Codeine regulations cause a few headaches

Some customers resent being questioned about their use of codeine – but overuse of the drug has become a problem, writes CLAIRE O'CONNELL

JUST OVER three weeks ago, a change occurred in Irish pharmacies that appears to have touched a raw nerve.

On August 1st, guidelines came into force meaning over-the-counter medications containing codeine now have to be stored out of view, and customers looking to purchase them have to talk to the pharmacist about why they need them.

“Codeine medicines should only be used when considered necessary, and for the shortest period necessary,” states a release from the Pharmaceutical Society of Ireland, which regulates the profession.

The PSI website adds that the aim of the guidance is to “ensure the safe and rational use of these medicines and to assist pharmacists in discharging their professional obligations to patients seeking advice, guidance or assistance in using these medicines.”

But some customers are disgruntled at being faced with questions when attempting to buy non-prescription medications that contain codeine.

“That sort of reaction has been seen in pretty much every pharmacy at some point or another since these guidelines came in,” says Darragh O’Loughlin, president of the Irish Pharmacy Union and a community pharmacist in Tuam, Co Galway.

The guidance is a “mixed blessing” for pharmacists, he says, as it increases their interaction with patients and members of the public who are looking for pain relief, but there’s also a “significant workload implication”.

“Where previously customers and patients might have been dealt with by counter staff in the pharmacy non-prescription medicine, now the pharmacist has to come out, and it interrupts the workflow of preparing prescriptions and so on,” he says.

The guidance makes no provision for a pharmacist who knows a patient and the reason they are seeking the medication, notes O’Loughlin.

“If someone comes in to me and I know he is using a particular product because he suffers from backache and it’s a recurring issue and he has had physiotherapy – I know this and he knows I know this, yet we still have to go through the procedure that’s set out in the guidelines,” he says.

“It would be a shame if a measure that was introduced to protect patients and make sure their use of medicine was safe became a tick-box exercise or a barrier to communication between pharmacists and their patients.”

The new guidance won’t stop people with a codeine addiction figuring out the right answers to the questions and moving from pharmacy to pharmacy to buy the medications, according to O’Loughlin, although he notes that if such a problem is recognised pharmacists are in a position to offer advice on dealing with it.

“The guidelines will be most successful in protecting people who have issues with over-reliance on codeine-containing medicines but don’t realise it themselves,” he says.

“And people who commence using these medicines are less likely to inadvertently develop problems, because now they are forced into getting advice from the pharmacist.”

Taking codeine too frequently to treat headaches can lead to changes in brain chemistry, and to rebound or medication-overuse headaches, according to Esther Tomkins, a nurse specialist in headache and migraine at Beaumont Hospital.

“Many of our headache patients would take as an acute treatment for headache.

“That’s all right if they are taking it episodically – a couple of times a month – but a lot of our patients would be getting headaches 15 or 20 days in a month,” she says, adding that frequent use of painkillers can become a crutch.

“Even though it’s not doing much to help their headache they are taking it because they are living in fear of the headache coming – a psychological component comes with that too.”

Interaction with the pharmacist can raise awareness and help people find support if needed, says Tomkins. So far she has not seen an increase in calls about codeine to the helpline she runs for headache patients, although she suspects that will happen.

Likewise, GP Dr Mel Bates has not had anyone come in and admit to overusing codeine. He points out that people may still be able to access the medication but they have to answer some questions first.

“They just have to accept that they will be quizzed as to what they are using it for,” says Bates, a spokesperson for the Irish College of General Practitioners.

However, many customers are embarrassed by the questions, according to Cormac Tobin, managing director of Unicare pharmacy. He laments the lack of patient engagement in the consultation process which led to the new guidelines, and questions the need to hide codeine-containing medication from view rather than having packets carry a warning.

“The product has attributes that are required by certain patients, that’s why it is on the market,” he says. “I think are a bit draconian – hiding something away from people doesn’t necessarily mean you are going to stop people who have an addiction.”

The chain, which has over 70 retail outlets in Ireland, has seen codeine- containing medication sales drop since the guidelines came into force, while sales of paracetamol-containing products have risen.

One consumer admits to an “unhealthy relationship” with codeine, and reaches for it frequently, even when he knows the level of pain doesn’t warrant that strength of drug.

In the past he has bought several codeine-containing medications together, with no questions asked. However, his experience has changed since the new guidelines came into force.

“I have been quizzed in the last 10 or 15 days, and I kind of resent it,” he says. “If it’s available over the counter I shouldn’t have to go through this merry dance every time I want a packet of Solpadeine.”

Another consumer, Jason Walsh, found himself suddenly in need of pain relief when he hurt his hand a few days ago. “It was nothing serious enough to trouble casualty about, but appalling pain nonetheless. I applied ice water but really needed some painkillers. Alas, the previous week I had been unsubtly steered away from Solpadeine as I had no reason to buy it other than for emergencies,” he says.

“As an adult, I should be allowed to make my own decisions, even at the risk of making a mistake. The new rules are an offence to adulthood and a symptom of an absurdly risk-averse society, not to mention a commercial and professional power-play on the part of pharmacists.”

For more information on medication overuse headache, contact the Migraine Association of Ireland. See migraine.ie or call the helpline 1850-200378