Corex cough syrup - no more OTC opioid dependence

Reducing codeine supply forces Corex users to the spiral of change

Corex Cough Syrup opioid dependence

Codeine cough syrup is no longer available over-the-counter (OTC) without a prescription. Record keeping by the dispensing pharmacist is now mandated by a new government notification. This one legislation will aid relapse prevention in abstinent Corex cough syrup addicts. Many former codeine addicts have relapsed after visiting their dispensary for another medication; the pharmacist casually offers opioid containing Corex cough syrup and provides a visual cue to trigger craving and retard their progress through the stages of change.

Codeine cough syrup addiction is fuelled by dispensaries that distribute litres of codeine in the form Corex Cough Syrup and other brands like Mits Linctus. The key ingredient in these ‘cough syrups’, Codeine, is derived from opium and is an addictive substance. Codeine containing cough syrup abuse made its entry to India in the 1990s and since then has contributed to the steadily increasing opioid dependence case-load.The estimated number of opium users in India is well over 5 million with codeine being a major oral source. Opioid dependence in a de-addiction centre increased significantly from 37 to 52% over the last three decades.

Relapse prevention at the pharmacy

Codeine dependent individuals are exposed to visual cues of Corex and other codeine containing cough syrups at every visit to the dispensary. Modification of addictive behaviours involves progression through five stages of change - precontemplation, contemplation, preparation, action, and maintenance. Individuals cycle through these stages many times before termination of the addiction. During relapse individuals regress to an earlier stage of codeine use. Stimulus control - avoiding or countering reminders of codeine use - is a key process for relapse prevention on the spiral of change. Cutting off easy access in the dispensary aids stimulus control and helps prevent relapse to codeine use. The common sight of multiple discarded codeine cough syrup bottle on stairwells would also disappear (see image).

Codeine cough syrup abuse prevention

1. Pharmacy-based approaches help in minimising the harm associated with OTC medicine abuse, and supporting and treating affected individuals.
• Removing products from sight
• Alerting or counselling customers to the abuse potential of products is effective.
• Refusing sales without a prescription
• Suggesting customers contact their doctor
• Supplying only limited amounts.
2. Raising awareness of the addiction potential of codeine cough syrup is necessary for both the public and the prescribers (many doctors are unaware of the ingredients that go into Corex and other cough syrups).
3. Preventing access is the domain of the government.  Regulating and monitoring codeine prescription and dispensing is a welcome step. The finance ministry is now attempting to enable tracing of batches of codeine containing cough syrups  to their suppliers in a bid to control smuggling of Corex and other codeine containing cough syrups.

Nature's vengeance

Unexpected help in relapse prevention by restricting supply has also come in the form of mother nature. Opium growers in Mandsaur, MP are ruing the increasing numbers of nilgai (Boselaphus tragocamelus) that have developed opioid dependence after chance grazing in farms that were once grassland. The nilgai now run amok and destroy swathes of poppy fields in search of their fix.

References

1. Debasish Basu, Munish Aggarwal, Partha Pratim Das, Surendra K. Mattoo, Parmanand Kulhara & Vijoy K. Varma. Changing pattern of substance abuse in patients attending a de-addiction centre in north India (1978-2008). Indian J Med Res 135, June 2012, pp 830-836
2. Richard J. Cooper. J Subst Use. Over-the-counter medicine abuse – a review of the literature. Published online Oct 3, 2011. doi: 10.3109/14659891.2011.615002. Apr 2013; 18(2): 82–107.
3. Gary Reid and Genevieve Costigan. Revisiting ‘The Hidden Epidemic’ A Situation Assessment of Drug Use in Asia in the context of HIV/AIDS. The Centre for Harm Reduction, The Burnet Institute, Australia. 2002. 
4. Prochaska JO, DiClemente CC, Norcross JC. In search of how people change. Applications to addictive behaviors. Am Psychol. 1992 Sep;47(9):1102-14.

Mental Health and Academic Performance in Children

10yr window to treat mental health problems affecting academic performance

Mental health & academic performance

Mental health has a direct impact on academic performance in children. Neglected childhood psychiatric disorders like ADHD and Learning Disorders adversely affect the child’s academic performance and educational attainment. Poor educational outcomes affect the child’s health, employment, and status as an adult. This is especially so for psychiatric conditions that are seen at 7 years and persist beyond 16 years of age.

Mental health disorders in children have a greater impact on academic performance than chronic physical illness. The presence of a single mental condition results in morel board exams failures and backlogs. This association is more than for chronic illnesses of the neurological, lung, heart, or digestive systems. Physical impairments are not associated with exam failures. More than half the teenagers who fail to complete their secondary education have a diagnosable psychiatric disorder. Mental health problems in childhood impede academic performance as the student is unable to take advantage of learning opportunities at school and at home.

Poor academic performance may be a marker for mental health problems in childhood. We screened secondary school students performing poorly at academics for mental health disorders. 2/3 of these children had at least one mental health disability. ADHD and Depression were the most common mental health disorders in this population. One third of the children had more than one mental health disorder. Our study showed that screening children who had poor academic performance would help in the early identification of treatable psychiatric disorders. This in turn would improve academic performance and subsequent adult outcomes.

Mental health problems in children negatively impact physical health, employment and social status as they grow into adults. These adverse health, employment and social status outcomes are especially seen in those children with psychiatric disorders at age 7 that persist to age 16. There is a large window of opportunity between ages 7 to 16 during which psychiatric disorders can be addressed to prevent adverse outcomes in adulthood.

Mental health problems in childhood have a higher impact on academic performance than chronic physical conditions. Psychiatric disorders account for a large chunk of school failures in children. Poor academic performance in children may be a marker for the presence of undetected mental health problems. Treatment of childhood disorders like ADHD improves academic performance. There is a decade window between the ages of 7 and 16 years to prevent adverse impacts on physical health, employment and social status by treatment of mental health problems that are resulting in poor academic performance.

References

1. Case, Anne, Angela Fertig, and Christina Paxson. "The lasting impact of childhood health and circumstance." Journal of Health Economics 24.2 (2005): 365-389. 
2. Stoep VA, Weiss NS, Kuo ES, Cheney D, Cohen P. What Proportion of Failure to Complete Secondary School in the US Population Is Attributable to Adolescent Psychiatric Disorder? Journal of Behavioral Health Services & Research, 2003, 30(1), 119-124.
3. Neville Misquitta, Sayyara Ansari. Prevalence of ADHD, Depression and Dysgraphia in School Children. 15th IACAPAP. New Delhi. 30-Oct-2002

What is normal? Dreams, the tiger and normality

What is normal? A 22-year-old man jumped into the tiger's enclosure at the local zoo on Saturday and was mauled on his back, stomach and thighs. The previous night he had dreamt that he was to free the big cat and that it wouldn't kill him. "See, it didn't kill me," he said. Doctors treating him said, "he has received injuries but he would be well soon ... he was not suicidal."

What is normal?

The concept of normality is at the core of mental health. Without a concept of what is normal one cannot identify the abnormal. In this post we explore the concept of normality from a mental health point of view.

Normality as Health

The WHO has defined health as a complete state of physical, mental and social well-being and not merely the absence of disease or infirmity. Later they added spiritual well-being to the definition. So health is a positive state, not just the absence of disease. This concept looks at normality from a biological or medical point of view.

Suicide attempts are an important marker for mental health illness. However, the mere absence of this particular marker does not rule out mental illness. But the young man’s actions do indicate a lack of judgement - would jumping into the enclosure free the tiger? and after freeing the tiger what next? A display of impaired judgement is often the first visible sign of a mental health problem.

Normality as an Ideal

Normality is a blend of all the elements of the mental apparatus leading to optimal functioning that seeks perfection. However, Sigmund Freud wrote that "A normal ego is like normality in general, an ideal fiction. Every normal person, in fact, is only normal on the average. His ego approximates to that of the psychotic in some part or other and to a greater or lesser extent; and the degree of its remoteness from one end of the series and of its proximity to the other will furnish us with a provisional measure of what we have ...". This psychological interpretation of what is normal was the first to conceive of normality and abnormality as different ends of the same spectrum.

Abnormality

Normality is also defined by the persons internal experience or "personal world" - the way they think or feel. Karl Jaspers, psychiatrist and philosopher, viewed the goal of eliciting signs and symptoms from the patient as an attempt to reach an understanding of their personal experience without any prior assumptions or bias. According to Jaspers, the "personal world" is abnormal when it is based on a disease condition such as schizophrenia, when it alienates the person from others emotionally, or when it does not provide the person with a sense of “spiritual and material” security.

Normality as Average

Normal is also a statistic. The field of psychology contributed further to the concept of normality and mental health by introducing objectivity through measurement. Take intelligence, for example. A graph plotting the distribution of individual intelligence scores (IQ) in the population would follow a bell-shaped curve. The middle range of this curve is considered as normal, and the extremes as significantly low or high intellectual ability. This normal as an average is in the context of the total group. When is it normal to jump into the tiger enclosure?

Normality as Process

Normality is also conceived as being the result of an interacting system. This process-concept emphasises changes over time as against a cross-sectional definition of normality viewed at a particular point of time. The trajectory of development of an infant into an adult is one such process of normal change. When seen against this background an act such as crawling is normal in infancy but would need explanation in adulthood.

Social Normality

Normality is also assessed from a social viewpoint. Is the person normal to others in the same society? Is the person viewed as abnormal by the person's society but normal by others from outside the person's society? Is the person normal in the person's society but abnormal when viewed by persons outside the society? The answers to these questions are directly impact whether the person will be labelled as mentally ill and associated with the stigma of mental illness. The answers are also medically important as they will impact the decision to seek healthcare.

In a world where young people are exhorted to follow their dream one also needs to consider the dream.

References

1. Coelho MT. [Conceptions of normality and mental health among prisoners in a correctional institution in the city of Salvador].Cien Saude Colet. 2009 Mar-Apr;14(2):567-75.[Article in Portuguese]
2. Freud, Sigmund. (1937c). Die endliche und die unendliche Analyse. GW, 16; Analysis terminable and interminable. SE, 23: 209-253.
3. Kaplan & Sadock's Synopsis of Psychiatry: Behavioral Sciences/clinical ...By Benjamin J. Sadock, Harold I. Kaplan, Virginia A. Sadock. 9th Edition. Lippincott Williams and Wilkins. Philadelphia. 2003
4. Jaspers, Karl (1997). General Psychopathology - Volumes 1 & 2. translated by J. Hoenig and Marian W. Hamilton. Baltimore and London: Johns Hopkins University Press
5. Sabshin, Melvin. Psychiatric perspectives on normality. Archives of General Psychiatry 17.3 (1967): 258.
6. World Health Organization. WHO definition of Health, Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19–22 June 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. In Grad, Frank P. (2002). "The Preamble of the Constitution of the World Health Organization". Bulletin of the World Health Organization 80 (12): 982.

Adult ADHD - Attention Deficit Hyperactivity Disorder at work

ADHD (Attention Deficit Hyperactivity Disorder) is thought to be a childhood disorder. However ADHD persists in adults in up to 50% of children diagnosed with the disorder. Hyperactivity, impulsivity and inattention; the hallmark symptoms of Attention Deficit Disorder in childhood have been described earlier. In Adult ADHD, symptoms change to reflect the child's development into adulthood. The symptoms related to hyperactivity gradually disappear by adulthood; however, those related to inattention persist. Adults with attention deficit disorder (ADD) are often distracted, and avoid tasks requiring sustained mental effort. This impairs functioning at home and at work.

Adult ADHD at work

Adults with ADHD experience employment impairments at every level; from the initial job search, to the interview and then during the employment itself. People with Attention Deficit Disorder are more likely to be have poor job performance, lower occupational status, less job stability and absenteeism. Men and women with attention deficit disorder earn less money, and are more likely to be unemployed.

Attention Deficit Disorder (ADD) has at times been portrayed as advantageous from a work perspective, as in the Economist, "in praise of misfits". This may be so in certain sectors where

• Hyperactivity and distractability find an outlet in the need to multi-task with multiple apps at a time.
• Impulsivity manifests as risk taking and an apparent fearlessness. 

This works for Attention Deficit Hyperactivity Disorder adults at the entry level of the IT industry. The physical, social and cultural environment help overcome functional limitations of adult ADD. However, the lack of focus, disorganisation and procrastination become evident when they are promoted in the organisation. It is at this mid-career stage that the adult with Attention Deficit Disorder seeks our help.

ADHD friendly workplace adjustments

Symptom	Adjustment
Inattention and impulsivity	Quieter room/positioning in office Flexi-time arrangement Headphones to reduce distractions Regular supervision to maintain course Buddy system to maintain stimulation
Hyperactivity/ restlessness	Allow productive movements at work Encourage activity Structure breaks in long meetings
Disorganisation, procrastination, and forgetfulness	Provide beepers/alarms, structured notes Regular supervision with feedback, mentoring Delegate tedious tasks Incentive/reward systems Regularly introduce change Break down targets and goals Supplement verbal information with written material

Adult ADHD is a treatable medical condition. Medication to correct the underlying neurochemical imbalance is the cornerstone of treatment for ADHD adults. The adverse impact of adult ADHD is experienced by the employee and the organisation. At the organisational level, workplace adjustments can provide a safe nidus for the ADHD adult to function effectively. At the individual level treatment can help reduce the associated emotional problems and absenteeism of adult ADHD.

References

1. Marios Adamou and colleagues. Occupational issues of ADHD adults. BMC Psychiatry 2013, 13:59 doi:10.1186/1471-244X-13-59
2. Biederman J, Mick E, Faraone SV. Age-dependent decline of symptoms of attention deficit hyperactivity disorder: impact of remission definition and symptom type. Am J Psychiatry. 2000 May;157(5):816-8.
3. de Graaf R, et al: The prevalence and effects of Adult Attention-Deficit/hyperactivity Disorder (ADHD) on the performance of workers: results from the WHO World Mental Health Survey Initiative. Occup Environ Med. 2008.
   
4. Jane L. Ebeje, Sarah E. Medland, Julius van der Werf, Cedric Gondro, Anjali K. Henders, Michael Lynskey, Nicholas G. Martin, and David L. Duffy. Attention Deficit Hyperactivity Disorder in Australian Adults: Prevalence, Persistence, Conduct Problems and Disadvantage. PLoS One. 2012; 7(10): e47404. Published online 2012 October 10. doi: 10.1371/journal.pone.0047404
5. Schultz S, Schkade JK. Occupational adaptation: toward a holistic approach for contemporary practice, Part 2. Am J Occup Ther. 1992 Oct;46(10):917-25.

Irresponsible Drinking & Regulation

Irresponsible drinking requires regulation to modulate its potential for harm. There are specific neurotoxic effects of alcohol drinking. The responsible individual needs to learn personal skills to refuse alcohol drinking when required to do so. The potential harm to society with irresponsible drinking and driving necessitates regulation at a societal level.

Regulating irresponsible drinking

Alcohol drinking and driving in Pune over New  Year's eve was markedly reduced as compared to last year. This year 145 drunk driving arrests were made as against 252 last year. This reduction was despite an increase in the total number of  arrests made in Pune for irresponsible drinking and driving in 2012 as compared to the previous year. The heightened deployment of police personnel manning 30 prominent points of the Pune roads on New Year's eve was apparently deterrent enough.

Alcohol drinking and liquor sales were down by 20-30% in September 2012 following a police raid on an unlicensed rural Pune nightspot. The uproar by its patrons and subsequent police action on liquor retailers and other restaurants resulted in the Pune District Wine Traders Association lamenting the impact of plunging alcohol sales at premium outlets and lounge bars.

Is regulation effective?

The effects of regulating alcohol drinking have been specifically studied.

• In Kentucky — the birthplace of bourbon whiskey and the home of many distilleries — dry districts had less alcohol-related auto accidents and drunk driving arrests. This should cheer the citizens of Chandrapur which will be the third district in Maharashtra state to go dry in a bid to curb irresponsible drinking.
• In Alaska, isolated villages that prohibited alcohol had lower rates of serious injury resulting from assault, and motor vehicle collisions. A local police presence in these dry villages further reduced the incidence of assault

Regulation of alcohol drinking is effective and necessary. It provides a deterrence to irresponsible drinking and illegal distribution of alcohol. Alcoholism treatment financially benefits the family. Regulating alcohol drinking works to benefit society.

References

1. Darryl S. Wood, Paul J. Gruenewal. Local alcohol prohibition, police presence and serious injury in isolated Alaska Native villages. Article first published online: 27 FEB 2006 DOI: 10.1111/j.1360-0443.2006.01347.x
2. Wilson RW, Niva G, Nicholson T. Prohibition revisited: county alcohol control consequences. J Ky Med Assoc. 1993 Jan;91(1):9-12.