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Codeine not for S3

Stephen Carbonara
From an Independent Professional Pharmacist Perspective

Issue 82: May 2009
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Given the current talk of codeine re-scheduling, I’ve decided to offer my opinion on the matter.
I believe that codeine is a significantly abused drug in the community (I witness it first-hand), and that something needs to be done to curb its use.
However I believe the NDPSC’s potential position is attempting to fix a problem using a scheduling system that is dated and ill-equipped for the job.
The S3 schedule is ill-adapted to contemporary pharmacy (it worked well in the past); but the resultant effect (which the codeine issue has now highlighted) will be an increasing presence of ‘busy pharmacists’.
S3 is assumed to restrict access, but contemporary pharmacists’ lack-of-time, sales-based remuneration model and resultant complacency will most probably result in a similar level of codeine abuse and a plethora of bothered pharmacists.
Who knows, maybe pharmacists may suffer from an increased frequency of headaches???.....you know where I’m going with this one!

My view is as follows:

Codeine should remain in schedule 2, but only when compounded in combination with one or more non-opiate therapeutically active substances as a 10mg-per-tablet dose, maximum recommended dose 2 tablets four times a day (total 80mg/day), and maximum pack size 24 tablets (3 days use at maximum dosage).
Or for liquids, maximum 0.2% concentration (20mg/10mL), maximum recommended dose 10mL four times a day (total 80mg/day), and maximum size 120mL (3 days use at maximum dosage).

Codeine should not be included with separate criteria in schedule 3.

Codeine should be included in schedule 4 in doses between 10mg-per-tablet and 30mg-or-less-per-tablet (or 0.5% or less for liquids) in combination with one or more other therapeutically active substances.

Otherwise codeine should be included in schedule 8.

This would ensure that all OTC purchases will be limited to a 24 pack of tablets; and that for greater quantities, a visit to the doctor will be necessary. Infrequent (legitimate) users should not mind purchasing 24 tablets, as their use is sporadic.
However abusers will not be able to purchase large quantities without the staff or pharmacist noticing; and if they did require larger quantities, they would be obliged to obtain a prescription.
For those who attempt to purchase more than one box, the staff will be alerted to a multiple-pack-buy and will inform the pharmacist (another option would be to have the point-of-sale computer disallow a multiple-pack-buy sale).

Smaller S2 pack sizes will allow pharmacists and staff to more frequently observe repeat shoppers, with a view towards greater intervention in specific cases rather than the blanket approach that is required for S3 sales.
Therefore this makes better use of pharmacists' time compared to the S3 approach which will result in a greater time burden.
I am critical of involving "Project STOP" or any other recording system that results in an increase in time burden on the pharmacist or staff.
Although an efficient recording system would be ideal; however this would require some sort of Medicare-swipe-upon-sale or eye-ball-scan-upon-sale, which requires a significant resources investment.
I believe that there must be an increase in employee numbers if a data-entry recording system is in place, otherwise pharmacists will suffer a decrease in staff-assistance-time, resulting in a net increase in time burden.
And I am doubtful that pharmacy owners will be willing to employ more staff due to a scheduling change!

The up-scheduling of codeine to S3 will only result in extremely busy pharmacists.
Pharmacists are diligent upon down-scheduling but are complacent upon up-scheduling. I am not confident that pharmacists in general, under the current S3 model, will be able to provide the required level of service to the public as a result of the NDPSC's potential decision on this matter.

Stephen Carbonara.

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