Codeine concerns widespread

Consumers oppose codeine upscheduling, as do a third of GPs, but concerns over pharmacists’ advice raised by survey

Most consumers and pharmacists oppose the upscheduling of codeine, and a third of GPs agree, new research reveals.

A survey conducted by researchers from the University of Tasmania and the National Drug and Alcohol Research Centre found widespread scepticism that the proposed upscheduling in 2018 would address issues of misuse.

Most of the 354 codeine consumers surveyed (83%) opposed restricting OTC codeine.

Their view was backed by 70% of the 220 pharmacists.

While most of the 120 GPs surveyed disagreed with the other groups, a significant minority (31%) also stated opposition to the upscheduling.

“Consumers, on average, questioned whether the proposed intervention would address the intended targets of minimising codeine-related side effects and risk of associated harm and dependence,” the authors said.

Many pharmacists expressed concern that regular GP visits to obtain codeine would be a time and financial burden, as well as create time issues for GPs. This view was not supported by GPs.

The authors noted that pharmacists reported concerns about their capacity to assist consumers in obtaining pain relief in the absence of OTC codeine.

This suggested “that for some pharmacists there may be a lack of awareness or lack of agreement around alternate OTC products with comparable efficacy.”

The study was published in the journal Drug and Alcohol Review.

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  1. Daniel Roitman

    It’s important to acknowledge that the up-scheduling is not designed to stop or completely address the issue of codeine misuse. So much more work needs to be done, but that is why the best policies are those that are complex, proactive and holistic. That said, while we won’t completely solve the problem, this is an important step in the right direction. There is a good reason why codeine is so tightly regulated in other countries. We as pharmacists cannot forget that we are health professionals first and business people second/third/fourth/last. I for one am not comfortable profiting from the misery of thousands of Australians.

    • Amandarose

      What about the miserable thousands in pain who have to grovel to a GP now? I personally use the occasional Mersyndol for tension headache/ back ache when it’s caused by being tense. It’s the bomb. Ibuprofen is also a favourite for other sorts of pain and aspirin is my first choice if I get a migraine but for a certain type of pain when you can’t seem to relax your muscles it’s fabulous. Though I suspect it would be without the Codeine.
      I suspect drug addicts will replace it with another addiction. I personally found using Med assist reduced codeine sales significantly as most other pharmacies don’t use it in our high abuse area. I don’t refuse sales to addict I just warn them, and slip the local addiction doctors details to them with good results. If you tone down the policeman and discuss things without judgement it’s so much better.
      On the rare occasion I have purchased these products you get two types of experience- the over zealous policeman getting your back up or asked nothing at all. One single positive experience and that was the assistant doing an awesome job offering advice without coming across as a policeman.

  2. William

    Naturally GPs have a financial incentive to get patients into the surgery so they can bill them. Bulk billing practices as well.
    If there is a perceived problem of overuse of codeine products then controls similar to recording using driving licence or passport identification should allow adequate monitoring.

  3. Debbie Rigby

    It’s important to note that there are other OTC analgesics that may be appropriate for the patient for acute pain (eg paracetamol, paracetamol/ibuprofen). For chronic pain, I think patients should be assessed and regularly reviewed by a GP. If codeine is appropriate for the patient, they will still have access to the drug. If they are misusing, overusing or abusing codeine combination products then it can only be positive that this is recognised and managed appropriately. Non-pharmacological interventions should always be discussed in the management of chronic pain.

    • Jarrod McMaugh

      The points raised by Debbie here regarding chronic pain are very very important. Whether or not codeine is appropriate for the treatment of chronic pain, this has not been an indication for the schedule 3 listings since they were placed in schedule 3.

      This means anyone who has been supplying codeine for chronic pain has not only been breaching the regulations, but they have been doing their patients a disservice, and arguably harming the profession.

      With regards to acute pain – I’m still not particularly convinced of the benefits of the combination paracetamol/ibuprofen… mainly because there is some evidence that NSAIDs should not be used in the first 24 hours after an acute injury, due to potentially slowing the healing process.

      I’m also not convinced that 8mg codeine is subtherapeutic, mainly because I don’t believe that the studies were powered in a way to address genetic variation in codeine metabolism… perhaps a moot point if enough of the population is a poor metaboliser….

      I am also very dubious of the study that finally turned heads to have codeine taken away from schedule 3 – the study stated that a large portion of deaths were associated with codeine use, but none of these deaths were attributed to codeine as the only opioid…… so the conclusion wasn’t really attributable to OTC codeine…

      Moot point again, since the definition of schedule 3 is for products that don’t require electronic monitoring… so move it should, regardless of therapeutic role.

      • Willy the chemist

        Agree Jarrod.
        There are some evidence of effective analgesia with 15mg codeine based medicines.
        OTC analgesia are not meant for chronic pain management, these conditions should be treated in conjunction with their GPs.

        S3 Codeine medicines are used for short term analgesia. For example at 8pm when the patient may require a ‘stronger’ analgesia for post-dental works. Maybe their panadeine forte just ran out. Maybe they need something for their throbbing headache.

        Real-time monitoring is the answer to abuse. Up-scheduling and making these medicines prescription only only shift the problem elsewhere.

        Even arguments that 30% of people who are ultra fast metaboliser. Do you think that having them prescribed will alter the ultra fast metabolisers?
        If you think so, I suggest you need more “evidence”!

        Community pharmacists are the coalface of primary health. We see, breathe, walk, talk and interact with real people.
        We don’t sit in front of an idea and expound on their theorem.

        • Jarrod McMaugh

          I agree with your further points Willy – what a nice change of pace for me!

          I’m a poor metaboliser – I’m one of those people for whom codeine is ineffective. If I have 2 x panadeine forte, i get mildly nauseous without pain relief. Tried tramadol about 14 years ago and was rewarded with rapid-cycling migraines due to the serotonergic aspect of this medication….. hopefully I’m never exposed to pethidine!

          For me, if I ever take pain relief, ibuprofen can have some effect, but I also have AF with a CHADS >2… so really it’s not a recommended course of action. I tend to avoid taking anything for pain and everyone around me gets to deal with my personality instead.

          My point here is that for me, none of the real options for pain relief are actually an option for me. I accept this, but not everyone is in the same position.

          I also agree with the point about monitoring – there will be no improvement in the impact of codeine when it goes S4. If prescribing was an answer to misuse, then we would have zero iatrogenic addition. Clearly this is not the case. What really worries me is that some members of the RACGP have actively described real time prescription monitoring an unnecessary burden on prescribers…. it worries me.

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