No increase in opioids since up-scheduling, but pharmacists disagree

‘This is a really good news story for GPs.’
 
That is GP Dr Evan Ackermann, past Chair of the RACGP Expert Committee – Quality Care and key author of the RACGP’s Prescribing drugs of dependence in general practice – Part C1: Opioids.
  
His comments are in response to a new study by Monash Addiction Research Centre that found that, since codeine was up-scheduled on 1 February 2018, there has been no increase in prescribed opioid use.
 
The study tracked opioid prescriptions across three years – two prior to the change, and one after.
 
‘When we looked at overall prescribing, so for weak opioids like codeine and strong opioids like oxycodone in Australia, those trends are actually coming down,’ Associate Professor Suzanne Nielson from Monash University told 7.30.
 
Dr Ackermann told newsGP that when the Therapeutic Goods Administration (TGA) wanted to up-schedule codeine, the RACGP backed the idea.
 
‘But it was a real battle because of the Pharmacy Guild and the way pharmacy approached it … they pushed that it wasn’t necessary,’ he said. ‘They sort of catastrophised and said, “This is going to increase the number of prescriptions of opioids”.
 
‘But this investigation by Monash research puts that all to bed. Opioid [use] has actually decreased.
 
‘We championed this … we’ve done the right thing, and [this study] showed that transferring the responsibility to general practice has resulted in a positive outcome.’
 
While Dr Ackermann is pleased by these results, Anthony Tassone, President of the Victorian branch of the Pharmacy Guild of Australia, disputes the findings of the study.
 
‘What we have seen, not only in my pharmacy, but pharmacies in general, [is] there has been an increase in PBS [Pharmaceutical Benefits Scheme]-subsidised codeine,’ he said.
 
Mr Tassone said prescriptions in his pharmacy are also being filled at a higher dosage because over-the-counter codeine is no longer available.
 
‘That’s a higher dose that you get on a prescription since codeine has been made prescription-only,’ he said.
 
The TGA up-scheduled codeine to a Schedule 4 drug last year because of evidence about its safety and effectiveness.
 
The RACGP created the ‘Upscheduling of codeine’ resource page in response to this change.
 
In its November 2018 report, Opioid harm in Australia: and comparisons between Australia and Canada, the Australian Institute of Health and Welfare (AIHW) said the number of deaths in Australia involving opioids had nearly doubled in the decade to 2016, from 591 to 1119.
 
Furthermore, the rate of hospitalisation where opioid poisoning was recorded as the main reason for admission rose by 25% during the same period.
 
‘Every day in Australia, there are nearly 150 hospitalisations and 14 presentations to emergency departments involving opioid harm, and three people [a day] die from ... opioid use,’ AIHW spokeswoman Dr Lynelle Moon said at the time.
 
‘In the case of both deaths and hospitalisations, pharmaceuticals opioids were more likely to be responsible than illegal opioids.’
 
In 2016, the most common types of opioids responsible for deaths were naturally derived, such as oxycodone, codeine and morphine, which were attributed to 550 deaths, followed by heroin (361 deaths).
 
In 2016–17, 15.4 million opioid prescriptions were dispensed under the PBS to 3.1 million people. Of those, oxycodone was the most commonly dispensed prescription opioid (5.7 million), followed by codeine (3.7 million). 
 
RACGP resources
Prescribing drugs of dependence in general practice – Part C1: Opioids
This guide aims to help GPs prescribe opioids appropriately in the general practice context. It is designed to discourage inappropriate use and reduce harms by providing GPs with guidance and practical advice regarding opioid therapy.
 
Prescribing drugs of dependence in general practice – Part C2: The role of opioids in pain management
This guide provides recommendations for GPs who are prescribing opioids for acute and chronic pain outside of active cancer treatment, palliative care and end-of-life care.
 
Upscheduling of codeine
This page is home to a broad range of clinical and educational resources, as well as a number of consumer-focused sources designed to help patients better understand and adjust to the change in policy.

codeine opioids prescription up-scheduling