Pharmacy urged to back codeine upschedule

Dr Bastian Seidel.

The RACGP has used International Overdose Awareness Day to tell pharmacy to support the codeine upschedule

August 31 is Overdose Awareness Day, held worldwide to raise awareness of overdose, reduce stigma and remember those who have died or been permanently injured due to overdose.

RACGP president Dr Bastian Seidel encouraged Australians to learn the signs and symptoms of opioid overdose.

He cited recent data which showed more Australians are now dying from pharmaceutical prescription opioids than from heroin overdoses.

“This is why GPs are supporting the Victorian and Australian governments’ moves towards real-time monitoring of controlled drugs including prescription opioids,” Dr Seidel says.

“We are also urging the pharmacy industry to back moves to end over the counter sales of codeine based medications – moves designed to save up to 150 lives a year.

“From February 2018 new national regulations will ensure people will need to see a doctor to be prescribed codeine based analgesics including some cough mixtures with codeine additives.

“With more than one million Australians taking codeine based medications every year, codeine addiction has become a serious problem for our community.”

But a spokesperson for the Pharmacy Guild expressed concern that “doctor shopping” can still occur following the upschedule of low-dose codeine.

“The Guild has for many years been at the forefront of advocating for and taking action to introduce tools that enable clinicians to identify and support patients at risk of dependence,” the spokesperson says.

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

“What is the RACGP doing about doctor shopping from 1 February?

“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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  1. Ron Batagol

    OMG- how many times does it have to be said!! Codeine OTC is dead and buried, and I’m not sure why any professional group would be seeking exceptions for a med. that objectively doesn’t work well at OTC strength doses and has, in any case, unpredictable efficacy in various patients ranging from useless to potentially toxic, depending on their genetic make up!
    Let’s face it- for 30-40 years, options for patients managing their own short-term analgesic relief have changed as have medications in many, if not most, areas of therapeutics, according to evidence, clinical experience and patient responses.
    What pharmacists can do best from 2018 is:
    1. Assist their patients in managing the transition to more effective OTC non-Codeine options, having regard to the potential benefits and risk profiles for those patients and
    2. Continue to be involved and provide advice to patients, utilising existing or evolving programs that document and record issues concerning patients carrying out “doctor of pharmacy” shopping, and/or those patients with other habituation or addiction problems, regardless of whether those medications are OTC or on script only.

  2. Jarrod McMaugh

    I’m very cynical about the comments from Dr Seidel for a number of reasons.

    First, Dr Seidel is on record as saying that codeine was available “virtually unsupervised”, which is preposterous. His mention of codeine for cough here shows that perhaps he is out of touch, since this is a schedule 8 medication.

    Second, Dr Seidel and other GPs seems to feel that harm from codeine will reduce just by the virtue of only being available on prescription. This is patently false and ignores a number of issues:
    1) Iatrogenic harm from opioids is a significant issue in Australia, which Dr Seidel highlights himself in his comments. The requirement of a prescription is not synonymous with safe use of medications.
    2) The idea that 2 groups of people – those with chronic pain that is poorly treated and people who are addicted to opioids – are not already seeing any prescribers at all is preposterous.
    3) The original research that was considered by TGA in their decision on codeine scheduling stated that OTC codeine was associated with a significant number of deaths. What has not gained a lot of publicity is that of these, ALL of the deaths were ALSO associated with prescribed opioids.

    The biggest problem I have is that stating these points has done little. I have been very vocal on the matter, and the responses from RACGP so far has been patronising comments, personal attacks, and being blocked on social media platforms. This is not the response we should expect from a professional body when there are legitimate concerns raised about their handling of the situation.

    What I expect to see is a very large publicly visible mess in February when the majority of people discover that they now require prescription. The majority of people do not use codeine very often, and so will have no idea of what is coming. For the majority of these people, the alternative treatments available OTC will be perfectly fine.

    For those who still wish to access codeine, there will be five outcomes, in varying incidence.
    1) Patients seeking codeine for legitimate pain will be treated as if they are drug-seeking
    2) Patients who are seeking codeine for addiction will be missed and prescribed opioids despite the harm that this will cause.
    3) Patients who are seeking codeine for addiction will be identified, yet still prescribed opioids despite the harm that this will cause due to stigma from prescribers around opioid replacement therapy.
    4) Patients seeking codeine for legitimate pain will receive adequate care.
    5) Patients who are seeking codeine for addiction will be identified and referred in to addiction/harm minimisation services.

    Now, I really hope that 4 and 5 are the most common outcomes, but I have grave fears that they won’t be…. especially since situations like 1, 2, and 3 are common now. I have repeatedly asked RACGP representatives for advice on what they are doing to ensure prescribers are ready for the change in codeine access, and the most recent response I received was “I won’t tell you, but thank you for your concern”.

    My fear is that prescibers are operating under a false sense of security that they are prepared for the changes, and that nothing more than the fact that a GP is now required to be involved is enough to deal with addiction.

    Between february and when Real Time Prescription Monitoring comes in to effect (which is still a long way off for states other than Victoria), the potential harm for patients who are addicted will be increased – not reduced – by the changes, since there will be no monitoring in place, and an existing monitoring system will be made defunct.

    One last point – when I raise this issue with prescribers, I often get accused of being concerned about lost sales rather than patient safety. Not only is this concerning to all pharmacists that this is the opinion doctors have of use, but it is deeply offensive personally given my involvement in harm minimisation advocacy. In a practical sense, it also makes little sense, since all prescriptions still need to be filled in a pharmacy (and will not likely have a dispensing fee, since GPs have stated they won’t prescribe low-dose codeine…) so this move increases remuneration.

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