Codeine quantities confirmed

No lasting increase in low-dose codeine use following upscheduling, TGA says, as study reveals pharmacists’ post-schedule experiences 

The Therapeutic Goods Administration (TGA) has found there was a temporary spike in the use of high-strength codeine after its 2018 upscheduling, but this subsequently diminished entirely over time.

The agency recently completed and released an analysis of trends in the PBS funded utilisation of high-strength codeine in the aftermath of the upscheduling. 

“The PBS-listed medicine of interest in the TGA’s latest analysis was paracetamol 500 mg plus codeine 30 mg,” the TGA said.

“We found that the PBS dispensing increased by 6.5 per cent in February 2018 when all low-strength codeine products were up-scheduled from over-the-counter to prescription only.

“However, the increase was transitory. It diminished in the succeeding months and, by 2019, the PBS dispensing of high-strength codeine had returned to the level before February 2018.”

For the first 11 months after up-scheduling in 2018, the estimated national total dispensing was 5393 kg, in comparison with a total of 5237 kg for the equivalent 11-month period in 2017, the TGA analysis found.

In 2019, the total dispensing was 4721 kg between January and October, in comparison with 4679 kg for the same period in 2017.

“The increased dispensing of high-strength codeine after up-scheduling was consistent with a scenario of codeine consumers switching from low-strength to high-strength products, it said.

“However, the increase has not lasted beyond 2018. Moreover, the level shifts starting in 2015 and then in 2017 suggest that TGA’s regulatory activities… have had a positive impact on the public awareness of codeine’s health risks, contributing to reduced codeine consumption and harms in Australia.”

Meanwhile, a new study has found that many Australian pharmacists indicated that the up-schedule had “not affected their practice to a great degree”.

The study, conducted in late 2018, surveyed 191 pharmacists, while 10 participated in an in-depth interview.

The majority of respondents supported the decision to up-schedule over-the-counter combination products containing codeine to some degree.

Some respondents said they were “relieved to have the pressure of having to determine if supply was warranted taken from them.”

This backed previous research finding that many pharmacists found it challenging to establish a therapeutic need, in particular due to the subjective nature of pain.

There were also concerns regarding the lack of time to have detailed consultations with people about their use of these products.

“Since the up-schedule came into effect, pharmacists reported that recommending pain management alternatives had become easier and was generally useful in encouraging patients to visit their GP and discuss how to effectively manage their pain,” said the authors from La Trobe University in Victoria, and the University of South Australia.

“It’s probably made it easier to recommend better products for migraines and yeah obviously referral to a doctor too…I haven’t found it difficult to recommend different products from codeine… [be]cause… the evidence just wasn’t there for them anyway really,” one pharmacist said.

Some pharmacists believed that any change in prescribing patterns may be because many patients were not visiting their GP to have their pain management reviewed, and doctors may be being more vigilant when prescribing codeine combination products.

“I think based on the scripts I’ve seen, it hasn’t really changed very much. It hasn’t pushed them to prescribe them any stronger,” one respondent said. 

Some of the pharmacists discussed a number of challenges following the up-schedule. These included a limited ability to assist people with short-term pain, concerns about side-effects and misuse of alternatives and they also discussed the challenges of identifying misuse; something that was also seen as a challenge prior to the up-schedule.

The study was published in the journal Pharmacy Practice.

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