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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