Sacrifice sales for patient safety
Pharmacies cannot optimally control OTC codeine sales, so the only real option is to switch these products to POM, says Terry Maguire…
A Zoom meeting was called in June by the Department of Health (DoH). The invitation list was made up of pharmacies with high sales of OTC products containing codeine. Just being on the invitation list itself was a cause for concern, I thought, as I dialled in.
I was unaware the DoH had such precise data but, due to the Controlled Drug Reconciliation Programme (CDRP), it is well informed about all my CD purchases. CDRP is a surveillance system set up following the egregious and over-zealous supply of about a million controlled drugs by one of our own to persons unknown, and for which he received a custodial sentence.
When this little scam was eventually detected - and that took our DoH some considerable time even though it was like not realising the Northern Bank robbery had happened - the red-faced civil servants vowed it would never happen again.
The CDRP is impressive in knowing, for example, the total number of diazepam tablets I purchase and reconciling this with prescriptions I dispense. More coming in than going out signals a potential problem and an investigation.
As codeine containing OTC medicines are schedule 5 CDs, these are also monitored in CDPR but since so few are supplied on prescription it’s easier to compare pharmacies and look for outliers.
The stimulus for the Zoom meeting was a complaint by a gastroenterologist at one of the Belfast hospitals. He was concerned about the increasing incidence of oesophageal damage due specifically, in his opinion, to Nurofen Plus abuse.
A case study was presented of a 25-year-old male arriving at A&E with severe pyloric stenosis and claiming to be taking 80 Nurofen Plus tablets daily. He was refused admission to hospital but returned to A&E within a week seeking more help. Admitted, he soon signed himself out and a few days later he was found dead at home.
Medics have long been concerned about OTC codeine. Ten years ago, the British Medical Association called for a major rethink on the availability of OTC codeine products. They claim that up to 4 per cent of the UK population are regular codeine users.
Back then, the Committee on Safety of Medicine had a look at the evidence but felt it unnecessary to change codeine’s OTC status. Instead, the Committee merely beefed up the pack warnings and patient information leaflets, so now addicts have clearer signposts to the medicines they should try out.
The CSM conceded that OTC codeine medicines lead to medication headache, a key contributor to codeine addiction as the individual thinks they have a tension headache when, in fact, they are suffering codeine withdrawal.
The CSM also found that the number of reports of misuse or abuse of OTC codeine/dihydrocodeine (DHC) compounds was exceedingly small (54 reports) compared to the volume of sales in millions of units. The Committee examined the literature and concluded that although misuse and abuse of OTC analgesics were without doubt significantly under-reported, “there was unlikely to be a huge hidden problem with these syndromes”.
The Zoom meeting was, to use the term euphemistically, interesting. The DoH, along with representatives from the newly formed SPPG (formally the Health Board), appeared surprisingly nervous. They have a legal enforcement role for controlled drugs, which for OTC medicines sales is more ambiguous and therefore more difficult to manage than it would be for POM supplies.
We do what we can. Some pharmacies simply do not supply Nurofen Plus but find that their sales of other codeine-based analgesics are still huge. We don’t stock the 32-tablet pack size as we find it keeps the real addicts out, and anyway, it is illogical to supply this quantity and then tell people the medicine is only for three days use. On some occasions we simply take the packs off the shelf for a week and that reduces visits from the pharmacy hoppers.
But all this amounts only to a large dollop of hypocrisy. Sometimes, in a fit of righteousness, I decide not to supply but I know that only means sending the user down the street to the next pharmacy. This is an age-old problem but one exacerbated by many issues, not least by product display and branding.
We need to be clear that pharmacies cannot optimally control OTC codeine sales and that the only real option is switching these products to POM which will ultimately remove them from the market.
For many pharmacy owners, it will be painful to lose the impressive sales they clock up, and that prospect was all too evident in that Zoom meeting. But for now, we have been warned.
Terry Maguire is a leading community pharmacist in Northern Ireland.