Winning ‘except-when’ status for codeine


prescription pad doctor

Have you ever had to sell something that you didn’t quite believe? Tough isn’t it, says pharmacist Peter Feros

But the scenario above is what we pharmacists are being asked to do in the lead-up to the end of OTC codeine-containing analgesia from 1 February.

Another analogy is acting as medicines coppers for the Government – a role pharmacists are asked too regularly to perform and one that gets in the way of the clinical relationship between the pharmacist and patient.

While there may be some valid clinical reasons for the decision by the Therapeutic Goods Administration, behind it is a view that pharmacists are not equipped to allow their safe, judicious use to relieve acute, rather than chronic, pain.

Irrespective of how many new training materials we receive to manage the transition, we know we will face a tsunami of complaints from worried and upset patients – the vast majority of whom will not be codeine-abusers and simply seekers of relief.

And what’s the reaction of someone in pain when they’re told they can’t have what usually offers some relief? We certainly can’t expect a calm, logical and measured response.

Especially when told that the strong pharmaceutical relief they seek can only be accessed via a doctor’s prescription. And especially when serving an area where immediate access to a GP is problematic. This covers most of Australia, but especially in rural areas where the healthcare goal of equity of access remains a distant hope.

The goal of gaining government agreement for an ‘except-when’ status, where pharmacists can use their professional judgement to provide patients with relief for acute cases, not chronic, has to be a priority.

One thing we can do to help this cause is to capture case studies of people who will be, or are, affected by the dramatic curtailing of access, and share them with our state and federal politicians.

Despite being a pharmacist and living in Sydney’s northern suburbs, I have my own case study that helped to really underline the issue of access:

On 24 April 2017 I had a stroke while holidaying in the UK. Following treatment and a return to Australia, two months later I woke on a Friday morning with a slight niggle in a back tooth. My regular dentist had no emergency bookings available and, as he doesn’t practice on weekends and I deemed it not an emergency, agreed to take the first available Monday booking.

Mid-afternoon the niggle progressed to a dull ache so I took 2 x 500mg paracetamol tablets. The pain was worse when I arrived home at 6.30pm so I took two more paracetamol tablets, and two more again before bed-time at 10.30pm.

At 12.30am I awoke with severe toothache.  After trying an Internet-listed 24-hour dental service, I was asked to leave a message which would be responded to within 10 minutes. That call never came so I booked an appointment with another dental practice for Saturday morning.

Mine was a pontine stroke and, not wanting to take another gram of paracetamol before time, I rode the pain until 3.30am when I took two Mersyndol Caplets which also contain codeine and doxylamine. This helped me sleep until 7.15am when the pain woke me again.

Because of the stroke, I have to take blood pressure readings morning and night. So I took my morning reading. Two days earlier, a hospital reading of my blood pressure was 130/94. Yet on this morning the blood pressure reading was 159/112!

So, in addition to arranging the dental appointment, I also arranged an appointment with my doctor to address the extremely elevated blood pressure and the severe pain. 

My GP suggested the elevated blood pressure was most likely due to severe toothache pain and resultant lack of sleep.

As a pharmacist, I keep a home formulary of medications including the codeine-containing Mersyndol. Without the Mersyndol, just like most citizens, I would have gone to the emergency department of Royal North Shore Hospital to get suitable analgesia. 

My GP:

  • prescribed endone for the severe pain;
  • changed my blood pressure tablets; and 
  • arranged a follow-up appointment.

After February 2018, when access to codeine becomes significantly restricted, most citizens with severe toothache, with or without other medical contraindications such as a history of stroke and high blood pressure, will have no other option than to go to a hospital to find doctors and painkillers at the one site.

Share your case studies with us and they can be brought to the attention of those lobbying for pharmacists to be granted ‘except-when’ status.

* Peter Feros owns multiple pharmacies and has for decades been a regular commentator on the business and profession of pharmacy.

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8 Comments

  1. jason northwood
    10/01/2018

    “we know we will face a tsunami of complaints from worried and upset patients ” according to that venerable resource Wikipedia a “tsunami” is a seismic sea wave that in no way can be used as a metaphor for the upscheduling of codeine.
    Tsunamis are difficult to predict – the TGA announced the upscheduling of codeine 14 months ago after considering this issue since about 2010. A tsunami has a wave period of about 12 minutes – I am sure consumers will forget all about the codeine upscheduleling after about March 2018 when they realize that it was all the placebo effect at work.
    Perhaps we need to stop using the word tsunami

  2. Andrew
    10/01/2018

    Do we not believe in evidence based practice anymore?

  3. Jerry Yik
    10/01/2018

    “We certainly can’t expect a calm, logical and measured response.”

    Why shouldn’t health professionals expect this from their patients? I certainly don’t hear about GPs copping abuse/snide remarks on the scale of which community pharmacists tolerate…

  4. Gavin Mingay
    10/01/2018

    So… “My GP: prescribed endone for the severe pain; changed my blood pressure tablets; and arranged a follow-up appointment.”

    Isn’t this what we want from making codeine prescription only?? See a doctor for more appropriate pain relief, fixing other health issues and follow-up treatment…

  5. Daniel Guidone
    10/01/2018

    This argument keeps going round in circles. I would like to respond to a few quotes by the author:

    “After February 2018, when access to codeine becomes significantly restricted, most citizens with severe toothache, with or without other medical contraindications such as a history of stroke and high blood pressure, will have no other option than to go to a hospital to find doctors and painkillers at the one site.”

    The suggestion that patients need to utilise the accessibility of a pharmacist for management of minor ailments and associated therapy is an argument for a minor ailments scheme with rights to prescribe medicines deemed to be safe and effective. The argument that emergency supplies should be ‘one shop stops’ and not prescriber + pharmacist can also be used by GPs to gain dispensing rights.

    “While there may be some valid clinical reasons for the decision by the Therapeutic Goods Administration, behind it is a view that pharmacists are not equipped to allow their safe, judicious use to relieve acute, rather than chronic, pain.”

    If there are valid reasons for the decision, then the decision appears to be valid. The fact is a significant-enough proportion of pharmacists were not supplying codeine in a safe and judicious manner.

    “The goal of gaining government agreement for an ‘except-when’ status, where pharmacists can use their professional judgement to provide patients with relief for acute cases, not chronic, has to be a priority.”

    Using professional judgment to supply codeine for acute, not chronic, cases is the exact situation before the scheduling change. This “except when” scenario proposed in this article is essentially keeping the status quo, which the author acknowledged there are valid clinical reasons to change.

  6. pagophilus
    10/01/2018

    “Have you ever had to sell something that you didn’t quite believe?” the article states. Yes, how about low-dose codeine-containing analgesics?
    Patients are addicted to the codeine, which is why they keep coming back for more. And pharmacists are addicted to the money they make by selling it, which is why they don’t want to give it up.
    We need to face the fact we have a problem, that people with either chronic pain or addiction are coming back regularly for their codeine. Pharmacists should not be involved in treating either of those conditions without a doctor involved.
    Codeine upscheduling – a good move.

  7. Andaroo
    10/01/2018

    Without commenting on any other aspect of this situation, of which I have plenty of personal feelings about. This financial incentive doesn’t exist to not sell anything as a pharmacy. And this will continue to be a reason, at least in part, for pharmacy owners to object to any change that restricts the sale of a good in a pharmacy. It will also always be part of the opposing argument, that any opposition to said change is motivated by money and greed. Pay pharmacists for service, not sale and problem solved. Except the govts costs will increase and employed pharmacists will have to take on the risk of a more self determative role, both of which, the likelihood of happening I doubt.

  8. Michael Troy
    11/01/2018

    Just Monday of this week gone. Woke up with a headache. Very rare for me. Had my first two paracetamol 500mg upon waking (0600hrs). Didn’t cut the mustard. 1000hrs, needed more relief. Found 2 of the last 4 paracetamol 500mg-codeine 15mg tablets in the pharmacy. (Along with drinking extra fluids and all the other tips and tricks for treating headaches). The next (and last two) para/codeine15mg tablets in my pharmacy were taken at 1400hrs, bang on 4 hours later to keep the headache at bay.
    I have aspirin-sensitive-asthma. With heat, humidity and pollen already making my asthma edgy at the moment there was no way that I was going near ibuprofen or other NSAIDS.
    If I didn’t, as a health care professional, have some of these tablets on hand, I would have to have been close to closing the shop, creating access of healthcare for all my customers. There is zero chance of a doctors appointment for 6 weeks in town. And there is also a severe shortage of pharmacists in my rural town, so no one to ring up as an emergency locum!

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