Over-the-counter codeine could be controlled with compulsory real time monitoring system

A shifting burden: Hunter pharmacist John Jones warns that people suffering migraines and toothaches may have to visit hospital EDs for late night pain relief when they are unable to see an after-hours GP come February. Picture: Simone De Peak
A shifting burden: Hunter pharmacist John Jones warns that people suffering migraines and toothaches may have to visit hospital EDs for late night pain relief when they are unable to see an after-hours GP come February. Picture: Simone De Peak

REMOVING access to over-the-counter codeine products will put unnecessary extra pressure on GPs and hospital emergency departments (EDs), a Hunter pharmacist says.

But that could be avoided if a real-time monitoring system, similar to the one already used for pseudoephedrine, was made mandatory at all pharmacies.

John Jones, a pharmacist at Shortland Pharmacy, said when the Therapeutic Goods Administration (TGA) makes codeine a prescription-only medicine from February 1, people suffering migraines and severe toothaches would present to hospital EDs when after-hours GPs were not available.

“The biggest concern is access to appropriate pain management for people who need short term analgesia with a codeine-containing product,” Mr Jones said.

“And there are certainly a number of situations where it is an appropriate, clinical option for pharmacists to recommend. It takes that clinical decision out of our hands. Worryingly, and more importantly, it is removing access for people who need it and then burdening other parts of the health system to cope with it.”

It could potentially make it more difficult for people with more urgent needs to be seen.

Solution: Professor Peter Carroll says real-time codeine monitoring will help.

Solution: Professor Peter Carroll says real-time codeine monitoring will help.

“We’re fortunate to have a real-time monitoring system called MedsASSIST, which is similar to Project STOP, that is used to monitor pseudoephedrine use,” Mr Jones said. “It’s a good way for us to look at the usage, and identify those people who have a problem, or who aren’t managing their pain appropriately, and then help them create a better pain management strategy.”

But Mr Jones said the system needed to be made compulsory for it to work effectively. It is currently voluntary, with only 70 per cent of pharmacies using it.

“It needs to be mandated, like Project STOP,” he said.

“At the moment, there is no way for GPs to monitor someone’s opiate use. So you can go and see three different prescribers, get three different prescriptions, and present to three different pharmacies, and no one has any idea.”

Peter Carroll, a pharmacology professor from the University of Sydney and the University of Notre Dame​, said rescheduling over-the-counter codeine products was “a silly solution.” 

“All evidence shows that the vast majority of people who buy the over-the-counter codeine-containing analgesics use them appropriately and safely for short term treatment of acute pain,” Professor Carroll said.

“I don’t think we should be disadvantaging these people, inconveniencing them, costing them money to go to the doctor, when we have a simple solution with the real-time monitoring.”

Professor Carroll said there was “no debate” the alternatives, a combination of paracetamol and ibuprofen, would work – for some.

“Hundreds of thousands” of people could not take ibuprofen, but they could take codeine, he said.

“The people who want to use them after February 1 will have no option but to go to a GP or hospital ED.”

Professor Carroll said 10 per cent of people with asthma could not take ibuprofen, others on blood thinning and some blood pressure medications were also advised to avoid it, for instance.

Change is afoot: The TGA will soon make codeine prescription-only.

Change is afoot: The TGA will soon make codeine prescription-only.

He said the claims that low doses of codeine were not effective, were “just not true.”

“There is evidence to show it is not true.”

Professor Carroll said if doctors did not bulk bill, patients would have to pay the Medicare gap, and may have to take time off work to go to an appointment.

“In some rural areas – you can’t get in to see a GP for two or three days,” he said.

“You don’t need a doctor to diagnose period pain every time, and you don’t need a doctor to diagnose a toothache or a migraine.

“The bottom line, and the most sensible way out of this – and this is what we’re asking [NSW Health Minister] Brad Hazzard, is to make the real time monitoring of over-the-counter codeine products mandated in all pharmacies.

“All sales would be picked up and allow the pharmacists to continue to giving up to a three-dose supply of this product for the short term treatment of acute pain.

“It will identify the people that are potentially having a problem, and allow the pharmacist to try and get them some help.”

Professor Carroll said the argument that pharmacists were only fighting the changes to “maintain selling the products” was a “silly argument.”

“Even if people get a prescription from a GP, they still have to come back and buy it at the pharmacy. It is not about that. It’s about the community.”