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A Not So Subtle Threat?

By Terry Maguire - 01st Sep 2022

codeine

A Zoom Call Meeting Raised Some Red Flags For Terry Maguire, With Community Pharmacists Identified As ‘the Problem’ When It Comes To Codeine Addiction.

A Zoom meeting, called in June by the Department of Health (DoH), invited representatives from pharmacies with high OTC codeine sales. Being on the invitation list itself was a cause of concern, I thought, as I dialled in. I was unaware DoH had such precise data, but due to the Controlled Drug Reconciliation Programme (CDRP), it is up-to-date on all my CD purchases. CDRP is a surveillance system set up following the egregious and over-zealous supply of about a million controlled drugs by one of our own to persons unknown, and for which he received a custodial sentence. When this little scam was eventually detected — and that took our DoH some considerable time, even though it was like not realising the Northern Bank robbery had happened — the red-faced civil servants vowed it would never happen again. 

The CDRP is impressive knowing, for example, the total number of diazepam tablets I purchase and reconciling this with prescriptions I dispense; more coming in than going out signals a potential problem and an investigation. As codeine OTC medicines are CDs, these are also monitored in CDRP but since so few are supplied on prescription, it’s easier to compare pharmacies and look for outliers. DoH assigns a score of 1 for an average supply. Our pharmacy came out with a score of 1.5; the reason we got the zoom meeting invite, but I was reassured, as it was not as bad as Belfast City Centre pharmacies, with scores ranging from 10 to 30. The data analysis is impressive: 8.6 million Nurofen Plus tablets sold to pharmacies in N Ireland in 2021, representing a 14.5 per cent increase on 2020. This is a staggering 6.6 tabs per person, when most in the population never take the medicine. 

For me, with my usual high level of paranoia, I read the event as a baseline-setter

The stimulus for the zoom meeting was a complaint by a gastroenterologist at one of the Belfast Hospitals, concerned about the increasing incidence of oesophageal damage due specifically, in his opinion, to Nurofen Plus abuse. A case study was presented of a 25-year-old male arriving at A&E with severe pyloric stenosis and claiming to be taking 80 Nurofen Plus tablets daily. 

He refused admission to hospital, but returned to A&E within a week, seeking more help. Admitted, he soon signed himself out and a few days later, he was found dead at home. 

Medics have long been concerned. Ten years ago, the British Medical Association (BMA) called for a major rethink on the availability of OTC codeine products. They claim that up to 4 per cent of the UK population are regular codeine users. Back then, the Committee on Safety of Medicine (CSM) had a look at the evidence, but felt it unnecessary to change codeine’s OTC status. Instead, the Committee merely beefed-up the pack warnings and Patient Information Leaflets, so now addicts have clearer signposts to the medicines they should try out! CSM conceded that OTC codeine medicines lead to medication headache, a key contributor to codeine addiction, as the individual thinks they have a tension headache when in fact they are suffering from codeine withdrawal. 

CSM found that the number of reports of misuse or abuse of OTC codeine/dihydrocodeine (DHC) compounds was exceedingly small (54 reports) compared to the volume of sales in millions of units. CSM examined the literature and concluded that although misuse and abuse of OTC analgesics were without doubt significantly under-reported, “there was unlikely to be a huge hidden problem with these syndromes”. 

The zoom was, to use the term euphemistically, an ‘interesting’ meeting. The DoH, along with representatives from the newly-formed SPPG (formally the Health Board), appeared surprisingly nervous. They have a legal enforcement role, which for OTC medicines sales is more ambiguous and therefore more difficult to manage than it would be for POM supplies. For me, with my usual high level of paranoia, I read the event as a baseline-setter. The matter was being raised and the DoH needed to be seen to be doing something, so if censure is to happen, it will be happening to community pharmacists at the coalface and not those in administrative ivory towers. We were politely being told that we have a problem, we were being made aware of it, and if things don’t change then DoH will be taking action, which could mean an uncomfortable visit to the Statutory Committee, or worse. 

In a slightly awkward break-out session, we were asked to discuss how things are and how things might be improved. We all have SOPs for sales of OTC medicines and for staff training. We all have means of identifying those frequent users and we take action if they appear too often. Some pharmacies simply do not supply Nurofen Plus, but find that their sales of other codeine-based analgesics are still huge. 

We don’t stock the 32-tablet pack size, as we find it keeps the real addicts out and it is illogical to supply this quantity and then tell people that the medicine is only for three days’ use. On some occasions, we simply take the packs off the shelf for a week and that reduces visits from the pharmacy-hoppers. 

But all this amounts only to a large dollop of hypocrisy. Sometimes, in a fit of righteousness, I decide not to supply but I know that that only means sending the user down the street to the next pharmacy. This is an age-old problem, but one exacerbated by many issues, not least by product display and branding. I suspect stricter rules on OTC supply in the South sends people North to pharmacy-hop. Perhaps this might explain high volume sales in Belfast city centre pharmacies. 

Back at the start of my career, sales of codeine linctus was the issue. There was a concerted effort to stigmatise sales and enforce better ethical standards. An argument was put forward that codeine linctus was no more effective compared to other cough suppressants such as pholcodine, which was not addictive. More than a few high-profile pharmacists were struck-off for excessive sales, and it worked. Forty years later, I would challenge anyone to get a supply of OTC codeine linctus in any pharmacy in N Ireland. 

Ironically, the explosion in OTC sales of codeine pain medicines flies in the face of the codeine linctus legacy. Codeine addiction is now a severe public health problem across the UK, and it becomes difficult to separate OTC codeine addiction from POM addiction, as many patients who trawl pharmacies for co-codamol 8/500 or Nurofen Plus also get supplies of stronger codeine painkillers from their GP. 

We need to be clear that pharmacies cannot optimally control OTC codeine sales and that the only real option is switching these products to POM, which will ultimately remove them from the market. For many community pharmacy owners, it will be painful to lose these impressive sales, and that prospect was all too evident in the Zoom meeting. 

We have failed to make the case for codeine painkillers that we made for codeine linctus. 

Codeine at OTC doses is ineffective as an analgesic. Co-codamol 8/500 is no more effective than paracetamol alone and is much less effective than a combination of ibuprofen and paracetamol. If pharmacists really want to support people to manage acute pain, we should not be recommending codeine-containing medicines. 

My esteemed and erudite colleague Des Corrigan covered the Australian experience in an excellent column in July, and I suspect that the switch that has come about ‘down under’ is coming our way very soon. In the meantime, we have been warned — and not so subtly.

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