Codeine claims and counter-claims


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Chief Medical Officer Brendan Murphy and the University of Sydney’s Peter Carroll have gone head-to-head on Radio National debating codeine efficacy and implication in overdose

The two spoke to the ABC’s Fran Kelly, with Professor Murphy explaining that the upschedule was happening for two reasons.

“Addition of low dose codeine to simple analgesics really adds very little if any additional benefit in terms of pain management,” Prof Murphy told Ms Kelly.

But the “main reason” is concerns about addiction, he said. Prof Murphy cited a statistic of 100 deaths a year from people misusing OTC codeine – a statistic which has been hotly debated in recent days.

People are dying of “a variety of drug overdoses but in a big study reported in the Australian Medical Journal, with a number of codeine-related deaths were looked at, at least 40% of them were related to over-the-counter codeine products; so sometimes they do take multiple drugs… but the main codeine-containing drug in 40% of the deaths in this paper were due to over-the-counter codeine,” he said.

Prof Murphy also told Ms Kelly that around 600,000 Australians are abusing low-dose codeine.

Peter Carroll countered the claim, saying he disputed the 100 deaths a year statistic and that the “vast majority” of people used low-dose codeine safely and appropriately for acute pain.

Yesterday (23 January) NSW Pharmacy Guild president David Heffernan queried the statistic, telling the AJP that it is “misleading” and defames the pharmacy profession.

Speaking to the AJP today after the Radio National broadcast, Mr Heffernan said that Mr Murphy needed to “set the record straight on the 100 deaths”.

“The public deserve better,” he said. “He said it was 40% deaths from OTC codeine, which is not true and at the end of the day it’s degrading to pharmacists to keep saying it.

“The 40% he quoted was 40% of the 40% they could identify with codeine, from one study which he did not identify. 

“He needs to set the record straight; or if he has other evidence to support his claims, he needs to produce it. Enough is enough on the spin.”

 

Codeine battle

Prof Carroll and Prof Murphy disagreed on a number of points in today’s broadcast, including who uses OTC codeine and how they use it.

Prof Carroll said that “at least 98% of people” who buy these products in pharmacy use them correctly and are at no risk.

But Prof Murphy countered with a claim that 20% of people who use codeine use it “chronically” and misuse it.

“Other data shows three-quarters of packs bought over-the-counter are used by these chronic abusers.”

Prof Carroll disputed claims that low-dose codeine adds little benefit when combined with other analgesics, and when asked by Ms Kelly why Painaustralia would support the assertion that it has little benefit, said, “they’re wrong”.

He said that MedsASSIST had been highly useful in tracking problem codeine users and warned that abusers would be enabled to doctor shop by the lack of a monitoring system post-1 February.

Prof Murphy told Ms Kelly the fact that a real time monitoring system (MedsASSIST) had been implemented to track OTC codeine sales showed that the drug was not suitable for the Pharmacist Only schedule.

“The definition of an over the counter drug, the S3 schedule, is that the drug is safe and not subject to misuse,” he said.

He also warned that people expecting to be able to receive a prescription for low-dose codeine from their GP post-upschedule may be disappointed.

“Doctors don’t prescribe useless drugs,” he said.

Instead, he expects that people seeking to manage pain will talk to pharmacist about paracetamol, ibuprofen and combinations of the two.

Listen to the full broadcast here.

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8 Comments

  1. Ron Batagol
    25/01/2018

    After all the “claims and counter-claims” have been put out there, the fact is that, in line with what has happened in 25 or so other countries, Codeine will go to S4 on 1st. Feb., and the well-established rationale for this has been debated ad nauseam, and I am not going to rake over those entrails again!

    I do agree with that Prof. Murphy that pharmacists will be in the ideal position to counsel and advise patients who were previously taklng Codeine products OTC, many of whom may use Ibuoprofen with or without Paracetamol, unless contra-indicated. (see also our article on AJP 22/1/18re: importance of restricting ALL Ibuprofen to pharmacies.( https://ajp.com.au/columns/side-effect-upschedule/)

  2. Jarrod McMaugh
    25/01/2018

    Two points of interest:

    1) “The definition of an over the counter drug, the S3 schedule, is that the drug is safe and not subject to misuse,” he said.

    This is not accurate – although it needs to be noted that if a drug requires monitoring via a system (such as medscheck or real time monitoring), this makes the drug unsuitable for schedule 3. So the end result is the same, but the assertion leading to it is not.

    The whole point of schedule 3 is medications that may not be safe if used inappropriately, therefore requiring pharmacist intervention.

    2) “Doctors don’t prescribe useless drugs,” he said.

    I’m wondering if Professor Murphy is going to stake his reputation on this.

    A very large proportion of the requests I receive for OTC codeine are generated by a recommendation from the person’s GP….. not to mention many other examples of questionable prescribing.

  3. BILL ARNOLD
    25/01/2018

    I am one of a diminishing number of pharmacists who remember Panadeine and Codral Red being introduced (RED for stronger pain). And explaining that it should give better pain management than Paracetamol or Aspirin. “But it costs more” was the general retort.

    My crystal ball is decidedly foggy, but I can just about see the following :

    * No mad panic in early February; most will have “a few packets”, and many have bought some just in case.

    * Most GPs will not have the time to do the “the talk” that they claim we should have been doing.

    * Most patients and most GPs will not be aware of the products already discontinued. And when I get an Rx for a discontinued product what then ?

    * An increase in hold ups and break ins. And some “disturbances” in surgeries when there are no appointments for three days.

    * IF markup and dispensing fee are considered, who will answer Today Tonight etc. ? “Last week this cost…. and now it costs….”

    * Most GPs, I suspect, will follow the line ” I will give you something with an effective amount of Codeine”. Think Panadeine and Mersyndol Forte. And Endone.

    * I can get easily Heroin on the street now. And if I smoke or snort that till I get to the Doctor……..

    * Hopefully, those who really do have a problem will be counselled about Opioid Replacement Therapies.

    Would like to hope I am wrong. We will know soon enough.

    Bill Arnold

    • Peter Crothers
      25/01/2018

      There is already some confusion around prescribing as GPs struggle to match what is listed on their drop-down software menus with what is actually available. Already we are seeing awkward scripts such as “Panadeine Forte 1 nocte prn (sub-therapeutic, right?) mdu” for the patient who was previously taking an average 2 x CO Strong Pain Extra once or twice a week. Nothing gained except $36.10 – or whatever it is now – charged to the taxpayer.

  4. Max Timmins
    25/01/2018

    “Doctors don’t prescribe useless drugs”, yet I’m already seeing prescriptions for Panadeine Extra in quantities up to 80, with repeats. Ha!

  5. pagophilus
    29/01/2018

    In the end someone has to make a decision. The decision has been made and we’ll see if the outcome is better. Sometimes you just need to “suck it and see”. Let’s await the next round of opioid addiction stats.

  6. Amandarose
    30/01/2018

    I had a good look at the MJA paper about codeine- it stated a massive rise in codeine deaths since 2000. It does not show results before 2000 to see if that year was a blip, it does not mention the drop since 2005.

    It does not mention pbs script numbers for codeine to see if that correlated with the deaths.
    It does state that the majority of deaths were multiple drug toxicity. 60% if codeine deaths did not differentiate between prescription and otc use. Of Those cases identified 60% where panadeine forte.

    It’s not clear how many cases are attributable to otc codeine.

    I personally think people with addictions will just find another product, it’s going to be a bumpy ride ad people adjust.

  7. bernardlou1
    04/02/2018

    So the TGA Up schedule a product that doesn’t work and doctors are now prescribing a product that doesn’t work.
    Correct me if I wrong, shouldn’t low dose codeine registration be cancelled all together? Why Up schedule a product that doesn’t work? And why 11 millions transactions through Medsassist doesn’t count?
    Let doctors prescribe better stuff such as Endone, OxyContin, Tragine, Palexia, fentanyl, norspan. These are better!! They do cost a lot. Patient will not only need to see a Gp but also a Pain specialist who charged $450 a visit. Its pocket change alternatively they can remain in pain.

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