A leading rheumatologist is predicting a ‘bumpy ride’ as over-the-counter codeine products come off the pharmacy shelves.
In a move welcomed by doctors’ groups – and opposed by the pharmacy industry – on 1 February combination codeine analgesics such as Nurofen Plus will become available by prescription only under TGA scheduling changes.
The decision is a win for evidence-based medicine, given low-dose codeine has negligible benefits over other simple analgesics and can cause significant harms, says Dr Sam Whittle, a senior consultant rheumatologist at the Queen Elizabeth Hospital in Adelaide and treasurer of the Australian Rheumatology Association.
But codeine re-scheduling will mean an adjustment for those using the products – even occasionally – a group he suspects includes a large proportion of rheumatology patients.
One in four rheumatoid arthritis patients (26%) report using opioids despite DMARD therapy, latest data from the ARAD shows.
“For those with inflammatory arthritis, we have got so good at treating them with modern disease modifying drugs but even when inflammation has subsided they often have persistent pain, which is something we don’t understand that well yet,” he says.
“It’s highly likely there is a relatively high proportion of codeine use, it may well be this change in scheduling reveals to our GP colleagues exactly how many are using it regularly enough to ask for a prescription.”
Explaining the risk-benefit profile of opioids “is a conversation I increasingly have with my patients”, says Dr Whittle, but he finds some patients have had positive experiences with combination analgesics and don’t accept the evidence.
“Many feel that codeine products are particularly effective for them and are worried if taken away their pain will escalate.
“It’s the role of the practitioner to reassure them we will manage their chronic pain and flares – and we can do that without OTC codeine.”
“If they feel they are needing regular codeine or other opioids that is a signal we don’t have a pain management plan in place – it’s an indicator of how we need to review our patients.
For those patients, the up-scheduling change “will be a real hassle”, he says.
The new rules – strongly opposed by the Pharmacy Guild representing pharmacy owners which spent months lobbying state and territory ministers to have it watered down – will bring us in line with jurisdictions around the world.
“It’s a necessary step, even if the next few weeks are bit of a bumpy ride,” Dr Whittle says.