150 tablets a day: Codeine rescheduling will put pressure on Hunter drug and alcohol services

AT the peak of his addiction, John was taking between 100 and 150 tablets containing codeine a day.

Drugs such as Panafen Plus – which contain ibuprofen and codeine – were readily available over the counter, and gave him an “amazing sense” of well-being, euphoria and contentment.

“Even the most mundane task is elevated with the use of opiates,” the Hunter man said.

John, not his real name, has been receiving treatment for his addiction, which began after a schizophrenia and anxiety disorder diagnosis, but he feared for the “droves of users” who would find themselves without a legal supply of opiates once the Therapeutic Goods Administration changed codeine to a prescription-only drug come February 1.

“Even in an ideal world, where those users, instead of turning to other drugs or illegal opiates like heroin, fentanyl, oxy, etc went and sought treatment at facilities, we can’t accommodate them because there aren’t enough beds/doctors/nurses and allied health care professionals in the system as it is to deal with our current problem, let alone an influx of new patients,” he said.

It is a fear echoed by Newcastle GP Dr David Outridge, who works in addiction medicine. He said it was difficult to know how big the problem was until the changes came into effect, but he had helped many patients who had been taking 90 Nurofen Plus a day.

“It’s hard to believe that the body can get used to that,” he said. “But codeine will create a very serious dependence.”

He said many people began taking codeine for pain relief, then began to enjoy the way it made them feel, and how it helped them cope.

“People become tolerant to the existing dose,” Dr Outridge said. “The body adapts to that level of opiate, and then trying to stop means you’re going into free-fall.”

Some ended up in intensive care with stomach ulcers, and kidney and liver damage. Dr Outridge warned that a different demographic of drug addict would emerge once the changes to the availability of codeine came into effect, and he was concerned that drug services were under-prepared.

He said opioid treatment programs were generally geared towards people who have been in the illicit scene – turning to crime, dealing, or prostitution to get their hands on opioid.

“What’s going to happen with this is that a completely different demographic of people are going to emerge. They might be running a business, they might be a student,” he said.

“And these people will find it difficult to fit into the existing public services. They may not seek help because of the fact those services tend to be more aligned with people who have been in a much heavier scene –rather than just going to a chemist and buying them over the counter.

“That’s why GPs are the ideal to take those clients on.”

Dr Outridge knew of about 20 “opioid maintenance program” prescribing doctors like himself in the area – not enough to cope with the influx of people who would need help come February.

“Some people will be able to come off their codeine. Others will not. They will be not just physically-dependent, but addicted, and those people will need some sort of opioid replacement program,” he said.

“There is just not enough prescribers of the replacement program medications, such as Suboxone, for those patients to be catered for.”

Dr Outridge said Suboxone – a combination of buprenorphine and naloxone – was a “very safe” alternative to addictive opioids, and a safe alternative to methodone – the established “gold standard” for opiate maintenance programs.

When it was introduced in France, all GPs could prescribe it, with no special training.

“Their opioid overdose death rate plummeted to negligible overnight, and it has been that way ever since.”

He would like to see more GPs become opioid maintenance program prescribing doctors to take on more of these patients.

“GPs are already fairly busy, but possibly the stigma attached to substance use means a lot of GPs don’t want to get involved with it.

“But the thing with the codeine-use demographic is that they are the normal people we see as patients anyway, they are not people with a forensic history. These are people who fit quite well into general practices.”

Professor Adrian Dunlop, Hunter New England Health’s director of drug and alcohol services, said it was difficult to gauge the scale of the problem until it happened, but he was confident local services would be able to meet the demand.

“We don’t have a good hard figure on exactly how many people are dependent on codeine,” Professor Dunlop said. “At best the figures are pretty woolly.

“We expect there will be people who are minimally-addicted, just using a bit too much too frequently, and they’ll stop. And then there will be a group of people who might need treatment.

“Their GP might work out a program with them which doesn’t necessarily include methodone or buprenorphine, but might include a more structured way to come off codeine. And then if that fails they might need methodone or buprenorphine maintenance.”

Nationally, less than five per cent of GPs offer the opioid treatment program.

“In the greater Newcastle area, there are 14.  Across the whole Hunter New England Health region, we think there are about 50,” Professor Dunlop said. “Patients should start talking to their GPs about their concerns now, not wait until the end of January.”

Professor Dunlop said if some of the accreditation “hurdles” for the treatment program were removed it might encourage more GPs to become involved. 

John, now middle-aged, had been diagnosed with schizophrenia in his twenties, when he also developed an anxiety disorder.

Initially, he self-medicated with marijuana. He admits it was a “terrible choice,” as it reinforced his anxiety and exacerbated his hallucinations.

“However, I noticed when I took pain killers for tension headaches, the euphoric effect of the opioids would temporarily alleviate my anxiety, as well as my headaches, and it soon became my drug of choice replacing marijuana altogether.

“My addiction dictated my entire life. In the beginning, before any regulations were in place, I could frequent the same pharmacies and just grab what I needed off the shelf no questions asked. Then when they started to bring in regulations, I had to drive up and down the coast doing pharmacy runs to stock up my supply.”

John ended up requiring bowel surgery due to complications caused by the volume of pills he was taking.

“Prior to that I was taking ridiculous amounts of antacids to treat the reflux from the ibuprofen, and vomiting every day when it got too much for me,” he said.

“If I tried to decrease the dose I would go through withdrawals quite rapidly – severe headaches, fever, vomiting.

“I hope the prevalence of codeine addiction is acknowledged when determining front line treatment services in the public and private sector. The public system is already inundated and is crying out for help.”

Professor Dunlop said there could be some “stockpiling” of codeine ahead of February, although he did not think it was likely a black market would develop.

“I don’t think, in Australia, we’re going to see what has occurred in the US, which is a rise of heroin-related deaths, but we do need to monitor it,” he said.

For help and advice for a drug or alcohol addiction, call 1800 422 599.