Rural doctors query Guild codeine access comments

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Rural doctors have weighed in on the codeine debate, saying they strongly support the TGA’s decision to upschedule

The Rural Doctors Association of Australia makes a point of calling for a real-time monitoring system, an issue which the Pharmacy Guild has said other doctor groups have not stressed enough.

“RDAA is calling on the Federal Government to continue to back the TGA’s decision, despite pressure from the Pharmacy Guild to make exemptions to the requirement for a prescription,” RDAA president Dr Ewen McPhee says.

“The TGA’s decision has very clearly been made in the best interests of patient safety, and it has been made with extensive consultation from medicines experts.”

RDAA says it sees the upschedule as the “critical” first stage of a two-stage process to improve patient safety where codeine is concerned.

“The implementation of a compulsory and legislated national Real Time Prescription Monitoring system – enabling doctors and pharmacists to track prescriptions for individual patients in real time – is the crucial second stage that should be introduced as soon as possible.”

Dr McPhee says that patients in rural and remote communities have particular difficulty getting treatment for addiction, including medication addiction.

He queried some of the points the Pharmacy Guild has made when discussing its “Prescription – except when” model.

NSW Nationals leader John Barilaro called on Australia’s health ministers last week to push for a reversal or compromise (prescription – except when) on the upschedule, from the Harden Pharmacy in the south-west slopes of NSW.

The small rural town is frequently without a doctor, a fact highlighted by Mr Barilaro in his comments. The NSW Guild’s new president David Heffernan was on hand to explain the compromise model at the time.

But Dr McPhee says that the RDAA had noted “with interest” comments made by the Guild that prescription-only codeine would be a problem for residents of rural towns due to difficulty accessing GP services, particularly after hours.

“What the Guild fails to mention, however, is that in many rural towns, pharmacies do not work extended trading hours anyway,” Dr McPhee says.

“The Guild also argues that, in towns where there is no doctor or a doctor shortage, patients may not be able to access codeine for temporary acute pain associated with conditions like headache, toothache or period pain.

“We would hope that the Guild supports the need to put the safety of rural patients at the highest level – we believe that, on balance, it is more important that rural patients are properly assessed by a trained doctor for their condition, before they are given codeine for a condition that may not require it.

“In many cases, there may be more appropriate and just as effective alternative medicines with lower risk for the patient.”

Dr McPhee says most rural and remote patients would want to see their GP before taking more significant pain medication.

“And in a large number of remote towns, the GP also dispenses medication as there is no local pharmacy.”

He says that to date the RDAA has not been consulted on “prescription – except when” protocols by the Guild and how they would apply in rural and remote communities, though the Association had previously met with the Guild to understand the model.

A spokesperson for the Pharmacy Guild told the AJP that “The Guild is open to consultation with any doctor group on the best way forward to ensure safe appropriate access for patients is maintained, with limited quantities, real time recording and clinical protocols.

“Our focus is on providing a common sense solution for appropriate and safe use of these medicines, especially in rural and regional areas where doctor access may be reduced.”

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  1. Ron Batagol

    By way of update, TGA has a summary of information on the decision and links to various resources covering this issue as of 12/10/17 at “Codeine Information Hub:

    There is also a very (concise and short!) summary of the pros and cons of the Codeine re-scheduling issue , in a letter written in August to TGA The National Coordinated Codeine Implementation Working Group, by The Faculty of Pain, the Aust. & NZ College of Anaesthetists at:

  2. Debbie Rigby

    Whilst access to GP services can be difficult in some rural towns, it is never justification for providing inappropriate medicines to consumers. There are alternate analgesics available OTC, as well as non-drug interventions. If acute pain syndromes eg headaches, migraine occur intermittently, patients could have a limited supply from previous prescriptions of codeine/codeine combination products. It’s not as if they will not be available still, just on prescription.

    • Jarrod McMaugh

      Debbie, the point you have raised here about utilising previously prescribed pain relievers for a newly presenting issue is directly against the concept of QUM.

      Regardless of whether access should be restricted or not, it is never appropriate for someone to use an acutely prescribed medication for a newly presenting condition without a specific treatment plan that ensures the patient can accurately identify a recurrence of symptoms as being due to the same condition.

      The last thing we need is someone thinking it is appropriate to treat newly emerging pain with previously prescribed analgesics.

  3. Debbie Rigby

    To further clarify my comments on patients using previously dispensed codeine combination products – For recurring intermittent acute pain syndromes such as tension headache, migraine, dysmenorrhea, I think it is appropriate to use in these circumstances:
    – where the patient has been diagnosed by a GP, and considered differential diagnosis eg endometriosis, PCOS etc.
    – where the GP has provided a treatment plan for the patient (written or verbal) – when to take these meds based on presenting symptoms and when to visit the GP eg alarm symptoms, increased frequency or changed presentation
    Consumers should be able to self-manage these conditions as well as have an annual/biannual review, probably in conjunction with other visits or to get ongoing prescription.

    • Jarrod McMaugh

      If a patient is capable of self managing these acute pain syndromes after diagnosis with medication that has previously been prescribed, one would assume that they are also capable of discussing these acute pain syndromes with a qualified health professional about their history and prior treatments and obtaining a new course of treatment when required.

      For instance, they could discuss this with a pharmacist.

      This would avoid the need to have potent medications at home when not required and the risks of taking medications that are more potent than are required for the sypmtoms being experienced – “I have a headache… These PForte tabs will probably be fine for that”

      I think it’s very important to differentiate between the risks of codeine supply, and the expertise of pharmacists. Pharmacists are medication experts who are trained in differential diagnosis and recognise when to refer. Having a process that relies on GPs to diagnose, and patients to maintain an emergency supply of medications “in case” isn’t a better utilisation of the health care system than having a pharmacist supplying for acute recurrences; not is it safer.

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