A time for clarity


Pharmacy needs clarity and unity if it is to have a strategic approach to codeine rescheduling, says Rick Samimi

The codeine rescheduling issue has been challenging for community pharmacy. Despite the shots across the bows from the Australian Medical Association and a strong public media campaign to blend the codeine misuse issue with the broader misuse of prescription opioids, I believe these circumstances offer community pharmacy a great strategic opportunity to progress and strengthen our vital role in primary care.

At the national level, it’s encouraging to see the Guild and the Pharmaceutical Society of Australia (PSA) work closely in advocacy for retaining pharmacy accessibility of codeine for acute pain management once codeine becomes prescription only, and for the introduction of real-time monitoring. It’s a reminder that cooperation, collaboration and the soft application of power within ‘the tent’ usually trumps blind opposition, obfuscation and poorly strategised power, wielded bluntly outside ‘the tent’.

In NSW, the looming prescription-only status of codeine has triggered a degree of alarm and hand-wringing among some pharmacists and this has been exacerbated by poorly informed and supported statements aimed at causing anxiety among members during the NSW Guild elections. They point to the loud protests and badgering by the AMA as a benchmark to be attained by the Guild when opposing government decisions.

There are times when it is undoubtedly appropriate for the Guild to utilise its full political capital in resolute opposition to government initiatives or decisions. These times are characterised by the magnitude of the threat to the broader viability of the community pharmacy network, the unintended consequences that threaten public health and our ability to support our services to the community. The most urgent and current example of these is the ‘demagogic’ statements in the poorly consulted and researched Interim Pharmacy Review.

The up-scheduling of codeine on the other hand, while a huge issue of concern for the entire profession, does not fulfil these criteria.  There’s no doubt that withdrawing the schedule 3 status for codeine combinations will have many unintended consequences, and the Guild’s comprehensive proposal, in consultation with the PSA, can and will address the critical issues.

The proposal not only meets safety and excessive use/dependence concerns, it also removes the unwanted impact on the majority of patients who may occasionally require advice on relief from acute pain and will use codeine-containing analgesia safely and appropriately. The proposal considers situations where immediate access to a GP is difficult – a common occurrence, especially in regional and rural areas – as well as substantial out-of-pocket costs in metro areas where bulk-billing levels are low (not to mention increased costs to Medicare), and other areas of the health system such as emergency departments inundated with requests for minor acute pain management.

The joint Guild/PSA proposal asks government to enable pharmacists, under appropriately specified guidelines & circumstances, to provide pain relief support for acute pain. It asks government to delay the 1 February date for codeine’s up schedule to ensure regulatory instruments are in place to support people seeking relief from acute pain, and requests that a real-time monitoring system be mandated. Such a system will reap much useful data and should not be viewed as simply a mechanism to police the dispensing of codeine.

These are sensible responses to an issue that has evolved from health policy into the broader social policy environment over the past decade, and collected numerous advocates with entrenched views along the way. The Guild has been working hard in the background on this issue and I am optimistic that our views have been heard and understood. Certainly, Health Minister Hunt’s recent support for real-time monitoring backs this view.

In NSW, I have now met The Health Minister Brad Hazzard on three separate occasions in the past few weeks. The Minister is acutely aware of all angles of the debate, including the Guild’s comprehensive proposal with PSA support, and is working with me to find the most practical way forward.

Therefore, now is not the time to cause unnecessary anxiety among members, or to spend all of the Guild’s political capital – and it will require it all to be spent to be successful – when our proposal offers a comprehensive solution that entrenches the role of pharmacists in primary care, especially in the management of acute pain.

Taking a ‘bigger picture’ view of pharmacists’ expanded professional role, we need to continue evolving and asserting pharmacy’s position in primary care and there is much we can do to relieve pain in the community and educate consumers about effective pain management strategies. Pharmacists are already well trained to do so and pharmacies offer Australian consumers the most convenient access to pain relief and management services.

I note that the Australian Prevention Partnership Centre, which is leading a new pain prevention project, cites the need to put in place measures that:

  • identify early interventions to reduce risk of developing chronic pain and assessment for relevance to Australian primary care settings;
  • identify screening instruments to detect people at risk of developing chronic pain and assessment suitable for different primary care settings;
  • develop and trial a local mapping tool for local need and capacity for early intervention at Primary Health Network level; and
  • develop and trial tools to assist locally sustainable plans for improving local early interventions for people at risk of chronic pain or poorly managed pain.

These all seem like measures that pharmacists and pharmacies are ideally placed to contribute to. Taking pharmacists out of the pain management loop and only relying on the prescribing skills of GPs would be retrograde and only increase pain and suffering in the community.

* Rick Samimi is NSW President of the Pharmacy Guild of Australia.

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