An exploration of over-the-counter codeine misuse in regional Tasmania

Misuse of over-the-counter (OTC) codeine is a global public health concern. There is increasing evidence of significant patient harm and burden to healthcare systems, including codeine dependence, gastric and renal morbidities and even death. Knowledge and understanding of the experience of OTC codeine misuse and recovery is critical to the design of effective prevention and intervention strategies. While scholarly research into OTC codeine misuse has increased in recent years, few studies have specifically examined the perspectives of OTC codeine misusers. There is little research about OTC codeine misuse in rural and regional areas and studies about OTC codeine misuse utilising mixed methods designs are scarce. To address these identified gaps within the existing literature, this study utilises a mixed methods approach to explore accounts of OTC misusers living in regional Tasmania, Australia. The study's convergent mixed methods design involved: (1) an innovative approach to Q Methodology incorporating a Delphi technique, and (2) qualitative interviews. By harnessing the strengths and integrating the findings from both approaches, the mixed methods design enabled a more rigorous exploration and understanding of the OTC codeine misuse experience than could have been achieved by using either approach alone. For the Q Methodology strand, ninety-nine self-identified long-term OTC codeine users living in North or North West Tasmania completed the 46 statement online Q sort. Twenty-six of these participants were classified as dependent on OTC codeine; having achieved a score of five or higher on the Severity of Dependence Scale (SDS), and their responses were included in the Q analysis. The 26 Q sorts were statistically analysed using principal components analysis followed by varimax rotation, using the program PQMethod version 2.35. Factor interpretation was undertaken using Watts and Stenner's crib sheet method. For the qualitative strand, fifteen of the self-identified long-term OTC codeine users who completed the online Q sort were recruited to undertake semi-structured telephone interviews. The interview transcripts were analysed with the aid of NVivo qualitative data analysis software version 12, using an abductive approach to qualitative content analysis. The results from each strand were analysed separately and then integrated. The findings provide insight into the experience of OTC codeine misuse, contribute to the existing body of OTC codeine misuse literature and provide guidance for policy and interventions. There were four key findings about OTC codeine misusers: (1) the identification of two distinct accounts of misuse; (2) use of OTC codeine to self-treat physical pain, stress and mental health conditions; (3) a gradual transition from use to misuse and growing awareness of a problem; and (4) the ability to recover via self-change. The discovery of two distinct accounts suggests that the experience of OTC codeine misuse is not universal and that a range of strategies may be required to optimally tailor interventions and guide policy. The findings indicate that the inclusion of strategies to: improve the management of pain, stress and mental health conditions, raise self-awareness of problematic use and the potential for self-change, and increase social and web-based supports, should be considered when designing health policy initiatives that aim to reduce OTC codeine misuse. The research has a number of strengths, including originality and rigour in its design and conduct. It has methodological significance, having contributed a new approach to Q sample construction and identified and critically examined inconsistencies and challenges with the use of Q Methodology, the Delphi technique, and addiction terminology. The research was, however, not without limitations, including the use of relatively small sample sizes, the possibility of recall bias amongst participants who were not current misusers and the conduct of the research just prior to the up-scheduling of OTC codeine in Australia. Further research is suggested to explore whether the two accounts are present among other population groups, to ascertain whether other accounts of misuse exist, and to examine differences in the effectiveness of interventions between the groups.