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CODEINE-containing drugs are now prescription only, and poisoning presentations have dropped accordingly. But there’s little evidence so far that patients with chronic pain have turned to alternate opioids for relief, according to new research.
Published in the MJA, a study from Princess Alexandra Hospital in Brisbane has found that codeine-related presentations had fallen by 53% following the rescheduling of all codeine-containing products to prescription only.
Researchers analysed data from 2235 patients who presented to Princess Alexandra Hospital with poisoning during the 12 months preceding the rescheduling of codeine on 1 February 2018, and 2516 during the subsequent 12 months. Despite the 13% increase in total presentations, the number of codeine-related presentations was 53% lower during the second period: 163 presentations before rescheduling and 77 presentations after.
“The numbers of presentations involving 30 mg codeine products, the status of which was unaffected by rescheduling, were similar for the two periods (52 before, 60 after rescheduling). In contrast, the number of presentations involving codeine products affected by the change (< 30 mg) was 85% lower after rescheduling (111 presentations before, 17 presentations after rescheduling),” wrote the authors, led by Dr Keith Harris, a toxicology fellow at Princess Alexandra Hospital.
The researchers also found that the decline in codeine-related presentations was not associated with a rise in alternative opioid-related presentations (185 alternative opioid-related presentations before, 178 after rescheduling).
So, where are codeine users going for their chronic pain relief?
Dr Harris said, in an exclusive podcast, that he believed there were multiple factors at play.
“We looked at all the other presentations we see for alternate opiates, and that remained stable [before and after rescheduling] as well,” he said.
“When you look specifically at the drugs we thought were more likely to get changed in [for codeine-containing products] – oxycodone and tramadol – they actually went down by about 20% over that period as well.
“One of the major concerns [about the rescheduling was] whether people would turn to alternate opiates. We can’t tell that exactly from our data because we didn’t look at prescription data, but certainly from our presentations, it doesn’t look like that’s what’s happened.
“Where is the line drawn between chronic pain and dependence?” Dr Harris asked. “There could be that gray area where there’s some people whose chronic pain – when they stopped taking the codeine – is actually more to do with dependence.
“Certainly, there’s been a general conversation and a change in approach to opiates. Certainly, in the last couple of years, even in our emergency department, we’re looking at opioid prescription practices, and [we’re getting] calls from GPs not wanting to prescribe opiates in patients who have dependence.
“So maybe we’re seeing all of this happening at the same time.”
Dr Harris said before seeing the data he believed that the rescheduling of codeine-containing products by the Therapeutic Goods Administration was “a reasonable thing based on the evidence”.
“We were seeing there a lot of mixed product ingestions and some toxicity resulting from them. We were seeing a gradual increase in presentations. In 2015, we had 133 then it came up to 160 in the following year and then 165.
“So, the rescheduling seemed like a reasonable thing to do. And certainly, it seems like a positive story at the moment in terms of the changes that we’ve seen.”
Dr Harris said that so far in 2019 the Princess Alexandra Hospital’s toxicology unit was on track for another slight increase in total presentations.
“But again, we’re looking at about the same number of total codeine presentations, so around that sort of 75 mark, coming from that previous rate of about 160. So, it looks like it has been maintained this year as well,” he said.
“It will be interesting to see if this is maintained into the future.”
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And yet the # of Paracetamol goes largely unchecked! People who are seeking pain management are still in the same position. The idea that codeine was unregulated is a joke, you have always required a script for stronger Codeine.
Show me where the # of codeine related cases was relating to products with 12.8mg of codeine? Look @ the big picture. A script for this $ in Dr pockets what a joke! Your research is flawed Dr’s for Dr’s
Prior to rescheduling, the majority of emergency department presentations involving OTC codeine combination products (<30mg) were presentations involving paracetamol products. Someone who overdosed on OTC codeine/paracetamol combination products would reach a potentially lethal dose of paracetamol long before they had ingested a dangerous dose of codeine. It is not surprising that the number of presentations involving OTC codeine have reduced given the changes in scheduling. As the hospital has reported a 13% increase in poisonings over this time period, it would be interesting to know what percentage of presentations involved paracetamol toxicity.
Anonymous here again.
No further reaction! I wonder why?
Chronic pain and its co-linked issues of personal loss, illness focus, “something to fix it”, medical responsibility for care, family disruption and the wider psycho social consequences surely deserve a response from the medical community.
Why should this, such state of silence, be so? It “begs” a question.
Perhaps, with the recovery of the person’s endorphins (suppressed by the oral opioid intake) it transpires that there has been a revelation that the “chronic pain” was a self, or iatrogenic, caused condition. Thus, there is no ‘question’ to “beg”, as the side-effects of an opioid are resolved in the sustained absence of the opioid, and the hyper-algesia of withdrawal never arises and the chronic pain has gone.
Hence there is no need to go and seek treatment from elsewhere – not least for musculo-skeletal discomfort – where prescription is not evidence-based. Nor to end up in an ED, dare it be said, a common initial source of opioids.
The Canadians, with their extensive knowledge of cannabis in all its forms, consistently hold to the view that cannabis has no effect on pain, such as in reducing symptoms. This is a position held by the British Pain Society. Medical practitioners need to be aware of the evidence, admittedly held to be conflicting.
Salbutamol and chloromycetin should be rescheduled too.
Dr Katelaris is almost correct. Drug dependant patients are now substituting “medical” cannabis for other drugs of dependence like codein.
More and more chronic pain patients are abandoning allopathic drugs and turning to cannabis based treatments for better overall effect and less unwanted side effects.
We await with interest the apology from the Pharmacy Guild for the apocalyptic predictions they made that never turned out to be factual. What is being observed is pretty much exactly what the overseas and local evidence predicted would happen. Codeine is an erratic analgesic drug with lots of side effects, including dependence, and isn’t appropriate for use in chronic pain patients. This is a great step towards tidying up the regimens of many poorly treated patients.
Perhaps some of the overdose patients have gone to other hospitals, for whatever reason, and are not known about at Princess Alexandra Hospital..