Respectable Addicts? Identity and Over-the-Counter Medicine Abuse Richard CooperLecturer in Public HealthScHARR, University of Sheffield

2. Overview • 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

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

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

7. OTC Abuse Literature • Relatively little empirical research into OTC abuse. • No evaluation of treatment. • No clear patterns as to those affected.

8. OTC Abuse Literature • Addiction (codeine) • Euphoria (dextromethorphan) • Risk of other abuse (e.g. alcohol, illicit drugs) • Electrolyte imbalance (laxatives) • Convulsions/acidosis (chlorphenamine) • Economic cost • Accidents • Adverse effect on jobs and relationships Primary Medicine of abuse • Gastro-intestinal irritation, haemorrhage , death (ibuprofen) • Rebound headaches (paracetamol and ibuprofen) • Hypokalaemia/acidosis (ibuprofen) Additional Ingredient SOCIAL OTHER PHYSIOLOGICAL

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

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

11. OTC Abuse Responses • Some evidence of attempts to manage/reduce abuse: • Pharmacy-based (hide products, refuse sales, record sales,) • Harm-reduction intervention pilot – GP referral • Proposed contract/reduction scheme in pharmacies? Year long APPDMG8 reported in 2009: • Training for doctors, nurses and AHPs • Increased awareness of problem • Recognition/support for on-line help • 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

12. Qualitative Study

13. Methods Semi-structured, qualitative telephone interviews with 16 key stakeholders of organisations with interests in OTC medicines Stage 1 Semi-structured, qualitative face to face/phone interviews with quota sample of 10 pharmacists and 7 MCAs from community pharmacies in UK Stage 2 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

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

17. Initial use • 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). • Medicines were all codeine/DHC (Nurofen Plus, Co-codamol, linctus) but some pseudoephedrine, and sedative antihistamines “Physical pain doesn’t 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. • 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 “[...]I’ve 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 don’t think I realised there was codeine in it at all”Aylsa (Nurofen Plus) “Well, I mean I suppose on a really bad day and this hasn’t 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, it’s not a high. Literally, I zone out”. Rachel (co-codamol 8/500 tablets) ‘[…] 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 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. • Formal GP/DAAT help resisted by some for fear of recording problem. • Pharmacy involvement neutral – easy to bypass questions. • On-line support offered confirmation/self-treatment but engagement low “[…] my own private GP […] he just laughed and said, ‘don’t be so stupid, stop taking them’. On the other hand, what is he supposed to say? ” Richard “I went to my doctors and I would either try my best, you know, with the prescribed dihydrocodeine but 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 it’s something you handle yourself’. At this sort of level, if you know what I mean?”Dwain “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

21. Identity Claims Personal All opioids Alcohol? Managing appearances Hidden Family Social

22. Addict Identity “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 • ‘Addict’ or ‘addiction’ mentioned by all participants. • Variety of drug seeking behaviours described: • Withdrawal experienced • Loss of control over self/consumption • ‘Rituals’ of specific brands • Elaborate and methodical routes to visit pharmacies to avoid detection • Covert, hidden activity – (work, public but some used friends, family). • Shame identified by some – in deceiving, hiding addiction. • On-line forums used to confirm (validate?) addict status. “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 can’t believe that I have done this to myself. You know I find it really hard to understand.” Karen “[...] my wife is, in fact in many ways, keeping an eye on me in that sense. She’ll 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 wouldn’t mean I’d take part online, but it would I think part of my process.” John

23. Not like other addicts but… “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 don’t. I look like your normal middle aged woman.” Rachel • 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: • Pharmacology of substance – e.g. codeine as opioid • Dependency symptoms – withdrawal, dose • 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. “I think in society it’s 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 can’t 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. That’s just a social concept isn’t 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. It’s painfully obvious people look at me and think ‘what on earth is somebody like her doing in a place like this’. Because I don’t have a can of Heineken in my hand or tram marks up my arm or stand outside smoking” Theresa

24. Professional identity “[…]there are lots of people out there like me, that are intelligent professionals [...] I don’t 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 couldn’t stop and even when I got ill and had this huge gastric bleed, I still can’t believe that as an intelligent woman.” • Frequent discourse of claims relating to occupational or social status. • Used to distinguish them and their situation from other forms of addiction. • Attempts to assert knowledge: • About pharmacology • Medicine doses/active ingredients • 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. “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 that’s 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 haven’t 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 can’t be an addict. I am.” John “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

25. Discussion

26. Discussion questions • Is the ‘respectable addict’ a viable category? Linked to Reith’s9 claim that addiction originated as a ‘middle class’ concern about control (cf productivity in working classes)? • Or is there a danger, after Hacking10, of ‘making up people’ and spreading even further the web of addictive types? • A moral concern about legitimate use and deviant abuse? • Is a lesser category of pseudoaddiction11 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. • 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. • 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). • Qualitative study limitations – recruitment through websites, self-selecting participants, not able to capture. “

28. References • 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 2003 • Paxton R and Chapple P. Misuse of over-the-counter medicines: a survey in one English county. Pharmaceutical Journal 1996;256:313-315 • Matheson C, Bond C & Pitcairn J. Misuse of OTC medicines from community pharmacies: a population survey of Scottish pharmacies.Pharmaceutical Journal 2002;269:66-68 • 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;268:179-182 • Wazaify M, Shields E, Hughes CM and McElnay JC. Societal perspectives on over-the -counter (OTC) medicines Family Practice 2005;22:170-176 • 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 2010 • Ford C and Good B. Over the Counter drugs can be highly addictive. British Medical Journal 2007;334;917 • 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);283-300 • Hacking I ‘Making up people. In Heller M et al Reconstructing Individualism Stanford Uni Press 1986 • Bell K & Salmon A. Pain, physical dependence and pseudoaddiction: redefining addiction for ‘nice’ people. Int Journal of Drug Policy 2009;20:170-178 • McIntosh J & McKeganey N. Addicts’ narratives of recovery from drug use: constructing a non-addict identity. Social Science and Medicine 2000;50:1501-1510

29. Funded by the Pharmacy Practice Research Trust Richard CooperLecturer in Public HealthScHARR, University of Sheffield Richard.cooper@sheffield.ac.uk