Codeine: what’s on the agenda?

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TGA, Guild and PSA have all released new guidance for pharmacists in the lead up, while lobbying for changes still continues in the background

The TGA has released its latest “tips” for pharmacists, to guide them when talking about codeine with patients.

A brief overview of these tips includes:

  • Asking open-ended questions about pain;
  • Managing expectations;
  • Informing the patient about your scope of practice;
  • Using empathy and validation combined with a setting of clear boundaries; and
  • Framing conversations around protecting the patient from opioid-related harms.

It also warns that some consumers may seek to stockpile codeine-containing medicines prior to 1 February 2018.

“These medicines are not indicated for chronic pain and can cause dependence. Therefore, you need to ensure supply is consistent with quality use of medicines principles,” says the TGA.

Meanwhile, the Pharmacy Guild and PSA are currently co-developing resources to assist pharmacists in the leadup to the upschedule, after receiving a funding boost from the government.

PSA has developed a new member hub for codeine on PSA website:

The new centralised codeine hub includes “CPD, resources and information on PSA’s advocacy work related to codeine” following the TGA’s decision to re-schedule codeine-containing medicines.

And the Guild has published a Pharmacy Checklist to help you plan and prepare for the 2018 upscheduling of codeine.

Areas of preparation include staff awareness, training, protocols, inventory, stock management, adjusting schedule 4 areas, organising materials, talking to patients and carers, and more.

The Guild continues to advocate for the creation of a special category for codeine-containing medicines, known as ‘Prescription Only-except when’.

“The Pharmacy Guild acknowledges that in a minority of cases codeine is being used inappropriately for the treatment of chronic pain. However, without an exception to enable pharmacists to continue supplying these medicines for the treatment of temporary acute pain many responsible users would be disadvantaged, with a loss of convenience and increased out-of-pocket costs as well as increased costs for government,” explains the Guild.

If this model goes through, pharmacists will need to adhere to strict protocols, and use a real-time monitoring system to record purchases and identify patients who are misusing and who require referral and support, it says.

Progress is being made at state level including in NSW.

NSW Guild President Rick Samimi says he has been lobbying relentlessly over the past few months, along with colleagues across the country.

“I am still driving the Guild proposal to the decision makers,” Mr Samimi tells AJP.

“I met the NSW Health Minister [Brad Hazzard] again last week, as well as a number of politicians. The Minister is very cooperative and switched on about the problems we’re trying to address.

“The PSA at a National level are working with the National Guild, and the PSA NSW branch is working closely with us at the Guild NSW Branch.”

The NSW Branch of the PSA is lobbying for low-dose codeine-containing analgesics to remain an OTC therapeutic option for the management of acute, short term pain.

“Community pharmacists have the knowledge base and competence to counsel patients regarding the effective and safe use of these products, and the vast majority of patients who use the products do so safely and appropriately for short-term use, and are at no risk of becoming dependent on codeine,” says PSA NSW Branch President Professor Peter Carroll.

Professor Carroll says forcing people to visit a GP to get a prescription in order to still use the products will be problematic, as many will not be able to get an immediate appointment and, because of the rescheduling, will be forced to suffer unnecessary pain.

The NSW Branch Committee has communicated its’ views to the PSA National Board, and says it has “resolved to immediately pursue an advocacy strategy designed to inform NSW politicians and the NSW Health Minister of these issues in order to try and have the rescheduling of codeine-containing products delayed, or not implemented at all”.

In the meantime, the Guild says pharmacists should continue to use MedsASSIST and update patients about the changes.

“I encourage all pharmacists to make sure they keep using MedsASSIST. Also, talk to each patient face to face about the changes coming up, and explain the situation – don’t wait until it’s too late,” says Mr Samimi.

“It’s really important to keep using MedsASSIST. Real-time recording will address most if not all of the safety concerns and pharmacy shopping concerns surrounding codeine products.”

Guild National President George Tambassis also reminded Pharmacy Connect delegates in early September about the importance of MedsASSIST regarding codeine products.

“MedsASSIST has reduced sales of these medications by close to 20%. Our real-time monitoring system works, but the government is going to a system where there’s no monitoring. This level of monitoring will not happen through GP clinics.

“Guild resources are becoming available to help with your advice to patients if you and your staff are struggling with how to explain the issue to patients.

“Our strong advice is that you must tell your patients about the reschedule before the 1 February changeover. You can’t expect them to deal with it when they’re hit with it unexpectedly.

“And tell patients to tell their local MP if they are unhappy with the rescheduling.”

Which medicines will be affected by the upschedule?

  • Paracetamol+ codeine 500 mg + <15 mg (e.g. Panadeine®, Panadeine Extra®, Mersyndol® etc.)
  • Ibuprofen + codeine 200 mg + < 15 mg (e.g. Nurofen Plus®, Panafen Plus® etc.)
  • Aspirin + codeine 300 mg + <15 mg (Aspalgin®, Codis Disprin Forte® etc.)
  • Cough and Cold medicines (e.g. Codral Original Cold & Flu®, Demazin Day & Night Cold & Flu® etc.)

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1 Comment

  1. jason northwood

    Interesting article from almost 4 years ago

    Rowan compares the “normalisation” of codeine-mixed drugs such as Nurofen Plus (codeine and ibuprofen), Panadeine Extra (codeine and paracetamol) and Mersyndol (codeine, paracetamol and doxylamine succinate) with what happened with Bex. “It’s the normality, or domesticity of the tablet,” he says. “The tendency for people to say, ‘I’ve had a stressful day, I’ll take some tablets’, is greater than it was in the Bex era. Whether it’s taking some over-the-counter codeine or popping a few Valium or Xanax, it’s creeping in.”

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