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What would better patient and doctor education about codeine look like? I think it’ s important for doctors to speak to the risks of using codeine for prolonged periods of time. People can develop dependence once they start building some sort of tolerance to codeine. They potentially start taking more of it and that’ s when they start running into problems. I think that’ s one clear message doctors need to get out when prescribing these medications.
It’ s also important for doctors to carefully assess for other morbid problems – the mental health problems, background of substance abuse problems, and history of chronic pain – because we’ ve seen all of those markers among these deaths. They often fit hand-in-hand with increased risk for overdose when you look at the profile of overdose deaths.
I think it’ s important for doctors to carefully assess all of those issues when they’ re prescribing codeine.
In light of all these complex factors behind overdoses, would your research indicate that codeine should be prescription only? That’ s a difficult one for us within the context of our research. We did try to assess the source of codeine in relation to the deaths, whether it was over-the-counter or prescription codeine, but we were unable to because a lot of data was missing.
Why were most of these deaths accidental? I think about a third of people who had [ codeine-related overdoses ] had a history of chronic pain, so I think potentially we’ re looking at people who were having issues with their chronic pain. Perhaps it wasn’ t being managed sufficiently by the medications and in some sense they’ re trying to top up to [ ease ] their pain, not realising the increased risk of using other drugs at the same time.
Why are older women and people with mental illness more likely to overdose on codeine? Those were the groups [ most represented ] among the intentional overdose deaths. I think that suggests those groups are at particular risk of intentional overdose.
It’ s important for doctors to assess carefully when they’ re prescribing codeine and any of these other opioid medications.
How do the rates of codeine overdoses, both accidental and intentional, compare with rates for other opioids? We did look at these deaths in context with heroin and stronger Schedule 8 opioid deaths – with opioids like Oxycodone and morphine.
In 2009, the codeine-related death rate was at about 8.7 per million population, whereas the heroin deaths in 2009 were at 16 per million population, as were the rates for the stronger opioids. So the stronger opioids tend to come up a bit more frequently but the codeine deaths are still of concern, given that people often look at codeine as a weaker opioid and perhaps a safer alternative.
What are some of the strategies that could help prevent these overdoses? Doctors talking to the risks you can run into with these drugs, particularly with codeine. In other works, we’ ve seen an increase in people presenting for treatment for codeine problems. That suggests there are people out there who are developing problematic patterns of use. I think it’ s important [ to be educated about that ].
Also, given that codeine is still available over the counter, I think pharmacists probably have a role to play in terms of talking a bit more openly with customers about the risks associated with use of these drugs as they come in to buy them.
Would pharmaceutical companies and lobbyists also have the responsibility to be more open about the use of codeine? Absolutely. I think there was recently a change in terms of how these products, particularly the over-the-counter ones, are labelled.
They all come with warnings but maybe it’ s good to have a conversation with a pharmacist, or even some kind of referral for medical advice, when you’ re taking these sorts of drugs.
Codeine use and misuse has been going around for a while. Why has there been a significant flare in public discussion now about this issue? What’ s prompted it? I think probably in about 2006 we started seeing a shift towards greater use of some of the stronger opioids in this country for pain that wasn’ t related to cancer.
With that increase, we also started to see some increases in harm. Because codeine is one of the weaker opioids, it’ s potentially seen as safer. It’ s probably also – and I can’ t say this for sure because I don’ t have the figures – being used a bit more commonly, whether in conjunction with the stronger opioids or not.
I think as we’ ve started amassing some of that data and having a look at some of the harms in more detail, people have started to think there’ s something going on here and we need to respond. ■
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