Reader Response to IMJ Article: “Codeine Usage in Ireland – A Timely Discussion on an Imminent Epidemic” by E. McDonnell

C. Kennedy¹, E. Duggan², K. Bennett³, D. Williams⁴, M. Barry¹

1. Department of Pharmacology and Therapeutics, Trinity Centre for Health Sciences, St James’s Hospital, Dublin 8
2. National Poisons Information Centre, Beaumont Hospital, Dublin 9
3. Division of Population Health Sciences, Royal College of Surgeons in Ireland, St Stephen’s Green, Dublin 2
4. Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin 9

Dear Sir,

We read with interest the article by McDonnell regarding an imminent codeine epidemic in Ireland. We commend the author for highlighting this important healthcare issue. The author outlines numerous concerns including codeine shopping, the lack of medical supervision for over-the-counter(OTC)/non-prescription codeine supply and the increase in prescribing addictive medications.

We follow with great interest the opioid epidemic in the USA. Originating with the intent to address patients suffering, its long-term consequences include widespread addiction partly driven by the profits available to treating physicians and pharmaceutical companies, among other factors.¹

However, we know of no reliable evidence to suggest a similar epidemic is imminent in Ireland. We acknowledge that there is a difficulty in measuring the extent of codeine use, as OTC sales data are commercially sensitive. We have used a surrogate marker, codeine poisonings, to examine the misuse of codeine.² In our paper, we found a reducing trend of codeine poisoning from 2005 to 2016, possibly a result of the focus pharmacists and their educators have placed on safe supply of codeine for many years. Our analysis of the Primary Care Reimbursement Service data did not reveal an increase in reimbursement of prescription-only codeine products or more potent opioids over a similar period. Also, our study reported a significant reduction in codeine poisonings, in keeping with the prevailing trend, after guidance by the Pharmaceutical Society of Ireland to restrict codeine supply. However, further restriction of codeine to prescription-only is of questionable benefit and may be detrimental.

Firstly, prescription-only codeine supply would place an additional burden on our strained primary care system. It is in contrast to health policies in the UK and elsewhere which have reclassified medicines from prescription-only to pharmacy supply in order to improve patient access, reduce national drug budgets and alleviate the workload of general practitioners.³ Secondly, McDonnell considers primary care as an ideal setting to address codeine misuse. There is a risk that prescribers escalate treatment to more potent prescription-only opioids inadvertently.⁴ Indeed, the author discusses her concerns regarding the increase in prescriptions of addictive substances in primary care. Thirdly, a broader definition of ‘medical supervision’ is required to encompass health professional supervision. Community pharmacists are adequately trained and well positioned to tackle the issue of codeine misuse with improved systems and policies. We agree with the author’s suggestion to centrally monitor codeine supply. This could be pharmacy rather than prescription based. Such an intervention would all but eliminate ‘codeine shopping’ and is eminently possible with today’s technologies. Monitoring systems have been used elsewhere and would enable both the accurate measurement of codeine misuse as well as the real-world effect of future policy interventions.⁴

We agree a discussion regarding codeine addiction is necessary and as timely now as ever. Options other than reclassifying codeine to prescription-only need to be considered in the first instance. The use of the phrase ‘imminent epidemic’, for which there is no robust evidence, may not be appropriate when a rationale debate between all stakeholders is required.

Corresponding Author:
Cormac Kennedy,
Department of Pharmacology and Therapeutics,
Trinity Centre for Health Sciences,
St James’s Hospital,
Dublin 8
Tel: 01 8962667
Email: [email protected]

References
1. deShazo R. D., Johnson M., Eriator I., Rodenmeyer K. Backstories on the US Opioid Epidemic. Good Intentions Gone Bad, an Industry Gone Rogue, and Watch Dogs Gone to Sleep. The American Journal of Medicine. 2018;131(6):595-601.
2. Kennedy C., Duggan E., Bennett K., Williams D. J. Rates of reported codeine‐related poisonings and codeine prescribing following new national guidance in Ireland. Pharmacoepidemiology and drug safety.
3. Rutter P. Role of community pharmacists in patients’ self-care and self-medication. Integrated pharmacy research & practice. 2015;4:57-65.
4. Carroll P. Three claims used to justify pulling codeine from sale without a prescription, and why they’re wrong. 2018. Available from: https://theconversation.com/three-claims-used-to-justify-pulling-codeine-from-sale-without-a-prescription-and-why-theyre-wrong-87257 (accessed 21/03/19)

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