February 2018

The what, when and why of the codeine rescheduling

Misuse of prescription and over-the-counter medications is a growing issue in Australia. One particular problem is the misuse of codeine, which is found in many common over-the-counter medications for pain, colds and flu, and cough syrups. This misuse can cause opioid dependence and can be deadly, with the Australian Medical Association reporting that deaths relating to codeine more than doubled between 2000 and 2009.

Dr Suzanne Nielsen, senior research fellow at the National Drug and Alcohol Research Centre (NDARC) at the University of New South Wales has been investigating codeine misuse.

“There are an increasing number of people who are experiencing problems with codeine,” Suzanne says.

“Although exact data on how many Australians are developing problems with codeine is not clear, in our convenience samples one in five codeine people who use codeine meet criteria for dependence,” she says.

In order to help reduce harms related to codeine, the Therapeutic Goods Administration (TGA) announced in 2016 that it would change how codeine can be accessed.

Although exact data on how many Australians are developing problems with codeine is not clear, in our convenience samples one in five codeine people who use codeine meet criteria for dependence.

Dr Suzanne Nielsen

Dr Suzanne Nielsen

From 1 February 2018, medications that contain low doses (15mg or less per tablet) of codeine that have previously been available over-the-counter in pharmacies and supermarkets require a doctor’s prescription. The change makes Australia consistent with Japan, the United States and many European countries.

Medications that are now prescription-only include:

  • Nurofen Plus
  • Mersyndol
  • Panadeine
  • Some cold and flu medicines
  • some cough syrups
  • Any of the generic painkillers and pharmacy medicines that contain codeine.

Codeine belongs to the opioid family, which also includes heroin, morphine, oxycodone and fentanyl, which are powerful and addictive painkillers. Codeine is commonly used to treat pain, coughs and diarrhoea.

But despite the fact that codeine is in the company of such strong drugs, the TGA reports that the low doses of codeine that’s in these common medicines has little effect on symptoms when compared to products without codeine.

For people currently misusing codeine, the change in access (rescheduling) could trigger some significant issues, says Crios O’Mahony, project lead at Penington Institute.

I’m concerned that people who are misusing codeine are stockpiling it. They may alternatively move on to other drugs, which might make things more dangerous.

Crios O’Mahony

“The rescheduling is going to make codeine harder to get and the idea is that you have to go to a doctor to get a prescription,” Crios says. “But I’m concerned that people who are misusing codeine are stockpiling it. They may alternatively move on to other drugs, which might make things more dangerous.”

Crios says that there is also concern that users could switch from swallowing codeine to injecting it or injecting other types of medication. Injecting affects a drug’s potency and the speed that it hits the system. This also brings all the risks of injecting, including vein damage and blood-borne virus transmission from sharing injecting equipment.

While the misuse of codeine may relieve pain and even provide a feeling of euphoria, there are many negative side effects. If a person begins to take more and more of the drug to achieve the same effects this brings the risk of decreased lung function and other medical complications including organ damage, coma and death.

What’s more, codeine-containing medicines that are currently available over-the-counter are usually combined with either paracetamol or ibuprofen. Long term use of high doses of paracetamol can result in liver damage and the most severe adverse effects of long term ibuprofen use include serious internal bleeding, kidney failure and heart attack.

Suzanne says there is still the prospect of people accessing codeine through prescriptions. She adds that preliminary research with people who use codeine indicated that most were unlikely to use other drugs or alcohol.

“The research also said that codeine users wouldn’t be turning up to emergency departments, which was a concern of ours. But what they did say was that they were likely to visit a GP to seek an alternative, so that’s what we’re expecting.”

Crios says that NSP workers should talk to their clients who misuse codeine about the possible effects of the rescheduling change and to use it as an opportunity to discuss safer drug use and drug treatment.

“This is an opportunity to engage with clients and provide them with information. NSP workers should also talk about overdose risk and using filters to reduce the risk of harm, because if people start injecting codeine or using other drugs, then that increases the risk of overdose.”

The Australian Medical Association and the Pharmacy Guild of Australia were at odds over the rescheduling decision, with reports that the Guild was lobbying in October 2017 for exemptions to be made, arguing that it would unfairly impact rural residents and place pressure on doctor’s services.

But Suzanne says that the Guild and the Pharmaceutical Society of Australia are working to help implement the change and educate pharmacists and customers.

Crios believes that more funding for drug treatment should have been provided alongside restricting access to codeine.

“Some people will bear the change very well and some people will struggle. There’s going to be people who misuse codeine who don’t think of themselves as drug users because it comes in a nice packet and it comes from the pharmacy, and they may not have been in touch with services to provide them with the support that they need,” he says.

Suzanne adds that NSP workers can help support clients manage their pain through alternative medications.

“We need to see how we can support people getting their pain managed and that’s what frontline workers need to convey, that codeine is not the most effect way to manage pain and there are safer and more effective ways to do so.

“People can be reassured that there are options available.”

Alana Schetzer

Tips for NSP workers in talking to clients about the codeine rescheduling:

  • Help clients to develop a plan to manage reduced access to codeine
  • Refer them to a bulk billing GP for alternative medication
  • Mention the dangers of doctor shopping
  • If the client is injecting any tablets, talk about safer injecting including using sterile equipment and filters, and vein care
  • Be prepared to talk about drug treatment including rehabilitation and/or opioid substitution therapy.