TY - JOUR
AU - Pahoki, Sanja
AB - Abstract Objectives This study aimed to gain a better understanding on perspectives of over-the-counter (OTC) codeine users and issues relating to codeine dependence in the community pharmacy setting. Examining OTC codeine users' experiences aimed to promote better understanding of OTC codeine dependence, and inform pharmacy practices. Methods Utilising a qualitative research methodology we conducted interviews with 20 participants who were OTC codeine users and met DSM IV criteria for codeine dependence. Key findings Key themes identified included experience of participants acquiring OTC codeine and participants' interactions with pharmacists. The OTC codeine-dependent participants found it generally easy to access OTC codeine, describing ‘standard’ questioning, minimal intervention from pharmacists and only occasional refusal to supply. A better appearance and presentation was generally linked to easy codeine supply. Conclusions The experiences of participants suggest a number of barriers exist to effective intervention for OTC codeine dependence in the community pharmacy setting. Identification of these barriers will provide an opportunity to more effectively target interventions to reduce harm related to OTC codeine products. Increased involvement of pharmacists in OTC codeine sales was associated with help-seeking by codeine users. addiction, codeine dependence, pharmacist, pharmacy, qualitative research Introduction Over-the-counter (OTC) codeine is supplied directly from pharmacies to customers without a prescription in a number of countries. In Australia, codeine is available in combination products with simple analgesics for purchase without a prescription. Products with 8–15 mg of codeine phosphate combined with simple analgesics such as paracetamol, ibuprofen and aspirin are available for purchase, with regulatory changes implemented in May 2010 requiring that the pharmacist be personally involved in all sales of OTC codeine and that pharmacists determine a therapeutic need for the product, giving a maximum of 5 days' supply. Prior to this change smaller pack sizes and lower strength products could be purchased with no pharmacist involvement, and packets of 72 and 100 tablets could be purchased without a prescription. Research has shown that non-prescription codeine containing analgesics are associated with serious harm and dependence,[1–3] and evidence of misuse of these products has been reported in many countries.[4] Codeine is an opioid with an identified abuse liability.[5,6] When codeine is combined with simple analgesics, the consumption of high doses of simple analgesic such as ibuprofen in these combination products has been reported to cause serious morbidity with life-threatening complications.[7–10] This makes reducing harm from codeine consumption an important public-health challenge, particularly for pharmacists who are at the interface of codeine supply. Some studies have examined codeine dependence with quantitative methodologies,[6,11] finding that codeine-dependent patients were younger than non-dependent codeine users, commonly reported chronic pain, rated their health as poorer than non-dependent codeine users and had a higher representation of females compared with other samples of opioid dependent people. Mental health problems are also common amongst this population.[12] Using a web-based survey methodology, we were able to compare two samples of people who used OTC codeine products, those that used codeine and met criteria for codeine dependence and those that used codeine and did not meet the same criteria.[11] This study described 800 participants, 137 of whom met criteria for codeine dependence, with the remaining 663 being OTC codeine users who did not meet these criteria. This study described a convenience sample of codeine-dependent people who were different on many characteristics to previously described opioid dependent samples from Australia. The sample was largely employed, many having tertiary educations, and few previously sought help for their codeine dependence. While these studies are helpful in understanding general characteristics of those that develop codeine dependence, further information is required to develop a better understanding of OTC codeine dependence, the impact of OTC codeine dependence on community pharmacies and to inform possible prevention strategies. One useful research methodology to better understand the nature of non-prescription codeine dependence is qualitative research.[13,14] Conducting qualitative research enables issues to be explored in detail revealing information that cannot be captured through quantitative methods.[13] Few studies have examined pharmacy customers' perceptions of pharmacists' roles in the supply of non-prescription medications. A recent report on OTC medications from the UK examined health professionals' and codeine users' perceptions of OTC medications. This study, using a qualitative methodology found there were areas that are challenging for pharmacists in identifying and intervening where misuse of these medications is suspected.[15] Similarly a systematic review of published and grey literature also identified a number of studies with pharmacists reporting their perceptions of misuse of medications in UK.[16] These surveys, using a self-report methodology, found that pharmacists in the UK have consistently reported ongoing concerns with misuse of OTC medications such as codeine-containing products. For example, a postal survey sent to community pharmacies (n = 1091 in 1995, n = 1162 in 2000) found 67.8% and 68.5% of pharmacies respectively suspected OTC medications were being misused, with misuse of OTC codeine consistently reported in both surveys.[17] A separate survey sent to 180 community pharmacies in Bro Taf, Wales, also found 66% of pharmacies reporting current OTC medication misuse, with opioid-containing preparations being the most commonly reported.[18] In this study the most common strategy for dealing with misuse was refusing the sale or claiming they were out of stock, with frequency of visits and customer appearance being common factors that raised pharmacists' suspicion of OTC misuse. Few studies outside the UK, to the authors' knowledge, have directly examined the relationship between the pharmacist and their customers in relation to the supply of OTC medications. In this study, from Australia, we completed qualitative in-depth interviews with 20 people who met criteria for codeine dependence from Melbourne, New South Wales, and Tasmania. In this paper, we specifically focus on the relationship between the OTC codeine user and the pharmacist. We report on OTC codeine users' experiences around OTC codeine use and acquisition to promote better understanding of dependence on these products, and to inform health professionals such as pharmacists to improve pharmacy practice. Methods Subjects and setting A convenience sample of 20 Australian OTC codeine-dependent people, referred to as participants in this paper, responded to advertisements placed at the end of a separate internet survey about codeine use,[11] or through study advertisements placed at alcohol and drug services and other public services. Participants were screened to determine dependence to codeine as per DSM IV criteria using a DSM IV checklist. These 20 people, who were assessed to meet criteria for codeine dependence, were interviewed and the responses relating to their experiences in community pharmacies form the focus of this paper. We achieved saturation with this sample size allowing for enough data to ensure exploration of the issues in detail. Data collection The qualitative in-depth interview schedule was piloted, refined and reviewed by key experts to maximise the relevance of the questions to participants. The semi-structured format enabled participants to reflect their own experience and discuss issues whilst allowing unanticipated issues to emerge. The interview explored pathways to problematic use, use patterns and codeine acquisition, and experiences with pharmacists. We completed interviews in person where possible (n = 8) and offered telephone interviews as required (n = 12). Participants were remunerated AUD 30 for time and/or travel. Analysis The qualitative interviews were transcribed verbatim. We completed an initial content coding[19] of key themes and a validation process between the researchers of themes emerging from the data before final analysis was completed[19,20] utilising NVivo 8 software (QSR International Pty Ltd, Melbourne, 2008). Ethical approval The Victorian Department of Human Services Ethics Committee, Australia, approved all aspects of the study. Results Participant characteristics General characteristics The sample recruited was 60% female and just less than 40 years old on average (Table 1). Most participants reported a pain condition and were exceeding therapeutic doses of codeine (Table 1). Table 1 Characteristics of 20 codeine-dependent study participants, Australia Participant characteristics . . Mean age in years (standard deviation) 39.1 (10.8) Gender (% female) 60 Reported pain condition (%) 80 Exceeded therapeutic doses (%) 80 Reported history of illicit drug use 25 Previous treatment for alcohol or drug dependence (including codeine dependence) 55 Participant characteristics . . Mean age in years (standard deviation) 39.1 (10.8) Gender (% female) 60 Reported pain condition (%) 80 Exceeded therapeutic doses (%) 80 Reported history of illicit drug use 25 Previous treatment for alcohol or drug dependence (including codeine dependence) 55 Open in new tab Table 1 Characteristics of 20 codeine-dependent study participants, Australia Participant characteristics . . Mean age in years (standard deviation) 39.1 (10.8) Gender (% female) 60 Reported pain condition (%) 80 Exceeded therapeutic doses (%) 80 Reported history of illicit drug use 25 Previous treatment for alcohol or drug dependence (including codeine dependence) 55 Participant characteristics . . Mean age in years (standard deviation) 39.1 (10.8) Gender (% female) 60 Reported pain condition (%) 80 Exceeded therapeutic doses (%) 80 Reported history of illicit drug use 25 Previous treatment for alcohol or drug dependence (including codeine dependence) 55 Open in new tab Codeine and other substance use Types of codeine-use patterns Three types of codeine-use patterns emerged from the descriptions of codeine users. The first group was characterised by their refusal to exceed therapeutic doses, though this group still meet criteria for codeine dependence. Whilst this group would often take the maximum dose of these medications recommended, they often described the medications as ineffective for pain and described a cycle of continuing to use the medications despite their limited effectiveness and worsening pain. Some descriptions were consistent with medication overuse headache. The second group appeared to be recreational codeine users. They described some control over use by means of careful and somewhat time-consuming procedures extracting codeine from combination products. This group was aware of some harm-reduction techniques. They did not typically describe a medical reason for continuing to use codeine. The final group were those using high doses, in extremely dependent patterns of OTC codeine use. Participants described taking multiple packets of tablets a day. This group reported significant escalation of doses from initial use, and often experienced severe harms including hospital admissions and gastrointestinal damage as a result of their codeine use. Graphic descriptions demonstrated the desperation experienced by this third group: “I knew and by that stage, when I was having that many … I mean I kind of, when I started to feel really sick, trying to get them down, I got back down to 36 in one go and even that was pretty difficult because you'd retch trying to get them down but you just knew you needed to get them in there to make you feel OK again.” (Female, aged 42 years) Other substance use Participants in this sample did not generally describe current illicit drug use or significant histories of illicit drug use. The most common illicit drug use described was occasional cannabis use by a smaller group of participants. Experience with using prescription opioid use was commonly described, with some participants describing a history of prescription opioid use prior to transitioning to OTC codeine products. In some cases, as described below, cessation of prescription opioids led to OTC codeine use: “I was on the Endone for about a month and then of course, then they gave me Panadeine Forte, I was on that for I think about 6 months and then of course it all stopped and then I was told to just use OTC.” (Female, aged 38 years) Almost half of the sample described previous use of benzodiazepines. Most participants drank infrequently with three describing problematic alcohol use at some time in their lives. Codeine acquisition Most participants described access to OTC codeine as ‘easy’ and they mostly reported purchasing OTC codeine themselves, or on some occasions stealing it from pharmacies. Very occasionally they reported that family members purchased the OTC codeine for them. Participants described pharmacists' responses largely fell into two clear categories. It seemed that either they purchased OTC codeine with virtually no pharmacist interaction, or, the sale was refused with limited discussion. A few participants also described confusing interactions where they could see the OTC codeine on the shelf but the pharmacist would deny it was in stock and not sell it to them, but this was a less common interaction. Participants found that their appearance strongly influenced their ability to access OTC codeine. “I would always dress in my suit or tie to make sure that I looked professional, and I had my nice professional glasses on … and I looked responsible so they would sell me 48 tablets at a time, I was able to get my day's supply … When I wasn't in my business suit and when I was in my track pants and in my jumper um, they looked at me warily, and a couple of them wanted to know my name, and wanted to write it down.” (Male, aged 42 years) Participants used strategies such as purchasing additional items to reduce suspicion. “I think being a middle-aged woman helps you know because you don't look like some raving drug addict and I usually try and also buy something else … I mean the money I've wasted on purchasing other products, because that way it looks like I'm legitimate you know.” (Female, aged 44 years) Participants' experience of attending pharmacy It was interesting to explore participants' perceptions of their interactions with pharmacy staff. Codeine users described difficult interactions with pharmacists, and made efforts to minimise interaction with pharmacists, which were often viewed negatively. One participant described how she feared the pharmacist asking her about her OTC codeine consumption and how embarrassing this would be for her. “I probably would have been too embarrassed, walked out and thought I'll never go back there again and I would have gone somewhere else.” (Female, aged 38 years) This participant later described how she had made the decision to seek help and ended up on a buprenorphine programme (an opioid agonist treatment programme). Her experience was quite different when she returned to the same pharmacy. “They were very good actually I must admit. They were exceptionally good. I mean obviously they ran the (opioid substitution treatment) programme there so it made it easier, like you know they were dealing with it all the time, but once I was open about it, they actually, they wanted to know, they were very interested and they were very supportive …” (Female, 38 years) Another participant found pharmacists only really began to get involved once a serious problem developed. He felt information about the risks needed to be given to him earlier, before his use had escalated to the point where he was no longer receptive to such information. “In the beginning (information about risks of opioid dependence) would have (been valuable), it would have in the beginning, but when I was addicted I wouldn't have been interested … it would have to be early in the piece.” (Male, aged 42 years) Experiences of questioning by pharmacists The OTC codeine-dependent participants described their main interaction with pharmacy staff as involving ‘standard questions’. Pharmacists would ask them what the product was being used for and explained the maximum dose: ‘don't take more than eight a day’. Little additional questioning was described by participants. No participant described an experience of a pharmacist directly raising concerns about abuse or dependence or suggesting they seek assistance with OTC codeine dependence. Participants expressed a strong desire to avoid questioning by the pharmacist and would actively employ strategies to avoid questioning such as attending ‘easy’ pharmacies where less questions were asked, speaking to staff they knew would not ask questions or buying smaller quantities rather than asking for larger packs. “… if I go at the weekend it's the weekend pharmacists who don't know me and they want to know why I'm taking it. …” (Female, aged 58 years) Some participants reported changes in the past 18 months (coinciding with implementation of regulatory changes), with pharmacists beginning to question them more about OTC codeine purchase. “I must admit that maybe in the last 12–18 months I have been asked a lot more by pharmacists, like is it, is it for yourself? Have you taken them before; you know der-der-der-der? Which I had never had as much.” (Female, aged 37 years) “… lately chemists have been asking me for my driver's licence. They've just started getting more strict about it. Up until, it's only been the last few months. Up until then nobody has ever asked me for any ID.” (Female, 50 aged years) Some participants did not like having to give explanations about their OTC codeine use to the pharmacist. “I do feel a little bit indignant. It's like come on, it's me but they don't know me and I know they have to ask those questions.” (Female, aged 37 years) “I don't need to have to explain myself to a 25 year old why I'm buying something.” (Female, aged 58 years) There was a sense of confusion as participants wondered why they were asked these questions and what impact would it have on their purchase: “… they're most strange questions … I mean, who in their right mind would say why are you using it? No real reason! (laughs). It's just the strangest questions that they ask.” (Male, aged 35 years) In addition, there appeared to be lack of awareness regarding the role of the pharmacist in regulating supply of medications, and ensuring that OTC codeine was sold only for medicinal purposes. Confusion also existed around the use of personal information. “… a couple of them wanted to know my name, and wanted to write it down, or type it into their computer and I didn't know what that meant. … I didn't know whether it went just to that pharmacy or whether it spread the word around to other pharmacies as well. I still don't know in fact.” (Male, aged 42 years) One participant chose to purchase the lower-strength OTC codeine products, containing 500 mg of paracetamol and 8 mg of codeine phosphate, (which at the time did not require an interaction with the pharmacists) to avoid being questioned. He recalled the humiliation of this experience: “… they just looked at me like I was a junkie, like a really dicey, they just sort of gave me the, like an interrogation, what do you need this for and I felt like such a criminal.” (Male, aged 25 years) Experience of refusal to sell OTC codeine Refusal at one pharmacy tended to result in participants going to a different pharmacy to purchase the product, and were not described to be accompanied with any discussion about OTC codeine harms, risk or dependence. Some pharmacies were described as more cautious around OTC codeine supply, while other pharmacies were not as vigilant. “It's funny, the only people that did [question me about codeine use] was the store in, the chemist in [location]. I only went there like three times I think but they said ‘look you've had this pack every couple of days or every 3 days and we're going to refuse to sell them to you’. But I don't know, it seemed strange to me, it's a little community sort of chemist, I thought OK you'll have to stop [going there] … whereas the ones that weren't [in another location] didn't really cotton on or didn't really care … I just kept buying them and no one ever said anything, never questioned me.” (Male, aged 21 years) Participant accounts indicated reluctance from pharmacists to intervene: “The pharmacist that I always go to, where I get the methadone from and that I did get the buprenorphine from, he's known me for 20 years and so he's the one who sold me a lot of OTC preparations and he said to me the other day, he said ‘now that you're on methadone, please don't buy any more OTC codeine preparations’ and I said ‘no, I have no intention of buying anymore’ and he said ‘oh good’.” (Female, aged 50 years) Despite often negative descriptions of interaction with pharmacists, interactions were identified as a crucial ‘red flags’ that were associated with codeine users making decisions to seek help for their codeine dependence. As demonstrated below, participants reported that an outcome of being questioned regularly and visiting multiple pharmacies was a trigger to seek help, as they began to question how they were using OTC codeine. “I thought I can't continue on like this. Like I think it was the stress of going to each, you know different pharmacy every day and planning my whole day around getting a packet of codeine every day because I used to go almost every day to get a pack.” (Male, aged 21 years) “… you knew that with all those questions you couldn't come back again in a day or 2 days. If you bought a 48 box they would wonder where they had gone to and they probably wouldn't give them to you. So you'd shop around but I remember towards the end, just before I really sought help, that at some chemists they would take your licence … I don't know why, but they'd take your licence and just record your details and that you'd taken a box and that started to bother me and I thought well geeze if it gets to this how am I going to sort of keep going with it.” (Female, aged 38 years) Discussion This study provides insight into some of the difficulties in addressing OTC codeine dependence in a pharmacy setting. The experiences of these OTC codeine-dependent people suggest it is easy to acquire OTC codeine, with infrequent refusal and limited pharmacist intervention, though it was consistently reported by OTC codeine-dependent people that pharmacists were asking more questions of codeine purchases recently, coinciding with the change in scheduling for OTC codeine requiring a pharmacist's intervention in every sale, and raised awareness around codeine dependence as a result of these changes. Questions from pharmacy staff were described to be ‘standard’, rarely covering anything other than asking the reason for use and a statement of the maximum dose. Codeine users did not describe pharmacy staff offering information regarding risks of dependence on codeine. It was common in this study that ‘better appearance’, for example wearing business suits rather than tracksuit pants, was linked to successful acquisition. Participants reported purchasing large quantities with no difficulties when dressed in business suits, suggesting that appearance may give pharmacists a false impression that there is less risk, or that they are more reluctant to confront people who appear mainstream compared with those whose presentation suggests lower socio-economic status. Thus, providing objective ways to assess appropriateness of OTC codeine supply is a clear challenge for pharmacists. While the qualitative nature of the research gives important insights into a little-researched area, there are limitations to be mindful of. A convenience sample was used for the codeine-dependent participants, which, while this sampling approach is well accepted and commonly used to recruit hard-to-reach populations, it means that this sample may not be representative of all codeine-dependent users. A key strength of this study is that these individuals' detailed responses give considerable insight to some of the challenges that exist with OTC codeine supplies and provide a good platform for further research. The saturation of themes regarding pharmacy supply, and the similarity of the sample characteristics with previously reported samples of OTC codeine-dependent people,[9] suggest that the sampling strategy did recruit a sample OTC codeine-dependent people that was comparable to other OTC codeine-dependent people previously described in the literature, reducing concerns of sampling bias due to the recruitment methods. These findings were consistent with other research into OTC medication misuse, with a common theme being the easy acquisition and standard questioning by pharmacists and pharmacy assistants.[15] The strategy of claiming to be out of stock was also reported in this study, and elsewhere,[18] though the effectiveness of this strategy when customers can see codeine products in stock is questionable. Real-time prescription monitoring has been identified as critical for preventing pharmaceutical misuse,[21,22] and has been implemented with prescription products.[23] Use of real-time monitoring of sales may also be of use with OTC codeine products, enabling pharmacists to access information about recent OTC codeine purchases by patients requesting codeine products. The findings of this study support the need for monitoring systems to provide pharmacists with information about recent codeine purchases to assist in detection of overuse of these products by pharmacy customers. The experiences of our participants suggest a need for better education for the general public in relation to the role of the pharmacists, especially when questioning is involved so that both consumers and pharmacists are clear on their responsibilities. Despite questions being considered ‘standard’ by participants, pharmacist were described to be hesitant to raise concerns about codeine dependence, and were not described to ask direct questions on this topic. Refusal to supply codeine was described as occurring only rarely by this group of OTC codeine-dependent people. An important finding for pharmacists' practice was that the questioning and ‘hassle’ of shopping around for OTC codeine were ultimately important drivers in participants realising something was wrong and eventually seeking help. This suggests that increasing pharmacist intervention in OTC sales may reduce harm by assisting people to seek help. This study identified difficulties raising sensitive topics in a community pharmacy setting, and reluctance by codeine-dependent people to engage in such discussion, possibly because they do not identify their use as problematic at the time. The challenges for pharmacists identified through these participants' responses were consistent with other studies of pharmacists, finding that pharmacists were not sure about when and how to intervene, and describing a lack of information about customers to support decisions about supply.[4] Pharmacists themselves have described a lack of confidence in identifying codeine dependence, in some cases using appearance and stigmatised images of substance users as a guide to identify who may have trouble with codeine dependence, and being hesitant to risk offence by intervening where pharmacists are not certain that a person may be codeine dependent.[11] Dealing with addiction and mental health is an area that other studies have identified as challenging. A study examining pharmacists' attitudes towards discussing psychiatric medications with patients, compared with cardiovascular medications, found that pharmacists were less comfortable discussing medications and symptoms for mental health conditions, with issues of adequate privacy, lack of training identified as barriers.[24] Butler and Sheriden[25] also identified a lack of training as a contributor to pharmacists' reluctance to undertake harm reduction interventions such as counselling. Possibly as a result of some these challenges, the main intervention was described to be refusal to supply OTC codeine, rather than also addressing the difficult issue of problematic use or dependence with customers in a pharmacy. Given the serious harms that have been identified with codeine dependence,[3] missing this brief intervention opportunity may have serious health consequences for codeine users. Pharmacists appear to be in a difficult position to intervene with OTC dependent people, with participants describing unwillingness to engage with pharmacists, and, in the absence of real-time medication records, pharmacists having little information to be certain that OTC codeine is being used inappropriately. Training and clear guidelines for pharmacists on appropriate responses to suspected problematic use or dependence are vital if OTC codeine remains available without prescription. A further challenge is the timing of pharmacist intervention in codeine sales. Responses from participants suggested that pharmacists only intervene once patterns of frequent purchase have been established, missing a valuable opportunity for early intervention or prevention. A ‘universal precautions’ approach, where all patients are screened for risk, and a minimal standard of precautions is applied to all patients, has been suggested for prescription medications, and may be able to be adapted for use with OTC codeine.[26] This approach has the potential to reduce stigma and ensure that a minimal level of protection is applied to all patients. Conclusions This study identified a number of challenges and opportunities for pharmacists when interacting with OTC codeine-dependent people. Challenges included a lack of objective ways to assess patients who were codeine dependent, leading to use of factors such as appearance to assess possible risk. Codeine users also deliberately avoided pharmacist interaction, adding further barriers to effective intervention. The experiences of codeine users suggest a number of barriers exist to effective intervention for OTC codeine dependence in the community pharmacy setting. Describing these barriers will provide opportunity to more effectively target interventions to reduce harm related to OTC codeine products. One positive finding was that the increased involvement of pharmacists in all sales of OTC codeine, as required in Australia, was related to increased help-seeking by OTC codeine users. Increased questioning and ‘hassle’ of buying OTC codeine was linked to self-identifying that OTC codeine use had become problematic by participants. Declarations Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose. Funding The Victorian Department of Health, Australia, provided funding for this project. Authors' contributions SN and JC designed the study. All Authors were involved in the data analysis and writing of this article. All Authors state that they had complete access to the study data that support the publication. Acknowledgements We wish to thank the participants for sharing their stories as part of this study. We would also like to thank Sarah MacLean for generously reviewing a draft of this manuscript and providing suggestions. References Chetty R et al. Severe hypokalaemia and weakness due to Nurofen (R) misuse . Ann Clin Biochem 2003 ; 40 : 422 – 423 . Google Scholar Crossref Search ADS PubMed WorldCat Dyer B et al. Hypokalaemia in ibuprofen and codeine phosphate abuse . Int J Clin Pract 2004 ; 58 : 1061 – 1062 . Google Scholar Crossref Search ADS PubMed WorldCat Frei MY et al. Serious morbidity associated with misuse of over-the-counter codeine-ibuprofen analgesics: a series of 27 cases . Med J Aust 2010 ; 193 : 294 – 296 . Google Scholar Crossref Search ADS PubMed WorldCat Cooper RJ . Over-the-counter medicine abuse – a review of the literature . J Subst Use 2011 ; 1 – 26 (early online; doi:10.3109/14659891.2011.615002). Google Scholar OpenURL Placeholder Text WorldCat Rossi S , ed. 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Google Scholar Crossref Search ADS PubMed WorldCat Footnotes † [Correction added on 30 November 2012, after first online publication: Scope of study in the title has been updated to read “...over-the-counter codeine supply from the codeine consumer’s perspective”.] Author notes Address as of September 2012: The University of Sydney, New South Wales 2006, Australia. E-mail: suzanne.nielsen@sydney.edu.au © 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) © 2012 The Authors. IJPP © 2012 Royal Pharmaceutical Society
TI - Opportunities and challenges: over-the-counter codeine supply from the codeine consumer’s perspective
JF - International Journal of Pharmacy Practice
DO - 10.1111/j.2042-7174.2012.00247.x
DA - 2013-05-20
UR - https://www.deepdyve.com/lp/oxford-university-press/opportunities-and-challenges-over-the-counter-codeine-supply-from-the-dhdSQ1YKii
SP - 161
EP - 168
VL - 21
IS - 3
DP - DeepDyve
ER -