Author: Amanda Lyons
GPs are on the frontlines of the battle against codeine misuse.
The first shots in what could be described as Australia’s codeine wars were fired on 20 December 2016, when the Therapeutic Goods Administration (TGA) made the decision that medicines containing codeine should be up-scheduled and no longer sold over the counter.
It was not long before the troops began to rally.
The Pharmacy Guild of Australia (the Guild) immediately embarked on an offensive that involved intense lobbying of state and territory governments to protect codeine sales. This led to strong pushback from the medical community and a war of words in the media. Dr Michael Gannon, President of the Australian Medical Association (AMA), labelled the Guild ‘irresponsible and unprincipled’, while RACGP President Dr Bastian Seidel accused the Guild of putting money ahead of patient safety.
‘While [codeine-containing medicine] sales represent a lucrative financial return of over $150 million a year for the pharmacy industry, patients are paying for this with their lives,’ Dr Seidel said.
In turn, the Guild accused the medical community of ‘hurling abuse and playing political games’.
But it appeared that, in the meantime, the Guild had managed to pull off a coup, recruiting all state and territory health ministers, except for South Australia, to its cause. This was evidenced in a joint letter to Federal Health Minister Greg Hunt from these seven ministers, urging him to reconsider elements of the up-scheduling of codeine, and also indicating they might allow their own separate exemptions to the TGA ruling.
Despite this pressure, Hunt held firm and even announced at the RACGP’s annual conference in October that, ‘the Guild has reversed its position and has accepted the up-scheduling in full’. But while the Guild has stated its pharmacists have been keen to ensure a smooth transition for patients through the changes, it has yet to confirm it has stopped fighting for exemptions, saying instead that it is still waiting for responses to its proposals from the state and territory governments.
Dr Seidel appealed to health ministers to put the safety of patients first, rather than the financial concerns of the pharmaceutical industry.
‘The evidence is clear: codeine is dangerous and the current situation is leading to severe health outcomes,’ Dr Seidel said. ‘We need to see policy and decision-making driven by evidence, not by industry interest. Codeine products must not be available over the counter without a script.’
Casualties of war
While this debate rages within the medical community, the battlefield is increasingly littered with casualties.
The rate of codeine-related deaths almost tripled in the period between 2000–09, from 3.5 per million to 8.7 per million. In addition, the Australian Institute of Health and Welfare (AIHW) has found that painkillers and opioids are the most commonly misused pharmaceutical, with three out of four misusers doing so with an over-the-counter codeine product.
Jessica Khachan – who lives with her husband and two teenaged children in Sydney in what she describes as ‘a normal suburban household’ – lived with a codeine addiction for two years and knows she could have been one of those statistics.
‘Every day I get today is a blessing. I think, what a gift. Because I know a lot of people have died from it. I could have died,’ she told Good Practice.
Jessica’s addiction began when her dentist prescribed hydrocodone, a codeine-containing medication, after she had some wisdom teeth removed. Although she was already in recovery from alcohol addiction, Jessica thought the medication would not be a problem because it was prescribed by a healthcare professional.
When the two-week course of hydrocodone ran out, Jessica visited the chemist and bought a packet of Nurofen Plus. It wasn’t long before she found she needed the pills to get through the day – although she didn’t think of this as an addiction, as such.
‘I felt I needed them to cope,’ she said. ‘When I took them it made me feel normal. And when I didn’t have them, I felt like I couldn’t do anything. I was in this cycle where I just had to have a supply of Nurofen Plus and I would be calm and life was okay.
‘But it did take its toll, I did start to get really sick.’
After two years of constant use, Jessica was ingesting up to four packets of Nurofen Plus – as many as 92 tablets – a day. She would visit a series of chemists and pharmacies around north-west Sydney in order to buy the pills she needed over the counter.
‘No-one ever stopped and said anything about addiction,’ she said. ‘The only comments I ever got when I bought them were, “Have you ever had these before?”, and “Don’t forget to take food with them”, and that was it.
‘Some of the pharmacists I saw repeatedly, maybe weekly or every two weeks, so you’d think that someone would have caught on. But the drugs were easy to get.’
Two years after first being prescribed the hydrocodone, Jessica was admitted to hospital weighing 30 kg, her hair falling out and her skin green from anaemia. She also had a very large stomach ulcer that caused excruciating pain, leaving her unable to walk.
While in hospital, Jessica received six blood transfusions and was told to have no more anti-inflammatories – ever.
‘I haven’t had any since,’ she said. ‘I never want to go back to that, it was a horrible place to be, mentally, physically, for everyone around me.’
ScriptWise, a non-profit organisation dedicated to reducing prescription medicine misuse in Australia, refers to people like Jessica as ‘accidental addicts’, because they take codeine-containing medications for legitimate reasons without understanding the risks of prolonged use.
‘There’s a massive gap of health literacy about these medications. People don’t understand they are purely a short-term option,’ Bee Mohammed, CEO of ScriptWise, told Good Practice. ‘The lack of information and knowledge by patients around how addictive these medications can be is obviously a huge issue that needs to be addressed.’
It can be hard for some, including healthcare professionals, to understand the nature of addiction. However, the addictiveness of codeine is backed by clear evidence.
‘[Codeine] is a prodrug, so it’s converted to morphine by the liver,’ Adj Prof Tim Greenway, Chief Medical Adviser of the TGA, told Good Practice. ‘Some people are ultra-rapid metabolisers, while others don’t metabolise codeine to morphine at all and get no effect.
‘The blood levels of morphine from the same tablet can vary 40-fold between people, so it’s a very dangerous drug for a small, but significant, section of the community.’
Another problem is that codeine is not necessarily particularly effective in providing pain relief, which can lead patients to take increasing amounts.
‘[Codeine] really doesn’t do patients any good and by the time they’re on so many tablets a day they’ve become tolerant to it and addicted,’ Dr Milana Votrubec, GP and Chair of the RACGP Specific Interests Pain Management network, told Good Practice. ‘So people need more and more to get less and less joy out of it.’
In fact, when used for some types of pain – such as headaches and migraine, for which the Guild has argued codeine should remain accessible – the drug can exacerbate the problem
‘I have an example of somebody who was taking Nurofen Plus and ibuprofen to manage headache,’ Dr Votrubec said. ‘The more they got the headache, the more they took the tablets, and as soon as the tablet had worn out the headache recurred.
‘They were actually enhancing the headache by taking these drugs.’
With no way to tell who will and won’t become addicted to codeine before they take it, the TGA, with the backing of healthcare bodies throughout Australia, decided its free availability was not a risk worth taking.
‘The decision was taken after much consultation with the ACMS [Advisory Committee on Medicines Scheduling]. That includes all states and territories, pharmacists, doctors, toxicologists, and also taking into account the evidence base, the history in Australia and increasing international concern about these products,’ Adj Prof Greenaway said.
‘It’s a sensible decision designed to protect the Australian community.’
Troops on the ground
The RACGP, along with many other healthcare bodies in Australia, is supportive of the TGA’s decision, but there is no doubt it will have an impact for GPs and their patients. Many have expressed concerns that, come February, GPs will be facing a wave of patients seeking access to the codeine on which they have become reliant.
‘One of my colleagues – who’s a bit facetious – said he’d shut shop for his general practice and put a little trellis table outside with just a script pad and write out codeine scripts, because that will be the big ticket item for February,’ Dr Votrubec said.
Research carried out by the TGA seems to support an initial uptick in such patients, at least in the short term.
‘Modelling shows that [patient requests for codeine from GPs] will increase,’ Adj Prof Greenaway says. ‘But the longer-term modelling shows it will abate.’
However, Adj Prof Greenaway made the further point that although the idea of this imminent wave may seem intimidating, it also presents a positive opportunity.
‘The people coming for prescriptions are those that really need to be seen by GPs, because they’ve either got chronic pain or they’re addicted,’ Adj Prof Greenaway said. ‘We’re encouraging people to go and talk to their GPs. If they’re thinking, “I need my Panadeine to get going”, then they’ve got a problem.’
Mohammed agrees, seeing the up-scheduling as a chance for a proactive approach in general practice.
‘If GPs are aware of their patents being on codeine, it’s the perfect opportunity to have that conversation, presenting the evidence that codeine is not effective over a long period of time and of the risk of dependency,’ she said.
However, not all addicted patients are readily identifiable. Adj Prof Greenaway believes there is a hidden addiction problem within Australia, seemingly evidenced by some of the pushback the TGA has received from the public.
‘Codeine should not be used for chronic pain and yet, clearly, from some of the reactions we’ve got people out there are using it chronically,’ he said. ‘They’re addicted to it and they may not even know that.’
This is the aspect of the up-scheduling that might seem most intimidating for GPs, as such patients can be difficult and time-consuming to treat and not all GPs are familiar with the processes required.
‘The problem is, you can’t just stop [using codeine],’ Dr Votrubec said. ‘The weaning process is that of any opioid. It’s a very small amount reduction per week, not per day. And patients need to be motivated.’
Additionally, if patients stockpile medications before the February up-scheduling, they may present to GPs in several instances, rather than just one.
‘You may not see them all coming up in February, but also in March, April, May as they start to see the effects of not being able to get their usual fix,’ Dr Votrubec said.
A recent poll conducted by the RACGP on whether GPs feel adequately supported to handle the upcoming change in codeine availability found that the majority wanted more resources and information.
The Federal Government seems to have responded to such concerns with a funding boost of over $1 million for this purpose, some of which has been apportioned to the RACGP. The RACGP has also provided resources for GPs dealing with codeine prescribing and dependence, both on its own and in conjunction with the TGA.
These resources can provide clinical assistance for GPs grappling with codeine-addicted patients in practice. But Jessica Khachan also has some advice for GPs from a human point of view, emphasising the importance of approaching the issue with empathy and compassion.
‘People from all walks of life are dealing with these issues,’ she said. ‘Patients just need someone to let us know we’re not alone, that it’s not so shocking, it’s common and there is help out there.
‘Addiction is nothing to be ashamed about, because it is an illness and we need help.’