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Clinical Atlas Prestige · Evidence-first

Psych MEQs / SAQsAddiction psychiatry — pharmaceutical and OTC misuse

Psych MEQs / SAQs · Addiction psychiatry — pharmaceutical and OTC misuse

Codeine combination dependence and OTC misuse (MEQ)

FRANZCP-style MEQ on pharmaceutical/OTC misuse: Frei-type codeine-ibuprofen morbidity, OAT for pharmaceutical opioids, 2018 rescheduling, gabapentinoids, and motivational engagement.

20 marks20 min
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
A 38-year-old woman is referred from gastroenterology after admission with melaena, haemoglobin 78 g/L, and a bleeding gastric ulcer. She discloses taking 25–35 codeine–ibuprofen combination tablets daily for 3 years, previously purchased over the counter from rotating pharmacies and, since 2018, via three different GPs. She also uses pregabalin 300 mg three times daily bought from a friend ‘to sleep’. She denies injecting drugs, rejects the word ‘addict’, and asks only for ‘stronger painkillers so I can stop the chemist ones’. (i) Formulate the substance problems and key medical risks. (ii) Outline acute and definitive management including whether opioid agonist treatment is appropriate. (iii) Explain the relevance of Australian codeine rescheduling. (iv) Address gabapentinoid co-use. (v) Describe how you would engage her given identity conflict about addiction. (20 marks)

Model answer

Reveal model answer

(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]

Common errors

  • Refusing OAT because the opioid was “only codeine from a chemist.”
  • Treating the ulcer alone and discharging without addiction plan.
  • Ignoring pregabalin–opioid synergy.
  • Inventing exact statute numbers for prescription monitoring.
  • Pure confrontation that ends the interview. [1][3][5][6]

Examiner notes

High-scoring answers name Frei, Nielsen codeine review, Cochrane pharmaceutical OAT, Cairns rescheduling, Evoy gabapentinoids, and Cooper identity, and integrate medical and addiction plans.[1][2][3][4][5][6]

References

  1. [1]Frei MY, et al. Serious morbidity associated with misuse of OTC codeine-ibuprofen analgesics Med J Aust, 2010.PMID 20819050
  2. [2]Nielsen S, et al. Identifying and treating codeine dependence: a systematic review Med J Aust, 2018.PMID 29848240
  3. [3]Nielsen S, Tse WC, Larance B. Opioid agonist treatment for people who are dependent on pharmaceutical opioids Cochrane Database Syst Rev, 2022.PMID 36063082
  4. [4]Cairns R, et al. Codeine use and harms in Australia: evaluating the effects of re-scheduling Addiction, 2020.PMID 31577369
  5. [5]Evoy KE, et al. Abuse and Misuse of Pregabalin and Gabapentin: A Systematic Review Update Drugs, 2021.PMID 33215352
  6. [6]Cooper RJ. Over-the-counter medicine abuse: a qualitative study BMJ Open, 2013.PMID 23794565