Codeine – The Real Opium of the Masses…

In June 2022 the Department of Health (DoH), invited pharmacies with high sales of codeine containing painkillers to a Zoom meeting. 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 on our commercial activity but due to its Controlled Drug Reconciliation Programme (CDRP) it tracks all controlled drug purchases and supplies. CDRP is a surveillance system primarily designed to identify egregious and over-zealous supply of prescription-controlled drugs but as codeine over-the-counter (OTC) medicines are also controlled these medicines are monitored. The CDPR system easily identifies pharmacies whose sales are greater than the average so we were invited for a pep-talk.

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 an over-the-counter codeine containing analgesic. 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. The case made was that the overuse of ibuprofen in the medicine caused the gut damage whereas the reason it was being taken in such high quantities was for its narcotic effect.

Medics have long been concerned. Twenty years ago, the British Medical Association (BMA) called for a major rethink on the availability of OTC codeine products. They claimed back then that up to 4% of the UK population are regular codeine users. At that time, 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 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”.

At our zoom meeting the DoH, along with representatives from SPPG (formally the Health Board), appeared surprisingly nervous. They have a legal enforcement role for controlled drugs which for OTC medicines sales is more ambiguous and therefore more difficult to manage than it would be for prescription supplies.

There is in my opinion a real problem with opioid abuse generally across N. Ireland and we are well ahead of other regions of the UK. It’s a combination of prescription and over-the- counter abuse and indeed GPs in the last few months have been brought together to identify ways and best practice that might address the problem they are having with repeated requests for stronger codeine containing medicines. There is clinical justification in some cases for use of stronger opioids in pain management but frankly they are largely ineffective in managing chronic pain.

Over-the-counter codeine pain are no more (perhaps less) effective than paracetamol or ibuprofen alone. Indeed, the most effective painkiller you can buy without prescription is a combination of paracetamol and ibuprofen. The only reason codeine containing OTC medicines exist is that this the lowest legal daily dose of codeine that can be sold without prescription. As a pharmacist I would never recommend a codeine containing OTC medicine for any type of mild to moderate pain.

Pharmacists do what we can. Some pharmacies simply do not supply Nurofen Plus for example but find that their sales of other codeine-based analgesics are still huge. We don’t stock the thirty-two tablet pack size as we find it keeps the real abusers out and it is illogical to supply this quantity and then tell clients that the medicine is only for 3 days use. On some occasions we simply take the packs off the shelf for a month and that reduces visits from the “pharmacy-hoppers”.

But all this amounts only to a large dollop of hypocrisy. For regular and persistent visitors, and perhaps in a fit of self- righteousness, I often 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.

We need to be clear that pharmacies cannot optimally control OTC codeine sales and that the only real option is switching these products to prescription only which will ultimately remove them from the market. They then are under the full management of GPs and it’s clear from prescription use that GPs too are struggling to control supply.