Over-the-counter opioid misuse may be missed during addiction treatment

22 Aug 2023

An article published this month in the Medical Journal of Australia by Turning Point’s addiction trainee registrar, Dr Richard Bradlow, has identified a risk that dihydrocodeine misuse may be missed in clinical practice due to a lack of knowledge.

An intake worker looks at a clipboard while talking to a client at a hospital reception desk.

Changes due to codeine rescheduling

After the rescheduling of codeine in February 2018, which now requires a prescription, dihydrocodeine is Australia’s only over-the-counter opioid available.

Media reports suggest that misuse of dihydrocodeine may have increased since 2018. However, the ‘National Drug Strategy Household Survey 2019’ did not show increased use of dihydrocodeine in 2018 and 2019, and the extent of dihydrocodeine misuse in the past 3 years is unknown.

Rikodeine misuse

Usually mixed with soft drink or alcohol, the dihydrocodeine mix is referred to as “lean”, “purple drank”, “purp”, “sizzurp”, “syrup”, or just Rikodeine.

Regular use of dihydrocodeine can lead to opioid use disorder.

The drug cannot be detected during standard urine drug screening, and cannot be requested in most commercial pathology labs in Australia.

Two patients, who gave their permission to have their experiences profiled in the article, had been using Rikodeine for years to supplement their other drug use when they sought treatment in a Melbourne outpatient addiction service. The first patient’s use, which he described as “vitamin water”, was initially missed by the clinical team.

A peer worker later accurately identified the purple liquid, which was confirmed by the patient who described it as “lean”.

Recommendations for clinicians

The article recommends screening for dihydrocodeine use during clinical assessment in order to better manage clinical approaches to opioid use.

These approaches may include appropriate dosage and choice of medication, as well as supportive patient education about the harms caused by misuse.

Appropriate treatment for both patients described in the article led to them successfully stopping their use of non-prescription opioids.

Read the article, which includes advice for clinicians under “Lessons from practice”.

The findings will also be presented as a poster at the 2023 APSAD Scientific Alcohol and Drug Conference.