A Comparative Exploration of Community Pharmacists’ Views on the Nature and Management of Over-the-Counter (OTC) and Prescription Codeine Misuse in Three Regulatory Regimes: Ireland, South Africa and the United Kingdom

Abstract

A comparative exploration of community pharmacists' views on the nature and management of Over-the-Counter (OTC) and Prescription codeine misuse in three regulatory regimes; Ireland, South Africa and the United Kingdom. AbstractMisuse of codeine containing preparations is a public health concern given the potential for associated harms and dependence. This study explores the perspectives of community pharmacists in three regulatory regimes on issues of customer misuse of over the counter (OTC) and prescribed codeine containing preparations. A qualitative design comprising six focus groups (n=45) was conducted in Ireland, United Kingdom, South Africa. Transcripts were analysed using the constant comparative method of content analysis. Pharmacists described popular codeine containing products; the need for improved medicine information and warning labels. Issues around legitimate availability of codeine and regulatory status; presence of therapeutic need; difficulties in customer-pharmacist communication; business environments and retail focus were raised. Participants also discussed how they identified customers potentially misusing codeine; customer pharmacy 'hopping' and difficulties in relationships between pharmacists and prescribers. Specialist training; reimbursement for customer consultation; screening and brief interventions; visible referral structures and assisted community pharmacy detoxification were discussed as ways to manage the issues. The study highlights the difficulties encountered by community pharmacists operating under various regulatory regimes when supplying codeine containing preparations in negotiating patient awareness and compliance and dealing with misuse and dependence. Key WordsCodeine containing preparations; Misuse; Community pharmacy; Pharmacists; RegulationWhat is known about this topic 2  Over-the-counter (OTC) and prescription codeine containing products, as dispensed in pharmacies, have the potential for misuse and dependence. Different countries have different regulations with regards to the provision and display of codeine and level of pharmacist intervention at point of sale. Strategies which prevent and address codeine misuse include screening, information provision and referral. What this paper adds Pharmacists in Ireland, South Africa, and the UK have multiple roles and face a number of challenges related to financial and time resources; perceptions of the pharmacist profession and advising on safe and appropriate use of medication, not only codeine. Pharmacists have their own ways to identify customers who may be misusing codeine, but customers' strategies such as 'pharmacy hopping' and some use of online pharmacies make this challenging. Support and referral interventions are provided by pharmacists, but these are not standard, and more information is needed on which services to refer customers to for codeine misuse.

Impact of Up-Scheduling Medicines on Pharmacy Personnel, Using Codeine as an Example, with Possible Adaption to Complementary Medicines: A Scoping Review

“…In addition, it was reported that when codeine was regulated to Schedule 3, some pharmacists were concerned about their clinical competence not being sufficient to help patients with pain management without the aid of over-the-counter CCPs [24]. It was consistent in most of the studies that the up-scheduling of codeine required additional educational training for pharmacists in the area of pain management, counseling skills, and the handling of drug misuse [13,23,24]. This could imply that, if a change in CMs scheduling were to eventuate, pharmacists, pharmacy assistants, and pharmacy technicians would need to undertake professional training in the area of CMs to build on their evidence-based CMs knowledge.…”

“…Some pharmacists felt that it gave them confidence to discuss with patients any codeine-related problems [25]. Some pharmacists would attempt to address a patient's concerns and recommend alternatives to minimize codeine use [13,23]. Other pharmacists felt that rescheduling to Schedule 3 prompted them to upskill in the area of pain management [23].…”

“…Some pharmacists would attempt to address a patient's concerns and recommend alternatives to minimize codeine use [13,23]. Other pharmacists felt that rescheduling to Schedule 3 prompted them to upskill in the area of pain management [23]. Following the second up-scheduling to Schedule 4 for any product containing codeine, it was reported that the up-scheduling actually created an opportunity for patients to openly discuss their pain issues with the pharmacist and seek non-codeine strategies to manage their pain [23,24].…”

Medicines containing codeine: perspectives of medical professionals in the Republic of Ireland

“…How this questioning should precede at the point of sale should be examined in closer detail. A qualitative study of pharmacists working in Ireland found that refusing codeine usually resulted in the product being bought elsewhere (29).…”

Codeine misuse and dependence in South Africa: Perspectives of addiction treatment providers

“…The focus of this study was to complement previous epidemiological research [1] and research on pharmacists [8] and GPs [5] conducted in SA by investigating the perspectives of addiction treatment providers regarding treatment for codeine misuse or dependence. Specific objectives included documenting: (i) the kinds of professionals providing treatment; (ii) the settings in which treatment is provided; (iii) the kinds of interventions delivered; (iv) the reasons patients come to treatment for codeine-related problems; (v) the barriers to their accessing treatment; (vi) the training needs for addiction treatment providers in terms of addressing codeine misuse and dependence; (vii) the best means for receiving additional training, should it be required; and (viii) ways to improve treatment or initiate innovations in this area.…”