Doctors fire salvo over codeine deaths

The PSA and Guild have expressed disappointment after an RACGP spokesperson said OTC codeine is “out of control”

Royal Australian College of General Practitioners president Bastian Seidel said in a statement over the weekend that “codeine addiction has become a serious problem for our community”.

“The consumption of these medications is currently running out of control with over 16 million items being sold over the counter in pharmacies every year,” he said.

“Up to 150 Australians are now dying from codeine-related overdoses each year – double the number ten years ago,” he said, citing Trends and characteristics of accidental and intentional codeine overdose deaths in Australia, which found that for every two Schedule 8 opioid-related deaths in 2009, there was one codeine-related death.

Dr Seidel said many more people were now seeking help for codeine addiction.

“While these sales represent a lucrative financial return of over $150 million a year for the pharmacy industry, patients are paying for this with their lives.

“The Therapeutic Goods Administration’s decision to reschedule over-the-counter codeine-based medications is being strongly endorsed by medical and community groups, and follows similar action in many other countries.

“The Pharmaceutical Society of Australia and the Pharmacy Guild’s efforts to lobby government to continue over-the-counter sales have undermined the collaborative work by governments and health professionals across Australia through the Nationally Coordinated Codeine Implementation Working Group—particularly its work to develop information and resources for GPs, pharmacists and patients in preparation for the change in February 2018.

“I’m calling on the PSA and the Pharmacy Guild to support the TGA’s decision to end over the counter sales—or remove themselves from the working group immediately.

“It’s time these pharmacy peak bodies committed to this much needed public safety initiative.”

PSA national president Dr Shane Jackson told the AJP that the comments were “not helpful” and ignored a key issue.

“What’s being lost in this whole debate, unfortunately, is that there’s this focus on codeine at the expense of the larger issue around prescription opioids,” Dr Jackson said.

“It’s being suggested that the upscheduling of codeine will solve the opioid issue that we have in this country. And that’s simply not correct.”

A spokesperson for the Pharmacy Guild agreed.

“Doctor groups need to address the absence of any real time recording for medicines containing codeine once they become S4 prescription medicines next year,” the spokesperson said.

“One need only read multiple coroners’ reports to know that making medicines prescription-only does not prevent their abuse.

“The majority of codeine-related deaths are a result of high-strength medicines that are prescribed by doctors and/or as a result of combination of medicines consumed by patients. 

“The statistics cited by the RACGP are eight years old – and they show one codeine-related death for every two opioid related Schedule 8 (controlled prescription drug) deaths. What does the RACGP propose to do about doctor shopping?”

A changed landscape

Dr Jackson also warned that it was quite possible that, as has been suggested by some stakeholders, doctors would prescribe codeine in higher strengths than those currently used by consumers who buy it over the counter.

“We just don’t know what’s going to happen post-February 1. And that’s why we need a considered approach about opioids in general, which considers mandatory real-time monitoring across the country, as we’ve advocated for a very long time.

“If all jurisdictions would mandate real time recording of all opioids, including codeine – as we’ve recommended, for example by using MedsASSIST – then we would almost eliminate the abuse of codeine-containing analgesics.”

He told the AJP that it was “frustrating” that the RACGP had chosen to discuss OTC codeine in the context of financial return for pharmacies.

“It’s a therapeutic issue,” he said. “When we’re trying to work together as health professionals to achieve an outcome of improving the health of patients, I don’t think turning the debate to economic issues, as a backhander to another professional group, is helpful – especially when I think health professionals on the ground think this debate, and issues between organisations, are not helpful to their cause.

“What we’ve advocated is that codeine-containing analgesics have a place for acute, short-term pain, when provided using a framework of real time monitoring, so that you can eliminate abuse and help people who are misusing the product for short-term pain by referring them to their GP – but making it available for acute short-term pain.”

The Guild and PSA say they will continue to advocate for access to low-dose codeine in certain situations of acute pain, with appropriate safeguards.

“We’re not trying to overturn an upscheduling process, but equally we recognise that patients should have access to this product for acute pain,” Dr Jackson said.

“So we’re trying to ensure some flexibility… pharmacists are appropriately trained to be able to provide it with the appropriate support mechanisms in place.”

He reminded stakeholders that the TGA decision to upschedule was made using data before MedsASSIST was rolled out and changes were made to pack sizes.

“So the landscape has changed since that decision was made, and we need to recognise that.”

“I think most people use it (low-dose codeine) appropriately, and the information through MedsASSIST would suggest that. We do have a gap in that 30% of pharmacies aren’t using MedsASSIST, and that’s why we’re calling on jurisdictions to make real time monitoring mandatory.”

The Guild spokesperson also highlighted data which showed MedsASSIST had had a significant impact on OTC codeine sales.

“In one group of pharmacies using MedsASSIST, over-the-counter sales of codeine products fell 31% compared to the same six month period the previous year.

“Community pharmacists are voluntarily continuing to use MedsASSIST as a clinical tool to support their patients and refer them where appropriate for more intensive pain management and addiction support, including to their GPs.”

The Guild has no plans to leave the working group, the spokesperson said.

“The TGA itself has recognised the strong and positive contribution of the Guild and the PSA in the working group, and is keen for us to continue that contribution.

“Community pharmacists will be on the frontline talking to people when these medicines are upscheduled, so they are crucial to the working group.

“GPs must work with pharmacists to ensure safe transition – especially for acute pain sufferers – and referral where necessary.

“The Pharmacy Guild of Australia will continue to press for a common sense exception to codeine up-scheduling so that patients can continue to access these medicines for the temporary relief of acute pain from their pharmacist in accordance with a strict protocol, which would include the mandatory use of real time recording.”

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