It’s more important than ever to keep using MedsASSIST, writes Jarrod McMaugh
Access to codeine, and the risks associated with inappropriate use, has been a very contentious topic. It will continue to be contentious. The decision to change the schedule of all codeine-containing products to be prescription only is seen by many to be an end to the debate, and yet it is only a small piece in the path to dealing with the issue.
Unfortunately, there seems to be a groundswell of opinion that making codeine prescription-only in all forms from February 2018 will somehow fix the issue, and that we can stop worrying about it. 12 months left and it won’t be a problem any more.
There is a flaw to this logic, though. The fact that rescheduling is seen as the answer to codeine misuse shows that this change is going to lead to no changes (at best) or worsening problems for patients at risk of addiction.
The most worrying trend that I have seen expressed so far is that MedsASSIST isn’t worth using now. “The problem will go away in a year; the process will be out of our hands; everyone will need to see a doctor anyway.”
This is a disappointing trend that highlights the fact that too many pharmacists aren’t really invested in the best health outcomes for their patients; they are invested in whatever processes make their day run the smoothest. This is a problem for all pharmacists – employees and employers, discounters and service-model pharmacies.
What exactly is the flaw in changing the schedule of codeine to prescription only? It’s two-fold; made up of the fact that this will reduce monitoring of codeine use, and that this change is seen as a solution to the problem, rather than being a piece of the solution that requires other pieces working together to be effective.
No one can deny that addiction to opioids is a terrible outcome for any of our patients. Doing what we can to reduce this should always be a high priority for any profession that is interested in harm minimisation and quality use of medicines. Unfortunately, the interests of those at risk of addiction has been lost in the political back-and-forth over the role of health professionals.
During the debate over schedule change, and after the decision was made, there were commentators who saw this as a win for prescribers, with Dr Bastian Seidel going so far as to state that up until this decision, “OTC codeine combination analgesics have been sold over the counter in pharmacies, virtually unmonitored or unregulated.” 1
This is quite a disappointing comment, as it shows that the interests of some professional bodies are focused on scoring points more than actually understanding the nature of the issue.
To make matters worse, there were regular comments from Evan Ackermann suggesting that any point of view that attempted to address the wider issues in the debate were driven only by commercial interest, even going so far as to say that “requesting a real-time drug monitoring system is just passing the buck and irresponsible.”2
An extraordinary comment to make, given that access to information about an individual’s use of opioids is a key piece of government policy in reducing harms from medications in Australia.
This brings us to the question – what is the answer to opioid addiction in Australia? We need to look at the harms associated with opioid use in Australia; so what better place to look than the study that raised the issue of codeine access in the first place – “Trends and characteristics of accidental and intentional codeine overdose deaths in Australia.”3
This study has some very interesting data, but the conclusions drawn from it are worrying. Specifically, where codeine was in any way involved with a patient’s morbidity or mortality – even if it was not the causative agent – then this instance was ascribed to codeine as the cause, leading to a conclusion that codeine (regardless of the source) was responsible for the outcome.
This flaw was highlighted in October 2015 by a respondent to the article, Dr Laurence Mather PhD FANZCA FRCA, when he noted the following:
“In this report, attribution of the deaths as codeine ‘overdose’ or ‘related’ is problematic. The pharmacologically pertinent effects of codeine are ventilatory depression, cough suppression, and emesis.
“Certainly, these effects can lead to fatalities, particularly at doses also producing depression of consciousness. However, no information is given as how these deaths were (or might have been) attributable to ‘codeine overdoses’.
“The ingestion of codeine and the occurrence of death in someone are not pharmacologically synonymous with death by ‘codeine overdose’ or even being ‘codeine-related’. The majority of deaths (83.7%) were reported as ‘mixed drug toxicity’, with only 7.8% as ‘codeine toxicity’, as characterized by the morphinoids-drug screen algorithms. In the presence of polypharmacy and/or comorbidities, with unknown codeine dosing forms and doses, and with unknown codeine biofluid concentrations, even in those deaths where other medications or substances were not detected (and there is no information as to what may have been detectible and/or dismissed), it is really not possible to ascribe the deaths to codeine other than by suggestion.
“Hence, conclusions regarding codeine ‘overdose’ or codeine ‘related’ deaths do seem a pharmacological over-stretch.”
Unfortunately, this has been overlooked in the discussion on the safety and appropriateness of access to codeine.
At this point, discussing the validity of the decision to change the schedule of codeine is a waste of time. The decision has been made, and we need to focus on other areas that are required to minimise the risk of harm.
I mentioned earlier that changing the schedule of codeine is only a piece of the puzzle to addressing the risks of opioid misuse. The second (of three) piece of the puzzle is adequate funding of health services for addiction treatment and prevention.
Addiction treatment is woefully underfunded in Australia. Pain specialists are difficult to access, and addiction specialists are even harder to access.
The number of prescribers in Australia for opioid replacement therapy is too low to cope with the number of patients at risk of (or living with) addiction. This is marginally increasing due to the ability of doctors to take on up to five suboxone patients in some jurisdictions , but this is not enough to address the needs of the population.
There is a tendency to excuse drug-seeking behaviour and miss the signs of addiction amongst clinicians who are not recognising addiction in patients. This may be due to inexperience, or it may be due to the stigma associated with addiction.
Comments like “none of my patients are addicted to their pain medications” or “I think I can recognise addiction when I see it” are all too common, and they downplay the statistical certainty that every health professional in Australia has some patients who require help with addiction.
The third piece of the puzzle is real-time information available to clinicians when deciding on an appropriate treatment. For many patients, Meds ASSIST has been the only tool available that has been able to provide valid and reliable information about a patient’s use of opioids and risk of addiction.
This isn’t to say that MedsASSIST is a perfect tool – it suffers from some flaws. This is why real-time monitoring is a piece of the puzzle of opioid risk. Despite this, at the moment, this is the only tool that is recording the use of codeine-containing products in Australia. Will we be able to say this next year?
Real-time monitoring is one of the outcomes we need in legislative change in Australia to address opioid addiction. When the schedule change for codeine was announced, I was dismayed… not because codeine shouldn’t be prescription only, but because making this change before real-time monitoring exists in Australia will dramatically reduce the political will required to make real-time monitoring a reality.
The history of real-time monitoring in Australia has been very troubled. Many states have a warrant or approval-style method wherein doctors are required to be the only prescriber of opioids for a patient. While my experience in most states is limited, it is my understanding that ACT is the only jurisdiction that effectively implements this in a manner that actually restricts prescribing.
Many of the states are in the process of developing or implementing a real-time monitoring system. Of these, none of them address any medications outside of schedule 8.
These monitoring systems aren’t extensible (ie able to take into account other schedules), and they aren’t flexible (ie able to take into account specific molecules). This means that from 2018, most codeine will be “virtually unmonitored” as Dr Seidel puts it, even if a real-time monitoring service is put in place.
By not having a real-time monitoring service in place that can monitor all opioids and specific medications identified by clinicians as being subject to misuse (ie benzodiazepines, quetiapine, pregabalin), the process of changing the schedule of codeine will increase harms, as monitoring with the only current system available – MedsASSIST – will be considered unnecessary, since codeine will be prescribed.
Herein lies a major problem with the arguments for schedule change as the only thing required to address opioid addiction harms – prescribers are no better at identifying or addressing addiction than pharmacists are.
Doctor shopping cannot be addressed with this change in schedule. Dose escalation can and will occur when patients only have the option of prescribed pain relief.
Without real-time monitoring in place, the risks to patients will increase with this change, unless pharmacists continue to utilise MedsASSIST, even for prescribed codeine.
MedsASSIST… who needs it now? Everyone.
Jarrod McMaugh is a community pharmacy practitioner in the northern suburbs of Melbourne. He has extensive experience in developing and delivering professional services in the community pharmacy setting.
3: Medical Journal of Australia, Med J Aust 2015; 203 (7): 299.