LONG WAITING LISTS and a lack of pain specialists are being blamed for a rise in patients becoming dependent on codeine-containing painkillers.
Fresh concerns have been raised about codeine addiction as over 1.1 million prescriptions for codeine-based products, such as Nurofen Plus and Solpadeine, were issued last year.
The figure has prompted discussions around tightening restrictions on the addictive ingredient, up to and including axing over-the-counter sales.
Fine Gael’s health spokesperson Colm Burke this week said that the Health Products Regulatory Authority’s (HPRA) review of the sale and supply of these drugs should be “concluded urgently” and that stakeholders should be listened to before any changes in prescribing practices.
Between 2018 and 2021, sales of Solpadeine increased by 12 per cent and Nurofen Plus sales increased by 11.5 per cent.
Over the same period, the sale of non-codeine over-the-counter painkillers grew 23.8 per cent.
According to pharmacists and patients, this is a symptom of a poor national health service that has discouraged people from going further than their pharmacy.
Pharmacist and entrepreneur Laura Dowling says limiting access to codeine-containing painkillers without providing additional supports could be “detrimental” to patient health and finances.
Long waiting lists and limited specialists means some patients have had to manage their chronic pain themselves, leading to long-term codeine usage, despite manufacturer warnings.
A “proper programme” is needed for addicts coming off codeine, Dowling said, “because it’s not a nice drug to try and come off and withdraw from”.
“They will need constant support from the doctor, pharmacists, nurses and also social workers in some instances”, she said.
According to Dowling, some people have had to go on methadone to help end their dependence on codeine.
There is also concern that if access to the painkillers are restricted suddenly, patients will try to acquire it illegally from unregulated sources.
Dolwing added: “There’s a lot more thought that needs to go into it.”
Martina Phelan from Chronic Pain Ireland said that increased use of over-the-counter painkillers has been a problem “for quite a long time” and that HSE under-resourcing is nothing new.
“You’re waiting a minimum of two years before you can get a referral to a pain specialist”, she said.
“Even now, trying to get into a GP with GP shortages, you’re waiting two weeks before you can see a GP.
“So people that are in pain, their only recourse if they want to have any quality of life is to go into a pharmacy and buy what’s available over the counter.”
Healthcare inequality
Suggested supports include more accessible pain clinics, more pain specialists and multidisciplinary healthcare teams in communities “that can help patients to deal with their pain with or without medication”.
“There are other treatments available, but at the moment they’re all private so there’s nothing available to public patients other than medications and procedures done by pain specialists”, Phelan said.
As of 2021, there were chronic pain management consultants in the country, or the equivalent of fewer than 17 full-time specialists.
Some low income patients in receipt of state disability allowance are paying for private healthcare “because the waiting lists are so long”, Phelan said.
“There’s definitely an economic disparity.”
This disparity, she added, would increase if codeine-based medications were only accessible by GP prescription.
Dowling said that an overnight change in prescribing rules would “cause an awful lot of anxiety and angst amongst the public that do use”.
The cost of prescriptions for these patients should be considered, she said.
“That could be detrimental to someone’s health, stress levels and financial responsibilities as well if they don’t get free GP care.”
Currently, non-medical card holders can pay up to €65 per GP visit.
Addiction
Dowling, who has worked in a community pharmacy for more than 20 years said that she hasn’t seen “any change” in codeine prescribing or use in recent years.
However, addiction is “always going to be a problem”.
“We have opioid receptors in our bodies and it’s easy for us to become addicted… some people more than others”, she said.
“Sometimes it will start with OTC [over-the-counter] codeine and it will increase to other forms of opioids or other products.”
Phelan says it would be “hugely irresponsible” to cut access to the painkillers without backup supports for those who have become addicted, including those who “don’t even realise they’re dependent on them”.
Women
“Most people that come in and buy [codeine-based medications] do use them responsibly”, she said.
“I would see a lot of people with dental pain, with headaches, and then also period pain”, she said.
Codeine products can be effective in alleviating toothaches, headaches and period cramps. Since Feminax, another codeine-based painkiller, was discontinued in 2018, “women were left with no alternative but to take something like Solpadeine”.
“Women will often come in looking for Nurofen Plus or Solpadeine for that time of the month and we won’t be able to give them anything if it goes prescription-only”, Dowling said.
“They’ll have to go to the doctor and pay a doctor’s fee to get a prescription for it.”
In a statement, the Irish Pharmaceutical Healthcare Association (IPHA), which represents the manufacturers of codeine-containing drugs, said they “can be, and are, used appropriately by many people”.
Spokesperson Eimear O’Leary said: “We believe the measures put in place by the Pharmaceutical Society of Ireland (PSI) in 2010 are appropriate, robust and support the status of these over-the-counter medicines as second line treatment for acute pain.
“We have worked closely with pharmacists to develop a range of tools and guidance to support them in difficult conversations and in furthering education of the public regarding their pain management. “
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