Guild to doctors: stop hurling abuse


doctor wearing boxing glove

The Pharmacy Guild has rejected claims it’s putting profits ahead of patient safety

“Chemists are putting profits ahead of patient safety as they try to fight new rules that will make Panadeine and Nurofen Plus prescription only, doctors claim,” writes health reporter Sue Dunlevy in an article which appeared in News Corp media today.

“The powerful Pharmacy Guild of Australia has rejected claims by the nation’s peak GP group that it is trying to buy a change in the policy through $340,000 in donations to political parties.”

Ms Dunlevy cites a letter from five stakeholders – the Royal Australasian College of Physicians, Consumers Health Forum, Painaustralia, the RACGP and Rural Doctors’ Association of Australia – to State and Territory Health Ministers regarding the upscheduling of codeine.

In the letter, the stakeholders write that:

  • “Codeine is not effective for treatment of chronic (long-term) pain.
  • “There are serious risks of harm associated with codeine use, including death, toxicity and dependence.
  • “There are over-the-counter alternatives available that are a combination of ibuprofen and paracetamol that have been found to be a more effective analgesic than over-the-counter codeine containing analgesics.
  • “Multidisciplinary pain management is the most effective way to treat chronic pain.”

The open letter expresses concern that lobbying by the Pharmacy Guild has “gained traction” with State and Territory Health Ministers.

“The Guild’s proposed alternative model carries a serious risk of increased harms and potentially preventable deaths and cannot be supported by the medical community or consumer advocates.”

Ms Dunlevy writes that the Guild “has accepted $200,000 of taxpayers’ money to develop a consumer education program to manage the change”.

“Despite this, pharmacists who stand to lose up to $120 million in medicine sales have now written to all state governments asking them to make an exception to the prescription rule.”

RACGP national president Dr Bastian Seidel told Ms Dunlevy that the Guild is “trying to introduce policy by chequebook by donating large amounts to state and federal parties to gain open access to decision makers”.

The article is the latest in a series of articles by Ms Dunlevy which have been critical of the pharmacy sector and the Pharmacy Guild.

The Guild responded to the article today with a statement in which it said it “rejects the outrageous and baseless claim that it is putting the commercial interests of pharmacies ahead of patients in relation to the upscheduling of codeine”.

“On the contrary, the Guild’s arguments have been driven solely by the need to maintain convenient access for patients who use these medicines legitimately, and the safeguard of real time monitoring for at-risk patients with addiction issues.

“Rather than continuing to throw mud, Australians want medical groups like the AMA and RACGP to come to the table and take responsibility for the very real patient issues that doctors will need to manage from 1 February when these medicines become prescription only.

“There is no real time monitoring at the doctor level in any mainland State or Territory to prevent doctor shopping, which is in contrast to pharmacies where there is real time monitoring of codeine in every State and Territory.”

The Guild says it is “indisputable” that there will be a significant rise in GP visits from 1 February, by patients seeking prescriptions and advice regarding low-dose codeine.

“How will already overstretched doctors manage this increase in demand, including in regional and rural areas and elsewhere where there are already long wait times to see a GP?

“The Guild respectfully requests that doctor groups stop hurling abuse and playing political games, and focus their efforts on addressing these very real and urgent patient issues.

“As always, the Guild and pharmacists around Australia stand ready to work with their medical colleagues, government and consumer groups in the best interests of patients.”

The debate has moved across the Tasman, with Radio New Zealand reporting that pharmacists are “lobbying” against a proposal to upschedule codeine in New Zealand as well.

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9 Comments

  1. Tim Hewitt
    19/10/2017

    But Sue, pharmacists dont want codeine available to treat chronic pain.. our patients need it for acute pain (you know, toothache and finger jammed in car door etc..) Sue, you need to ask your doctor friends why they continue to prescribe codeine by the bucketful (all on NHS authority scripts..) to treat chronic pain, if there is no role for codeine in the treatment of chronic pain?!!.. please explain RACGP and Sue Dunlevey??

  2. Great to see that at least one pharmacy organisation can see that the call by medical experts in the field is the right one! see below:

    Yesterday at 3:40pm: “Today medical groups united to remind Australian health ministers of the dangers of
    codeine overuse”.

    SHPA strongly supports this position, remaining the first and only pharmacy
    organisation to advocate against the use of medicines with sub-therapeutic
    doses of codeine for mild to moderate pain, as part of our five Choosing Wisely
    Australia recommendations: http://the.shpa.org.au/2kXSDgr

    • Jarrod McMaugh
      19/10/2017

      Out of interest, The PSA and The Guild are calling for a complete solution to codeine.

      Scheduling change

      Introduction of an accredited training program to train pharmacists to supply prescription pain relief without a prescription in specific circumstances.

      Increased funding and support for the Infastructure required to increase treatment of pain, addiction, and pain in those who are addicted to opioids (including increased access to specialists, referral pathways, and utilisation of pharmacists in opioid substitution.

      Development of Real Time Prescription Monitoring.

      SHPA may support the first point, but is not currently involved in any of the other points.

      In the meantime, for their trouble, the guild and PSA are accused of being driven by profits.

      Not only is this not true; not only is this not justifiable based on the messages the guild and PSA have communicated; not only is this an attempt to undermine the importance of those points above (some of which would not be necessary if prescribers abided by their own guidelines…. Such as not using opioids for non-cancer chronic pain); but significant money has been spent by the guild in creating MedsASSIST, and by the Guild and PSA in developing resources for patients and pharmacists alike. I get why medical groups would want to use the straw man argument that pharmacists are only interested in profits, but when other pharmacists echo this sentiment without a second thought is very disappointing.

      In the mean time, there are individuals who have commented on the issue of codeine who have been paid to provide their expertise and knowledge in consulting with companies that market ibuprofen and paracetamol combination products – those products that will likely replace codeine OTC items (therefore potentially profitable). While it is legitimate for experts to consult for private companies (something I have done on several occasions) – it is also customary for those people to make this information clearly known when they make public comments that benefit these companies.

      How about all those people who want to criticise PSA and the Guild spend 5 minutes thinking about why the two largest and representative groups in pharmacy would want to work on this topic if it were just about profits…. Pain isn’t going anywhere. Treatment for pain will still be through pharmacy. This has been the case with all medications that have had schedule change.

      Perhaps – just maybe – the reason for criticising schedule change isn’t about profits, but is instead about the poor solution this provides for the problem it is supposed to address.

      • Firstly, the prospect of large-scale real-time prescription monitoring is a great move and the medsASSIST model has been a great template for this. Let’s hope it eventuates, with appropriate funding in the near future!

        I don’t want to buy into rights and wrongs of the exchanges of accusations and finger-pointing between pharmacy and medical groups on this issue. Frankly, I think all that is not just unedifying, but is also unworthy of an objective professional discussion of an important issue of concern.

        Also, whether or not there are people who are paid to promote their knowledge of Ibuprofen and Paracetamol to interested marketers of these products, does not affect the objective and established facts about codeine risks versus benefits.
        Frankly, in my view, both of these issues are peripheral the core issue of managing pain relief for patients/clients post February 2018.

        The fact is that Codeine is going to S4 in 2018, because accumulated evidence and clinical experience has shown a vast spectrum of individual analgesic effectiveness/ineffectiveness within the community, driven by individual genetic factors. In (VERY) approximate terms, around 1%-2% of patients (ultra-rapid metabolisers) obtained good pain relief but were at risk for
        morphine toxicity even within the usual therapeutic range. 5%-10% of patients (poor metabolisers) got little or no relief, even at higher
        doses, and the vast majority of the population ( extensive and intermediate metabolisers) only received a “mini-morphine hit” and didn’t get much pain relief from Codeine at the recommended dose levels of OTC Codeine-containing products.

        I am not sure what purpose would be served by having pharmacists allowed to supply emergency “Codeine pain relief” in specific circumstances, with specific training or not?

        The logic of such a proposal rests on the premise that Codeine is some sort of essential and unique medication that patients/clients need to have for emergency pain purposes until they can see a doctor. In any case, we have the established National Standard for the Uniform Scheduling of Medicines and Poisons (SUSMP), and when Codeine becomes S4, then, by definition, throughout Australia it will be a prescription-only medication. (Obviously, it goes without saying that, as with any other S4 medication, pharmacists will be able to provide an emergency supply of a Codeine-containing medication in a situation where the patient has evidence of a previous script, until they can see a doctor).

        With regard to pharmacist-accredited programs to assist patients/clients to transition to an alternative pain relief option, hopefully before rather than after February 2018, I would have thought that the most useful and productive outcome for patients would be for pharmacists to have a program available to best assist their patients/clients to make that transfer.

        To me, this seems to be the most important service to the patients that pharmacists can do, and pharmacy organisations and their educators need to be directing their energies to and focussing on assisting pharmacists in that regard, between now and February 2018, and not being distracted with infantile and puerile turf wars, regardless of who started them, or trying to seek to contrive a one-off “emergency exception” to a nationally-legislated Poisons Control issue.

        (Btw TGA’s “Codeine Information Hub” 12/10/17 at at:https://www.tga.gov.au/codeine-info-hub
        is well worth a read).

        • Jarrod McMaugh
          20/10/2017

          Ron, you raise some very good points, with some errors that I will correct, but you are still missing the big picture. Everyone focuses on low dose codeine and OTC access, but this is the catalyst for change, not the real issue.

          There are going to be major problems in February. This is because medical groups have taken no action to deal with this change. Not one thing.

          Medical groups are going to be the ones who now see all patients who wish to obtain codeine. What resources have RACGP or ACRRM or AMA or RACP or any other medical group developed to help patients and prescribers? NPS has, but they don’t have the access they should have…. And at this point there are no GP detailing programs being delivered. PSA has developed resources. The Guild has developed resources. No one else has. Isn’t that interesting.

          To your points, and the problems with them:

          Paragraph 1: RTPM
          RTPM. In Tasmania it is schedule 8, and not Automated.
          ACT has a strong permit system, but not real time.
          WA, NSW, SA, NT, QLD…. Nothing yet
          VIC – well developed but still 12 months from deployment. It also covers items other than S8.. IE codeine. I know how good the Vic program is because I have been involved in the DHHS meetings.
          Federal program is the same as Tas, and is only S8.

          When medsASSIST is made redundant in February, there will be no RTPM. Will people who say that OTC sales are responsible for so many deaths now accept responsibility for all of the deaths that continue after they are all S4?

          Paragraph 2: you don’t want to get involved, yet your response here was basically that SHPA is the only pharmacy group doing the right thing. I have a lot of respect for your knowledge & experience Ron, but you’ve already involved yourself in the fingerpointing multiple times.

          My response is I guess a way of pointing back, because while SHPA is right to say codeine needs to be S4 (as are ALL people in this conversation), scheduling does not go anywhere near far enough to deal with the issues that scheduling is trying to fix

          Paragraph 3: managing conflict of interest would be a core part of this discussion Ron. The entirety of the argument that doctors groups have levelled at PSA and the Guild has been one of financial interests over patient safety; or conflict of interest. It is supremely ironic therefore that a individual may be on the payroll of a company that markets a I+P product who is making a public case for the use of these products to pharmacists.

          Paragraph 4: it seems that people want to focus only on the lower doses. Those of which my pharmacy doesn’t recommend, and only patients using it have been recommended/referred by a GP – without script I might add.

          What you describe is very well understood variation in pain response to codeine. 8mg codeine converts for the average person to around 2-3mg morphine. Have you ever had a dose of morphine this low? I have, and it was very effective at reducing pain.

          That’s still a moot point, since PEW will likely bypass that strength for the very reasons you state.

          Paragraph 5: this would be an expansion of the role of pharmacists to further meet their scope of practice & expertise, as demonstrated by pharmacists who utilise this system in New Zealand, and similar systems in Canada & the UK

          Paragraph 6: your description seems to be couched in the premise that combination codeine would be the only use of PEW.international literature & practice very strongly makes a case for multiple medications & indications.

          In addition, there is no provision to supply emergency doses of codeine in any S4 strength at the moment. This is S4D, thus exempt from such provisions and illegal.

          Paragraph 7: PSA has done this already, and is developing more. the guild has done this, and is developing more. We don’t operate on one thing at a time. The amount of work PSA does behind the scenes on every issue affecting pharmacy is enormous; I assume it is so with the guild as well. It would be naive to think that each group only works on one aspect of any issue at a time.

          Paragraph 8: you would think this is important, wouldn’t you. I’ve already stated that PSA and Guild are doing this now, while medical groups are completely unprepared.

          With regards to peurile turf wars … It goes far beyond turf – it goes to the disdainful & unprofessionally insulting way in which some doctors talk about pharmacists.

          When I started in advocacy, I discovered an attitude that is as caustic as racism or sexism. I’ve been told my opinions mean nothing because I’m not a health professional. I’ve been told that I clearly do not understand health issues, and that my role is to do as I’m told, not to question.

          I’ve seen some doctors in representative roles say that pharmacies don’t understand cold chain, or are not medication experts, that we can’t understand pathology, that we are unqualified in all of the areas that we are specifically trained. I’ve been told that my only interest in providing disease state screening services is to scare people in to buying things. I’ve been told that trying to create a opioid replacement service in my pharmacy must not happen because it would affect the income of the neighbouring GPs. I’ve seen our profession described as a rotting corpse buried in a shallow grave. I’ve been threatened with being reported to AHPRA for refusing to dispense setraline to a 6 year old child because I should just do what I’m told.

          Do not tell me that pharmacists do not need to address these things and fight back against them. Just like the far more serious and damaging types of bigotry I mentiobed in sexism & racism, these things perpetuate because people believe they won’t be stopped by polite society.

          On these matters, when it comes to defending pharmacists from unfounded, ludicrous claims, I won’t ever be quiet. We deserve better than just sitting back and taking it.

          On the matter of the discussion on codeine, I won’t sit back and allow people to say that legitimate concerns on safety, practicality, and filling gigantic gaps in capacity are “all about money” because those who say this or believe it are ignorant of the bigger picture, and they need to re-examine their position we are saying that the Titanic is heading for an iceberg, while critics are saying that we just want to sell more iron sidings…..and those people who actually have a financial conflict of I retest talk about the deck chairs.

          • 20/10/2017

            Thanks Jarrod, for providing the detail of what is happening with RTPM in each State/Territory. It certainly does seem very fragmented. I agree-RTPM needs to be embraced at a National level as an integral part of the overall
            solution to the Codeine overuse and addiction problem.
            As you say, there is not any indication to date that the powerful medical lobby groups are showing any signs of being pro-active. For this to happen would obviously require funded resources and also time, which we have precious little of, before the February 2018 deadline!

            However, (hot “off the press”), now, with the passage of legislation in Victoria for RTPM, and suggestions that it will be rolled out nationally by the end of 2018, maybe there’s some hope the horizon

            Whether it is practical and legally achievable or not, for what it is worth, I think it is nonsensical for anyone to suggest that peak pharmacy groups would compromise their integrity, by seeking an exception to the S4 Codeine requirements under strictly-controlled conditions and requisite training, “for profit motives”. Apart from the overriding ethical issue, how could anyone think that an additional profit would ensue, given the embedded additional counselling and referral time and effort that would be entailed!

            I guess we all have different approaches to the best method of “fighting back” against such ridiculous assertions. I have no problem with clearly and objectively rebutting
            such assertions and re-stating the facts.
            While I understand the temptation to look for issues to diminish the credibility of those making such assertions, my “finger-pointing” that you have alluded to, is simply that the debate then inevitably descends into a “he said”, “she said” level, which, sadly, diminishes the credibility of both sides!

            Finally, it is important to raise an important medication safety issue in the Codeine debate, that has not, to my knowledge, been mentioned in public discussions, this being the likely increased use of self-selected NSAID products after Codeine goes to S4:

            As most will be aware, I have had past involvement, together with renal and cardiovascular experts in
            having TGA, via the then ADRAC Committee, re-issue the warning on renal risks of a “triple whammy”event, even with short-term use of NSAIDs.
            Also, I successfully had TGA place the warning on children and infant OTC packs of NSAID products, concerning caution in use with dehydration or other fluid-depletion
            situations, and the need for prior discussion with a doctor or pharmacist in such situations.

            With the recent trend towards the greater use of combination antihypertensive medications in the one tablet/capsule, often containing an ACE Inhibitor or ARA with a diuretic, when Codeine goes to S4, I wonder how many more of these patients with analgesia problems and maybe compromised renal issues, will, rather than seeking professional pharmacist advice, choose to go directly to the supermarket or general store, to self-select an NSAID product, thereby putting themselves at risk for a “triple whammy” adverse renal outcome?

            A “perfect storm” in the making? Yet we still allow small
            packs of NSAID analgesics to be sold in general stores, and not restricted to pharmacy- go figure!

  3. GetOutOfPharmacy
    20/10/2017

    I’ve been following this story in the news, and my opinion is the AMA’s criticism of the Guild is entirely accurate & warranted.
    As usual, the Guild is furiously lobbying (they say “advocating”) any politician it can find, and attempting to buy influence to weaken the intent of codeine upscheduling, all to maintain the nice fat profits from a historically good earner. The Guild ignores the harm caused by unchecked supply by some of its members, using smokescreens like the useless voluntary MedsAssist rubbish. Shame Guild, Shame!

    • Ronky
      23/10/2017

      And it ignores the overwhelming evidence of lack of benefit and significant risks to ALL users even when these medicines are supplied within the approved indications and dosage.

  4. Ronky
    23/10/2017

    The Guild’s psychological denial state has now become truly pathological. The Guild would have us believe that all of the experts on medicines regulation, pain, addiction, rural health, consumers, etc. have all got it wrong on codeine and only the Guild really cares about patients’ health – not about dollars, of course, Heaven forbid!
    This has gone beyond flogging a dead horse to digging up a horse’s rotting corpse and trying to give it CPR.

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