People who have been overusing codeine may switch to alcohol misuse after Thursday’s upschedule, one expert warns
And it’s likely to be those overusing codeine only a little—to treat pain conditions—who are most at risk, says Cameron Brown, clinical director at The Cabin Sydney, an addiction treatment clinic.
“The ones who are overusing [codeine] totally will be those who tend to easily enough find something else they can transition to – they’re probably in that addiction state of mind,” Mr Brown told the AJP today.
But people overusing codeine only a little may be likely to “compartmentalise” and not consider themselves at risk of addiction or adverse events linked to misuse of OTC codeine, he says.
“Because codeine has been accessible, you can buy it over the counter, they think it’s not really a problem – they think ‘somebody would cut me off it was a problem’,” he says.
“It’s the same with alcohol, it’s so easily accessible.”
Following reports that around one in five codeine users have tried to stockpile low-dose codeine ahead of the 1 February schedule change, Mr Brown says that some users may “become panicky” as their supplies run out and try to stop taking the opiod altogether.
“But some will transition onto other things, like alcohol. From what we know, a lot of codeine users are hidden users. It’s not as though their family or friends know about their codeine use, or the extent of their pain in some cases,” he says.
“My concern is that they won’t seek further treatment – or more appropriate treatment – for pain because they’ve already become uninterested in other OTC medicines. They’ve probably got preconceived ideas about how useless paracetamol is, for example.
“And from my experience, working with codeine users and prescription medicine overusers, is that they tend to be poly drug users. They may be using codeine to manage pain, but also use things like alcohol to manage stress.
“So if they’ve removed the codeine from their regime of medicines, they’re probably going to rely more on something else – usually something they already know.”
Alcohol is frequently used to manage stress caused by pain, particularly chronic pain, and the expectation of further pain down the line, Mr Brown says.
“It’s not necessary about pain per se, but more the management of the consequences of pain.”
Other codeine overusers may turn to less-accessible drugs such as marijuana, he says, but this will not be an option for everybody because of its illicit nature – many codeine overusers do not have a history of seeking illicit drugs – as well as the fact that its use is harder to hide than alcohol.
“There’s actually a lot of research suggesting that marijuana can be a really good gateway out of opioid dependency,” he adds. “It has some benefits for pain management and is a lot safer, magnitudes safer, than opioids.
“So it’s something that people could definitely transition to, but it’s an atypical pain reliever so not as accessible.”
Mr Brown urged pharmacists to be on the lookout, well after the upschedule and as patients’ stockpiles dwindle, for those who may need help for not just codeine misuse, but other methods of self-medication.
“I think there’ll be a lot of work for pharmacists over the next couple of months,” he says.
“For pharmacists it’ll primarily be about education, and also a little bit of conflict management as well, when people come in not realising that the upschedule has occurred. They’ll be dealing with irritable people who have finished their codeine and coming in expecting more.
“It’s about having good boundaries – a case of, ‘I’m not going to stand and have an argument with you for 35 minutes because you want codeine’ – but also good referral pathways. Ensure all staff are aware of referral pathways should they become concerned about a patient.
“People have gotten into a mindset that they can go and get Panadeine or codeine and they’ll feel better.
“People think, ‘it’s not a higher schedule, I can just go to the pharmacy and get it OTC, why would I have a problem with it’?
“When you get those people into treatment, unless you actually ask about OTC medicines, people don’t report it – people focus on prescription medicines.
“So I think this is a good decision that’s probably come a bit late.”