Psych · Addiction psychiatry — pharmaceutical and OTC misuse
Pharmaceutical and over-the-counter drug misuse
Also known as OTC drug abuse · Non-prescription medicine misuse · Codeine dependence · Gabapentinoid misuse · Loperamide abuse · Dextromethorphan abuse · Purple drank · Pharmacy medicine dependence · Prescription drug diversion · Pharmaceutical opioid dependence
Exam-exhaustive fellowship reference on pharmaceutical and over-the-counter drug misuse — codeine and Australian rescheduling, gabapentinoids, loperamide cardiotoxicity, DXM, antihistamines, purple drank, diverted psychotropics and stimulants, pseudoephedrine precursor control, assessment, OAT for pharmaceutical opioids, and regional policy deltas. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- High-dose loperamide misuse — obtain ECG immediately; risk of QRS/QTc prolongation, VT/VF, and cardiac arrest
- Combination codeine-paracetamol or codeine-ibuprofen chronic mega-use — screen for hepatotoxicity, GI bleed, anaemia, and renal injury while treating opioid dependence
- Opioid overdose from pharmaceutical opioids or loperamide — ABC, repeated naloxone as needed, then link to OAT and take-home naloxone
- Assuming pharmacy or OTC origin means low addiction or medical risk — a classic exam and clinical trap
- Abrupt cessation of high-dose gabapentinoids or sedating agents in dependent patients without a plan
- Punitive exclusion from care for pharmacy-sourced dependence or gabapentinoid-positive urine without a safety plan
Meet the patient
A 34-year-old nurse presents to her GP with iron-deficiency anaemia. She takes something for headaches — thirty-two tablets a day of a codeine-ibuprofen combination she buys in bulk from several pharmacies. When the GP uses the word dependence, she replies: I can't be an addict. I am a nurse.[1][4]
That sentence — Cooper's qualitative title — is the central teaching point of this topic. Pharmacy origin does not confer immunity from dependence, organ injury, or overdose. The fellowship task is to dismantle the myth without dismantling the person.[1][2]
References16ShowHide
- [1]Cooper RJ. 'I can't be an addict. I am.' Over-the-counter medicine abuse: a qualitative study BMJ Open, 2013.PMID 23794565
- [2]Fingleton NA, Watson MC, Duncan EM, Matheson C. Non-prescription medicine misuse, abuse and dependence: a cross-sectional survey of the UK general population J Public Health (Oxf), 2017.PMID 28985351
- [3]Van Hout MC, Norman I. Misuse of non-prescription codeine containing products: Recommendations for detection and reduction of risk in community pharmacy Int J Drug Policy, 2016.PMID 26454626
- [4]Frei MY, Nielsen S, Dobbin MD, Tobin CL. Serious morbidity associated with misuse of over-the-counter codeine-ibuprofen analgesics: a series of 27 cases Med J Aust, 2010.PMID 20819050
- [5]Nielsen S, MacDonald T, Johnson JL. Identifying and treating codeine dependence: a systematic review Med J Aust, 2018.PMID 29848240
- [6]Cairns R, Schaffer AL, Brown JA, Pearson SA, Buckley NA. Codeine use and harms in Australia: evaluating the effects of re-scheduling Addiction, 2020.PMID 31577369
- [7]Schaffer AL, Cairns R, Brown JA, Gisev N, Buckley NA, Pearson SA. Changes in sales of analgesics to pharmacies after codeine was rescheduled as a prescription only medicine Med J Aust, 2020.PMID 32200566
- [8]Noghrehchi F, Cairns R, Buckley NA. Hospital admissions for paracetamol poisoning declined following codeine re-scheduling in Australia Int J Drug Policy, 2023.PMID 37116402
- [9]Smith RV, Havens JR, Walsh SL. Gabapentin misuse, abuse and diversion: a systematic review Addiction, 2016.PMID 27265421
- [10]Evoy KE, Sadrameli S, Contreras J, Covvey JR, Peckham AM, Morrison MD. Abuse and Misuse of Pregabalin and Gabapentin: A Systematic Review Update Drugs, 2021.PMID 33215352
- [11]Schifano F. Misuse and abuse of pregabalin and gabapentin: cause for concern? CNS Drugs, 2014.PMID 24760436
- [12]Eggleston W, Clark KH, Marraffa JM. Loperamide Abuse Associated With Cardiac Dysrhythmia and Death Ann Emerg Med, 2017.PMID 27140747
- [13]Swank KA, Wu E, Kortepeter C, McAninch J, Levin RL. Adverse event detection using the FDA post-marketing drug safety surveillance system: Cardiotoxicity associated with loperamide abuse and misuse J Am Pharm Assoc (2003), 2017.PMID 28073687
- [14]Miuli A, Stigliano G, Lalli A, Coladonato M, D'Angelo L, Esposito F, et al. "Purple Drank" (Codeine and Promethazine Cough Syrup): A Systematic Review of a Social Phenomenon with Medical Implications J Psychoactive Drugs, 2020.PMID 32748711
- [15]Nielsen S, Tse WC, Larance B. Opioid agonist treatment for people who are dependent on pharmaceutical opioids Cochrane Database Syst Rev, 2022.PMID 36063082
- [16]McKetin R, Sutherland R, Bright DA, et al. A systematic review of methamphetamine precursor regulations Addiction, 2011.PMID 21895829