THE extent of the Australian community’s problem with codeine dependency will reveal itself over the coming months as the full effect of this month’s rescheduling of the drug to prescription-only is felt.

Dr Hester Wilson, Chair of the Royal Australian College of General Practitioners Addiction Medicine Network, said that she was not sure there would be a “tsunami of people seeking help” for codeine dependency, as some had predicted. But, she said, there would be a range of patient responses to the regulatory change.

She said that many people will be able to easily transition to using safer, more effective over-the-counter analgesic products, while others may have more difficulty.

“Some people have been taking 40–60 tablets a day, [and subsequently] having to race around to various pharmacies to get access to the medicines and having significant side effects from them, including gastric bleeds and liver and kidney issues, and also becoming dependent,” she said.

Writing in the MJA this week, researchers from the National Drug and Alcohol Research Centre at UNSW Sydney, reported the findings of a systematic review of 41 eligible studies on the identification and treatment of codeine dependence.

They said that doctors should be on alert for signs of opioid use disorder in patients.

“Careful questioning about recent patterns of use, the reasons for taking codeine, and withdrawal symptoms upon cessation may help identify when a patient should be comprehensively assessed for an opioid use disorder,” they wrote.

“Our review of codeine-dependent people indicates that approximately equal proportions of men and women are involved; their mean age is greater than for patients treated for problematic use of other opioids, the prevalence of mental health comorbidity is high, identification of dependence is often delayed, and patients experience serious complications [such as gastric bleeds] associated with excessive consumption of combination products that include codeine,” the authors wrote.

They also described the evidence for several treatment strategies including opioid taper, opioid agonist treatment, and psychological therapies, and found that there was low quality evidence indicating that positive outcomes could be achieved with opioid agonist treatments, combined with psychosocial adjuncts.

“In particular, buprenorphine treatment undertaken according to current guidelines was commonly described,” they wrote.

“Studies of opioid taper found that relapse was common (consistent with taper for opioid dependence in general). Taken together, the treatment studies and case reports provide evidence that opioid agonist treatments, combined with psychosocial adjuncts, may be suitable and acceptable to patients. The evidence, albeit low in quality, indicates that positive treatment outcomes could be achieved with these approaches.”

Lead author Dr Suzanne Nielsen told MJA InSight that previous research had shown codeine dependency to be a “very hidden problem” and that the systematic review found a high prevalence of comorbid mental health problems in codeine-dependent people.

“People are quite embarrassed or ashamed to have developed a problem with a pharmaceutical medication, particularly an over-the-counter one. So, I think when we look at our treatment data, that’s likely to be the tip of the iceberg, because many people try to manage it themselves or don’t seek help,” Dr Nielsen said in an MJA InSight podcast.

Dr Wilson said that the rescheduling of codeine provided GPs with the opportunity to help patients who had developed problems with codeine.

“It’s a chance for us GPs to help people who are having trouble with codeine and are at risk of really significant harm,” Dr Wilson said. “And it’s also a chance to actually diagnose [underlying clinical issues] and consider what are safe and effective treatments for the individual’s particular issues.

“My concern is that we will see some people just being given bigger doses of codeine, which don’t actually address the complexities of some of the issues.”

Dr Wilson said that aside from its potential to cause harm, codeine was “not a great opioid”. She said it was a prodrug that was metabolised to morphine, but patient responses varied.

“Some people don’t metabolise it at all, and others metabolise it very strongly,” she said.

“If you’re thinking that a patient has enough pain that they need morphine, don’t treat them with a drug that you don’t know quite what it’s going to do.”

Dr Matthew Frei, Clinical Director of Turning Point, Eastern Health, said that there was growing awareness of the broad impact of codeine dependency in the community.

“Codeine dependency doesn’t discriminate. You don’t have to be someone who has been in and out of jail, living in the criminal underworld to be an opioid dependent person,” he said, adding that it could be a 40-year-old woman, working part-time and living in suburbia who could develop a codeine dependence.

Dr Frei said that he also hoped that the rescheduling would encourage more GPs and pharmacists to get involved in managing opioid dependency with drugs such as buprenorphine and naloxone.

“The silver lining in this process is that it will hopefully encourage more GPs and pharmacists to get involved in opioid treatment,” he said.

While Dr Frei acknowledged the many competing demands in primary care, he said that, with support, GPs could become more involved with management.

“It will require something of a culture change, and is a fairly big step for many GPs,” Dr Frei said.

Dr Nielsen agreed that patients with codeine dependency could often be effectively managed in the primary care setting.

“These patients have great prognostic indicators – they do have good social support, they are often employed, they don’t have histories of other substance use, they don’t have history of injecting opioids,” she said.

However, Dr Wilson said that many unanswered questions remained about how GPs would manage patients with codeine dependency in the primary care setting.

“For the vast majority of GPs, managing opioid dependence is not seen as part of what they do, it’s seen as more specialist management,” she said, adding that time and funding limitations in primary care also restricted GPs’ involvement in the management of codeine and other opioid dependency.

Dr Wilson said that there were guideline changes in the pipeline in NSW which would allow GPs to commence patients on buprenorphine or naloxone, and GPs in South Australia were already doing this.

But, she said, greater support was needed.

“We are not going to have GPs knocking on the door and wanting to do this work, unless they have support from the drug and alcohol setting. We need to be able to step up and provide that support for GPs,” said Dr Wilson, noting that efforts were underway to provide better support for GPs, including initiatives by Primary Health Networks.

“There is good work happening in that space, and drug and alcohol services are attempting to respond to these initiatives, and work with their Primary Health Networks to better manage opioid dependency.”

 

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Poll

There's an emerging group of patients who are just discovering that they are codeine dependent
  • Agree (40%, 33 Votes)
  • Strongly agree (23%, 19 Votes)
  • Neutral (20%, 17 Votes)
  • Disagree (12%, 10 Votes)
  • Strongly disagree (5%, 4 Votes)

Total Voters: 83

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9 thoughts on “Hidden codeine dependency set to reveal itself

  1. Anonymous says:

    I really wonder if this has been a good move or not. Sure there are people who are taking too much Codeine but what do patients with chronic pain do now. There are many patients who were on small doses of codeine for years and well controlled. Now they face regular extra visits on an over worked medical community, risk of being put on tricyclics, gabapentin , lyrica or high dose NSAIDS with GIT bleeding and hypertension or God forbid oxycontin.
    Their whole world is turned upside down and as they are busy and will not be viewed as urgent they will feel like putting up with the pain.
    It is time we had some sympathy for our chronic pain patients and find a better solution.
    Cars kill but we do not ban driving .

  2. Randal Williams says:

    I think this should have been phased in over a longer period, with pharmacists and GPs exhorted to counsel patients each time codeine requested, indicate its unavailability long term and the need to find better pain strategies. Although there was advance publicity about removal of paracetamol/codeine and ibuprofen/codeine from pharmacy shelves , most of it was left to the last minute, driving patients to stockpile the medication. In this transition period I believe pharmacists should be able to supply small amounts eg six tablets to a patient in need, especially where immediate GP services are not readily available. I think the process has been rushed, and unnecessarily harsh on those dependent on the medication. prolonged use of buprofen/codeine has the potential to do more harm than paracetamol/codeine, and i have no problem with ibuprofen /codeine being removed from pharmacy shelves.

  3. Anonymous says:

    Dependencies on any pharmaceutical are generally not good. But really hidden dependencies to Codeine, where is the concomitant evidence of Paracetamol overdose? Nowhere to be found, oh what a surprise, NOT.
    Ok so if it can be unequivocally proved that there is a significant rate of such a dependence what is the the cost Vs the cost of primary risk negating education and increased costs to Medicare to obtain a prescription? Indeed such information must be on the public record else we have been dudded again by brainless do gooders.
    I’d like to bet that this Nanny State backward measure will cost taxpayers more than it will save.

  4. Randal Williams says:

    in reply to Anonymous there is no evidence of paracetamol overdose but there is evidence of a rise in peptic ulceration with complications such as gastroduodenal haemorrhage and perforation in those addicted to ibuprofen/codeine. Typically these have been young women initially taking the medication for dysmenorrhoea.
    I would have been happier to see this taken off pharmacy shelves but regular paracetamol /codeine ( 8gm only) left to the pharmacist discretion to dispense.

  5. Anonymous says:

    In reply to Randal Williams, indeed you are correct in regards to ibuprofen/Codeine however, as you are well aware the problem is the Ibuprofen and not the Codeine! In addition, and you may also agree that it is repugnant and offensive that advertisers are now using high volumes of Ads to plug the benefits of Voltaten Rapid for pain relief. So we are sure to see a further increase of the complications to which you refer.

  6. Anonymous says:

    Brace yourselves not for tsanami of hidden codeine addicts but for a tsanami of GIT bleeds as chronic pain patients deprived of their panadeine and trying to do without will turn to NSAIDS and unaware of the danger will take too much.
    I saw on the TV tonight an add stating that an NSAID was just what was needed for acute pain but no mention of side effects.
    Good GPs have been relieving pain by asking their patients to take panadeine for years and check to see that the dose is satisfactory. It wasn’t broken and did not need fixing.
    I suspect the problem is that the experts deal with true addicts and fail to realise that normal patients are sensible as are their GPs. Wrong move.

  7. Anonymous says:

    In response to tsunami of GIT bleeds. 100% agree.
    Without going into detail the Australian measures to restrict Codeine use are purported as being in the public interest because of a “hidden epidemic” bare the hallmarks of yet another knee jerk reaction by Australian authorities who all too often are heavily reliant on research conducted in the USA because of funding shortfalls.
    Erin Krebs and colleagues have conducted a vast amount of valuable research into Codeine usage however, it is not all relevant to Australia and the Australian health system.

  8. Anonymous says:

    Randall Williams, “the process has been rushed” LOL!

    The proposal was first formally considered TEN YEARS ago. At that time a compromise proposal was agreed that reduced the pack sizes of the low (subtherapeutic)-dose codeine products and made them legally require a pharmacist’s personal intervention in the sale. This didn’t work, abuse, misuse and adverse events caused by the products continued to escalate. The proposal was considered again in 2015, the decision delayed until 2016, after an impact statement found the health benefits in dollar terms would be 20 times the costs. The date of effect of the change was delayed until 2018. This has been the longest, most thoroughly considered, most widely consulted and most publicly transparent decision in the history of medicines regulation in Australia, which is just catching up with most other developed countries where all codeine has been prescription only for many years, even decades.

    Compare e.g. France which announced last July that similar codeine products would go to prescription-only, to take effect THE NEXT DAY.

  9. Anonymous says:

    The current tsunami of GIT bleeds/gastric perforation is in fact one of the main reasons for this change. Just one hospital spent $1million over 5 years treating patients who had overdosed on ibuprofen/codeine combinations to get high on the codeine.

    We should now see a lot FEWER overdoses of NSAIDS, which are nonaddictive; patients rarely if ever overdose on NSAID-only products.

    Anon #6, logically you should have been much MORE appalled by the TV ads screened before 1 Feb stating that an NSAID/codeine combination was just what was needed for acute pain but no mention of side effects.

    And no the codeine/paracetamol combination is not much better. Paracetamol overdose is more insidious (patients notice few symptoms until days later when the liver has been irreparably and often fatally damaged.

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