‘Codeine road trips’ less likely, but there’s still a way to go

sad woman with pills

The number of stories such as the tale of “Britney,” who reportedly goes on cross-border trips to buy codeine, are likely to have plummeted since the introduction of MedsASSIST, stakeholders say.

These stakeholders are calling on the remaining 30% of pharmacies which have not implemented MedsASSIST to consider using the tool.

Yesterday ABC News reported that Britney (not her real name) undertakes “codeine road trips” between south-west Victoria and South Australia, having identified which pharmacies will sell her codeine-containing analgesics without entering her name into the MedsASSIST database.

The Pharmacy Guild’s Anthony Tassone, who was interviewed for the ABC story, told the AJP today that roughly 70% of pharmacies are now using the decision-making tool.

He says that since MedsASSIST was introduced, he has not had any first-hand experience or heard anecdotal feedback about stories as extreme as Britney’s, marking her as a potential outlier.

And researcher and pharmacist Penelope Wood, a pharmacotherapy clinical adviser at Western Victoria Primary Health Network in Geelong, told the AJP that since MedsASSIST was introduced she has seen fewer Britneys seeking codeine-containing OTCs.

“We’ve had people driving around this area, around Geelong, Colac and Apollo Bay, and when I’ve been working in community pharmacy, which I still occasionally do in Geelong, I’ve had people showing up with a Colac address and thought, ‘What are you doing all the way over here?’” Wood says.

“But this was before. Post MedsASSIST I haven’t heard much of it.”

However, there is more work to be done to encourage pharmacists to work with patients to address the underlying problems leading to codeine misuse.

A modified Delphi study conducted earlier this year by Wood and colleagues suggested that stakeholders feel misuse of, and dependence on, OTC codeine-containing analgesics are currently “poorly and haphazardly identified” in pharmacy.

This study identified several potential strategies to help reduce OTC codeine misuse and addiction, including identification (using a real-time national monitoring database to monitor product sales), communication (additional intensive training to improve pharmacist communication on the issues), and referral (development of a well-defined referral pathway pharmacists can use when they identify people who may be at risk).

Another study examined the response to a covert simulated patient approach in which pharmacies were approached for Nurofen Plus; the findings indicate that adequate counselling was received for 25% of product purchases in two scenarios.

Wood told the AJP that she had had some misgivings about MedsASSIST initially, concerned that it would be used as a gatekeeping tool, rather than as a way of identifying patients who might need help to manage their pain or their codeine misuse; however she is encouraged by how it is being used in practice and by work being undertaken to help pharmacists use it to open conversations.

“My biggest concern when it first came out was that it would be used as a policing tool,” she says.

“When we did the simulated patient study, our simulated patients found that if they didn’t have ID, they were refused sale and in some cases turned away and not offered treatment at all.

“I found that very frustrating. Even if somebody doesn’t have documents, we should as pharmacists still be offering an alternative. There are plenty of other alternatives to codeine.

“And this was my concern with MedsASSIST, that pharmacists would say, ‘Nope, you’ve had too many of these, see you later,’ instead of, ‘Let’s have a chat, do you need this for pain, or do you think your body might have become a bit dependent on it?’”

She says that work being done by the Guild and the PSA to outline pathways for treatment for patients, when pharmacists identify through MedsASSIST that a patient has purchased a significant amount of codeine-containing analgesics, could go a long way to assist patients into treatment for pain or addiction.

“That’s what this project is about – how can we make sure the patient gets into treatment? What protocols can we develop for GPs and pharmacists to work together?”

The missing 30%

But both Tassone and Wood warn that unless the remaining 30% of pharmacies adopt the tool, people like ‘Britney’ will not all be given the help they need.

“It’s my understanding that this girl was still getting codeine this way post-MedsASSIST, because not everybody’s using it,” says Wood.

“There’s still 30% of pharmacies who don’t, and word gets around; people talk to each other.”

“The latest data shows that over two million transactions have been recorded through MedsASSIST, with approximately 40,000 sales of codeine-based products being denied,” says Tassone, pointing out that yesterday’s ABC News article could have been interpreted as stating that 40,000 cases of codeine dependence have been identified.

“This means that in 40,000 documented instances a pharmacist has made a decision that codeine was not the most appropriate treatment at that point in time, which could be for a variety of reasons.”

He says that “the vast majority of consumers will support the use of such a tool if they understand why it’s being used”.

“Some pharmacists may have a view of ‘let’s wait until it’s made mandatory,’ but we may not get that opportunity if the TGA makes a decision that it should be upscheduled,” Tassone warns.

“So it’s essential to put forward our case that codeine can be made available OTC in a safe and appropriate way with clinical support tools.”

Wood also called for a nationwide real-time prescription monitoring tool, a call which the Guild and other stakeholders have made several times over recent months.

“Without that, we’re not going to see real change,” Wood says. “We’re still having a problem with oxycodone – if we upschedule codeine and don’t introduce this tool, people will just doctor shop instead of pharmacy shopping.”

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