Codeine Banned In Australia: Why The Arguments Don't Add Up

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From February 1, 2018 all products that contain codeine will only be available for sale in pharmacies with a prescription. This means you won’t be able to buy brands like Nurofen Plus, Panadeine or Panadeine Extra over the counter at your local pharmacy without a prescription from your doctor.

Three claims have been used to justify pulling codeine from sale without a prescription - and they're all wrong

The decision was made by Australia’s drug regulator the Therapeutic Goods Administration (TGA). It was based mainly on the fact that codeine can cause dependence, and its misuse has led to addiction and even death. These facts are not in dispute.

But claims withdrawing such products from sale without a prescription will reduce codeine use are misleading. Nor is it correct to say, as some do in applauding the TGA’s decision, there is no evidence painkillers combined with lower doses of codeine aren’t any more effective in providing pain relief than the painkillers alone. Here are three common claims made about codeine-containing products that are untrue.

#1 Low-dose codeine doesn’t improve pain relief

Painkillers such as codeine, ibuprofen and paracetamol act in different ways to reduce pain, and they are sometimes combined into the one tablet to produce greater pain relief. Products such as Nurofen Plus and Panadeine Extra contain 15mg or less of codeine (considered a low dose) combined with either ibuprofen or paracetamol in the one tablet.

Some doctors and organisations have claimed that painkillers, such as ibuprofen and paracetamol, are just as effective when used alone, as when they are combined with a low dose of codeine. Evidence does not support this claim.

In fact, few clinical trials have been carried out to assess how effective it is to add low dose codeine to either ibuprofen or paracetamol. And of these, some have tested doses not generally used in Australia. However, two trials 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).

#2 Making codeine products prescription-only will reduce codeine use

Department of Health data give an idea of doctors’ patterns when it comes to prescribing codeine-containing products to patients under the Repatriation Benefits Scheme. Under this scheme, low dose codeine products can be obtained by veterans for a concession price with a prescription.

The data show 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.

Judging by this, if current users of low dose, codeine-containing products for the short-term treatment of acute pain are forced to visit a doctor, they may potentially receive a prescription for a higher strength codeine product. This may not reduce codeine use, but could increase it.

In 2015-2016, there were more than 3.7 million prescriptions written in Australia for products containing 30mg of codeine and 500mg of paracetamol. It has also been reported most opioid (a drug that acts on the opioid receptors, such as codeine and oxycodone) use in Australia is from prescription products, with over the counter codeine products accounting for only 6% of total opioid use.

#3 Taking paracetamol and ibuprofen in combination is a better way to treat pain

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. But there are many people who should not take ibuprofen, or only take it with caution. These include people

  • with aspirin sensitive asthma (ibuprofen may worsen their asthma symptoms, and potentially cause an acute asthmatic attack)

  • with gastrointestinal disorders such as Crohn’s disease, and those with kidney impairment (ibuprofen may make their condition worse)

It also includes 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)

  • low dose aspirin for protection against heart attack and stroke (ibuprofen may reduce the protective effect).

Real-time monitoring

Making codeine-containing products only available with a prescription is unlikely to help those who may be misusing codeine. 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.

There is no such monitoring of prescription codeine-containing products in doctors’ surgeries. So, there is no way of identifying and helping those people who may be doctor shopping to obtain multiple prescriptions for the products.

The ConversationIt makes no sense to change from a system where the small percentage of people who may be misusing the products can be identified and helped, to one where they cannot.

Peter Carroll, Honorary Professor, Pharmacology, University of Sydney

This article was originally published on The Conversation. Read the original article.


Comments

    My son gets major migraines, for which Painstop nighttime was a godsend. It used to knock him out almost immediately, even at 14, allowing him to avoid the worst of the migraine itself. He would then sleep through the night, avoid pain and vomiting and the agony of his migraine. These migraines don't occur often but they occur enough to be an annoyance. We've seen neurologists who have advised that due to their infrequency, we just have to 'put up with it'.

    Thanks to some stupid fucks who decided to stuff around with Painstop, we can no longer get it. It had codeine in it, and because they decided to mix it with drinks etc, we can't get it anymore. The other medications we need for him now, the Panadol with codeine in it, which is less effective but better than nothing, we now need to go to a goddamn doctor and get a prescription for, rather than me just stopping in at the chemist and grabbing some.

    This country is fucked with how it's turned into some bullshit Nanny state, seriously. I have to now see my son go through agonising migraines, watch him vomit when they come along, watch him in agony. All because the Govt wants to overreact because a severe minority of people are stupid...

      This drug is being used by people as a recreational drug and its ruining families. So I for one am happy for this to happen, get this drug monitored and stop people from buying up and overdosing on codeine to get that high.
      Lets not turn out like America and have an Opioid epidemic due to this drug being so easy to buy.

        I live in America. You are right, there is an Opioid epidemic. In America, ALL Opioids are available by prescription only, none are available over-the-counter. Unfortunately, requiring a prescription does not control availability on the street corner.
        I personally know a pharmacist (chemist) whose pharmacy was broken into several times. On some occasions the thieves got in by literally breaking through the wall or through the roof. Those stolen medications are then available without a prescription.
        I don't know about Australia but in the US we have a real problem with illegal drug use. By illegal drugs I mean drugs that are not legal with or without a prescription. The fact that there is no legal way to purchase those drugs certainly does not make them unavailable. That suggests that requiring a prescription will do little to reduce the availability of illegal codeine. It might even exacerbate the problem because illegal drugs are often of unknown potency making death by overdose more common.
        Two reasons for reducing Opioid use in America are the high number of patients seen in emergency rooms because of an overdose and the significant number of those patients that do not survive.
        Death tends to ruin families, too.

        I'm not buying this story about recreational Codeine use. Just saying something like this doesn't make it true. Any search for recent evidence or research in the area of recreational opiate use doesn't back up this claim.

        Guess what.. You can't get a habit from over the counter codeine preps, the Paracetamol will shut your liver down, long before you become addicted. You can't ease the pain of a habit with otc codeine preps, there isn't enough of the drug and codeine has an extremely short-acting half-life. People will buy illegal drugs. Medicare will be hit A LOT harder. Pharmacists do not agree with the new laws. Doctors do not agree with the new laws. Politicians are idiots. The USA is the worst country on earth. You are a fool.

          But what's to top you simply dissolving 15 pills containing 15mgs of codeine with paracetamol in a glass of cold water then filtering out the paracetamol with a coffee drip filter?

      I feel ya mate. That's fucking horrible.
      Meanwhile, California has just legalised recreational marijuana.
      Weren't the Libs supposed to be the party of 'less government'?
      Oh wait, that's only when it applies to corporate regulation. Unfortunately doesn't apply to relieving a child's pain or letting women do what they want with their bodies. My bad

      Last edited 21/01/18 7:41 pm

      There are alot of better and potentially safer medications to manage a migraine. The therapeutic guidelines don't list codeine based products for the treatment of migraines. Have a chat to your pharmacist or doctor. May be able to help further. Migraines are not fun stuff, hate to see your son suffer.

        I did. Painstop was recommender. Now its not available.

          I too get intermittent migraines, maybe once every couple of months. I found mersyndol works really well and only half a tablet! so even though it's going to become prescription you wouldn't need to get it as often. I prefer the chemmart brand, it makes me less fuzzy the morning after. I wonder if this would help your son. My daughter also finds it works for her.

            Thanks for the advice, I will definitely get him to give it a try :)

      We limit heaps of things because people are stupid though - a huge chunk of our legal system only exists because people are either (1) stupid, (2) selfish, or (3) both. With that being said though, the only thing I use codeine for is migraine pain. I've talked to a few doctors, as I'm sure you have, and since every migraine suffer is a little different, the typical response is "if you have something that works to treat the worst of it, keep doing it." For me, that's codeine, a dark room, and a couple of hours sleep - in fact, the ineffectiveness of paracetamol is one of my early indicators that what might just be a headache is probably going to turn out to be a migraine. The infrequency of my migraines, fortunately, is going to mean an annual trip to the doctor (which, hopefully, I can handle coincidentally at another appointment)

        Yup. If I can't get a triptan inta me in time, codeine's the only over-the-counter thing that's helped take the edge off the razor pain long enough to get some (shitty) sleep and wait for the motherfucker to pass. There have been times where even that hasn't worked over a long duration, and a trip to ER for an injection has done the trick. Or the out-of-hours home doctors... but for fuck's sake, wouldn't you know it, people are trying to fuck that up as well.

        It frustrates me so much that there are people dedicating so much time and energy to shutting down what few avenues I know work for treating medical problems.

        Important note: Not trying to just have some fun, getting a buzz or getting high, but treating fucking medical problems. That shit is frustrating enough without it turning into a game of snakes and motherfucking ladders.

        So now I've gotta go take a fucking half-day at my expense to waste a GP's fucking time getting me a script, and face the always-fun choice of deciding if I'm going to pay extra out of pocket because of this horse shit, or book an extra three or four fucking weeks in advance to try and find a fucking bulk-billing GP in this bloody city who'll see someone who isn't a senior or on a fucking low-income health-care card, additionally turning the half-day waiting-room appointment into a full day, because why the fuck are politicians so god damn hell-bent on destroying public health care?

      Not to mention that its going to increase the amount of people visiting GPs and stretch the medicare budget that is already being cut by the LNP.

      Drugs are drugs, tested/untested. Meanwhile in Canada and US its perfectly okay for doctors to prescribe marijuana and legally I might add. Yet completely unethical to smoke a joint in a five mile radius and I'm not even a smoker.

      In the US. there are drugs that are taken to relieve migraines when they start, you do not take them every day (in fact, you can't take them that often). If there are similar drugs in Australia then there should be no reason to "just put up with it."
      Two of the drugs my wife has used are Almotriptan (brand name Axert) and Naratriptan (brand name Amerge). You might see if these or similar drugs are available for your son. Be persistent, if one doctor can't or won't help, find another reputable doctor that can and will help.
      I'll bet if those neurologists' children had sever migraines they would not be told to just put up with it.

    https://www.tga.gov.au/final-decision-re-scheduling-codeine-frequently-asked-questions

    "Why has this decision been made?
    This decision has been made by the TGA, based on the evidence and advice provided through a lengthy consultation period.

    Codeine is a commonly used medicine of abuse. Low-dose codeine (less than 30 mg) is currently available in a number of formulations in pharmacies over the counter (OTC) for consumers to self-administer. These include cough and cold preparations, and analgesic preparations combined with other pain relief medicines such as aspirin, paracetamol or ibuprofen. There is substantial evidence of harm from the abuse and misuse of low dose codeine-containing medicines.

    For most individuals, there is little evidence that low-dose codeine medicines are more effective than alternative medicines without codeine.

    The presence of low-dose codeine in widely accessible OTC combination medicines, and the development of tolerance and subsequent dependence on codeine, contributes to severe adverse health outcomes, including liver damage and death.

    Low-dose codeine-containing medicines are not intended to treat long term conditions; however, public consultation has indicated that this is how most consumers use these medicines.

    Additionally, some individuals, especially children, experience serious adverse reactions when given codeine, such as difficulty breathing and death.

    Given these issues, it is clear that alternative regulatory controls are required to drive public health benefits that outweigh the known risks of codeine use."

      Ok, a few things.

      Firstly, lifehacker neglects to mention that along with being an *honourary* professor, this guy is also a lobbyist for a branch of the pharmaceutical industry. As such he has an agenda which, in contrast to the tga & huge number of medical & health organisations (AMA, NHMRS, APA etc), may have nothing to do with the best interests of patients & consumers.

      Secondly, while i don't have stats, based on my own experience - including talking to drs in ed who tell me they see more people for codeine addiction & associated health problems than for any other drug, including meth - i suspect the minority of people addicted to codeine may be significantly larger than some suggest. And that's partly because a lot of them may not even know they're addicts - that might even include some of the people crying on here.

      Because the thing with otc codeine addicts is that most of them are "normal" people - lawyers, engineers, nurses, bookeepers, mums, dads etc. They don't look like stereotypical addicts & probably don't see themselves that way.

      But when the ban comes through & they've run out of their stockpile, suddenly they're gonna be in a whole world of pain that they never even conceived of & which they'd gladly swap for the inconvenience of having to make a dr appointment. People say there's gonna be this huge drag on the health system come feb 1st i & they're right. But it won't be people needing prescriptions for period pain or toothache - it'll be the stupid selfish minority coming out of the woodwork.

    You can find research to support arguments on both sides. What is completely overlooked is that it is also part of a turf war between GPs and Pharmacies.

      'You can find research to support arguments on both sides.'
      What a completely ignorant, dismissive, carpet-sweeping statement.
      Of COURSE you can find research to support arguments on both sides. The same can be said for literally ANY two points of view.

      What MATTERS though is where the overwhelming amount of evidence falls - and this article nails it.

    As someone who finds absolutely no pain relief from Codeine (due to what I believe is a genetic trait of not producing enough of the enzyme that metabolises the codeine) I believe its a great change, they used to put the stuff in Cold and Flu medication, I just want the Pseudoephedrine when I have a nasty cold like I did earlier this week. I don't care for the other stuff as it doesn't do anything for me.
    I believe a major issue is that Codeine can be addictive for some people, but by itself its not a major issue to your health but the paracetamol or the ibuprofen is regularly mixed with in higher regular use is extremely bad for your liver, and as a result people have died

    I'm a pharmacist and I wanted to provide my opinion. Making codeine script only just pushes the problem down the line, and potentially making it worse. Pharmacists have a system that allows live monitoring of codeine use, which requires logging of one's driver's licence number (or other gvt issued ID) and we can tell when, how many tablets a person has been purchasing and what type of pain they're treating. This allows us to refuse sales, advise on alternatives, or refer them to medical treatment. Doctors have no such system and thus have no idea if a patient has been doctor shopping, seeing multiple other doctors in the very same day for the same items. This will open the gates for codeine abuse worse than before. Early indications (purely my anecdotal experience, mind you) have also shown doctors willing to prescribe stronger and more addictive painkillers such as Panadeine Forte, oxycodone and morphine.

    Throw in clogged up and busier doctor's surgeries, as well as forcing people to take a day off to see a doctor just to manage legitimate pain, it's hard to see an improved cost-benefit ratio with this move.

    Unfortunately, the actions of a small percentage have greatly increased the cost and inefficiency of an already burdened health system.

      A genuine thanks to you for providing insight from someone who will be affected in a rather significant way.

    Even if the arguments don't add up this article should have been published months ago. As such the upscheduling is in less than 2 weeks time and the legislation has already passed. The lobby to keep codeine as schedule 3 was extremely vocal and still they failed. As others have mentioned, the stupid few have again ruined things for everyone else.

    Here speaks a pharmacologist who has never worked in ed. You'll frequently see accidental paracetamol overdoses from people trying to get more codéine from these OTC Meds. having these small doses mixed with two drugs that people perceive as safe but are actually potentially lethal for the liver (paracetamol) and kidneys (ibuprofen), is not safe at all. At low doses (8-15mg) when taken properly, there is limited evidence of pain relief so I really can't see why they exist in the first place (AFAIK they are not available on the UK OTC at these doses)

      You assume the pharamacologist has never worked in Emergency Dept.
      I'm going to assume you do work there...

      How many paracetomol overdoses do you see? I'll take an average monthly figure.
      How many cases overall do you handle? (big city vs suburban / country hospital)

    I get migraines, have done since about the age of 12. First one Panadol worked, then two, then a Nurofen, then two. These days, two Panadol/Nurofen extra totalling 30mg of codeine ( the equivalent of 1 panadeine forte) is the only thing that creates a dent.

    I've also flirted with codeine abuse. After my dad committed suicide I was prone to taking up to 90mg at a time, just because I could. It was the side effect of constipation that ultimately won out.

    I support this ban. I'd also support lifting it under the following conditions:

    1) The PHARMACIST conducts the "do you really need this?" interview. Too often this was performed by a teller/assistant and it was way too easy to "lay it on" so they could tick the box.

    2) A national sales register to which all pharmacies had to log narcotic sales. Got through that pack fast enough to raise a red flag at the same pharmacy? Too easy to go down the street and get more. I've heard rumours of "e-scripts" in development, GPs can lodge at your pharmacy of choice so you aren't waiting around, a layer like this suggestion would be easy enough to implement at the same time.

    3) After a number of repeat visits, further supply is forbidden without a doctor's consultation and a script.

    4) Investment in research of legitimate alternatives. There is still A LOT we don't know about pain and pain management. I've told my GP only to prescribe codeine as a last resort, and asked if there is anything as effective that doesn't come with the high. There's really not, the meds we've tried don't work.

    I can't see a problem with over the counter codeine sales being reinstated under those conditions.

    I'm also a chronic migraine sufferer. I have done the whole medical thing including spending $560 on a specialist to be told to take aspirin. Not to take the tryptans I had been prescribed. To take 160mg of propranolol or maybe a tricyclic antidepressant. None of these things works for a migraine, at least not on me. Codeine does work, so now I have a prescription for double-strength (30mg codeine/500mg paracetamol). I just think it's dysfunctional to push this issue to doctors when the previous approach was effective. I was very annoyed when in October I was told by a pharmacist that the manufacturers had ceased production of the 15mg pills that had been effective for me for years. I wish these legislators knew what it felt like to have chronic migraine.

    I'm totally unconvinced by the arguments for making this stuff prescription only. I'm a parent of two 20 year olds, and I have seen how doctors have shifted to prescribing Oxycodone for many acute pain relief situations. It's become the goto pain prescription, where once you'd be given Codeine instead.

    The pencil necks at the TGA would have you believe that these products are used by people recreationally and will cause sick days.
    They have said that 80 to 100 people die every year from panafen plus. They dont mention the 1500 people who die from paracetamol overdoses each year.
    The Pharmacy Guild have conveniently forgotten to mention that a packet of nurophen plus will cost $40 after thursday. That doesnt include the $75 doctor fee.
    Its a big fat money grab, thats all it is.
    But they wont be the only ones making money.
    Of course people have been stock piling, they've stupidly created a black market. There will be pills available outside of the pharmacy for those lucky enough to find a supplier, others will overdose on paracetamol and a cocktail of crap that is still available over the counter.
    Deaths, caused by liver toxicity will spike, sick days will blow out, and the black market will flourish.
    The people who made this decision have not considered, women's monthly pain, dental work, a bad hip, a migrane or a staple to the testicle. They've pilled everyone into a junkie category and given us all the middle finger.
    Take thursday off folks, I am.

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