MEDICAL MATTERS:Are new codeine guidelines for pharmacists over the top?
JUDGING BY recent e-mails I have received from readers, and contributions to the letters page of this newspaper, people are less than enamoured with recently introduced guidelines on the supply of over-the-counter codeine products by pharmacists.
In practice, the guidelines mean that you can no longer go into a pharmacy, pick a packet of Solpadeine or Nurofen Plus off the shelf and pay for it. Preparations containing codeine are now stored out of sight of the public, in an area of the pharmacy “under the direct control” of the pharmacist. The change has discommoded those in the habit of using codeine-containing painkillers to treat sports injuries, joint pain and even hangovers.
According to one correspondent, who sustained injuries to his right shoulder following a minor motorcycling accident, “these new regulations are a complete farce”. He says he headed to his local pharmacy to ask for Nurofen Plus to deal with the pain. “The pharmacist refused to serve me this product on the basis that it has codeine in it and, under the new regulations, they could not sell codeine products for my complaint,” he writes. Having taken a non-codeine product, his pain was actually worse and so, some three hours later, he returned to the pharmacy and explained the situation – but was again refused the stronger painkiller.
“As a result of these new rules I spent the whole of last night writhing in pain. I got no sleep and I have missed a day’s work because of something so trivial and completely unnecessary,” the aggrieved reader says.
Calling on the PSI to reverse its guidance, he concludes: “These rules now give me no other choice but to purchase painkillers without prescription from the internet.”
Others have described being interrogated by pharmacists and have called for some sensitivity in the application of the new guidelines. One letter writer highlighted the issue of personal responsibility: “I think the pharmacist in question could have allowed me the responsibility I am entitled to for my own liver and kidneys, and have sold me the pain-relief drugs I had asked her for.”
Despite these concerns, as of late last week the PSI had received no formal complaints from the public. PSI registrar Dr Ambrose McLoughlin confirmed that, while it had received a number of calls requesting information about the guidance and had in some instances supplied details on how to make a formal complaint, none had yet been lodged.
From a regulatory perspective the initiative is all about patient safety. We are unusual here in not designating codeine as a prescription-only medicine. Indeed, for some time, both doctors and pharmacists have been concerned that the previous rules were excessively laissez-faireby international standards.
How dangerous a drug is codeine? It is a member of the opiate family, which means it is a similar type of medicine to heroin and morphine. It kills pain by acting on the same receptors as these highly regulated opiates.
Despite its milder action, it can cause side effects and can lead to addiction. Codeine problems tend to creep up stealthily on patients, many of whom start using the drug in combination with others for everyday ailments such as headaches.
For someone with a migraine or chronic back pain, combination painkillers are effective initially. However, their ability to kill pain wanes over time, and there is evidence of “medication overuse syndrome”, whereby greater doses actually make the pain worse rather than better.
Naturally, people take more tablets to counteract this, and eventually become addicted to the calming, relaxing effect of the higher codeine dose. When they try to stop taking the drug, they experience shivering, insomnia, aching joints and agitation. Eventually they need it just to feel normal.
I suspect the initial furore may well settle down. Pharmacists who have a relationship with an individual patient will be able to dispense codeine products more confidently.
But the initial reaction has given us interesting insights into how some people resent the intrusion of what they see as a “nanny state” into healthcare.