Guild pens open letter on codeine


Here is a list of ways the Pharmacy Guild has worked on the codeine issue, explains Executive Director David Quilty

Dear AJP readers

I must say that I find it unfortunate when an issue as significant as codeine is seemingly used as a political football.  

To ensure that your readers are not in any way misled, it is important to put a few facts on the table:

1. The Guild has for many years been at the forefront of advocating for and taking action to introduce tools that enable clinicians to identify and support patients at risk of dependence.

2. It is the Guild and community pharmacies that have put patients before financial considerations by proactively developing and implementing MedsASSIST, a national real time recording and monitoring system that identifies and supports patients who may be misusing codeine containing over-the-counter analgesics.

3. In the 18 months since MedsASSIST was introduced, it has been taken up voluntarily by more than 70 per cent of community pharmacies, with over 7 million purchases recorded.  There has meant an overall reduction in supply of about 15 per cent, with some pharmacies that use MedsASSIST experiencing reductions in the vicinity of 40 per cent.                            

4. Notwithstanding the financial impact of this significant reduction, community pharmacists are voluntarily continuing to use MedsASSIST as a clinical tool to support their patients and refer them where appropriate for more intensive pain management and addiction support, including to their GPs.

5. There is no national real time recording and monitoring system used by doctors to provide information on patients that might be misusing codeine (or other prescription medicines) by doctor shopping. With the up-scheduling of codeine, there will be little or no ability for GP prescribers to know if a patient who asks for codeine has not had the same medicine recently prescribed to them by another doctor.  

6. To the Guild’s knowledge, there has been no proactive action taken by any doctor groups to put in place a real time recording and monitoring tool to help identify patient misuse when codeine is up-scheduled (due 1 February 2018).                

7. It is not accurate to infer, as some have, that all fatalities from codeine are as a result of over-the-counter codeine. On the contrary, the vast majority are a result of high strength medicines that are prescribed by doctors and/or as a result of combination of medicines consumed by patients.  The statistics that are often used and have been cited in AJP posts are not up-to-date, quote the wrong years, and fail to differentiate between over-the-counter and prescription strength codeine containing medicines.

8. For many years, the Guild has led the push for a national real time monitoring system for Schedule 8 (Controlled Drugs), which are the cause of the majority of overdose fatalities in Australia.  

9. The Guild has acknowledged the rationale for the decision to up-schedule over-the-counter codeine containing analgesics, namely that these medicines can be addictive and are being used inappropriately by some patients with chronic pain.

10. The Guild is not seeking to reverse the up-scheduling decision. However, we believe that it is a blunt instrument that, on its own, will not address issues of addiction and could actually exacerbate them, particularly given the lack of any mandatory national real time recording and monitoring system for doctors and the likelihood that some patients will be prescribed high strength codeine containing products (with repeats).  

11. At the same time, 80 per cent of the more than one million patients who use these medicines annually do so on an occasional basis for the temporary treatment of acute pain and may be inconvenienced and face increased out-of-pocket costs. Some will be able to be supplied alternative medicines available through pharmacy. Others will have to visit their GP to get a prescription for these medicines or if they are suffering acute pain at night or on the weekend when a GP is not available, they will have to visit an emergency department or an after-hours home doctor service.

12. While not seeking to reverse the up-scheduling decision, the Guild believes it makes sense for there to be an exception, whereby pharmacists that have received additional codeine related training could in defined circumstances supply up to an agreed quantity of these medicines to patients for the temporary relief of acute pain, with a requirement to adhere to a strict protocol and use a mandatory national real time monitoring system like MedsASSIST.                              

13. The Guild is working with the PSA on this commonsense approach, which will mean that patients who use these medicines appropriately will not be unnecessarily disadvantaged, while receiving the clinical support and advice of a pharmacist who has undertaken codeine related training. It will mean these patients will not be unnecessarily visiting doctors, emergency departments and accessing after-hours home doctor services. At the same time, it will, through the use of the mandatory real time recording and monitoring system help identify patients who may be misusing and refer them to appropriate care, including their GP.  

14. At the same time, we are committed to working with community pharmacy owners, their pharmacist and pharmacy assistant staff and through them, their patients, to ensure that everyone is in the best position to manage the upscheduling of codeine. We are producing comprehensive training materials for pharmacists and pharmacy assistants, information to enable them to integrate the large number of patient conversations into their workflows and to assist with stock management, and practical information for patients.

These are the facts. I trust, that after reading them, your fair minded readers will recognise that neither the Guild nor community pharmacies are acting irresponsibly or somehow putting financial considerations before patients. Quite the opposite. As always, we are committed to working with all stakeholders, including organisations that represent medical practitioners on this issue. Regardless of whether our offer is taken up or not, we will be encouraging and helping enable community pharmacies to work closely with their local prescribers on this issue and are confident that this on-the-ground collaboration will be reciprocated.

David Quilty

Executive Director
Pharmacy Guild of Australia

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51 Comments

  1. Andrew
    24/07/2017

    Point 7 – “We’re reasonably convinced that OTC codeine didn’t cause every fatality, just some of them. Ergo it’s not our fault, we shouldn’t be punished, and we accept that the number of deaths that are attributable to OTC use is a reasonable societal cost”

    Point 8 – The guild shut down MedsAssist the morning after the upscheduling decision. It was reinstated by the Minister later that day (or week IIRC). Some commitment, eh?

    • Nicholas Logan
      26/07/2017

      I believe the Guild reinstated MedsAssist when the Minister finally acknowledged its value to Australian health care.

      • Andrew
        27/07/2017

        Indeed, which makes the Guild commentary about their strong and continued support for real time monitoring sound hollow.

    • Anthony Tassone
      27/07/2017

      Andrew

      The delegate of the TGA’s decision to up-schedule OTC codeine products came in mid December 2016.

      The Guild’s initial announcement to shut down MedsAssist was in late March 2017 following repeated unsuccessful attempts and calls for the system to be made mandatory.

      So the Guild did not shut down MedsAssist ‘the morning after the upscheduling decision.’

      Minister Hunt made a high level intervention to seek urgent advice on the necessary steps to strengthen the regulatory underpinnings of the MedsASSIST system via discussions with the Department of Health, the Therapeutic Goods Administration and the Office of the Australian Information Commissioner.

      It was in light of the Minister’s commitment and in good faith, the Guild held off the shut down until this advice is received at which time the Guild will assess with the Minister whether the necessary actions are able to be taken to allow this system to continue operating effectively until 1 February 2018.

      The Guild and its subsiduary GuildLink have funded the development and operation of MedsAssist along with ProjectSTOP previously demonstrating our strong commitment towards harm minimisation and prevention of diversion.

      Furthermore the Guild continues to advocate strongly and participate wherever possible with all levels of government to see the introduction of a Real Time Prescription Monitoring system.

      Anthony Tassone
      President, Pharmacy Guild of Australia (Victoria Branch)

      • Andrew
        28/07/2017

        lol, Anthony your commentary and reality are diverging more and more. Lots of next, not much to say.

        Save yourself the trouble next time.

    • Willy the chemist
      28/07/2017

      Andrew you talked tough. Let’s see you put some hard cash on a worthy project all by yourself, take a pay cut along for the public good. There are many good causes. Then you are entitled to criticise.

      I’ve been giving to 6 children at World Vision for many years.
      If I were to stop for any reasons, you’d criticise me for stopping….but I don’t see you giving (not saying you aren’t.).

      Do I see any profession tackling this big problem of realtime monitoring? But you’d attack the only profession that took any real meaningful actions. Hmm that’s how the world works nowadays yeah?

      • Andrew
        28/07/2017

        I spent quite a sum on a pharmacy degree that is now more or less worthless in the context I was wishing to practice – so don’t tell me I don’t have skin in the game.

        Not sure at the point of your virtue signalling on donations but I congratulate you on donating. My wife worked for WV and they do good work.

        What you might interpret as talking tough may be my frustration coming through at what seems like a crazy position totally at odds with community health (which is a pharmacist’s core duty) – any exception to the codeine upscheduling is will result in someone dying – that’s unequivocal. RTM will not overcome this issue – it’s easy to pharmacy shop, the customers know which shops are sloppy or too busy.

        • Willy the chemist
          28/07/2017

          No more invested than any other pharmacists. And a lot of us have more skin in the “game” having invested and borrowed so much more.

          The point is that it is the Guild as a private organisation and 70% of pharmacies as private enterprises who have supported MedsAssist.
          No other governmental, professions or organisations have initiated, funded or supported this up to that point.
          What is it? It provides RTM for codeine.
          What is the outcome? It reduces codeine sales whilst still giving assess to codeine OTC
          What are the consequences? The Guild (members) paid for the initiative (as in Project Stop). And community pharmacies (70%) took a cut to their profits in reduced sales.
          So Guild member pharmacists pay TWICE.

          So you ask, what is my point? The salient point is “Is your criticism of the Guild misplaced?”

          How is this related to World Vision?
          Metaphorically you now criticise me because I made a comment I’m going to stop giving to WV.
          And in the metaphorical sense, you are not giving to WV. Neither is anyone else.
          But you see it fit to criticise me for my intention to stop giving.

          Can you see the point now?
          Which other professionals have supported with time, initiative, money and actions? In the least, why are they not subject to critique? I don’t understand the hypocrisy in all these by so many. And they believe they are entitled to criticise when they have not contributed, and when other professions are not even doing the lifting?

          As community pharmacists, we spend hours each day advising and often dissuading our customers and patients from purchasing a product because we may believe it is of little benefit.
          Who gets paid for the advice?
          Who still have to pay for wages and running costs?
          What businesses often advice people not to buy something?
          Do any other health professionals provide advice routinely as a free service?

          Saying pharmacy degree is worthless just proves the point that you believe in rewards. In saying this, you are not wrong but in a moment of reflection, I hope you see the contradiction in what you are saying.
          Are you saying that pharmacy healthcare professionals offer no health outcomes?
          Well, if you think it does, then do you believe that working for nothing is still good cause?
          Even if it is, would you say it is just cause?

          I can even ask a metaphorical question, seeing your wife works in WV. Good cause. Would she work pro bono permanently?

          So why do people feel entitled to believe that Guild and member pharmacists should work for nothing?
          Rather than calling for this initiative to be publicly funded as it should always have been? Rather than lobbying for the adoption of MedsAssist as a working real time monitoring system now? Weird misplaced criticism?

          Is this tall poppy syndrome that we Australians have?

          • Andrew
            28/07/2017

            I don’t think it’s useful trying to quantify who has more at stake in this – I’m just trying to prosecute my opinion in a marketplace of ideas. Some agree, others don’t…that’s fine, I’ll just keep plodding along.

            Fundamentally my position is that pharmacy has its focus on business outcomes rather than patient outcomes and this is contrary to every stated goal of every health organisation in the land, including our peak body. Do you genuinely think that the pharmacy industry we have now is the best we can do? I’d argue it’s not even close to 50% with huge variation from store to store.

            That pharmacists are forced to provide the services that they do for free isn’t on. Fee for service. Where does the funding come from though? I can think of some major inefficiencies in the system that could make up the shortfall, I’m sure you can too.

          • Willy the chemist
            28/07/2017

            And neither is a statement that pharmacy profession is worthless. It serves no one any good. In fact it is destructive and antagonistic.
            Nor is it fundamentally correct to say that pharmacy is focus on business outcomes as the points I made is clearly evident that Guild and community pharmacy have really put actions before talk.
            And to balance the argument, no one has objectively state that for sustainability, pharmacy needs to be remunerated properly as well.

            You have a great point. No, pharmacy industry is not the best it can be now. Otherwise it will be a boring world, but on a serious note Australian pharmacies are one of the best working models. Australian healthcare is one of the best working models there is as well.
            Not perfect but better than most.

            Variability between practices, yes. And so is anything. So is the GPs and medical centres. So are government offices.

            Can we work towards a better model, yes, we can aspire to and really actions in the direction.

            Inefficiencies….and this is really the elephant in the room. Australia has so much bureaucracy and regulations…. for one, local council are an inefficiencies. Do they do good work. Yes. Are they inefficient, probably yes.

            But democracy is inherently inefficient as well.

            Shortfall. Go freaking lost! 🙂
            Shortfall is easily made up for with the waste from NBN, Myki, QLD contract for Grollo Commonwealth game developments …and on and on and on.
            Go freak… lost. Pharmacy has a shortfall because we have a real shortfall. Look at our award! Look at the carpenter / plumber award! Look at what the government pay for contracts and local councillors.

          • Andrew
            28/07/2017

            Thumbs up. Fundamentally I think we agree, thanks for the interesting discussion.

  2. Ronky
    24/07/2017

    Gee David, you must need a Stemetil for your dizziness after that marathon effort at spinning “alternative facts”. (Make sure you get a script for it though!)
    If something is so subject to abuse that you think that electronic monitoring of supplies is necessary, then ipso facto it is not something that is suitable for sale over the counter.
    You put financial considerations first and to the exclusion of patient health and everything else.

  3. Debbie Rigby
    24/07/2017

    Thanks for this summary David.

    In the interests of evidence-based practice, can you please direct me to the evidence supporting this statement: “80 per cent of the more than one million patients who use these medicines annually do so on an occasional basis for the temporary treatment of acute pain.”

    I am preparing a presentation, and would appreciate the reference.

    • M M
      27/07/2017

      Misuse and Dependence on Non-Prescription Codeine Analgesics or Sedative H1 Antihistamines by Adults: A Cross-Sectional Investigation in France
      Roussin, A, Bouyssi, A, Pouche, L, Pourcel, L, & Lapeyre-Mestre, M 2013, ‘Misuse and Dependence on Non-Prescription Codeine Analgesics or Sedative H1 Antihistamines by Adults: A Cross-Sectional Investigation in France’, PLoS ONE, no. 10. Available from: 10.1371/journal.pone.0076499.

      Dependence on Over the Counter (OTC) Codeine Containing Analgesics: Treatment and Recovery with Buprenorphine Naloxone
      Hout, M, Delargy, I, Ryan, G, Flanagan, S, & Gallagher, H 2016, ‘Dependence on Over the Counter (OTC) Codeine Containing Analgesics: Treatment and Recovery with Buprenorphine Naloxone’, International Journal Of Mental Health And Addiction, 5, p. 873, Academic OneFile, EBSCOhost, viewed 24 July 2017.

      Could Codeine Containing OTC Analgesics Sold in Romania be Used as Recreational Drugs?
      Dumitru Croitoru, M, Erzsébet, F, Erzsébet, V, Adelina, C, Monica-Simina, C, & Ibolya, F 2016, ‘Could Codeine Containing OTC Analgesics Sold in Romania be Used as Recreational Drugs?’, Acta Medica Marisiensis, Vol 62, Iss 3, Pp 309-312 (2016), 3, p. 309, Directory of Open Access Journals, EBSCOhost, viewed 24 July 2017.

      Misuse of non-prescription codeine containing products: Recommendations for detection and reduction of risk in community pharmacies

      Van Hout, M.C. and Norman, I., 2016. Misuse of non-prescription codeine containing products: Recommendations for detection and reduction of risk in community pharmacies. International journal of drug policy, 27, pp.17-22.

      Managing inappropriate use of non-prescription combination analgesics containing codeine: A modified Delphi study

      Gibbins, A.K., Wood, P.J. and Spark, M.J., 2017. Managing inappropriate use of non-prescription combination analgesics containing codeine: A modified Delphi study. Research in Social and Administrative Pharmacy, 13(2), pp.369-377.

      An ecological study of the extent and factors associated with the use of prescription and over-the-counter codeine in Australia
      Gisev, N, Nielsen, S, Cama, E, Larance, B, Bruno, R, & Degenhardt, L 2016, ‘An ecological study of the extent and factors associated with the use of prescription and over-the-counter codeine in Australia’, European Journal Of Clinical Pharmacology, 72, 4, pp. 469-494, Academic Search Complete, EBSCOhost, viewed 24 July 2017.

      The Separation of Codeine from Nonprescription Combination Analgesic Products
      Fleming, G, McElnay, J, & Hughes, C 2003, ‘The Separation of Codeine from Nonprescription Combination Analgesic Products’, Substance Use & Misuse, 38, 9, p. 1217, Psychology and Behavioral Sciences Collection, EBSCOhost, viewed 24 July 2017.

      The impact of codeine re-scheduling on misuse: a retrospective review of calls to Australia’slargest poisons centre
      Cairns, R, Brown, J, & Buckley, N 2016, ‘The impact of codeine re-scheduling on misuse: a retrospective review of calls to Australia’s largest poisons centre’, Addiction, 111, 10, pp. 1848-1853, Psychology and Behavioral Sciences Collection, EBSCOhost, viewed 24 July 2017.

      A Comparative Exploration of Community Pharmacists’ Views on the Nature and Management of Over-the-Counter (OTC) and Prescription Codeine Misuse in Three Regulatory Regimes: Ireland, South Africa and the United Kingdom

      Carney, T., Wells, J., Bergin, M., Dada, S., Foley, M., McGuiness, P., Rapca, A., Rich, E. and Van Hout, M.C., 2016. A Comparative exploration of community pharmacists’ views on the nature and management of over-the-counter (OTC) and prescription codeine misuse in three regulatory regimes: Ireland, South Africa and the United Kingdom. International Journal of Mental Health and Addiction, 14(4), pp.351-369.

      OTC codeine: Examining the evidence for and against
      Nielsen, S., Tobin, C. and Dobbin, M., 2012. OTC codeine: Examining the evidence for and against. Australian Pharmacist, 31(3), p.236.

      Myth: codeine is a powerful and effective analgesic
      Arora, S. and Herbert, M.E., 2001. Myth: codeine is a powerful and effective analgesic. The Western journal of medicine, 174(6), pp.428-428.

      Opportunities and challenges: over-the-counter codeine supply from the codeine consumer’s perspective
      Nielsen, S., Cameron, J. and Pahoki, S., 2013. Opportunities and challenges: over‐the‐counter codeine supply from the codeine consumer’s perspective. International Journal of Pharmacy Practice, 21(3), pp.161-168.

      • Jarrod McMaugh
        27/07/2017

        Mina, of all the people you could provide a summary of research to, Debbie is the pharmacist who would need it least. Her expertise in collating, interpreting, and disseminating research is very well demonstrated and respected.

        I think Debbie’s question was specifically looking for David to provide the data/research that he utilised in drafting this letter.

        • M M
          27/07/2017

          Im replying to David’s post. David has nothing to provide.

          • jason northwood
            03/08/2017

            Hi M M
            Thanks for that extensive list of literature related to codeine products.
            Do you have any data that would prove that the low-dose codeine products are safe and effective?
            There must be some clinical evidence , after all the products were evaluated by the TGA for safety and efficacy before they were registered on the ARTG because that’s what the TGA do.
            If, as some argue, there is no evidence of clinical efficacy then the TGA would never have registered them in the first place or would have removed them from the ARTG rather than changing to Schedule 4.

          • M M
            03/08/2017

            Yesterday, I posted the decision by French government to stop selling OTC codeine products and upscheduling them. (Btw, some of the references I posted have what you are looking for.. may you please copy them and check them, if you have the time).

            The realistic question is not the ineffectiveness of OTC codeine dose BUT overdosing .. if the objective of upscheduling to protect the public then this means we protect the public from misuse (overdosing) which makes the question about the dose of codeine in OTC products irrelevant.

          • Jarrod McMaugh
            03/08/2017

            The counter argument has always been that scheduling doesn’t reduce harm – it just alters access.

            Prescribing data for the RPBS, where all three strengths of combination codeine/paracetamol are subsidised, show that the majority of prescribers use 30/500, and a significant portion use authority quantities (100 on average).

            The issue is to reduce harm.

            Prescribing patterns show that codeine doses will increase. Prescribing patterns also show that there is a steady escelation over time wherein non-cancer chronic pain is treated (inapropriate) with stronger and stronger opioids.
            Data shows that rates of iatrogenic addiction are far greater for doses of opioids that are available as schedule 4 than for those in schedule 3.
            Data from monitoring software shows that the vast majority of purchasers are using OTC pain relief for acute pain or recurrent pain

            Concurrent to these issues:
            the number of harm minimisation prescribers is chronically low, and stigma is still very high.
            The number of GPs & specialists who work in chronic pain is chronically low
            Access to mental health services needed for addiction and for chronic pain is poor.

            In addition, RTPM is unlikely to be in place before schedule changes in February…. When a huge wave of patients with acute pain, recurrent pain, and chronic pain are going to present to GPs.

            Not only will these patients be potentially prescribed opioids despite an addiction due to lack of RTPM decision support tools, but many will also be inapropriate subjected to stigma & suspicion associated with drug seeking behaviour despite not actually drug seeking at all.

            All this could have been organised better if RTPM & education for prescribers had been implemented 18 months ago. Changing schedule before these two factors are in place is like trying to allow 1000 cars into a 500 space carpark at once, while constructing new levels in a way that closed off half the access ramps. It makes no sense.

            To think this has all come about because people have allowed their judgement to get in the way of logistical common sense. People see a study that says “deaths have occured in people taking codeine” yet very few people critically assessed the data and asked “how many deaths occurred when codeine was the only opioid?” The answer is zero, btw. Associating low-dose codeine with opioid deaths in Australia is like saying use of marijuana is associated with opioid deaths in Australia – yes there’s overlap but there’s just no actual risk of death compared to strong opioids.

          • M M
            04/08/2017

            Thank you for the long story. Kindly, refer to my previous references list.

          • Jarrod McMaugh
            05/08/2017

            Mina, providing a list of references isn’t the same as making an intelligent case for or against the topic at hand.

            Your response also ignored the point that I raised, which is that scheduling isn’t the “answer” – there are still a lot of things that need to happen before we are prepared to actually help people with their pain or with their addiction.

          • M M
            05/08/2017

            Thor case is invalid for two main reasons 1- you haven’t read my references which have answers to your question. 2- building an argument without valid referencing is a failure. Read my references again.

            I would send all these references to the minister of health with a one line letter

            “why OTC codeine products must be upscheduled”

          • Jarrod McMaugh
            05/08/2017

            Mina, seriously sometimes it’s like talking to a brick wall.

            Codeine is being scheduled to 4. That’s not in dispute, despite any addition of a mechanism for patients to access codeine in an acute situation without a script.

            As I have said, the issue we still have – and have always had – is the lack of resources available for chronic pain, the lack of resources for addiction, and the lack of resources to support GPs in appropriate prescribing.

            These issues are continually ignored by government and medical advocacy groups. Pharmacy organisations are continually trying to raise awareness on these aspects of the issue, and yet we approach February with little change in attitude or acknowledgement of the issues that will affect the health sector soon.

            Ironically, you’ve illustrated this attitude pretty effectively.

          • M M
            05/08/2017

            Jarrod, lets put things correctly.. you can do anything you want but this should planned for strategically (at strategic level) strategies are about holistic approaches where each manager and each individal should own the process(es) they are responsible for.

            Many fights and arguments between drs and guild and/or pharmacists on twitter. All of that will go no where.

            Rather than fighting for schedule 3.5, I was expecting the PGA and PSA to fight on behalf of the profession to be able to prescribe (this didnt happen), I wonder why!!

            After setting up the main healt care collaborstion strategy .. we set up a framework (this is different to legislative framework) .. this is a new approach. But it is the only approach that saves; time, money, creates more jobs, avoids duplication and streams real-time processes.

            These systems (frameworks) are being used everywhere in the world where efficiency and accuracy are needed.. they started implementing those systems about a year ago at Adelaide airport, bupa, and etc.

            Agreeing on a general strategy and using technology will help all HCPs to collaborate rather than argue.

            This takes us to another point “Innovation” I havent seen any of our pharma organisations has a clear “innovation strategy” having innovation strategy in place will help all HCPs compete positively. You will create a positive environment … e.g. we dont have remote dispensing like many countries in the world, we are still arguing is dispensing machines will reduce the need for pharmacists… ineffective supply chains (wholesalers) and other problems that may arise when technology.

            Re: supply chain; pfizer direct is an example of fast, short, cost effective supply chain.. but will we learn?? I doubt. Pfizer portal has many great functions.

            Hospitals have started using electronic prescriptions and have patient scripts and profiles on the cloud.. have we had all our pharmacies/pharmacists made aware of that? Can we all access it?

            We cant talk about leadership but we want it to be “only about codeine” this is where you will keep getting no support from other medical professionals (drs).

          • Jarrod McMaugh
            05/08/2017

            So Mina this is the point we often reach, and this is where I ask you to provide your opinion on how to implement the things you talk about.

            It’s all well and good to say “this is what should happen” but it’s the HOW that matters. Just like telling patients I lose weight is in ffrcive without a plan, saying “we need a collaboration framework” isnt an answer to the issue without a plan on how to achieve it.

            With regards to prescribing – that’s for the pharmacy board to work on…. And they are.

            With regards to Pfizer….. it’s arguable whether they are more efficient.

            lastly, you talk about innovation, but you also talk about a collaborative framework. These things rarely exist in harmony. Regardless of this, there is a significant investment of time and goodwill required to achieve this. For harm minimisation around codeine, we are running out of time. There is going to be a crisis in February around access to pain management and addiction management. The risk is that patients will be poorly managed due to poorly resourced prescribers escelating opioid exposure (as evidenced by RPBS data) rather than addressing chronic pain and/or addiction correctly.

          • M M
            05/08/2017

            No Jarrod the plan is not your. That is the point. You set the strategy that you want “at strategic level” implementing is about a specialised consulting company that has the tools to do what you want. You, myself , doctors and all other HCPs will be process owners .. previously I referred to and hashtaged on twitter bpm (Business Process Management) and ERP systems so we can read and start it from there. How starts by the moment we sit all together and agree on a few objectives (set strategy) and for the consulting firm to achieve what we need.

            e.g. We all hold professional degrees but that doesnt qualify any of us to fix electricity failures??

          • Dr Phil 42
            06/08/2017

            MM If the guild is so benevolent, then how come a generic Paracetamol/codeine 500/15 x 20 = $7.40 and Paracetamol/codeine 500/30 x 20 = $6.60.
            That is at ColesWortH. Its typically an even larger disparity at other pharmacies (what about yours?) – So to have something S3/OTC seems to have a price premium. Answer that conflict of interest and maybe I will listen to your other arguments.

            Jarrod, Once upon a time I was an OSP, no end of grief, the pharmacists who do their part are usually pretty idealistic (as was I), kind and generous with their time. Thus many burn out and its not consistent with a for profit business. It really should either be properly funded or put into a wider public system. If you have any better ideas?

            Both of you, I know! Why doesn’t the guild push for S3 Suboxone (say Max 8/2 mg, max one dose) and then you can do the messy job of dealing with dependence. Cost of supply $0, charge market value ?$6.20* a script and show those evil greedy doctors how cooperative community pharmacy should work.

            * Might have to factor in some extra ‘wastage’.

          • M M
            06/08/2017

            I am not sure where the question is.

          • M M
            06/08/2017

            I am not sure what the question is?

          • Dr Phil 42
            06/08/2017

            “Misuse and Dependence on Non-Prescription Codeine Analgesic” What can pharmacists do about it, and why they seem unhappy about it being rescheduled S3->S4?

          • M M
            06/08/2017

            I agree with up scheduling and those who are against up scheduling it have no strong reasons.

          • Dr Phil 42
            06/08/2017

            I am glad we can agree. But there are pharmacists (Guild / owners mostly) who are doing their utmost to fight the rescheduling. So my plan is to offer them a way that would justify prescribing opioids, but not codeine and instead OSP Suboxone, and watch them run away from that as fast as possible.
            Thus my argument is, either support Codeine being unscheduled or support pharmacy use of the OSP, (bonus Suboxone is a pretty good analgesic as well, certainly better than Codeine)

          • Jarrod McMaugh
            06/08/2017

            Philip, while you may see the responses in media and think this is indicative of all of the advocacy around this issue, there is a lot more going on behind the scene.

            You may also note that a significant portion of the narrative from pharmacists on scheduling is not whether it should/should not occur, but whether doing this will achieve what it is intended to do. I have significant doubts, and as a OSP in the past, you may have insight in to the attitudes and lack of workforce participation that fortifies these doubts.

            As for Suboxone – that is an excellent t idea. Let me just say that it’s not original. There is plenty of work on this as well…. Again, not visible in the media.

          • Jarrod McMaugh
            06/08/2017

            Mina that type of response characterises why so few people want to engage with you in any kind of discussion.

            The fact that you cannot see why people have an opinion that is different to yours that has as much validity as yours makes your contribution to almost every discussion negligible and worth ignoring

          • M M
            06/08/2017

            Despite of that neither you nor anthony or other psa and guild seniors ignore my discussions. Refer to my references list again .. when you finish reading them we can discuss. Starting a discussion with no evidence will not take you anywhere.

          • Jarrod McMaugh
            07/08/2017

            We have an obligation to engage Mina.

            When someone has questions or a differing opinion, it’s important to discuss it.

            When that person clearly isn’t interested in discussion…. Only argument…. Then it gets tired.

            There isn’t a single reference that you’ve posted that I’m not ready familiar with. Despite this, posting a lists of “references” without actually discussing them (in other words, actually referring to them) means nothing.

            To formulate a discussion, a thesis, an argument, you need to state your point, then you can provide the reference to back up your point. Then you discuss further in depth on the topic in order to address the questions or counterarguments of those who engage.

            What you have a habit of doing is making a statement without further discussion or examination of your point. you post a list of references here without providing context to them…. Do you feel they make your point, do they undermine your point? No one knows because it’s just a list without context.

            You also have a habit of raising basic economic theory and say how these concepts are the answer to all of the problems…. But you don’t say how they solve anything, how they should be applied, just that they are the answer to everything. That isn’t helpful, and undermines your credibility because it makes it look like you don’t actually understand the concepts you espouse.

            Lastly, you make comments like the one above…. They those who have an opposing point of view to yourself have no valid reason to hold that point of view. This is extremely naive. If you cannot understand the alternate point of view to your own, then you aren’t advocating for anything; you’re a pundit. Understanding the point of those you discuss any topic with is critical to progress and finding common ground. You don’t seem to want this.

            I would go so far as to say that you don’t even know the point that I have been making about codeine access & harm minimisation for the last 3 years.
            I can summarise your position pretty accurately. Can you tell me what mine is?

          • M M
            07/08/2017

            Again, I posted references for people to read then engage accordingly. You are familiar with? Maybe but you havent discussed any of them. I was asked my opinion on upscheduling which I have provided. It has nothing to do with accepting or refusing other people’s opinion.

            Harm minimisation? And codeine addiction?.. dont you see that Guild intervention on behalf of the profession was too late?

            When we call for real time monitoring we dont call for monitoring codeine only or s8 only we realtime every thing. That is my point.

            Creating schedule 3.5 will not solve anything. You havent even told me how we can classify codeine patients.. if we were going to put them in categories.. how many categories “we” can come up with? I use “We” because it is all about collaboration.. isnt it?

          • M M
            05/08/2017

            Re: pfizer.. if you ask them for data they will provide it to you. Their submission to kings review is good. In terms of supply chain efficiency they are doing better than our wholesalers.

            Re: codeine the question is how do you categorise OTC codeine patients and what is the % of each category?

          • Ronky
            07/08/2017

            No they were never evaluated for safety and efficacy because they already existed in the market for decades before the TGA was created.

          • jason northwood
            08/08/2017

            Really ? I was sure TGA was in existence before the invention and registration of Nurofen Plus and Panafen Plus. if we go by the Therapeutic Goods Act 1989 , the TGA was formed in 1989. Was ibuprofen + codeine available before then ?

          • Ronky
            08/08/2017

            I suppose they were grandfathered by analogy with the pre-existing codeine/paracetamol and codeine/aspirin products. i.e. the TGA had already accepted without evidence (and there still is no evidence to this day) that the low-dose codeine component provided additional analgesic effectiveness, and was safe, for the pre-existing products, and it had accepted that ibuprofen was safe and effective for the same purposes as aspirin and paracetamol, so it accepted the codeine/ibuprofen combo by deduction. And perhaps also out of fear that the manufacturers would appeal to the courts against any decision to ask for actual evidence. The TGA and its legislation are remarkably toothless. This has only worsened since the Pan affair.

    • Greg Turnbull
      02/08/2017

      Hi Debbie
      The KPMG Report “Economic Modelling and Financial
      Quantification of the Regulatory Impact of Proposed Changes to Codeine
      Scheduling indicates that:

      6% of Australians over the age of
      12 purchase at least one pack of low-dose codeine medicine per year.

      80% are ‘acute’ pain users,
      however they purchase 22.2% of all packs.

      19% are chronic therapeutic users
      and they purchase 76.5% of all packs sold.

      KPMG Report to the TGA, November 2016
      https://www.tga.gov.au/sites/default/files/economic-modelling-and-financial-quantification-regulatory-impact-proposed-changes-codeine-scheduling.pdf

      • Debbie Rigby
        02/08/2017

        Thanks Greg. But those stats don’t support the statement I highlighted.

        • Greg Turnbull
          03/08/2017

          Disagree.

        • jason northwood
          03/08/2017

          Please explain ? I think they do support the statement you highlighted , after all they are from the TGA’s very own Regulatory Impact Statement , so they must be true

      • Debbie Rigby
        02/08/2017

        Over 75% of combination products sold to manage chronic pain. Evidence shows opioids are not effective for chronic pain and use leads to dependence and overuse. Surely this is the challenge and one that the current scheduling has not met.

        • Jarrod McMaugh
          02/08/2017

          I’m not that is what is being said here Debbie.

          From reading that report, the term seems to refer to people who.utilise codeine containing products as their regular pain relief…. IE the first they they use,not necessarily using every day.

          Not much of a difference, but it’s not specifying a person treating chronic pain, and could include a person who uses a small packet every month for recurrent pain

        • Greg Turnbull
          03/08/2017

          Note that the Guild is not seeking the reversal of the upscheduling decision. The provision of these medicines under the proposed codeine ‘exception’ would be subject to strict protocols and mandatory real time recording.

  4. vixeyv
    24/07/2017

    Wholeheartedly back this. This is not a pharmacists vs doctors type scenario. This needs to solely be about concern for the patients affected. I would be curious to hear what the patients will want to say about this.

  5. Ronky
    28/07/2017

    Hilarious that he begins by deploring that the codeine issue has become “political” when it is the Guild and the Guild alone which has made it political. Boasting in its press releases that it has directly lobbied State and Commonwealth Ministers to try to get them to over-rule, reverse, delay or dilute the rescheduling decision, and claiming some success in this. Nobody else has involved politicians in the issue. The medicines industry, which has a lot more to lose financially, has accepted the decision.
    But the Guild, instead of working with everyone else to manage the transition, has decided to throw a months-long dummy spit and play the role of wrecker.
    We have had countless “last chances” to show we could handle codeine as an OTC medicine and we blew it. (or at least many pharmacy owners who can see only dollar signs blew it for the rest of us.) When it was first threatened that codeine go S4 in 2009 Blind Freddy could see it was a matter of when, not if, unless pharmacy owners pulled their socks up. Instead, the Guild did nothing, until hauling out the farcical MedsASSIST at the last minute. As the rescheduling decision states, even the data from MedsASSIST itself shows pharmacists continuing to inappropriately supply codeine repeatedly and for chronic conditions. (That’s not even counting the sales presumably not recorded on MedsASSIST because they would be too embarrassing to the seller.)
    And now the Guild says, “give us yet another try and this time we’ll get it right.” Sorry guys, you’ve lost all credibility among pharmacists and governments alike, despite all your frenetic lobbying and political “donations”.
    Interesting to see that France, one of the few other countries where codeine was still available OTC, has now made it prescription only, apparently effective immediately on the Health Minister’s announcement. I guess they don’t have a Guild there. Australia is now badly lagging world practice on codeine.

  6. John Smith
    05/08/2017

    quick observations: Pharmacies (owners) make $$$ of codeine containing products sales… Can someone guess how much?!!

    Government takes a decision to upschedule codeine containing products… bad news for owners, as turnover goes down, GP$ goes down, valuation goes down… (MINUS)

    PGA negotiates with the government to get more funds within the CPA and manages to get extra $600 million to fund existed services rather than new services as it was previously agreed on. (good news and thumbs up to PGA, owners think ) (PLUS)

    However, in the mean time the services provided require more time spent, maybe hiring an extra casual pharmacist, more $$$ expenses (MINUS)

    PGA wins the submission of cutting the penalty rates and for years prefer to keep the low award rate, and add more tasks on employees that leads to more pharmacists leaving the profession (workforce shortage) , following simple demand and supply the $$ salaries increase and that is more $$$expenses (MINUS)

    PGA adopts medsassist too late when TGA thinks about upscheduling, then decides to cease it for money issues ( employees get upset with PGA, not a smart move ) (MINUS)

    PGA calls for schedule 3.5, last trial to keep some of the profit

    PGA calls out for real time monitoring (GOOD MOVE) after how many years of pharmacies supplying codeine containing products and participate in addiction and dependence?!! (TOO LATE)

    The one thing I would say PGA has helped owners with is location and ownership rules… wait… restricting locations can also follow demand and supply law and of course we can see now pharmacies are sold over the market valuation by 300K out of pocket, so even that is not 100% efficient…(MINUS)

    Bottom line PGA is the employers body… Good luck 🙂

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