THE CODEINE CRACKDOWN
In less than three months, a raft of over-the- counter painkillers and cold medicines will become prescription- only in a bid to reduce codeine-related addiction and death. Liz Graham reports
If you take Panadeine Extra, Nurofen Plus or Mersyndol, prepare for big changes. On February 1, all codeine-containing medicines sold over the counter will become prescriptiononly. With about one million Australians taking medicines that contain codeine, the effects will be far-reaching, with greater demand on GPs and pain specialists, and thousands of people rethinking their relationship with this powerful drug.
Codeine access isn’t a new concern in Australia: Over the past decade there have been restrictions made, such as smaller pack sizes, making consumers speak to a pharmacist before purchase, and having voluntary codeine monitoring in many pharmacies. Compared to those inconveniences, what’s about to happen is a major disruption. But that’s a good thing, according to pharmacist and NPS Medicine Wise spokesperson Aine Heaney.
“If codeine were to come on the market today and be assessed, it probably wouldn’t make the cut in its low-dose form,” Heaney says. “It’s not a good pain reliever, plus it carries a high risk of side effects and dependence.” She adds that Australia is now “catching up with the rest of the world” with these changes – the US, most of Europe, Hong Kong and Japan already have codeine as prescription-only.
Here’s what the changes mean for you.
WHAT’S OFF THE SHELF
Codeine is an opioid, a type of narcotic, and over-the-counter medicines contain a “low dose” of between 5mg and 20mg per tablet. The medicines fall into two categories:
● Painkillers with codeine, including Panadeine, Panadeine Extra, Nurofen Plus, Mersyndol and generic pharmacy versions. All of these also contain another analgesic such as paracetamol or ibuprofen.
● Codeine-containing cough, cold and flu products (tablets and syrup), such as Codral and Demazin, and generic versions. Codeine is often combined with an analgesic and antihistamine and/or decongestant.
From February 1, all of these will require a prescription. It hasn’t yet been confirmed if the price of the drugs will go up, and at time of print, the states and territories were in discussions about including conditions for certain groups of the community. Some low-dose products could be reformulated without the codeine to remain over-thecounter, while others may disappear (GSK has said its entire over-the-counter codeine range, including Panadeine and Panadeine Extra, will exit the market on February 1).
Some people may not even know that a product they take contains codeine, and Dr Bastian Seidel, president of the Royal Australian College of General Practitioners, says that’s why pharmacists have started talking to customers: “They’re explaining that a prescription will be needed soon, so GPs are already getting patients wanting to talk about codeine and their conditions.”
THE PROBLEM WITH CODEINE
Recovered codeine addict Paula Ellis, 49, believes these changes will make a big difference. “I stopped using codeine medicine two years ago after I had kidney failure, but I would have done it earlier if codeine were harder to get,” she says.
Ellis’s story isn’t uncommon: She began taking her mum’s painkillers when she was just 13, for bad migraines and period pain. “That’s what was around, and it seemed to work,” she says. Over the next 34 years, she combined prescription and over-thecounter drugs in increasingly dangerous ways, often visiting multiple chemists in a day to stock up on codeine. “I felt like I couldn’t function without it – at my worst I was taking 40 tablets a day, as well as using Fentanyl, an opioid patch.”
Kidney failure two years ago (caused by long-term codeine misuse) was a turning point, and she began lowering the strength of her patch dose, before going into rehab to get off the pills. It wasn’t easy, but she’s now looking forward to her 50th birthday free from painkillers and being around for her two children and future grandchildren.
Ellis spent decades as an addict and now has long-term health issues, but she’s one of the lucky ones. Codeine-related deaths doubled between 2000 and 2009, and there are now as many as 150 codeine-related overdose deaths a year. Of these, 40 per cent are from over-the-counter products.
A recent study of codeine-related hospital admissions published in the journal Drug Alcohol Revue showed the average patient with chronic pain consumed 28 codeinecontaining tablets a day (several times the recommended dose) for at least two years, and cost the hospitals more than $1 million. Seidel says long-term use can also lead to liver and heart issues and internal bleeding.
So why is codeine so addictive? Quite simply, it’s because it becomes morphine once it’s metabolised by your body, Heaney explains, and some bodies metabolise it faster than others. “It gives a small euphoric effect and can also reduce anxiety,” she says. “Ultra-metabolisers get a quick hit, putting them at higher risk of dependence.”
For all the risks of addiction that codeine poses, many experts say it doesn’t even do its supposed job of easing serious pain. “In low doses, it’s no better than analgesics,” Heaney says, adding that in higher doses it helps acute episodic pain, like after surgery, but not chronic pain – a recent 12-month
study presented at a major US medical conference found that even higher-dose opioids don’t treat lower back pain better than ibuprofen or paracetamol.
Seidel says that 20 years ago doctors were told that codeine was excellent for treating pain, resulting in its widespread use. “We underestimated its harm, and we know now it doesn’t really work.”
WHAT TO DO NOW
A pharmacist can talk you through the options. “A sports injury may be best suited to an anti-inflammatory like ibuprofen, while central pain may need an analgesic like paracetamol,” Heaney says. The more information about the pain (what it feels like, Some of the products affected include Nurofen Plus, Panadeine and Panadeine Extra, Panafen Plus, Mersyndol, Dolased and Strong Pain Plus. where it is, when it’s worse), the more help you’ll get. Old remedies are often effective, she adds. “Things like elevation for a swollen ankle, or ice chips for a sore throat. We need to exploit the body’s natural analgesics.”
Seidel says that GPs want to come up with safer plans around codeine use, and gives the example of a patient of his who takes codeine for infrequent migraines: “She only has a supply for 48 hours, and if the symptoms continue, she has to see me.”
There’s no shame in telling a doctor how much codeine you take, Seidel says, adding that the most important thing is getting the right treatment. “There may be people taking codeine for what they think is a migraine but they’ve never had a formal assessment,” he says. “It could be another medical issue that presents like a migraine – they need to be assessed and treated properly.” If you take over-the-counter codeine regularly or daily, it isn’t recommended that you quit suddenly. “It will be different for everyone, but generally we don’t recommend cold-turkey.”
For chronic issues, a GP will ask about the pain and how it affects your life, and look at ways to manage it. “We’re not trying to eliminate pain any more, that’s not realistic,” Seidel says, adding that a multi-disciplinary approach is best. “We’re guiding away from medicines and more to manual therapies, exercise and relaxation techniques. There’s no quick fix – it’s a long game we’re playing – but many patients really can come off medicines they’ve been taking for years.”