How Resistant to Tampering are Codeine Containing Analgesics on the Market? Assessing the Potential for Opioid Extraction.
BACKGROUND
Misuse of opioid analgesics, in combination with diversion, dependence, and fatal overdoses, presents a serious problem for public health, which affects many countries worldwide. Within this context, tampering with opioids has been associated with serious harm. The aim of the present study was to assess the tampering potential of codeine combination analgesics on the market (containing codeine/non-opioid analgesics) by the extraction of codeine.


METHODS
Codeine was extracted from three combination formulations sold lawfully from licensed pharmacies without a medical prescription in Denmark and the UK. Extraction of codeine followed tampering procedures available on the Internet. The amounts of codeine and accompanying non-opioid analgesics in tampering products were analysed with liquid chromatography and tandem mass spectrometry (LC-MS/MS).


RESULTS
LC-MS/MS showed recoveries of the total amounts of codeine in tampering products of 81-84% from Product 1 (codeine/acetylsalicylic acid); 61-67% from Product 2 (codeine/ibuprofen); and 42-71% from Product 3 (codeine/paracetamol). Recoveries of non-opioid analgesics ranged between: 57-73% acetylsalicylic acid; 5.5-8.5% ibuprofen, and 5.0-9.2% paracetamol.


CONCLUSIONS
With the tampering procedures used, high amounts of codeine were separated from the accompanying analgesics in some, but not in all of the codeine containing formulations. Evidence-based medicine regulation, treatment for opioid dependence, and information to minimise risks to the public are essential components of an effective public health strategy to address the harms of tampering and misuse.


BACKGROUND
Marie Pedersen and Jensine Heiberg Foundation.
National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Addiction Sciences Building, 4 Windsor Walk, London, SE5 8BB, UK. Andreas.Kimergard@kcl.ac.uk.
Andreas
A
Kimergård
National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Addiction Sciences Building, 4 Windsor Walk, London, SE5 8BB, UK.
Paolo
P
Deluca
Department of Clinical Biochemistry, North Denmark Regional Hospital (Aalborg University), Hjørring, Denmark.
Peter
P
Hindersson
Department of Clinical Biochemistry, North Denmark Regional Hospital (Aalborg University), Hjørring, Denmark.
Torben
T
Breindahl
Analgesics; Codeine; Internet; Opioids; Risk assessment; Tampering