Australia’s drug regulator is looking into reclassifying about 150 codeine-based drugs as prescription-only. This means they will no longer be available for purchase over the pharmacy counter. The easy and widespread availability of these opioid medicines is causing a substantial level of harm.
Currently, lower-strength painkillers such as paracetamol, ibuprofen and aspirin can be bought almost anywhere, while drugs such as Nurofen Plus or Panadeine Forte can be bought only at pharmacies. These combine codeine with paracetamol or ibuprofen in order to tackle more severe pain.
These drugs may soon join the next, stronger level of painkillers, which require a doctor’s prescription because they pose an increased risk of side effects or addiction.
A stand-out case
Codeine’s potential for addiction is well documented. There have been calls from physicians in Australia, New Zealand and Canada to withdraw it from the market altogether.
Although the drug’s side effects can range from mild to more serious, it’s often the accompanying paracetamol or ibuprofen that’s more harmful to the internal organs. Potentially life-threatening complications include internal bleeding and kidney and liver failure. This increased risk of toxicity combined with the addictive effects of codeine is what makes these drugs so problematic.
Australia is unlike many other countries in allowing the purchase of codeine-based narcotics without a prescription. In some countries, such as the Maldives and the United Arab Emirates, possessing a codeine-based drug without an authenticated doctor’s prescription can potentially lead to deportation or imprisonment. In Greece, any amount of codeine is illegal. Travellers can only bring it into the country if they have a valid prescription.
Codeine-based painkillers are only supposed to be supplied by Australian pharmacists following assessment of need and risk of addiction. But patient interaction is often very basic and retail pharmacy is competitive, so punters are almost never refused sales.
What’s more, some pharmacists are unsure how to assess if a person is seeking drugs beyond their therapeutic need, or how to manage “codeine tantrums” when sale is refused. Some Australians take “codeine road trips” – travelling long distances to visit multiple pharmacies and purchase large quantities of these drugs.
Codeine by itself is a weak pain reliever. Most of its painkilling effect is produced when some of the drug is broken down or metabolised by the liver into morphine. But there’s quite a lot of variability in how different people metabolise codeine, which can significantly influence how much morphine they produce.
Some people are hypermetabolisers, putting them at risk of serious and sometimes life-threatening toxicity. Others might get negligible amounts. But since codeine-combination painkillers are available without a prescription, there’s a common misbelief in the community that they’re inherently safe.
For most people, no more than six tablets in 24 hours is still safe if they don’t use the drug for any longer than three days. But others become addicted and use more than a whole pack each day.
Most people just trying to ease their pain are often unaware of the risk of addiction and possible life-threatening effects of codeine-combination painkillers.
One of the first Australian studies that showed the serious effects of codeine-based narcotics looked at patients presenting for opioid dependence in nine hospitals across Melbourne and rural Victoria between 2005 and 2008. It showed that 27 Australians had to go on opioid-replacement therapy, usually reserved for heroin addicts, just to get off codeine.
Seven years later, many more Australians have sought treatment for addiction or serious injury as a result of these painkillers. Making codeine-based painkillers prescription-only will help put a stop to this preventable but lethal problem.
The take-home message here is that just because codeine-combination painkillers are still available without prescription doesn’t mean they’re safe! People must use them strictly as directed and be aware of their potential addictive and toxic effects.
These drugs should be used for the shortest time possible at the lowest dose. Use should not be continued if they don’t seem to be working.
The change will not disadvantage people in acute pain because newer medicines that combine paracetamol with ibuprofen provide better pain relief - without the risk of codeine addiction and its dire consequences.