What you said: Codeine goes S4


A roundup of thought-provoking comments regarding the TGA’s decision to upschedule products containing codeine

There weren’t many positive comments. Pharmacy veteran Ron Batagol said: “This decision by TGA is long overdue, and simply follows a worldwide trend to restrict the unrestricted availability of Codeine.”

“Upscheduling of barbiturates 25 or 30 years ago got rid of them as drugs of choice for sleeping – now replaced by benzos such as Temazepam – a lesser evil. Maybe codeine based meds will go the same way as barbiturates in another quarter century!” commented Philippe.

More than anything, readers voiced concerns about MedsASSIST and the implementation of a real-time monitoring system.

“Prescription codeine without real-time monitoring and prescriber accountability will further the codeine burden. GPs are inadequately qualified to manage chronic pain despite having a full clinical picture,” said Michael Post.

“My stance on this has always been that schedule change or not, there is no solution without RTPM as part of the strategy. This isn’t going to fix the issue, it will just transport the problem more directly into the doctor’s offices, while still maintaining the problem in pharmacy (since all supply must come through pharmacy),” added Jarrod McMaugh.

“The decision on whether to schedule or not isn’t in itself a good or bad decision – the issue is that it doesn’t address the problem. This is a band-aid that will create large costs for Medicare.”

And David Haworth also brought up the issue. “The worry now for me is the pharmacies using MedsAssist will stop using it. A big mistake. A codeine seeker will cotton on to Dr Shopping and multiple scripts and multiple repeats. This I have already seen out west. Doctors can’t monitor this but MedsAssist has a chance. These patient already Pharmacy shop and the next extension is Dr Shopping.”

“So now people misusing codeine products will have to doctor shop as well as pharmacy shop. What we really need, if privacy laws can be worked around, is a real time patient medication supply history that health professionals – not just pharmacists – can access,” PharmOwner said.

Many people were not happy with the decision and were not afraid to say so.

“Terrible decision by the TGA. If a patient has been overdosing on codeine, and all of the codeine products on S2/S3 are sold as combinations, surely these patients are overdosing on paracetamol or NSAIDs also,” said Raymond Li.

“An illogical decision given that the majority of traceable codeine-related deaths are from prescribed codeine,” argued Nicholas Logan.

medication pills drugs
Codeine-containing OTC medicines will be upscheduled from 1 February 2018, the TGA announced on Tuesday.

“This is not the right decision,” said one pharmacy retail manager. “The pressure on our already drowning healthcare system will be insurmountable!  Medsassist has not been in practice long enough. This decision is far too hasty.”

“The other very serious but unmentioned impact is the bottom line! Codeine makes up 5 out of 10 of the top OTC lines in our pharmacy.”

Another pharmacy retail manager said: “I’ve been in contact with my other health professional friends this morning. Doctor is happy, nurse is happy, pharmacist unhappy….so many different things to consider, lots of changes to me made.

“I suppose we can try and look at this positively from one of the many perspectives. Given that the decision doesn’t come into action until 2018 and we know about it now, it gives us time to educate our customers, and encourage customers, especially those that we feel may not have been managing their pain effectively to seek doctors advice for alternate options.

“Also Maxigesic and Nuromol will become the best option (which we all know is clinically proven to be more effective that codeine combinations anyway) and easier to sell to the customer. Trying to be positive, although I do worry about the backlash or potential violence that pharmacies could face from certain people who will not understand that the decision was out of our hands.”

And even a patient commented on the AJP story sharing their concerns.

“From a patient perspective, I think the new decision has positives and negatives. I cant afford to see the gp as well as I am currently studying full time. I think the current rules are ok where we have to provide our drivers license. I disagree with the new regulations of no sale at all. I cant afford pay anymore money to see anymore doctors every 6 weeks. I understand misuse is an issue but that will always be the case with anything. Thank god I am leaving this crapy country soon. Its definitely going downhill quick. I am sick of the over regulations!!” said Jane Palmer.

PPA’s Matt Harris argued that the Guild played a role in the decision as pharmacy’s largest lobby group.

“Surely the Pharmacy Guild can’t be that surprised at the govt’s decision to upschedule codeine?” he wrote on social media.

“The Guild needs to accept its role in the government’s decision to up-schedule codeine. You can’t preside over a system that has seen pharmacists’ workloads increase, the rise of a discount model, and appalling low pay and expect that there won’t be any consequences.”

Many large organisations also put forward their views on the issue. Read more here:

Guild responds to codeine decision

ASMI on codeine

PSA on decision

RACGP and NPS MedicineWise respond to upscheduling decision

Reasons for upscheduling: TGA

You can also participate in our forum on the issue.

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9 Comments

  1. Kevin Hayward
    22/12/2016

    The grumblings about Australia upscheduling codeine make no sense to me, whats all the fuss about?

    I have always followed the advice of the BNF (British National Formulary) ” Compound analgesic preparations containing paracetamol or aspirin with a low dose of an opioid analgesic (e.g. 8 mg of codeine phosphate per compound tablet) are commonly used, but the advantages have not been substantiated. The low dose of the opioid may be enough to cause opioid side-effects (in particular, constipation) and can complicate the treatment of overdosage”

    Bearing this in mind I have always been reluctant to supply a compound product where a monotherapy would be safer and may be just as effective. For example in dental pain the BNF says “Combining a non-opioid with an opioid analgesic can provide greater relief of pain than either analgesic given alone. However, this applies only when an adequate dose of each analgesic is used. Most combination analgesic preparations have not been shown to provide greater relief of pain than an adequate dose of the non-opioid component given alone. Moreover, combination preparations have the disadvantage of an increased number of side-effects.”

    • Ron Batagol
      22/12/2016

      I agree with Kevin.
      The change to S4 in 2018 is happening here anyway, and is in line with trends in many other countries.

      Leaving aside the specific addiction issue, over the years , with easy community access to Codeine, we have had a drug for which there was a vast spectrum of individual 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.

      With Codeine going to S4 in 2018, I would suggest that pharmacists will have the opportunity to have an increased positive influence in assisting patients with pain relief, since, it seems quite obvious ( already occurring!), that the manufacturers will start to move over and promote NSAID/Paracetamol alone or as combination products as a first-line for pain relief.

      So, think of the increased counselling opportunities:

      Paracetamol: Safe within properly assessed weight-adjusted dose range, but hepatic risk caution at high end and repeated use.
      NSAIDs: Managing G-I issues and potential adverse renal consequences in susceptible groups requiring counselling ( fluid-compromised, but otherwise healthy individuals, the very young and elderly, including those with who are otherwise renally -compromised, and the cautions that we are aware of, in people with cardiac issues).

      Let’s face it. Pharmacists are, hopefully for the most part, already carrying out advisory and counselling roles with OTC products containing these drugs, but pharmacist intervention and counselling opportunities will be more prevalent, with the likely scenario of greater numbers of requests and sales, of Paracetamol/NSAID products.

      • Sahar Khalili
        22/12/2016

        The stats are in guys – I can confirm: Ron is a robot.

        Or severely out of touch.

        “Increased counselling opportunities”? Do you even practice anymore?

        • John
          23/12/2016

          Indeed, ‘a big trend’ in Germany in the 30s turned out to be awful. This Neoliberal govt just wants to finish off everyone with chronic pain

        • Debbie Rigby
          21/07/2017

          RESPECT
          Criticise the comment or provide an alternate view, but please don’t attack the person.

    • Kaveh Sarraf
      23/12/2016

      I personally think all this will do is push those with addiction issues towards other products that are readily available OTC. Things like Rikodeine, Dextromethorphan and Phenergan to carry them over till they get their next Codeine script filled.

  2. JimT
    22/12/2016

    Making them Prescription only, doesn’t stop the problem. Those who are desperate will doctor and pharmacy shop to get supplies. Assuming they will be private scripts, it misses the chance of multiple supplies being picked up. All supplies need to go through a “Pseudo Stop” style of database, as should any drug of potential abuse. Such a simple solution is already available………..

  3. Tien
    22/12/2016

    MedsAssist purpose and influence has just been superseded by upscheduling. Patients will soon assess why bother seeing the GP to get a script for paracetamol/codeine 500/10 when they can request stronger meds like paracetamol/codeine 500/30 or tramadol, or even Oxycodone. Maybe all in larger quantities.

    Pharmacist will ask themselves, is it worth their effort in time/labour/benefit to continue using MedsAssist, which will soon be discarded like a Apple IOS upgrade, where the previous operating system is no longer supported and relegated to obsolescence.

  4. John
    23/12/2016

    I can only assume that the people who made this decision have no idea how bad chronic pain is, and think everyone has unlimited funds to see doctors. Also that those doctors will be totally understanding of the diabolical invisible pain that some people have

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