A better solution is needed for codeine-containing medicines says Warwick Plunkett, in our final UTS Pharmacy Barometer article
Responses to the UTS Barometer survey about the removal of over-the-counter (OTC) medicines containing codeine this year has raised questions about the role pharmacists play in the real-time monitoring of patients on prescription opioid drugs.
The MedASSIST tool, which closed down after pharmacists stopped selling non-prescription codeine medicines in February, had played a significant role in identifying opioid addicts.
The UTS Pharmacy Barometer results from November 2017 showed the vast majority of pharmacists were very comfortable using MedASSIST. Overall, the tool achieved a comfort reading of 7.46 out of 10, which meant most pharmacists felt confident identifying patients at risk of codeine dependence and help them find the best clinical support.
It was quite pleasing that more than half of the pharmacists surveyed in the Barometer said they felt adequately prepared to deal with an OTC codeine abuser. However, the levels of comfort were much higher for pharmacists likely to have more life experience – pharmacy owners or managers – compared with employed pharmacists.
Despite the obvious success in the rollout of this monitoring tool, there remains reluctance in some states to see it universally implemented. I believe it’s now time we had a national approach to dealing with real-time prescription monitoring. Tasmania has a monitoring program and there are plans to introduce systems in Victoria and the ACT within the next six months, but other states continue to lag. Pharmacists are capable of playing an important role in helping to identify and counsel patients at risk of opioid abuse. I’m sure pharmacists would see this as being part of their normal professional activity.
We just need to look at the success of Project STOP, which was introduced by the Pharmacy Guild of Australia more than a decade ago to combat the pseudoephedrine problem. That real-time reporting process helped put an end to significant sales of pseudoephedrine to addicts. I’m not sure why there is resistance to introducing a similar regime to look at potential codeine and other opioid abuse.
At the same time, I don’t believe moving medicines that contain codeine from OTC to prescription only has led to great outcomes for patients, especially the small proportion who are potential addicts. Not only do patients looking for pain management need to schedule and pay for a GP visit, the prescription products they receive are usually two to three times stronger than the ones they might have bought directly from pharmacists. The prescription medicines are more expensive, too, with most manufacturers stopping their production of OTC products containing codeine because they were no longer economically viable.
That is why I support moves to amend the scheduling system to allow pharmacists to dispense prescription-only products without a prescription when certain conditions are met. In the case of low-dose codeine analgesics, pharmacists would need to undergo training to help them better assess, treat and counsel patients at risk of codeine addiction in conjunction with the introduction of real-time monitoring.
Currently, pharmacists can’t play a formal role in supporting patients at risk of prescription opioid addiction. Without proof, pharmacists are unlikely to confront at-risk patients. Even if a pharmacist refuses to dispense a prescribed drug, the patient can always find a pharmacy that will. All pharmacists can do is assist customers with alternative pain management treatments, but they have little authority or training to help change behaviours.
An effective national real-time monitoring system, alongside a more sensible scheduling regime and better training for pharmacists, would certainly be elements of a cheaper and better longer-term solution for patients on codeine and less appropriate stronger opioid medicines.
Warwick Plunkett is a national director of the Pharmaceutical Society of Australia
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