Schedule changes didn’t dent codeine misuse


codeine tablets, glass of water

Changes made to OTC codeine combination products in 2010 failed to make a dent in the growing misuse of the products, a new study has found.

But the new codeine real-time monitoring system may succeed where rescheduling failed, says one pain expert.

The researchers, from the University of Sydney and Children’s Hospital Westmead, performed a retrospective review of calls about codeine misuse to the NSW Poisons Information Centre (Australia’s largest poisons centre) between 2004 and 2015.

The database contained 400 cases of codeine combination analgesic misuse during the period.

When analysed, the data showed that the frequency of cases increased significantly from 2004 to 2015, with an average annual percent change of 19.5% for paracetamol/codeine, and 17.9% for ibuprofen.

“No significant change in trend was seen at any time, including following 2010 rescheduling,” the authors write.

“Misuse of codeine combination products appears to be increasing in Australia. Limited rescheduling in 2010 failed to curb this increase.”

But if the study was to be done again in five years, the codeine misuse landscape could look different, pharmacist and pain expert Karalyn Huxhagen told the AJP today.

“Moving the schedule from pharmacy only to pharmacist only, while it allowed pharmacists to identify patients that they would see more often, still didn’t give us access to dispensing records from other pharmacies,” Huxhagen says.

“So you only saw your own isolated purchases. And the problem is that codeine-seeking customers became very adept at moving around to vary their purchases to avoid being detected.

“This is why programs such as MedsASSIST are being welcomed by community pharmacy.”

She agrees that misuse of codeine-containing OTCs is growing, “but that’s not pharmacy’s fault”.

After pack sizes were reduced to combat misuse, customers simply became more clever and careful about planning their purchases, she says.

She said a colleague recently found several packets of a Mersyndol-type drug thrown over her back fence – each label with the same person’s name and the same date, from four different pharmacies.

More than a few codeine-seeking customers have also been misusing the children’s pain reliever Painstop.

“Sometimes they’ll come in and ask for five bottles at a time!

“I certainly do think things could look very different in five years because of MedsASSIST. It gives us a support tool to have a firmer discussion with the customer, with the knowledge, hopefully, that they will go to the next pharmacy and get exactly the same firm discussion about going to see a physio, or taking magnesium, or using heat wheat.

“Combined with pharmacists applying their knowledge, it’s a great tool.”

Huxhagen cautions that pharmacists will need to be able to offer advice and education about alternative strategies for pain management, including visiting GPs and other allied health professionals such as physiotherapists and occupational therapists.

However she says she is concerned that some GPs will write scripts for stronger drugs, and that this should be avoided.

“The other side of this problem is that pharmacists have always needed to offer guidance about the alternative – what do you offer to patients who are so caught up in their pain cycle, whether it’s rebound headaches or chronic back pain?

“Even when they go to the GP they’re often given things that are so sedating or overpowering that they come back to the pharmacy and say, ‘I want lower-dose codeine, I can’t function on this higher level narcotic medicine’.

“The GP handing out high-level narcotics is not fixing the problem or the fact that the patient wants to work, function and have their pain managed.”

Last week the TGA again delayed announcing its final decision on the possible rescheduling to prescription-only of codeine-containing medicines.

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3 Comments

  1. Nicholas Logan
    17/05/2016

    Very good points Karalyn. 60% of the traceable, codeine related deaths between 2000 and 2013 were from prescribed codeine rather than OTC codeine so clearly up-scheduling is not the answer. A well managed and convenient OTC supply delivered with a suite of options will be revolutionary for acute pain management in Australia.

  2. Jim Wallace
    17/05/2016

    MedsASSIST is a great program, but it won’t work unless it’s adopted universally.

  3. Russell Smith
    17/05/2016

    So this study amounts to slightly less than 40 cases per annum over 10-11 years, and if approx 60% of these related to prescribed pain relief, then approx 40% related to otc pain relief – that is, if the study can be related to the deaths scenario – which may not necessarily be the case. However 40% of 40 cases is only 16 cases, so instead of no significan trend being seen at any time, including upscheduling, theres no significant anything to report on here to do with pharmacy at all. In reality its more to do with just a few stupid people misusing medication, and neither pharmacists nor upscheduling is likely to have much effect on the stupidity of these individuals. Anyone got any evidence to the contrary?

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