Codeine combination dependence and OTC misuse (MEQ)

(i) Formulation and risks. Likely opioid use disorder / pharmaceutical codeine dependence with loss of control, multi-source supply, and continued use despite life-threatening GI harm. Concurrent non-medical gabapentinoid use. Medical risks: recurrent GI bleed, anaemia, renal injury from chronic NSAID load, opioid withdrawal if abrupt stop, overdose synergy (opioid + pregabalin), and possible occult paracetamol exposure if other combinations used.^[1][2][5]

(ii) Management. Acute: complete GI resuscitation/endoscopy pathway; check FBC, iron, U&E, LFTs; do not abrupt-stop high-dose opioids without a plan. Definitive: stop combination NSAID-opioid products; multimodal non-opioid pain and headache plan; offer OAT (buprenorphine or methadone) — Cochrane supports OAT for pharmaceutical opioid dependence; alternatively carefully supervised taper only if lower complexity and strong supports. Naloxone supply and education; addiction follow-up; single-prescriber/pharmacy agreements; prescription monitoring review.^[2][3]

(iii) Rescheduling. From February 2018 Australia made codeine prescription-only. Evaluations (Cairns) show reduced codeine use and harm signals at population level — relevant policy context, but individual dependent patients still need treatment access, not abandonment.^[4]

(iv) Gabapentinoids. Misuse/diversion well documented; additive sedation/respiratory risk with opioids. Review indication, deprescribe/taper collaboratively, avoid street supply, document risk discussions, and do not use a single positive screen as sole reason for cruel expulsion from life-saving OAT without a safety plan.^[5]

(v) Engagement. Expect rejection of “addict” identity when medicines are pharmacy-sourced (Cooper). Use motivational interviewing: reflect GI near-miss, elicit her goals (parenting, work, pain control), offer a medical frame (“your brain and body adapted to daily opioids”), and collaborative choice between OAT and structured taper rather than moral lecture.^[6][2]