Rescheduling codeine‐containing analgesics reduced codeine‐related hospital presentations

Harris, Keith; Jiang, Andrew; Knoeckel, Robert; Isoardi, Katherine Z

doi:10.5694/mja2.50400

Cited by 14 publications

(15 citation statements)

References 2 publications

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“…In contrast, methadone, when represented as OMEs, was supplied in the largest volume, yet there were relatively fewer poisonings associated with its supply, which may reflect the tight control over methadone which is provided predominantly in daily supervised doses in community pharmacies under the framework of opioid agonist treatment [ 27 ]. Similarly, following the removal of sale of codeine as an over‐the‐counter medicine in Australia in 2018 [ 28 ], we observed clear reductions in the rates of harm, consistent with reductions in codeine‐related hospitalizations [ 29 ] and poisons information centre calls [ 30 ] reported elsewhere. Tapentadol and oxycodone–naloxone are of interest, given their relatively large supply volumes in the later years of observation yet relatively low rates of poisonings.…”

Section: Discussionsupporting

confidence: 81%

Pharmaceutical opioid poisonings in Victoria, Australia: Rates and characteristics of a decade of emergency department presentations among nine pharmaceutical opioids

et al. 2021

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Background and aims Pharmaceutical opioids are a significant contributor to the global ‘opioid crisis’, yet few studies have comprehensively distinguished between opioid types. We measured whether a range of common pharmaceutical opioids varied in their contribution to the rates and characteristics of harm in a population‐wide indicator of non‐fatal overdose. Design Retrospective observational study of emergency department (ED) patient care records in the Victorian Emergency Minimum Data set (VEMD), July 2009 to June 2019. Setting Victoria, Australia. Cases ED presentations for non‐fatal overdose related to pharmaceutical opioid use (n = 5403), where the specific pharmaceutical opioid was documented. Measurements We compared harms across the nine individual pharmaceutical opioids most commonly sold, and considered where multiple opioids contributed to the overdose. We calculated supply‐adjusted rates of ED presentations using Poisson regression and used multinomial logistic regression to compare demographic and clinical characteristics of presentations among nine distinct pharmaceutical opioids and a 10th category where multiple opioids were documented for the presentation. Findings There were wide differences, up to 27‐fold, between supply‐adjusted rates of overdose. When considering presentations with sole opioids, the highest supply‐adjusted overdose rates [per 100 000 oral morphine equivalents (OME); 95% confidence interval (CI)] were for codeine (OME = 0.078, 95% CI = 0.073–0.08) and oxycodone (OME =0.029, 95% CI = 0.027–0.030) and the lowest were for tapentadol (OME = 0.004, 95% CI = 0.003–0.006) and fentanyl (OME = 0.003, 95% CI = 0.002–0.004). These rates appeared related to availability rather than opioid potency. Most (62%) poisonings involved females. Codeine, oxycodone and tramadol were associated with younger presentations (respectively, 59.5%, 41.7% and 49.8% of presentations were 12‐34 years old), and intentional self‐harm (respectively 65.2%, 50.6%, and 52.8% of presentations). Relative to morphine, fentanyl [ 0.32 relative risk ratio (RRR)] and methadone ( 0.58 RRR) presentations were less likely to be coded as self‐harm. Relative to morphine–buprenorphine, codeine, oxycodone and tramadol presentations were significantly more likely to be associated with the less urgent triage categories (respectively 2.18, 1.80, 1.52, 1.65 RRR). Conclusions In Victoria, Australia, rates and characteristics of emergency department presentations for pharmaceutical opioids show distinct variations by opioid type.

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Section: Discussionsupporting

confidence: 81%

Pharmaceutical opioid poisonings in Victoria, Australia: Rates and characteristics of a decade of emergency department presentations among nine pharmaceutical opioids

et al. 2021

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“…9 One strategy was to reschedule analgesics containing codeine from being available over-the-counter to Schedule 4, requiring a prescription for supply. 10,11 The states and territories are now introducing real-time prescription monitoring. This provides the prescriber with an up-to-date history of the patient's supply of high-risk psychoactive medicines to help identify those with an established or emerging problem.…”

Section: Real-time Prescription Monitoringmentioning

confidence: 99%

Real-time prescription monitoring: helping people at risk of harm

Dobbin¹,

Liew²

2020

Aust Prescr

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Misuse of opioid analgesics and other psychoactive medicines is a serious and increasing problem in Australia. Measures are being taken to try and prevent this progressing to a public health crisis like the opioid overdose epidemic seen in the USA. One measure is real-time prescription monitoring. This provides real-time information about the patient's supply of psychoactive medicines which have a high risk of being misused. Having identified a patient at risk, many factors may delay appropriate management or result in the patient being discharged from care. These factors include subconscious negative stereotyping, a focus on preventing 'doctor shoppers' diverting psychoactive medicines, and a fear of sanction by regulators. The Medical Board of Australia provides guidance about good practice. Patients should be treated with respect, free from bias and discrimination, and without prejudicing care because of the belief that their behaviour has contributed to their problems. seeking psychoactive medicines for their intoxicating effect or for trafficking. 2 Trust is basic to the doctor-patient relationship. When this is exploited by a drug-seeking person it may cause negative feelings and indiscriminate refusal to continue treatment for other patients assumed to be fraudulently seeking prescriptions. The focus on preventing 'doctor shoppers' may influence this attitude but, like any other medical condition, patients with multiple providers will benefit from a patientcentred approach. Escalating opioid prescribing There was a 15-fold increase in the supply of prescription opioids between 1992 and 2012. 3 During this time several new, potent opioids and many new formulations were marketed in Australia. Approximately three million Australians now use opioids each year. About 2.5 million report lifetime non-medical use of pharmaceutical drugs. In 2016 more than 700,000 Australians used opioid analgesics non-medically to achieve a drug effect. 4 Every day there are nearly 150 hospitalisations, 14 emergency department presentations and three deaths involving opioids. 5 Increasing numbers of people are being treated in alcohol and drug clinics or being prescribed medicines to treat pharmaceutical opioid dependence. Opioids and benzodiazepines are commonly involved in overdose deaths. Non-medical use of opioid

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“…As rates of problematic opioid use and overdose grow in high income countries, epidemiologic signals of exposure and harm have increased year by year. It is therefore encouraging to read evidence of a downward trend for one category of this complex crisis described in two papers in this issue of the Journal …”

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confidence: 98%

“…Further, the review by Harris and his colleagues of codeine‐related presentations to the Princess Alexandra Hospital in Brisbane found that the number of codeine‐related presentations declined by 53% after rescheduling (163 presentations in the 12 months preceding rescheduling, 77 presentations during the 12 months after rescheduling), largely attributable to fewer presentations associated with the rescheduled low dose codeine preparations (less than 30 mg); numbers of presentations involving other opioids had not increased. These findings are consistent with the fact that calls to the NSW Poisons Information Service about codeine‐related intentional poisonings (deliberate self‐poisoning, recreational use, other non‐therapeutic use) declined by 50.8% in the 12 months after upscheduling, with no increase in calls regarding prescription codeine or other prescription opioids …”

mentioning

confidence: 99%

From over‐the‐counter to prescription only: early results of the rescheduling of codeine combination analgesics

Dobbin

2020

Medical Journal of Australia

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2 Schaffer AL, Cairns R, Brown J, et al. Changes in pharmaceutical sales to pharmacies after codeine was rescheduled a prescription only medicine. Med J Aust 2020; 212: 321-327. 3 Harris K, Jiang A, Knoeckel R, Isoardi KZ. Rescheduling codeine-containing analgesics reduced codeine-related hospital presentations. Med J Aust 2020; 212: 328. 4 Degenhardt L, Gisev N, Cama M, et al. The extent and correlates of community-based pharmaceutical opioid utilisation in Australia. Pharmacoepidemiol Drug Saf 2016; 25: 521-538. 5 Annabel B, Scrymgeour M. Fork handles. Australas J Pharm 2017; 98: 74-75. 6 McAllister WB. The global political economy of scheduling: the international-historical context of the Controlled Substances Act. Drug Alcohol Depend 2014; 76: 3-8. 7 Derry S, Karlin SM, Moore RA. Single dose oral ibuprofen plus codeine for acute postoperative pain in adults. Cochrane Database Syst Rev 2015; CD010107. 8 Daniels SE, Goulder MA, Aspley S, Reader S. A randomised, five-parallelgroup, placebo-controlled trial comparing the efficacy and tolerability of analgesic combinations including a novel single-tablet combination of ibuprofen/paracetamol for postoperative dental pain. Pain 2011; 152: 632-642. 9 Cock V, Edmonds C, Cock C. Complications related to chronic supratherapeutic use of codeine containing compound analgesics in a cohort of patients presenting for codeine withdrawal. Drug Alcohol Rev 2018; 37: 731-737. 10 Frei MY, Nielsen S, Dobbin MDH, Tobin CL. Serious morbidity associated with misuse of over-the-counter codeine-ibuprofen analgesics: a series of 27 cases. Med J Aust 2010; 193: 294-296. https://www.mja.com.au/journ al/2010/193/5/serio us-morbi dity-assoc iated-misuse-over-count er-codei neibupr ofen-analg esics 11 Mill D, Johnson JL, Cock V, et al. Counting the cost of over-the-counter codeine containing analgesic misuse: a retrospective review of hospital admissions over a 5 year period. Drug Alcohol Rev 2018; 37: 247-256.

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Rescheduling codeine‐containing analgesics reduced codeine‐related hospital presentations

Cited by 14 publications

References 2 publications

Pharmaceutical opioid poisonings in Victoria, Australia: Rates and characteristics of a decade of emergency department presentations among nine pharmaceutical opioids

Pharmaceutical opioid poisonings in Victoria, Australia: Rates and characteristics of a decade of emergency department presentations among nine pharmaceutical opioids

Real-time prescription monitoring: helping people at risk of harm

From over‐the‐counter to prescription only: early results of the rescheduling of codeine combination analgesics

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