I manipulated the health system, but then the health system manipulated me, right? I mean look at this bullshit of allowing generic OxyContin on the market. I had a map of the city and I divided it up into quadrants, and I got drugs from clinics and emergency departments. He said it was less addicting and that the Tylenol in the Percocet was going to hurt my liver. I had been getting 10mg to 20mg, but I told him I was still having pain, so he just increased it, no questions asked.
I took that letter to every ER in the city and to walk-in clinics. In my opinion, that doctor purposely took advantage of people. He gave me enough Oxy to take away the withdrawal.
You took your oath, not me. But he made it clear that if I came back, this would never happen again. And I never went back. That was one of the most compassionate interactions I have had with an emergency room doctor. Methadone is an aide. Counselling and psychotherapy need to be offered as well.
But none of them were. I still went to doctors who were giving me stronger opioids, like hydromorphone. And then I went to buying heroin from the street. Oh my God, did they treat me like hell! First of all they did a urine test, which was fine.
It produces a lot of nausea and stuff. I went back to school. I graduated with two diplomas. One in addiction studies, one in counselling skills. Now, I work as a counsellor. My generalized anxiety disorder, obsessive compulsive disorder, ADHD — those are diseases. The addiction is how I coped. The opioid epidemic shows no sign of stopping. These extractions are possible because opioid salts codeine phosphate [1] , hydrocodone bitartrate [2] , oxycodone hydrochloride [3] have a higher solubility in water at lower temperatures than paracetamol [4] and ibuprofen [5].
The more water cools, the less paracetamol and ibuprofen the solution will retain in proportion to the opioid salts. Opioid extraction In some countries tablets are available over the counter in others these are available only by medical prescription that contain aspirin , paracetamol acetaminophen or ibuprofen in combination with codeine , an opiate.
See also Hot water extraction sv:CWE. Categories : Homogeneous chemical mixtures Opioids Solutions Drugs. Cookies help us deliver our services. Such findings are useful for comprehensive risk assessments of opioid medicines [ 35 ]. We describe and compare the experiences of two groups of participants: i those who only used CCM and ii those who used CCM and heroin.
Our analyses highlight that concerns of paracetamol overdose from CCM informed decisions to treat codeine tablets with CWE in both groups of participants. The prospect of removing paracetamol from CCM reflects prior research on factors which encouraged dissemination of CWE techniques on online drug forums [ 19 ]. In circumstances where prescription-only codeine which contain a higher ratio of codeine versus paracetamol than OTC CCM were temporarily unavailable from diversion, participants using CCM and heroin resorted to CWE of OTC codeine to continue their use of high codeine dosages without the risk of paracetamol overdose.
The only barrier acting against this form of tampering of psychoactive medicines found in the study was the amount of time required to collect enough boxes of OTC codeine and the amount of time required to treat codeine with CWE. This was evident amongst participants who only used CCM. Information about CWE online was accessed by all the participants and assisted uptake. From a harm reduction perspective, the possibility of removing paracetamol from CCM protected participants against the harms associated with paracetamol overdose such as hepatotoxicity.
More so, this was the case amongst the participants who had no alternative sources of opioids other than OTC CCM and were not ready to cease their use.
However, the variability of the amounts of paracetamol and ibuprofen left in extracted mixtures typically of an unknown quantity to people practicing CWE constitute a risk [ 14 , 20 , 21 ].
As such, the ease at which codeine can be obtained, their potential for tampering and the existence of recipes for CWE represent factors exposing people who are treating CCM with CWE to harm. Findings pertaining to the awareness of the harms associated with the non-opioid analgesics found in CCM highlight concerns of paracetamol overdose from the use of excessive doses and resonates with prior qualitative research on risk awareness amongst people with probable codeine dependence [ 30 , 36 ].
The influence of risk awareness on drug taking behaviours, included information gathering and taking precautions such as treating CCM with CWE. Changes in behaviour triggered by reports of harms and risks and subsequent dissemination of harm reduction drug using practices online and by word of mouth amongst people who use CCM resonate with reports of information-seeking and associated behaviour change amongst other populations of people who are using opioids.
There is evidence to support that people who use drugs will access information from multiple sources including television, from other people who use drugs, friends, relatives, online and print media to protect themselves from harm occurring [ 37 , 38 ].
Some of our findings identify issues which have been less well-described in the scientific literature. Previous research has shown that fluctuation in the heroin supply may trigger displacement activities such as seeking treatment and quitting, or using alcohol and benzodiazepines and diverted opioids such as methadone [ 39 , 40 , 41 ]. Our findings suggest displacement to codeine extracted from OTC CCM during periods of reduced availability in the heroin supply, or when prescription-only CCM were unavailable, otherwise undetected in empirical research [ 30 , 36 ].
These findings may reflect law enforcement activity targeting markets for heroin and stronger pharmaceutical opioids. They may also reflect changes in the commissioning and provision of structured addiction treatment resulting in increased unmet treatment needs leading to continued opioid use with sourcing of multiple types of opioids to avoid withdrawal and cravings as the result.
For all participants, failed attempts at CWE if the techniques are not used correctly means that high amounts of paracetamol in the extracted solutions could remain. Likewise, variation in employing the CWE procedures, for example by switching between different brands of coffee filters for each attempt at extraction or cooling the solutions to different temperatures each time, will likely yield varying results over consecutive attempts and lead to inconsistencies between the amounts of codeine and paracetamol or ibuprofen left in the extracted solutions [ 14 , 21 , 24 ].
This represents a risk of harm from paracetamol overdose such as hepatoxicity. This may not be known to people practising CWE. For the participants using CCM and heroin, it is important to note that no studies, as far as we are aware, have investigated the content of extracted solutions from CWE in regard to left over tablet fillers such as talc or starch used in the manufacturing of pharmaceutical tablets. Tablet fillers can cause serious harm when injected intravenously, including infections at the injection site and pulmonary emboli [ 4 , 43 ].
This poses a risk specifically to those who inject the extracted codeine. Diversion of medicines fuelled the availability of opioids on the illicit markets and played a role in decisions to treat codeine with CWE.
Importantly to the public health efforts initiated to curb the number of people experiencing dependence and withdrawal from psychoactive medicines [ 46 ], however, is that any changes in formulation of CCM or other regulatory intervention dramatically and abruptly affecting the present availability of CCM should take into consideration potential displacement to other opioids.
Furthermore, amongst people who are opioid dependent regulatory steps affecting the availability of CCM should be accompanied by offers of interventions and treatment of opioid dependence [ 47 ]. A limitation of this study is the small sample size of 14 participants. However, findings from qualitative research is not supposed to be empirically generalisable but instead have transferability to other contexts by relating patterns and themes to a known body of knowledge [ 33 ].
Data saturation at which no new data about a particular issue in this case CWE is raised in successive interviews [ 48 ] was not achieved due to the small sample size. The sample included in the analysis for the current article were predominantly male Furthermore, out of the nine participants who reported CCM and heroin use, Given that there is a lack of sufficient data in the topic of tampering of psychoactive medicines in England, we cannot say how the gender distribution in our sample of 14 participants reflects the gender distribution in larger cohorts tampering with psychoactive medicines in England.
In a case series reporting patients presenting to Emergency Departments in England with reported consumption of codeine and dihydrocodeine extracted from CWE all six patients were male [ 13 ]. As such, the sample included in our analyses may indeed reflect the characteristics of subpopulations engaging in this form of tampering of psychoactive medicines. Another limitation is that findings from the study cannot be generalised to all regions of England.
For example, variability in the use and local supply of heroin may impact the use of CWE differently across regions. The article provides new information about the tampering of psychoactive medicines in England in a field where data about CWE of codeine from CCM are scarce and calls attention to tampering techniques for risk assessments of opioid medicines.
For both groups of participants, concerns of paracetamol overdose from excessive CCM consumption as well as the availability of recipes for CWE on the internet influenced decisions to do CWE to reduce harm such as hepatoxicity. In those who only used CCM, the number of steps involved in extracting codeine required too much time and effort to make it worth the while.
Amongst those using CCM and heroin, CWE played a role in maintaining opioid use to avoid withdrawal during times of reduced availability of heroin. Overall, CWE methods seemed improvised and a challenge to harm reduction and yet the participants appeared knowledgeable about CWE and how to avoid the physical risk and harms of paracetamol overdose.
Globally, many implemented risk minimisation strategies have focussed on stronger opioids than CCM such as fentanyl, tramadol and oxycodone [ 51 ]. Yet, our study suggests that CCM pose a challenge in the availability of opioids by contributing to dependence, tampering of psychoactive medicines and problematic drug use in England involving both pharmaceutical opioids and illicit opioids heroin. Risk minimisation strategies need to take into account the possibility of CWE from CCM resulting in unknown doses of paracetamol if the techniques are not used correctly.
The dataset generated and analysed during the current study are not publicly available due to the respect of individual privacy. Participants received vouchers, as cash can easily be spent on CCM, drugs or alcohol. Furthermore, we opted to use vouchers to avoid having to carry large amounts of cash when conducting multiple interviews on the day or in the same area. However, for a discussion of the possible benefits of using cash as reciprocal payment, see Neale et al.
To provide context for interpretation, participants would require two boxes of OTC CCM or about 60 tablets containing 8 mg codeine and mg paracetamol to produce approximately mg free-base codeine maximum achievable dose from CWE without exceeding the upper limit of paracetamol in the extracted solution. To produce mg free-base codeine from CWE maximum achievable dose without exceeding the upper limit of ibuprofen , participants would require three boxes of OTC CCM or around 96 tablets containing Tampering of opioid analgesics: a serious challenge for public health?
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