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

The Sunday Telegraph (Sydney) - Body and Soul - - REPORT -

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.”

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