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A previously fit and well 35-year-old man was admitted with a haemoglobin concentration of 67 g/L, an albumin of 31 g/L, exertional dyspnoea, and lower leg oedema. He gave a history of daily epigastric pain for a year; worse on eating. He admitted to using over 100 Nurofen Plus per day for back pain. Gastroscopy revealed an acute gastric ulcer with active bleeding in the pyloric channel, severe gastritis and post-bulbar duodenitis with active bleeding (Figures 1&2). Figure 1. Acute pyloric ulcer with oedema and stenosis Figure 2. Post-bulbar duodenitis with erosions The patient was prescribed a reducing codeine dose as an opiate substitute for the Nurofen Plus and received counselling for his addiction. Follow-up gastroscopy showed healing of the ulcer, gastritis and duodenitis, however balloon dilation of the subsequent pyloric stenosis was required. Discussion Here we present one of four patients who have presented to our Service over the last 2 years with significant gastrointestinal pathology secondary to the gross overuse of combination non-steroidal anti-inflammatory drug (NSAID)/codeine products. It is well documented that NSAIDs cause a plethora of adverse effects, including NSAID-induced enteropathy,1 but the addition of codeine to NSAIDs in such products increases their addictive nature. In the 2007/08 New Zealand Alcohol and Drug Use Survey, the lifetime prevalence of prescription opiate abuse was estimated to be 2.3%. While data are not available regarding the abuse of over the counter codeine-containing products, addiction to these products has been of increasing concern.2,3 In November 2009, in response to this concern, the Medicines Classification Committee recommended a change in the classification for all products containing under 15 mg codeine in combination with another pharmacologically active substance from pharmacy-only to a restricted product.4 This reclassification as a pharmacist-only medication is hoped to reduce the availability of these products as a drug of abuse and thus reduce the clinical consequences such as were seen in this patient. This information was included in the Prescriber Update February 2010.5.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Claire Evans, Elective Medical Student, Department of Medicine, University of Otago, Christchurch; Teresa Chalmers Watson, Consultant Gastroenterologist, Christchurch Hospital, Christchurch; Richard Gearry, Associate Professor, Department of Medicine, University of Otago, Christchurchand Consultant Gastroenterologist, Christchurch Hospital, Christchurch

Acknowledgements

Correspondence

Associate Professor Richard Gearry, Department of Medicine, University of Otago, Christchurch, Consultant Gastroenterologist, Christchurch Hospital, PO Box 4345, Christchurch 8140, New Zealand. Fax: +64 (0)3 3640935

Correspondence Email

Richard.Gearry@cdhb.govt.nz

Competing Interests

- Intestinal toxicity of Non-Steroidal Anti-Inflammatory Drugs; Bjarnason I, Macpherson A; Pharmac Ther. 1994; 62:145-157.-- Ford C. Dependence on OTC drugs, Over the counter drugs can be highly addictive; Letters BMJ. (5 May) 2007;334:917-918-- Drug Use in New Zealand: Key Results of the 2007/08 New Zealand Alcohol and Drug Use Survey; Ministry of Health; 2010.-- Minutes of the November 2009 Medicines Classification Committee Meeting, www.medsafe.govt.nz-- Prescriber Update February 2010;31(1). www.medsafe.govt.nz-

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View Article PDF

A previously fit and well 35-year-old man was admitted with a haemoglobin concentration of 67 g/L, an albumin of 31 g/L, exertional dyspnoea, and lower leg oedema. He gave a history of daily epigastric pain for a year; worse on eating. He admitted to using over 100 Nurofen Plus per day for back pain. Gastroscopy revealed an acute gastric ulcer with active bleeding in the pyloric channel, severe gastritis and post-bulbar duodenitis with active bleeding (Figures 1&2). Figure 1. Acute pyloric ulcer with oedema and stenosis Figure 2. Post-bulbar duodenitis with erosions The patient was prescribed a reducing codeine dose as an opiate substitute for the Nurofen Plus and received counselling for his addiction. Follow-up gastroscopy showed healing of the ulcer, gastritis and duodenitis, however balloon dilation of the subsequent pyloric stenosis was required. Discussion Here we present one of four patients who have presented to our Service over the last 2 years with significant gastrointestinal pathology secondary to the gross overuse of combination non-steroidal anti-inflammatory drug (NSAID)/codeine products. It is well documented that NSAIDs cause a plethora of adverse effects, including NSAID-induced enteropathy,1 but the addition of codeine to NSAIDs in such products increases their addictive nature. In the 2007/08 New Zealand Alcohol and Drug Use Survey, the lifetime prevalence of prescription opiate abuse was estimated to be 2.3%. While data are not available regarding the abuse of over the counter codeine-containing products, addiction to these products has been of increasing concern.2,3 In November 2009, in response to this concern, the Medicines Classification Committee recommended a change in the classification for all products containing under 15 mg codeine in combination with another pharmacologically active substance from pharmacy-only to a restricted product.4 This reclassification as a pharmacist-only medication is hoped to reduce the availability of these products as a drug of abuse and thus reduce the clinical consequences such as were seen in this patient. This information was included in the Prescriber Update February 2010.5.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Claire Evans, Elective Medical Student, Department of Medicine, University of Otago, Christchurch; Teresa Chalmers Watson, Consultant Gastroenterologist, Christchurch Hospital, Christchurch; Richard Gearry, Associate Professor, Department of Medicine, University of Otago, Christchurchand Consultant Gastroenterologist, Christchurch Hospital, Christchurch

Acknowledgements

Correspondence

Associate Professor Richard Gearry, Department of Medicine, University of Otago, Christchurch, Consultant Gastroenterologist, Christchurch Hospital, PO Box 4345, Christchurch 8140, New Zealand. Fax: +64 (0)3 3640935

Correspondence Email

Richard.Gearry@cdhb.govt.nz

Competing Interests

- Intestinal toxicity of Non-Steroidal Anti-Inflammatory Drugs; Bjarnason I, Macpherson A; Pharmac Ther. 1994; 62:145-157.-- Ford C. Dependence on OTC drugs, Over the counter drugs can be highly addictive; Letters BMJ. (5 May) 2007;334:917-918-- Drug Use in New Zealand: Key Results of the 2007/08 New Zealand Alcohol and Drug Use Survey; Ministry of Health; 2010.-- Minutes of the November 2009 Medicines Classification Committee Meeting, www.medsafe.govt.nz-- Prescriber Update February 2010;31(1). www.medsafe.govt.nz-

For the PDF of this article,
contact nzmj@nzma.org.nz

View Article PDF

A previously fit and well 35-year-old man was admitted with a haemoglobin concentration of 67 g/L, an albumin of 31 g/L, exertional dyspnoea, and lower leg oedema. He gave a history of daily epigastric pain for a year; worse on eating. He admitted to using over 100 Nurofen Plus per day for back pain. Gastroscopy revealed an acute gastric ulcer with active bleeding in the pyloric channel, severe gastritis and post-bulbar duodenitis with active bleeding (Figures 1&2). Figure 1. Acute pyloric ulcer with oedema and stenosis Figure 2. Post-bulbar duodenitis with erosions The patient was prescribed a reducing codeine dose as an opiate substitute for the Nurofen Plus and received counselling for his addiction. Follow-up gastroscopy showed healing of the ulcer, gastritis and duodenitis, however balloon dilation of the subsequent pyloric stenosis was required. Discussion Here we present one of four patients who have presented to our Service over the last 2 years with significant gastrointestinal pathology secondary to the gross overuse of combination non-steroidal anti-inflammatory drug (NSAID)/codeine products. It is well documented that NSAIDs cause a plethora of adverse effects, including NSAID-induced enteropathy,1 but the addition of codeine to NSAIDs in such products increases their addictive nature. In the 2007/08 New Zealand Alcohol and Drug Use Survey, the lifetime prevalence of prescription opiate abuse was estimated to be 2.3%. While data are not available regarding the abuse of over the counter codeine-containing products, addiction to these products has been of increasing concern.2,3 In November 2009, in response to this concern, the Medicines Classification Committee recommended a change in the classification for all products containing under 15 mg codeine in combination with another pharmacologically active substance from pharmacy-only to a restricted product.4 This reclassification as a pharmacist-only medication is hoped to reduce the availability of these products as a drug of abuse and thus reduce the clinical consequences such as were seen in this patient. This information was included in the Prescriber Update February 2010.5.

Summary

Abstract

Aim

Method

Results

Conclusion

Author Information

Claire Evans, Elective Medical Student, Department of Medicine, University of Otago, Christchurch; Teresa Chalmers Watson, Consultant Gastroenterologist, Christchurch Hospital, Christchurch; Richard Gearry, Associate Professor, Department of Medicine, University of Otago, Christchurchand Consultant Gastroenterologist, Christchurch Hospital, Christchurch

Acknowledgements

Correspondence

Associate Professor Richard Gearry, Department of Medicine, University of Otago, Christchurch, Consultant Gastroenterologist, Christchurch Hospital, PO Box 4345, Christchurch 8140, New Zealand. Fax: +64 (0)3 3640935

Correspondence Email

Richard.Gearry@cdhb.govt.nz

Competing Interests

- Intestinal toxicity of Non-Steroidal Anti-Inflammatory Drugs; Bjarnason I, Macpherson A; Pharmac Ther. 1994; 62:145-157.-- Ford C. Dependence on OTC drugs, Over the counter drugs can be highly addictive; Letters BMJ. (5 May) 2007;334:917-918-- Drug Use in New Zealand: Key Results of the 2007/08 New Zealand Alcohol and Drug Use Survey; Ministry of Health; 2010.-- Minutes of the November 2009 Medicines Classification Committee Meeting, www.medsafe.govt.nz-- Prescriber Update February 2010;31(1). www.medsafe.govt.nz-

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