Govts and pharmacy should stop “dragging the chain” on codeine upschedule, says addiction specialist – but Guild says claims of more deaths are misleading and fear mongering
Dr Adrian Reynolds, president of the Royal Australasian College of Physicians (RACP) Addiction Medicine chapter, has penned an article for Croakey on the codeine upschedule debate, calling on pharmacists to work with doctors to “ensure that treatment optimisation and patient safety are prioritised ahead of commercial interests”.
“Most Australians don’t realise how much harm codeine can cause. In fact, medicines containing codeine are so harmful that in most parts of the world a prescription is required,” writes Dr Reynolds, who has worked in the drug and alcohol sector since 1983.
“Addiction specialists and general practitioners overwhelmingly support the rescheduling of these medicines, mostly because we see first-hand the consequences of these products being so freely available in pharmacies.
“Codeine is closely related to morphine… It often results in opioid tolerance, addiction, poisoning and, in high doses, can contribute to both accidental and intentional death,” he says, referring to the drug as the “fast food” of big pharma.
“When combined with paracetamol or ibuprofen, the addictiveness of codeine drives some people to increase the number of tablets taken as their body’s tolerance to the codeine builds.
“As a result of large doses of paracetamol or ibuprofen, serious damage can occur to the liver, kidneys and stomach and even cause death.”
He says the morbidity and mortality associated with codeine-containing combination analgesics is the main reason why doctors support tighter regulation when it comes to selling these medicines.
“There is no hidden agenda in pursuing greater medical oversight for codeine. Unpredictable pharmacokinetics, risks of codeine harm, addiction and the limited evidence of benefit when compared with much safer alternatives are among the reasons for restricting access to these medicines,” says Dr Reynolds.
Meanwhile the Pharmacy Guild continues to advocate for its ‘except-when’ prescription model, and gained a win this month after state governments expressed concerns over consumer access post-upschedule.
The Guild has also hit back at claims from doctors’ quarters that more deaths will result if some access to these medicines is maintained without a prescription, labelling such claims “misleading and fear mongering”.
“The debate has focused on long-term chronic pain management, while placing too little emphasis on the acute pain needs of thousands of Australians who use these low dose codeine analgesics safely and appropriately,” says the Guild.
“There is no question or dispute that codeine addiction to over-the-counter or prescription medicines is causing harm and deaths. The question is how best to address these issues.”
The Guild maintains it accepts the TGA’s decision to upschedule the medicines to prescription only, but says it is “calling for better use of pharmacists’ expertise in providing short-term pain relief for people who have acute issues and need to get through to their next available doctor’s appointment”.
However Dr Reynolds disagrees that the Guild’s proposed ‘except-when’ prescription model is appropriate.
“Most pharmacists are not trained in assessing and dealing with drug dependence and drug seeking behaviours and few community pharmacies are equipped with the private space required to have sensitive discussions with patients about these matters,” argues Dr Reynolds.
While he concedes a nationally coordinated and implemented real-time reporting and monitoring system is a” good idea”, Dr Reynolds argues a monitoring system on its own is not a solution to the problem.
In reference to the Guild’s concern about doctor shortages in remote parts of Australia potentially leading to chronic pain sufferers without pain relief, he counters that “codeine abuse and doctor shortages are two separate issues”.
“An appropriate response to the latter is for state and territory governments, together with the medical and pharmacy community, to link rural health care clinicians and specialist services. These specialist outreach programs would bridge the gap between general practitioners and specialist services.
“In some cases, people seeking over-the-counter remedies without a script may consider the combination of paracetamol and ibuprofen as a more suitable and effective option than codeine. If a pharmacist assesses the pain to be moderate to severe or these single or combination paracetamol-ibuprofen medicines are not effective, the patient should be assessed by their doctor.”