Codeine ‘scare campaign’ ignores harms: pain specialist

Efforts to retain pain and cold/flu medications which contain codeine on the Pharmacist Only schedule are misguided, says a pain expert.

“There’s a scare campaign going on, which really doesn’t take account of the facts and drug safety,” claims pain specialist Dr Michael Vagg, Director of Pain Matrix, a private pain practice, and a visiting medical specialist at St John of God Hospital in Geelong

“Harm from over the counter codeine continues and other countries have made a difference by making codeine prescription only.

“The TGA quite sensibly decided that the benefits from having codeine in some medications is low or non existent and the risks sufficiently high to restrict access by leaving the decision to doctors in discussion with their patients.

“In fact it brings Australia into line with many other developed nations including the United States, Germany, Belgium, Switzerland, Finland, Italy, Hong Kong, Japan, etc.”

Dr Vagg says there are claims that the increased cost to Australians of this decision could be as high as $257 million.

“This assumes that codeine containing cold and flu medications actually help people with upper respiratory infections and get them back to work, or that codeine-containing products should be used to treat headaches,” he says.

“In fact there is little evidence of that. Secondly it presumes that GPs will be burdened by the need to prescribe these medications when it’s unlikely that they will prescribe them because the evidence for their usefulness is so thin.

“There will naturally be a period of adjustment but on the whole there is unlikely to be a long-term cost of the magnitude suggested. In fact, it’s an opportunity for doctors and patients alike to inform themselves about best-practice management of some of these conditions.

“Pharmacists will be able to advise on alternative codeine-free products and if someone needs acute pain relief that needs an opioid medication, they should be consulting their GP.

“There is compelling evidence that when codeine is added to, say, paracetamol or ibuprofen in the doses found in OTC products, the pain relief does not improve.

“Is it worth the risks of abuse and serious side effects?” saysDr Vagg.

“The side effects of codeine alone include constipation, drowsiness, respiratory depression and addiction.”

Unsupervised increasing doses often leads to people ingesting toxic doses of paracetamol or ibuprofen, which compounds the harm caused, he says.

“There’s no question there’s real value to some medications being available over the counter without a doctor’s script,” acknowledges Dr Vagg.

“Things like acid lowering drugs for heartburn. But they have to be safe and effective.

“Codeine containing medications don’t meet that standard in the light of the latest evidence about their benefits and harms.

“Simply put, it’s more unreliable and harmful than we used to think, and safer, more effective drugs are available.

“The last time there was a push for greater codeine safety was five years ago. The decision then was to move the products to behind the pharmacy counter and limit the amounts allowed to each customer.”

Pharmacy staff should not be expected to assess whether a customer is codeine dependent, he says.

“They look just like you and me.  A study published in the Medical Journal of Australia in September this year showed there was actually a doubling in codeine related deaths between 2000-2013 and a large number of these deaths were attributed to accidental overdose,” says Dr Vagg.

“Keeping the supply of codeine non-prescription does not seem to have made the expected impression on public safety.

“The experience of the US, Switzerland, Germany and other countries in moving codeine to prescription-only is there has been a reduction in the number of codeine-related deaths. We’re really the only developed country that has a worsening codeine problem.

“Something that many people don’t realise is that our bodies metabolise (handle) codeine differently.

“There are some people who metabolise a high percentage of the codeine into morphine. There are some people who don’t metabolise it much at all.

“So it’s a highly unpredictable drug compared to some of the opioid and non-opioid alternatives a doctor might prescribe.

“The treatment of acute pain is a major public health issue but we need to be evidence-based and not run the risk of drug dependence and toxicity with OTC codeine when there are safer ways of lowering pain,” says Dr Vagg.

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