A changing landscape


Recent codeine survey reveals more consumers approve than disapprove of the upschedule – a shift from earlier surveys

An online survey of 1,028 randomly selected Australian adults conducted from 10th to 13th November has found about half (49%) of respondents support the decision to make codeine prescription-only.

Meanwhile 36% oppose the change, including 13% that “strongly disapprove”.

About 14% are undecided/don’t know.

More men than women supported the decision (52% vs 47%), while those aged 35-54 were least likely to support the decision and more likely to disapprove.

The highest percentage of “strong” disapproval (17%) was among the 35-54 age group.

The survey, conducted by Essential Research, found providing context to the upscheduling decision (i.e. mentioning that codeine is an addictive opioid only available by doctors’ prescription in many countries) raised the level of total support from 49% to 52%.

However despite additional context being provided, a full 15% of those aged 35-54 still “strongly opposed” the upschedule of codeine – a higher amount than the 13% in this age group that “strongly supported” it.

And while 37% of those aged 55+ opposed the decision, 55% supported it.

Young people had the strongest support for codeine going script only: a full 20% of those aged 18-34 “strongly supported” script-only codeine, and 21% “strongly approved” of the upscheduling decision.

Painaustralia, which commissioned the poll, says the results reveal that most Australian support rescheduling of codeine to prescription only.

“There are more effective alternatives to codeine for chronic pain,” it argues.

An earlier survey

These results differ from research earlier in the year that found most of the consumers surveyed (83%) opposed restricting OTC codeine.

However this research, published in the journal Drug and Alcohol Review, included about a third of consumer respondents (354) compared to the above study.

It also included 220 pharmacists and 120 GPs.

Of these, 70% of surveyed pharmacists opposed the upscheduling of codeine, compared with 31% of GPs.

How should doctors prepare?

Once codeine goes script only, the pressure will be on doctors to decide whether or not to prescribe the opioid – among other choices.

With about a third of consumers opposed to the upscheduling decision, according to the above survey results, this won’t be easy.

A new study published in JAMA Internal Medicine has found denials to requests of pain medication lead to significantly lower patient satisfaction of the doctor in question.

Further research suggests patients bring high expectations for pain control to their GP visits.

Doctors need to be trained to handle patient requests in a way that maintains satisfaction through engaging and informing patients, whether the request is fulfilled or denied, says Dr Joseph Ross, an Associate Professor from Yale University’s School of Medicine, in an accompanying editorial.

“We can train physicians to say no to other types of clinically inappropriate requests, while still reassuring patients and paying attention to their needs,” Dr Ross suggests.

What about pharmacists?

The PSA and the Guild have partnered together to create a codeine hub, with support resources to help pharmacists and pharmacy staff prepare for the upcoming change.

See the Codeine Resource Hub for more information.

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  1. Ron Batagol

    One important issue arising from the re-scheduling that myself and a colleague, Prof. Greg Peterson, have raised with TGA is that, after Codeine goes to S4, and if Ibuprofen continues to remain available for sale in supermarkets and other outlets, instead of restricting it to pharmacist-only supply, patients who may have been using Codeine, may increasingly seek to purchase Ibuprofen instead, without access to the professional advice of a pharmacist.
    Without pharmacist guidance and advice, any of these patients who have an
    underlying susceptibility to cardiac or renal adverse effects, may increase
    the risk of a cardiac or indeed a renal adverse event. This is particularly concerning from a renal viewpoint if they are taking an ACE inhibitor or ARB combination product which also incorporates a diuretic”, thereby placing them at a risk of a potentially serious “triple whammy” outcome. Time to restrict Ibuprofen supply to pharmacy outlets again?

    • Jarrod McMaugh

      You mean there might be some adverse outcomes as a result of this decision that the TGA hadn’t considered, or hasn’t made any plans to address despite being clearly evident?

      • Ron Batagol

        Yes, but this issue only arises because an earlier
        scheduling committee made a decision in 2003 to allow Ibuprofen to be sold in general stores, which included overseas data that, in our view, was not applicable to the assessment of the Australian proposal to consider allowing consumer self-selection of non-scheduled medication products in general store outlets.

        At the time, it was also it was stated that “the evaluator
        acknowledged that one of these studies excluded patients with
        contraindications”-i.e. the very patients most at risk from self-selection of non-scheduled medication products in general stores.

        Furthermore, since 2003, in particular the relatively new and increasing pattern of use of combination tablets containing an ACE inhibitor or ARB plus a diuretic for hypertension, has resulted in an increased potential risk of “triple whammy” renal adverse medication. events. In addition, there is greater use of antithrombotic drugs to reduce the risk of stroke in atrial
        fibrillation; the co-administration of these drugs with NSAIDs can result in major bleeding events.

        For all these reasons, whilst the TGA decision to
        up-schedule is based on a consensus of validated data and
        accumulated clinical experience, pharmacists need to be in
        a position to advise patients on the appropriate use of NSAIDs in this new environment, and they can hardly do that when their patients are still able to walk into a supermarket or general store and purchase NSAIDs without counselling and not realising that they may be at risk of adverse medical events!

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