Guild commercial interest risking patients: Kruys

A high-profile GP has accused the Guild of being a “disruptive factor in healthcare” over the codeine debate

RACGP Queensland chair Dr Edwin Kruys has written on his Doctor’s Bag blog that the Guild was undermining the codeine upschedule process, “putting patients at risk”.

“It is concerning that those who have been given responsibility to look after the health of Australians take decisions influenced by commercial interests instead of sound evidence and common sense,” he writes.

In a section titled, “Wheeling and dealing,” Dr Kruys accuses the Guild of behaving one way in public – that is, utilising Government funding to develop resources and education to help the sector transition to prescription-only low-dose codeine – and another “behind the scenes”.

He said that the way the Guild approached NSW Nationals leader John Barilaro, who called for a reversal or compromise on the upschedule, was “clever”.

“They picked a pharmacy in a town with no doctor, invited Barilaro, took a picture with him and issued a press release thanking the Deputy Premier for his support of the Guild’s ‘common sense’ proposal to allow pharmacists to continue to supply codeine, stating: ‘What are patients with headache, toothache or period pain meant to do in Harden when there is no doctor within a hundred kilometres for a week at a time? The AMA has no answer’,” Dr Kruys wrote.

He singled out a clause in the letter from State and Territory Health Ministers (bar the SA Minister) to Federal Health Minister Greg Hunt, in which they wrote, “some people managing chronic conditions with codeine medications will deteriorate as they abandon medication due to the out-of-pocket costs associated with accessing GPs for their prescription”.

“If it is true that people in regional areas are indeed ‘managing chronic conditions with codeine medications’ bought from a pharmacy than that is of course a concern as codeine should not be used for this purpose,” Dr Kruys wrote.

“The State Health Ministers seem to implicate in the letter that it is preferable to treat chronic conditions by self medicating with over the counter codeine purchased from pharmacies instead of going to a doctor to get appropriate treatment.”

Yet Guild president George Tambassis said in a media release over the weekend, following mainstream media reports on the letter, that the Guild and PSA were not seeking to overturn the TGA decision and that “prescription – except when” would pertain to the temporary treatment of acute pain only.

Commercial influence?

Dr Kruys writes that “cash for access” to politicians is “unethical”.

He cites a report in The Australian which pointed out that the Guild was one of seven Labor donors who had “cash-for-access” meetings recently with Queensland Health Minister Cameron Dick.

“Concerns have been raised for a while now that the Pharmacy Guild is able to influence healthcare decisions based on commercial principles instead of sound evidence,” he writes.

“The Guild regularly negotiates a massive agreement with the Australian Government to the value of $19 billion for dispensing PBS medicines. This begs the question how ethical it is that the Guild, at the same time, transfers money into the bank accounts of the political parties it is negotiating with.”

Dr Kruys says that the Guild’s preferred solution – which he identifies as “prescription – except when” with real-time monitoring via MedsASSIST – is “weak”.

This is because “codeine is not safe and there is unambiguous international evidence of harm and misuse” and “there are also serious problems with MedsASSIST.

“It is not an independent tool but owned by the Guild. Not all pharmacies use it so it is easy to get around for those who use codeine for the wrong purposes,” he writes.

“The Guild continues to accuse others that they have done nothing to monitor the use of drugs of dependence.

“This is also incorrect as many groups, including the AMA, RACGP and coroners have repeatedly asked for an effective national real-time prescription monitoring system, accessible by doctors and pharmacists.

“The Pharmacy Guild of Australia is increasingly becoming a disruptive factor in healthcare,” Dr Kruys writes.

“Protection of their significant commercial interests drives behaviour that is not always in the interest of the health of Australians. Feedback or criticism is met with aggressive counter punches. Working with the community pharmacy sector is becoming difficult for other health groups.

“I am not accusing anyone of backdoor deals but this whole codeine saga is not a good look.”

A spokesperson for the Pharmacy Guild responded to the blog by telling the AJP that “The biggest problem in relation to codeine harm stems from prescription medicines and the absence of means to curb doctor shopping—about which doctor groups do nothing, say nothing and pay nothing.

“Unlike the Pharmacy Guild which developed and funded MedsASSIST real time recording.”

Guild Victorian Branch president Anthony Tassone responded to Dr Kruys’ Twitter promotion of his blog by pointing out that the Guild developed MedsASSIST at its own cost, and that it does not charge for the use of the decision-making tool despite “significant” running costs.

“It’s not a ‘commercial’ solution, it’s a clinical tool,” Mr Tassone wrote.


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Doctors erupt over Nats codeine announcement

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  1. vixeyv

    Really tired of the AMA. Where is the collaboration, the “health team”? Its their way or the highway… what the Guild has recommended has been considerate and from a wider lens of looking at preventing doctor/pharmacy shopping. I think the GPs are losing business……

    • Jarrod McMaugh

      Kruys is RACGP, not AMA

      he also has a history of making comments that are suspect.

      He criticised vaccination without revealing the fact that he makes significant income working for travel vaccination providets, then claims there is no conflict of interest as he’s only a contractor.

      He regularly criticises pharmacists and makes comments that are inflammatory, but will not accept any constructive criticism or any discussion that points out that he or his colleagues INR representative roles in RACGP are perpetuating conflict with their choice of language.

      He intimated that he directly intervened in commercial arrangements between a pharmacy banner group and a pathology provider. If true, this would be a breach of ACCC regulations and federal law.

      Dr Kruys has demonstrated on numerous occasions that – on the subject of pharmacists – his commentary is biased and no reader should have any faith in the validity of any argument he makes in this area.

      • vixeyv

        Thank you Jarrod! Great to have your knowledge on his history. I think the RACGP is struggling for clients.

  2. vixeyv

    Drs main argument is that low dose codeine is not effective, but addictive. What?

    • Debbie Rigby

      The issue is that doses of codeine less than 25-30mg are not shown to be effective. Hence patients will take more than the recommended dose to achieve an effect. This can then lead to escalation of codeine intake, leading to dependence. In addition, harm can occur with these higher than recommended doses of codeine combination products due to toxicity from paracetamol or ibuprofen.

      • Jarrod McMaugh

        I’m not sure that this behaviour has been borne out in research.

        We know that this can theoretically occur, but is it prevalent? Especially with OTC only codeine?

        We know that the harms experienced by those taking excessive doses of any combination codeine product is from the combination item, not the codeine component.

        We could make the assumption that people treating any pain with paracetamol and ibuprofen combinations may also escelate due to their pain being inadequately treated…. If this were to occur, the harms would be greater than any other OTC product due to NSAID and paracetamol toxicity together.

        We know that dose escelation occurs when medication is prescribed. We also know that a significant proportion of OTC supply has been at the direction of prescribers. Moving to prescription only without other changes will just make it easier to track the source of codeine recommendation, without altering exposure for the better.

        What we need is accountability from prescribers as well. At the moment – as I have said multiple times – it is assumed that making codeine S4 fixes the issue, which it clearly does not. If it were capable of fixing anything, then there would not be any iatrogenic harm from opioids…. Not only is this not the case, but from the data TGA used to make their decision, we know that every death that involved OTC codeine also involved prescribed opioids (IE zero deaths in this study that are caused by codeine only, let alone OTC codeine only)

        The reason OTC codeine is being rescheduled is NOT because people have become addicted by escelating their use of OTC pain relievers on their own. The reason people have become addicted is because our health system (specialists, GPs, pharmacists) don’t deal with pain effectively, and dose escelation routinely occurs in a way that involves prescriptions and OTC. This may come to a head for people and their health professionals drop this person due to risk… Leaving a person with no recourse for their (now iatrogenic) addiction than to doctor shop and OTC-bulk-buy.

        Our system has not changed. While making OTC codeine in this situation harder to access can reduce harm, it does not address the problems in prescribing patterns, iatrogenic addiction, how we HELP people who have become addicted, and stigma. Without this, schedule change alone is going to cause significant harm for the specific cohort of people who are most at risk now from OTC codeine.

        We need far more recognition from general practice that iatrogenic addiction involves prescribers who don’t know how to adequately treat chronic pain.

        RACGP and ACRRM have a responsibility to their members and their patient’s to address this… They have not.

        NPS has a role here too. They have great resources, but have not yet utilised their field force to deliver face-to-face programmes or PPRs that address the issue.

        In 4 months, the schedule changes. When the problem of harm from opioids does not suddenly resolve, will those people who have only focussed on scheduling finally start to realise that scheduling solves nothing, it only transfers the problem 100% to prescribers?

        I doubt it, and I doubt those who continue to believe that people who criticise the impending changes as they are are driven by money will acknowledge just how poorly implemented this “solution” is.

        • vixeyv

          Bravo, Jarrod.

          You eloquently speak the truth of the matter here, and what a lot of pharmacists would be thinking. I’d like to think the “burden” of pain management can be transferred to prescribers, however (as usual), the pharmacists will intervene and monitor frequent usage where we can, with the added tool of potential doctor shopping if we still use MedAssist in addition to dispensing. Lol. I sincerely think a back-door cash handshake has happened between the likes of the RACGP and TGA.

        • Amandarose

          If you ever locum
          In a discount pharmacy the real issue becomes very apparent with many selling thousands of packs a month. The people coming in are obvious abusers and they come in droves. These same patients who avoid those with MedAssist and those that don’t see Codeine for $5 a box.
          The usual pharmacy I work for seeing hardly any- the occasional migraine where as 50% of the others in town feed the masses their codeine hit.
          If you have not noticed it it’s because you most likely are an ethical person don’t the right thing. Don’t assume all your colleagues are the same as the morality of pharmacists has a noticeable decline over time.

  3. Nicholas Logan

    His arguments are routinely bogus and hypocritical.

  4. Dr Edwin Kruys

    Excellent article, thank you AJP. Worth mentioning here is that Health Minister Greg Hunt has made it known that he will respect the independent TGA decision to upschedule. Today the Rural Doctors Association of Australia released a statement “Pharmacy Guild risks patient safety on codeine issue” and joins a large group of organisations supporting script only codeine, including Colleges, Health Consumers Australia and PainAustralia.

    • Anthony Tassone

      The Pharmacy Guild and Pharmaceutical Society of Australia joint proposal to allow access to low-dose codeine products without a prescription in exceptional circumstances is not trying to circumvent or reverse the TGA decision to upschedule codeine.

      What the proposal seeks to ensure is acute pain patients have access under specific criteria to these medicines which would be provided by appropriately trained pharmacists authorised to supply them under strict conditions with mandatory real time recoding in place.

      In other words, maintaining safe convenient access to these medicines for people using them appropriately, with mandatory real time recording to detect abuse or misuse.
      Despite the robustness of the proposal, there is a concerted campaign to try to discredit it, pointing to the dangers of codeine and its supposed ineffectiveness in low doses. The campaign ignores that at all times in consideration, development and advocacy of its proposal the Guild and PSA have acknowledged the risks associated with use of codeine.

      Sadly Dr. Kruys has sought to slander the Guild as an organisation in his rebuttal of the proposal. Despite being quoted in his blog;
      “I am not accusing anyone of backdoor deals but this whole codeine saga is not a good look.” the actual tweet that provided a link to the blog read “About addictive painkillers and dirty backdoor deals.”

      So which is it Dr. Kruys?

      The opposition arguments mostly rely on the dangers of codeine medicines which are already available only on prescription, and not specifically on the low-dose medicines subject to the joint Guild/PSA proposal.

      In fact, one of the Guild’s concerns is that removing complete access to these low-dose medicines will see more codeine prescriptions being written at a time where there will be no real time monitoring of codeine sales on mainland Australia, potentially adding to the already significant prescription codeine problems.

      The simple fact is that making medicines prescription only does not provide a ‘silver bullet’ solution to prevent their abuse.

      To date, 4,035 pharmacies (72 per cent of all PBS-approved pharmacies) are voluntarily using MedsASSIST and over 8.6 million transactions have been recorded. Of these, about 2 per cent have been for a ‘deny/non-supply’ and 1 per cent recorded as a safety sale.

      These 204,000 safety sale instances were where pharmacists identified potential dependence issues and counselled consumers about appropriate treatment options. Many of these instances also resulted in a referral to a doctor for further assessment.

      The upscheduling of codeine will also bring changes in consumer behaviour. A survey through community pharmacies between July and September 2017 with 856 respondents found;

      The majority of patients surveyed (71%) indicated that when codeine is upscheduled to become prescription only, their most likely course of action would be to visit a doctor to obtain a prescription for the codeine product they were using.

      – The majority of this group (70%) indicated they will not even consider alternative analgesics that will remain available over-the-counter.

      – A majority of patients (63%) also believed they will visit a doctor more often as a result of this change.

      – People currently using paracetamol and codeine combination are most likely to go to the doctor and less likely to use an alternative product. This may reflect a lack of suitable over-the-counter alternatives for these people.

      – 94% of patients supported pharmacists being able to supply codeine without a prescription under strict conditions including monitoring usage in a real-time recording system. This highlights the trust and confidence patients have in their community pharmacists.

      These findings if replicated on a national scale, will increase pressure on GP services, with potential increase in overall health costs.

      The looming upscheduling of codeine is of concern to the State and Territory health ministers all of which except the minister from South Australia have written to Federal Minister for Health Greg Hunt relaying stakeholder concerns about the “unintended consequences” of requiring a script.

      This issue is not and should not be about the Guild vs. peak medical bodies, pharmacists vs. doctors but a discussion of the best way to manage the transition of codeine to prescription only in patient interests and the Guild and PSA have sought consideration of a proposal that allows access under specific criteria with mandatory real time monitoring for acute pain without a prescription.

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

      • Dr Evan Ackermann

        Most people have accepted the regulators decision and moved on AT.
        The Guild and PSA should too.
        People and organisations who cannot abide by health system regulator decisions, forfeit and right to practice in that health system.

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