Three wrong statements on codeine

Peter Carroll takes a look at three recent claims around codeine

Recently several claims regarding codeine have been circulating which I believe are untrue.

Claim: Paracetamol and anti-inflammatory medications, alone or in combination, are adequate OTC treatments for most types of acute pain 

Commonwealth Chief Medical Officer Professor Brendon Murphy stated recently that paracetamol and anti-inflammatory medications, alone or in combination, are adequate OTC treatments for most types of acute pain. 

I believe this statement is not true for the hundreds of thousands of Australians who should not take ibuprofen at all, or only take it with caution.

These people include those with aspirin-sensitive asthma (ibuprofen may worsen their asthma symptoms, and potentially cause an acute asthmatic attack), and those with renal impairment or gastrointestinal disorders such as Crohn’s disease (ibuprofen may make their condition worse).

In addition, many people take medicines which may have a serious drug interaction with ibuprofen. These include people taking warfarin or other anticoagulants used to prevent blood clots (ibuprofen may increase the risk of bleeding) and those taking some medicines used in the treatment of high blood pressure or heart failure (ibuprofen may increase blood pressure and reduce kidney function).

Clearly ibuprofen alone, or ibuprofen combined with paracetamol will not be adequate OTC treatments for most types of acute pain experienced by these people. If the proposed rescheduling of OTC codeine-containing products to prescription only goes ahead these people may have no effective OTC treatment for their acute, short term pain. If this is the case, they will have no option but to visit a doctor to obtain a prescription for a codeine-containing product.


Claim: The amount of codeine in OTC codeine-containing analgesics is not efficacious

SHPA Chief Executive Kristin Michaels has been quoted as saying that the SHPA does not recommend sub-therapeutic doses of codeine for the treatment of mild to moderate pain, and says the SHPA has long advocated for reducing the availability of codeine-containing medicines, which it deems “ineffective”.

It is certainly not true to claim that the amount of codeine in low dose OTC codeine-containing products is not efficacious.

An Australian study has reported that 1000mg paracetamol combined with 30mg codeine phosphate (equivalent to two Panadeine Extra caplets) produced significantly greater analgesia than 1000mg paracetamol alone (equivalent to two Panamax or two Panadol tablets) 1.

It has also been reported that 20mg codeine base combined with 400mg ibuprofen (equivalent to 2 Nurofen Plus tablets) produced significantly greater analgesia than 400mg ibuprofen alone (equivalent to two Nurofen tablets) 2.

Both Panadeine Extra and Nurofen Plus, along with other brands containing the same ingredients in the same strengths, are available as OTC Schedule 3 medicines.

I therefore believe the evidence shows that in currently available OTC products the addition of low dose codeine increases the analgesic effect relative to either ibuprofen or paracetamol alone.


Claim: 100 people die each year from codeine-related deaths

ScriptWise has also said that it estimates 100 people die each year from codeine-related deaths.

I believe that this claim is not accurate.

A study published in the Medical Journal of Australia reported that in Australia between 2000 and 2013 there were 113 deaths (9 per year) which were thought to be specifically caused by codeine 3.

This study also reported that the vast majority of deaths were due to intentional or accidental overdose, and in the cases where the codeine product could be identified, the majority of deaths involved a prescription codeine product, not an OTC codeine product.

National Coronial Information System data for the period 2007 to 2011 also gives data relating to codeine deaths, and while the data can be a little difficult to interpret, I believe it shows that over the 5 year period there were 121 deaths (24 per year) where codeine was presumably directly responsible 4

It is also important to note that these studies cover periods from 2000 to 2013 and from 2007 to 2011. They give no figures for the past four years, and include data collected a decade or more ago.

I believe it is wrong to claim that codeine-containing products are killing 100 Australians a year. In fact, it seems meaningless to quote any figure as to the best of my knowledge there is no evidence to show what the current figure actually is.


Suggested solution to the proposed codeine upscheduling

I strongly believe that the NSW Health Minister, Mr Hazzard, and other state Health Ministers should introduce mandatory real time monitoring into all community pharmacies for the supply of low dose codeine-containing analgesics, and allow pharmacists to continue to supply these products without a prescription (up to 3 days’ supply) for the treatment of acute, short term pain such as migraine, toothache and period pain.

This will allow pharmacists to identify and help the small number of people who may be misusing the products, while at the same time allowing the vast majority of consumers who use the products appropriately and safely for the short term treatment of acute pain continued access to the products without a prescription.


  1. Macleod AG et al (2002) Australian Dental Journal 47(2),147-151
  2. McQuay H.J et al (1989) Pain 37, 7-13
  3. Roxburgh A et al (2015) Medical Journal of Australia 203(7), 299e1-299e7

Professor Peter Carroll is from the School of Medicine, University of Notre Dame and Discipline of Pharmacology, University of Sydney

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1 Comment

  1. Bruce ANNABEL

    As usual Professor Carroll makes a lot of sense with his comments on the subject of codeine and backs them up with evidence. As a migraine and asthma sufferer I find panadeine works well dealing with migraines, while avoiding drugs that trigger asthma as Peter mentions.

    In Adelaide last week after suffering a migraine I visited a pharmacy to buy panadeine and discovered because of supply chain their stock had been cleaned out. An OTC alternative was suggested by an assistant that was inappropriate for me.

    Having to visit a GP to obtain a script for my type of intermittent need seems ridiculous particularly if the prescribed s4 item is of a higher strength.

    Those pharmacies who fully embraced MedsAssist identified quickly the OTC codeine abusers and weeded them out compared with the genuine patients in need such as myself. Those pharmacies lost some business but they proved how well the system worked including transferring many patients to efficacious alternative therapies.

    But, as I understand from Professor Carroll, codeine abuse is minor compared with other opioids has the bigger issue and an opportunity to address it ben missed? As I wrote in Mal Scrymgeour and my December 2017 AJP column:
    ‘There’s no doubt MedsAssist adopted by the majority of community pharmacies has been incredibly effective in recording and detecting misusers of OTC codeine. In our view, making MedsAssist mandatory for all pharmacies would have been a much smarter move all round which, with a bit ofthought and vision, had the potential to become the central record of all opioids supplied be that PBS, OTC or private scripts.’

    If pharmacies captured the supply of these using a broad recording system identify those patients perhaps excessively reliant on all forms of opioids may lead to interventions and interaction with GPs in the interests of patient health and reducing morbidities.
    1 February is just next Thursday and I’m concerned pharmacy in general and some of their patients aren’t prepared for the change and there may be some unintended consequences for all stakeholders including some patients, pharmacists and their assistants, general practitioners and government.

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