Crackdown on codeine a response to dangerous behaviours

ISthe rescheduling of codeine this week to prescription-only an example of over-regulation that will make it harder for Australians to access pain relief, or a necessary measure to help prevent opioid-related harm in the community?

This has been a polarising debate in the health sector and the wider community since the Therapeutic Goods Administration (Australia’s regulator for medicines and other therapeutic goods) flagged potential changes to the availability of over-thecounter products containing codeine in April 2015. As of yesterday, February 1, all codeine-containing products available in Australia require a prescription, following similar regulatory changes in the US, Germany and Japan in recent years.

Codeine is an opioid painrelieving medication that is converted to morphine in the body in most people. Notably, the ability to convert codeine to morphine varies among individuals, so the response to codeine can differ markedly.

Until now codeine has been available without prescription in combination with other pain-relieving medications like paracetamol and ibuprofen. Codeine-containing products have been widely used in Australia, with over 27 million codeine containing products supplied by pharmacies each year, over half of which were sold overthe-counter.

Codeine containing products have been popular non-prescription pain relievers for the simple reason people have found them to be effective for short-term pain (eg dental pain, joint pain, headaches).

The difficulty with this is that these products contain two active pain-relievers, and there is debate about whether codeine actually provides pain relief additional to that of the other pain-relieving ingredient present in the product.

The most recent well controlled study found there was no difference in the level of pain relief experienced by patients with acute pain who took a combination of simple analgesics (paracetamol and ibuprofen) compared to those who took products containing codeine (or other opioid medications) at similar doses to Australian over-the-counter products.

Put simply, there is a lack of compelling scientific evidence that products containing codeine, when given in low doses like those found in overthe-counter products, are more effective than other pain reliving medications available without prescription.

It is important to recognise that over-the-counter products available from pharmacies are generally intended to be used for the management of short-term minor conditions (eg colds, heartburn, tinea). Despite the way in which some people used over-the-counter codeine products, they were never intended to be taken on a long-term basis for chronic pain. Ongoing pain or inadequate pain relief should always be discussed with a health professional.

The main problem with codeine, even in the low doses in over-the-counter products, is that over time tolerance occurs. This means higher and higher does are needed for people to feel the same relief from their pain. This creates a risk that people will take more than the recommended amount to achieve adequate

People are better off combining simple analgesics to relieve pain, says Luke Bereznicki

pain relief, which increases the risk of problems associated with codeine as well as the other pain-relieving medication in the product (eg stomach ulcers, kidney or liver failure). Withdrawal effects can occur which potentially lead to continued use of codeine and the use of higher doses over time.

For a significant number of people this pattern of use has led to serious problems (including cardiovascular disease, kidney and liver damage), and there have been a series of deaths each year in Australia attributed to excessive codeine use. Additionally, overuse of codeine-containing products is a common reason for people to seek treatment for drug dependency. For example, of the people seeking treatment for opioid dependence in a study in Sydney, about 40 per cent had been using codeine as their only opioid substance, and more than 8 in 10 of these reported having only used over-the-counter codeine.

While some people will find the rescheduling of codeine-containing products frustrating and inconvenient, the reality is that there are other effective pain-relieving products available for shortterm use without prescription from pharmacies.

Pharmacists are an important source of information and advice about pain management, and will refer patients to their general practitioner if over-thecounter options are not suitable or if they prove to be ineffective. There are a range of options including prescription medication, non-medicine options (eg physiotherapy, exercise, relaxation techniques) or referral to a specialist or pain management clinic.

The rescheduling of codeine to prescription-only is intended to be a step towards reducing opioid-related harm, but obviously is it only one part of the solution to a very complex problem we face in our community. It may take some time to adjust to the change, but there are a range of alternative options available to manage pain.

If you are worried about how you will manage without codeine, talk to a health professional. There are several support services available, including NPS Medicine-Wise (1300 633 424) and the Pain Link Helpline (1300 340 357).