Right: Addictive medicine specialist Dr Hester Wilson: '... 50 per cent of people who use opioids for more than a few days have a real risk of becoming dependent.'
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Arguments supporting the over-the-counter sale of codeine products
1. Most users of over-the-counter codeine products are using them as directed for pain relief
Opponents of banning over-the-counter codeine sales argue that the majority of users of these medications are being penalised because of minority misuse.
A spokesman for the Pharmacy Guild of Australia, Greg Turnbull, has stated, 'Lots of people use codeine safely and appropriately to deal with migraines, toothache and period pain. A bureaucracy telling them "No, you can't have that" won't be well received.'
Turnbull has further noted that Therapeutic Goods Administration (TGA) figures demonstrate that the vast majority of users take the product as recommended. The statistics demonstrate that about 80% of codeine consumers bought only 20% of the volume sold over the counter, meaning that while a minority may be abusing the medication, a majority were using it safely.
Turnbull further stated, 'The people who say they use it every week are exactly those who shouldn't be, but the majority using it safely are not being taken into consideration.'
ustralia-news/2018/jan/04/codeine-ban-sparks-consumer-complaints-and-fears-of-stockpilingThe Pharmacy Guild of Australia has proposed a modification to the ban on over-the-counter codeine sales which it argues would remove the unfair disadvantage about to be suffered by the majority of responsible users of the drug.
In a media release issued on August 14, 2017, the Pharmacy Guild stated, 'The Pharmacy Guild of Australia will continue to press for a common sense exception to codeine up-scheduling so that patients can continue to access these medicines for the temporary relief of acute pain from their pharmacist in accordance with a strict protocol, which would include the mandatory use of real time recording.'
Expressing the Guild's position, New South Wales pharmacist, Simon Horsfall, has urged the New South Wales Health Minister to allow an exception to the over-the-counter sale ban, asking him, ' to allow pharmacists to give people in acute pain a limited three-day supply in conjunction with mandating real-time monitoring that is already in place in the majority of pharmacies...
This would allow pharmacists to identify and help those people who may be misusing the products, while at the same time allowing the vast majority of people who use the products appropriately and safely for the short-term treatment of acute pain continued access to the products without a prescription.'
2. Making these products available by prescription only will make them more difficult and expensive for pain-sufferers to access
It has been claimed that making codeine products available only via prescription will unreasonably limit people's access to pain relief.
New South Wales Pharmacy Guild president, John Heffernan, has stated, ' The upscheduling will increase cost and inconvenience for patients who currently use these over-the-counter medicines safely and appropriately - It will clog up doctors' surgeries, while offering no solution to the problem of doctor shopping for prescription medicines - the overwhelming cause of codeine-related deaths in Australia.'
It has been suggested that the difficulty may be particularly great in rural areas. It has been claimed that in some rural areas, a GP appointment has to be made weeks in advance, while there are fears that already over-burdened emergency departments will be even further congested. Pharmacy Guild Branch Committee member Karen Carter has warned of both the inconvenience and the added cost. She has claimed, ' Emergency departments' and GPs' time are already needed for other things, while it would put a lot of pressure on one doctor towns.
Up-scheduling will increase the cost of Medicare due to more GP visits. A $6 dollar sale becomes at least a $36 Medicare cost. The inconvenience will increase costs to patients who go to private GPs with much higher out of pocket costs.'
A report prepared for the Pharmacy Guild by Cadence projected that there would be an additional 8.7 million GP visits as a consequence of up-scheduling low-dose codeine combination medicines at a cost of $316.44 million as a result of patients attending a doctor for these scripts.
In October 6, 2017, health ministers from all states and territories - except for South Australia - signed a letter to federal Health Minister Greg Hunt expressing concern about the proposed ban. The letter stated, 'There is concern that this will be felt particularly acutely in rural and regional areas where access to GPs is already low, and that some people managing chronic conditions with codeine medications will deteriorate as they abandon medication due to the out-of-pocket expenses associated with accessing GPs for their prescription.'
A study published by the Macquarie University Centre for the Health Economy in March, 2014, found that when asked what they would do if the pain relievers for their condition became unavailable over the counter: 63% of respondents said they would see their doctor, 24% said they would do nothing, 15% said they would use a home remedy and 7% said they would 'supplement'.
Critics have used this study to suggest that banning over-the-counter sales of codeine would result in significant increases in doctor visits. It has also suggested that there would be others whose pain would be treated inadequately.3. Codeine in combination with other painkillers is an effective source of pain relief
Supporters of the continued over-the-counter sale of codeine in combination with other pain killers claim that this is an effective form of pain relief. They note that studies supposedly disproving its effectiveness are based on preparations that do not have the same levels of codeine as medications sold in Australia.
Supporters of the continued ready availability of codeine-in-combination medications point to two trials that have shown products containing paracetamol and codeine, and ibuprofen and codeine, in concentrations equal to those in Panadeine Extra and Nurofen Plus respectively, are effective. An Australian study showed after dental surgery, 1000mg of paracetamol combined with 30mg of codeine phosphate (equivalent to two Panadeine Extra tablets) produced significantly greater pain relief than 1000mg of paracetamol alone (equivalent to two Panamax or two Panadol tablets). Another study, also looked at pain following dental surgery. It showed 20mg of codeine combined with 400mg of ibuprofen (equivalent to two Nurofen Plus tablets) produced significantly greater pain relief than 400mg of ibuprofen alone (equivalent to two Nurofen tablets).
4. Prescription-only supply of codeine products may not result in reduced use of codeine
It has been argued that making codeine available by prescription only may not reduce the overuse of the drug.
It has been claimed that monitoring of drug-use by real-time recording and comparison of purchase is presently better available through pharmacies than through medical clinics. Pharmacies have introduced a real-time monitoring system for over the counter sales of codeine-containing products, which allows the pharmacist to identify and help those people who may be misusing them. The Pharmacy Guild has claimed its reporting system, called MedsASSIST, was already working well to record and track purchases of codeine, and stamp out abuse of the drug. The Guild's national president, George Tambassis has stated, 'More than 4 million transactions have been recorded since March (2016) when the system was introduced across Australia. Of these transactions, pharmacists have denied sales to some 70,000 patient because of identified risk factors. Nearly 50 per cent of patients denied a sale were referred to their doctor for more treatment.'
There is currently no such monitoring of prescription codeine-containing products in doctors' surgeries. So, critics claim, there is no way of identifying and helping those people who may be doctor shopping to obtain multiple prescriptions for the products.
Victoria claims to be the most advanced state in terms of introducing a mandatory real-time monitoring system involving doctors and its system is not expected to be in place until the end of 2018.
It has also been noted that supplying codeine products through prescription may not result in reduced use because doctors may over-prescribe. Currently, under the Repatriation Benefits Scheme, war veterans using low-dose codeine products receive a concession price if they purchase the product via prescription. Department of Health data shows that when doctors have the option to prescribe paracetamol combined with either 30mg, 15mg or 8mg of codeine, more than 90% of prescriptions are written for a 30mg codeine product.
It has been claimed that a prescription-only mode of supplying codeine medications will only work if doctors are properly informed and prescribe carefully. Peter Boyles, Chief Pharmacist of Tasmania, has stated, 'If you are getting more opioids than are safe, and benzodiazepines and other agents that increase your overdose risk, it doesn't matter if you are going to the same doctor. You don't need to doctor shop if you are getting everything you might want.'
Australian Self Medication Industry executive director Deon Schoombie? has claimed that forcing people to go to their doctor for codeine tablets ran the risk of them walking away from their general practitioners with even stronger drugs. Mr Schoombie stated, 'It just shifts the problem [to doctors]. Does it solve the problem? I doubt it.'
5. Other forms of medication or treatment may not supply the same relief or not be suitable for particular pain sufferers
Opponents of the ban argue that there may not be readily-available alternative medications or treatments to replace over-the-counter codeine products.
It has been claimed a combination product containing ibuprofen and paracetamol would fill the gap left by the unavailability of low-dose codeine-containing painkillers. However, opponents of the ban on over-the-counter sale of codeine products note that not all pain-sufferers will be able to use these combination painkillers.
There are many people who should not take ibuprofen, or take it only with extreme caution. These include people with aspirin sensitive asthma (ibuprofen may worsen their asthma symptoms, and potentially cause an acute asthmatic attack). It is also contraindicated for those with gastrointestinal disorders such as Crohn's disease, and those with kidney impairment (ibuprofen may make their condition worse) and for people taking medicines that may have a serious drug interaction with ibuprofen. These include: Warfarin and other medications used to prevent blood clots (ibuprofen may increase the risk of bleeding); some medicines used in the treatment of high blood pressure or heart failure (ibuprofen may increase blood pressure and reduce kidney function) and low-dose aspirin for protection against heart attack and stroke (ibuprofen may reduce the protective effect). Critics maintain that there will be a large group of pain-sufferers for whom the recommended replacement medication of ibuprofen and paracetamol in combination will not be a suitable alternative.
Numbers of consumer forums have indicated dissatisfaction with the decision to ban over-the-counter sale of codeine, suggesting that for some forms of pain it is the most suitable remedy and that having to visit a doctor is inconvenient. Among posts made on the Essential Baby site in December, 2016, were the following. ' I'm a bit disappointed as I sometimes get really bad headaches that only codeine works for. I never know when I will need it'; ' I get classic migraine with aura. If I take a couple of Panadeine Extras/Nurofen Plus when the aura starts I can head off the worst of the pain and just be disoriented and hung over instead. Not being able to acquire simple pharmaceuticals can mean the difference between being functional or completely non-functional 60 minutes from now. Appalling decision that will clog up GPs' waiting rooms...'; 'I use Panadine/ Panadine Extra/Nurofen/Nurofen Plus for migraines. If I take these early enough I avoid terrible pain and can function. Seems like a waste of doctors' time when someone needs something stronger than panadol but not something like Endone...'
On December 31, 2017, The Sydney Morning Herald referred to the instance of 60-year-old Karen Baines who said she often took Nurofen Plus or Mersyndol to treat her knee and ankle pain, and had already tried Panadol and Panamax with no satisfactory effect.