Hospital pharmacy backs upschedule

The Society of Hospital Pharmacists has sided with medical groups in their stance on the regulatory decision

Last week, all State and Territory Health Ministers except for South Australia’s new Minister, Peter Malinauskas, put their names to a letter calling for the Federal Minister to address concerns about the codeine upschedule.

Medical and health consumer advocates responded by publishing an open letter to State and Territory Health Ministers this week, calling on them to uphold the TGA regulatory decision to make codeine prescription-only.

The letter, signed by the Royal Australian College of General Practitioners, Royal Australasian College of Physicians, Consumers Health Forum of Australia, Rural Doctors Association of Australia and Painaustralia, reiterated key findings from the TGA’s review on codeine.

These findings included that codeine is not effective for treatment of chronic (long-term) pain, and that there are serious risks of harm associated with its use.

Now the SHPA has joined the ranks, for the first time publicly expressing its support for the upschedule.

Chief Executive Kristin Michaels says the SHPA strongly backs the stance in the open letter.

“As a regulatory decision based on robust evidence, empowering pharmacists and clinicians to provide better quality patient care, SHPA has long welcomed the TGA’s recommendation to upschedule codeine-containing medicines as prescription-only,” Ms Michaels tells AJP.

“On behalf of our members who provide treatment to patients with chronic and acute pain, as well as opioid misuse and dependence in both primary and acute settings, SHPA supports all government initiatives that prioritise patient safety.

“SHPA proudly remains 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.”

SHPA’s Choosing Wisely recommendation is based on evidence that doses of codeine less than 30 mg every six hours are no more effective than paracetamol or an NSAID alone.

“Therefore, combination products that contain low dose codeine should not be recommended for mild to moderate pain,” says the SHPA.

Meanwhile the Pharmacy Guild has questioned how doctors will be able to manage the predicted influx in patients following the upschedule.

“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?” it asks.

Some pharmacy academics have also expressed concerns.

Professor Peter Carroll, from the University of Sydney’s Discipline of Pharmacology and the University of Notre Dame’s School of Medicine, says the TGA’s decision “will merely force these people to visit a GP, where there is no Australia wide real time monitoring of prescriptions for codeine-containing analgesics,” he says.

“This has the potential to allow people to ‘doctor shop’ and visit numerous GP practices to obtain multiple prescriptions.”

The evidence relating to opioid misuse and death reveals it is mostly prescription opioids that are contributing to the problem, he adds.

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  1. Mark Jacobs

    What’s that saying about a dead horse?
    I can’t believe the Pharmacy Guild is still pushing such a mute point. The evidence is clear: current S2/S3 codeine containing products are not effective for chronic pain management.
    ( + more

    The issue is that all these organisations are throwing around words and terms, mixing them in with facts, to confuse not only the public, but other health care professionals that may not deal with the discipline of pain management and addiction.

    I am a pharmacist, and I support the up-scheduling. Here is my quick-list of reasons why:

    1. Codeine pharmacokinetics is simply unpredictable in a varied population. CYP2D, CYP2D6, CYP2D6. This is drilled in us in pharmacy school yet somehow becomes irrelevant in the clinical setting? The currently available data on the consequences are sketchy at best. However, it is a point for further investigation. I suppose it doesn’t support an argument for or against up-scheduling as rx codeine users would also be affected. More research needed.

    2. Codeine related deaths are on the rise: Codeine, not oxycodone, morphine .. codeine

    3. Of the deaths, where data was available, ~50% were prescribed codeine products (bad doctoring really) but, ~40% had used OTC codeine (bad pharmacisting): This to me suggests that consolidating the source is important in monitoring patient outcomes. There are two key potential points of consolidation: pharmacist or doctor. Only one of those has the relevant training necessary and/or the power necessary to expand on dose range, frequency, combination, formulation etc…

    4. Let’s not pretend that codeine products are not some of the most profitable pharmacy lines. Fast movers, low-intervention time, low-overhead, big mark-up .. they sell themselves (isn’t addiction just great for business!). I am not saying all pharmacists or pharmacies operate in this manner, but I have worked in enough places to see the professional laziness and financial greed.

    5. We were never trained! As pharmacists, we were never trained on addiction intervention and management. Yet somehow we are expected to do a few online modules (via PSA/Guild/Other) and be able to identify and refer pxs successfully to a GP? For every success story out there, which I commend the pharmacists on, there are countless failures. It is all of course, anecdotal, which leads back to the need to look at the evidence available on: “The benefits of pharmacist intervention in acute pain management”. Oh yeah, no one wants to do that research article, we just want to sling words that run along the lines of “think of the children”
    (This is pretty good for those interested:

    6. Finally, I believe the studies out there are largely flawed in design. The MJA study above highlights that many patients on admission to hospital did not disclose their codeine use immediately. This is a good representation of the real world where people that ARE addicted are not quick to tell you they are addicted. So, what data are we looking at? Where is it coming from? Who collected it? How was it collected?
    These questions (and more) are hopefully answered by systematic reviews where possible, or further research where not possible. Two areas the bodies advocating for/against have failed to adequately investigate.

    What I think the Guild/PSA/Pharmacy bodies should do is:
    1. Commission research into the benefits pharmacists offer when it comes to pain management, OTC acute pain management, addiction intervention etc… Then use that research as the evidence.
    Which is basically how science works: Hypotheses –> test hypotheses –> conclusion –> new hypotheses –> repeat
    This process has worked for several programs currently (and previously) available under the CPA.

    2. Develop the real-time prescription monitoring system before any other organisation then sell it to the government. Make it the most bullet-proof system available. Governments love to buy ready-made products. It is cheaper for them than long-term tendering processes.

    If you haven’t already, have a look at Prof Carroll’s (whom I love and respect a great deal!) opinion article titled the Codeine Dilemma in Oct AJP. Prof Carroll highlights some fantastic points and perspectives.
    However, opposite the opinion piece, on page 21, is a huge advertisement for a product with little to no supporting evidence. If an outsider (say a doctor perhaps) was to read our journal, how can they take anything we say in there seriously? A question for another time.

  2. Andaroo

    I’m a pharmacist, and a intermittent codeine user for adjunct pain relief in conjunction with diazepam for muscle spasms from a herniated disk in my lower back from 15 years ago. This happens 3 times per year for 3 days medicated each time. And I am also a once a week on average sufferer of headaches, with the once every two month migraine thrown in for good luck.

    I am not alone in the thought that, low dose codeine (in my case ibuprofen + codeine) isn’t effective, is the most anger inducing phrases one could think about when trying to find a box of the aforementioned pain killer while one of the aforementioned conditions is flaring up. And no, i don’t want to take 30mg tabs, or tramadol, or endone while i’m at work, that would be somewhat irresponsible to say the least. Not forgetting the fact that I wouldn’t be able to get to the doctor for the required script in the first pla……*mutters off into the distance

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