Docs ‘missing the point’ on codeine harms


The Guild has told doctors to “get real” about tackling the harms caused by opioid misuse

Guild president George Tambassis was responding to today’s RACP statement on codeine, criticising it for its lack of focus on doctor shopping and real-time monitoring.

The Royal Australasian College of Physicians today reaffirmed its support for the 1 February 2018 upscheduling of low-dose codeine to Prescription Only.

“Codeine addiction has become a major public health issue and we believe that the TGA’s decision to place greater restrictions around the sale of medicines containing codeine is based on good medical evidence,” RACP President Dr Catherine Yelland said.

“Australia is one of the few countries where codeine products can be bought over the counter. In most of Europe, the United Arab Emirates and Japan these medicines can only be sold with a prescription.

“We believe these changes, which are being led by the TGA, are proportional to the problem that has emerged and align with the approach taken by other jurisdictions.”

Dr Yelland cited data which shows that more than 6.3 million Australians aged 14 or older use OTC codeine-containing analgesics each year.

She cites “many reports” of misuse, addiction and secondary harm.

Meanwhile, president of the Chapter of Addiction Medicine, A/Prof Adrian Reynolds, said the harms caused by codeine addiction are significant.

“Addiction is a serious medical condition which should be avoided at all costs,” A/Prof Reynolds said.

“Addiction specialists have seen the number of patients with addiction to over the counter codeine grow at an alarming rate.

“People with persistent pain should talk to their doctor to develop an appropriate treatment plan. This may include a referral to see a pain specialist or pain management clinic to manage their condition on an ongoing basis.”

But the Pharmacy Guild says that the RACP is “missing the point” when it comes to codeine misuse.

RACP’s statement is remarkable for its omission of any reference to the need for real-time recording and reporting of prescription drugs of concern, it says.

George Tambassis said that throughout the entire debate over the upscheduling of medicines containing codeine, doctor groups have avoided addressing the issue of real-time recording and reporting.

“According to the Penington Institute, between 2008 and 2014 Australia experienced an 87% increase in prescription opioid deaths, with the increase in rural regional Australia a shocking 148%,” Mr Tambassis said.

He cited data from the Bureau of Statistics released this week which showed almost 70% of drug-related deaths in Australia in 2016 were a result of prescription drug abuse.

The ABS data showed that a person dying from a drug-induced death in 2016 was most likely to be a middle-aged man, living outside a capital city, misusing prescription drugs such as benzodiazepines or oxycodone and taking several medications at once.

“Despite this the medical profession has done little or nothing to bring about a national real time recording and reporting system,” Mr Tambassis said.

Mr Tambassis said the Pharmacy Guild recognises the reality that some patients misuse over-the-counter medicines containing codeine, which was why it introduced the MedsASSIST system in 2016 to record and report on usage.

“So far more than 4,000 pharmacies—or more than 70% of all PBS-approved pharmacies—are voluntarily using MedsASSIST,” Mr Tambassis said.

Around 9 million transactions have been recorded by MedsASSIST, with a sharp reduction in codeine sales, and referrals of thousands of patients for further pain management.

“There is no dispute that overuse and dependence on these codeine containing medicines can cause harm or fatalities. The question is how best to address it—and shifting medicines to prescription only is demonstrably a flawed solution,” Mr Tambassis said.

The Guild is proposing a limited exception to the upscheduling of these medicines to allow pharmacists to supply them under strict protocols and with mandatory real time recording, for the benefit and pain relief of patients using the medicines safely and appropriately.

It says that in contrast, doctors want to shift to a prescription-only regime with no monitoring and a demonstrated track record of doctor shopping, abuse and harm.   

 “Doctors need to embrace real time reporting and recording of prescription drugs so that we can reduce the horrendous number of deaths from drugs prescribe by doctors,” Mr Tambassis said.

“Let’s get real about our commitment to protecting Australians from opioid misuse.

 “Increasing prescriptions without a real time recording and reporting system can only exacerbate the problem.”

 

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7 Comments

  1. Pene Wood
    29/09/2017

    Neither group has acknowledged that codeine is inappropriate for chronic pain/long term use and whether it’s supplied as a prescription or OTC is actually a mute point, it shouldn’t be supplied at all and people should be offered alternatives and educated about this.

    • Anthony Tassone
      29/09/2017

      Hello Pene

      One of the key objectives and intentions of the joint Guild/PSA proposed model is to facilitate patient access to low dose combined analgesics containing codeine to manage acute pain. Neither the proposal or the protocols are advocating or attempting to justify chronic use of low dose codeine products.

      Through this proposal it is also intended to help reduce the burden on medical practitioners and the public health care system and free up already limited resources to focus on more chronic pain conditions.

      Mandatory real time monitoring and recording of low dose codeine products will enable data collection of supply and professional intervention to allow analysis to help inform public health policy.

      Anthony Tassone
      President, Pharmacy Guild of Australia (Victoria Branch)

      • Andrew
        29/09/2017

        Considering the lack of evidence, proof of harm and abuse, and availability of safer and demonstrably more effective options (than OTC low-dose codeine), how does the guild/PSA reconcile this proposal with the professional practice standard “1.7.2 Actively engages the patient in informed decision making by providing evidence-based advice on available pharmacological, nonpharmacological and lifestyle management choices.”

        Any provision of OTC codeine is incompatible with evidence based practice.

        • Jarrod McMaugh
          29/09/2017

          Actually Andrew, the evidence for the main product that is being touted as a replacement for low-dose codeine combinations (ie paracetamol plus ibuprofen) doesn’t have a great deal of evidence for it outside of acute pain relief for dental pain.

          I did a significant amount of research on it when writing the update on acute pain issues (headache, migraine) for the next APF; and there is actually very little supportive evidence for anything other than acute dental pain.

          Of course this doesn’t mean it can’t be used for any other acute pain issues, under the clinical judgement of any pharmacist – which is exactly the rationale for the use of CCOTC products up until now.

      • Pene Wood
        24/01/2018

        Codeine containing analgesics aren’t first line for the majority of acute indications either and because of the variability in the metabolism of codeine that we can not tell by looking at a patient it is not a viable option that pharmacist should be recommending anyway acute or chronic. In my opinion if the pain is strong enough to warrant an opioid it is strong enough to be checked out by a GP or a hospital.

        • Jarrod McMaugh
          24/01/2018

          Notwithstanding the issues of codeine harms, as pharmacists we absolutely have the ability to determine a person’s capacity to metabolise codeine.

          There are also a significant number of patients who have been advised to use low-dose codeine for their regular acute pain due to their inability to take other OTC items, or who have found that these products treat their pain well. Access to OTC CC-analgesics isn’t always about “first line” treatment, sometimes it is about utilising a treatment that has been found to be effective and safe for ongoing use.

          We know also that there are a significant number of people who misuse codeine-containing products, ending in poor outcomes. Realistically, the number of people harmed by combination codeine products is lower than those helped… but the size of the harm is bigger than the size of the help.

          There is also the issue of inconsistent application of standards of care, as you’ve described in the past…. but I am far from convinced that making these items prescription-only changes that at all. If anything, I’m very confident that the attitudes we regularly see in those practitioners who can and should provide ORT will be applied to those people who are at risk of harm… the outcome will be that overall harm probably won’t be reduced.

    • Jarrod McMaugh
      29/09/2017

      opioids in general are inappropriate for long-term treatment of non-cancer or non-palliative pain – this is a major issue that is still not adequately addressed, and part of the reason why the focus on codeine scheduling has been “stealing the limelight” away from the more important issue of RTPM.

      Suddenly there’s be no iatrogenic harm or addiction because codeine won’t be available OTC? A lot of people have to wake up to the reality of the harms that are being caused by chronic use of opioids… while we have GPs who are willing to prescribe opioids inappropriately (such as not applying for a permit or having a relevant history) we’ll continue to have an issue, and whlie we have pharmacists who are willing to fill scripts without question, or supply OTC items without applying their clinical role, then we’ll continue to have issues.

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