If codeine were a newly discovered medication, it would not be registrable in Australia today, given what it is known about its poor profile of benefit and harm.
Codeine was first isolated from the opium poppy in the 1830s and came into common clinical use before careful scientific analysis of its effectiveness was required.
Readers may not be aware but codeine, as a derivative of opium poppies, is closely related to morphine and this is one reason why the Faculty of Pain Medicine believes it should only be available with a prescription.
The faculty is one of many medical specialist groups and professional organisations who support the Therapeutic Goods Administration's decision to restrict codeine in the interests of patient safety from February 1.
This approach has already been adopted in more than 25 countries including the United States, Japan, France and Hong Kong.
Like morphine, codeine can cause opioid tolerance, dependence, addiction, poisoning and in high doses, even death. It is estimated that one in 10 people cannot metabolise codeine to morphine while others are rapid metabolisers. This leads to variability in effectiveness and adverse effects. Regular use of medicines containing codeine, for example for chronic pain, has led to some consumers becoming addicted to codeine without realising it.
Codeine products have been estimated to be a factor more than 100 deaths in Australia each year. A 2015 study into codeine deaths, published in the Medical Journal of Australia, found that codeine-related deaths increased from 3.5 per million in 2000 to 8.7 per million in 2009, with 1437 deaths recorded during that time. These deaths came from over-the-counter and medically prescribed codeine.
Unlike codeine, alternatives such as paracetamol and ibuprofen are not opioids and are not addictive. This makes them suitable over-the-counter medicines. The TGA's decision to restrict access to codeine to medical prescription only is a reasonable measure to protect the safety of our community.
We need a system to effectively monitor codeine use. This is best achieved as part of a robust, national real-time prescription monitoring system that protects people from misusing all opioids, including codeine. A medically based monitoring system would mean requests for codeine prescription could be assessed in the context of the person's medical history.
There is also a need to provide sufficient resources to treat people who may have developed dependence on medications such as codeine.
The debate around codeine has highlighted the debilitating impact of chronic and acute pain. One in five Australians now live with chronic pain.
Let's use this debate to start a national conversation around pain management and health policy, to ensure those living with chronic pain are not forgotten.
Medication has only a small part, if any, to play in pain management over the longer term. Simply attempting to relieve pain by medication is not an effective solution.
A national pain strategy that addresses and resources the needs of those with chronic pain through accessible rehabilitation and multi-disciplinary pain management programs will improve our healthcare system, optimise the recovery of individuals and increase the wellbeing of our community.
- Dr Chris Hayes is dean of the Faculty of Pain Medicine at the Australian and New Zealand College of Anaesthetists.