Layer 1

C+D readers want codeine linctus to switch from P to POM, poll shows

Exclusive
MHRA: We are keeping the legal status of codeine linctus under review

Over two thirds of pharmacy professionals who responded to C+D’s snapshot poll believe that codeine linctus should be reclassified as a prescription-only medicine (POM).

Of the 150 respondents to the poll – which ran on the C+D website from March 11–22 – 105 (70%) said they think codeine linctus should be reclassified from a pharmacy (P) medicine to a POM, while only 15% of respondents thought it should not be reclassified.

Twenty-three (15%) respondents said they no longer stocked the product.

Result

Do you think codeine linctus should be reclassified from a P medicine to POM?
Yes
70%
No
15%
N/A, we don't really stock this product anymore
15%
Total votes: 150
Codeine products “under review”

These findings come as the Medicines and Healthcare products Regulatory Agency (MHRA) told C+D last month that it is keeping the supply of codeine-based products “under review”, following a rise in concerns of over-supply or of it falling into the wrong hands.

Following the results of C+D’s snapshot poll, a spokesperson for the medicines regulator said: “The MHRA continuously monitors the safety of all medicines and seeks advice from the Commission on Human Medicines and its expert working groups on whether regulatory action is required when there is significant new evidence of a safety concern.

“The MHRA is keeping the legal status of codeine, including codeine linctus, under review and will consider all sources of evidence and information relating to this issue,” the spokesperson said.

Addiction concerns

Helen Devoy, a community pharmacist at Reach Pharmacy in Glasgow, said while reclassifying codeine linctus could help to tackle codeine addiction, she is concerned about a lack of support available to deal with the issue.

“Switching codeine from P to POM might make some people actually realise they are addicted and spur them on to tackle the issue. But, where will they go? Who will help them?” she asked.

Chris Campbell, a locum pharmacist based in Scotland, said: “We have such a bad codeine problem, cutting legitimate supplies would lead to a significant number of ‘addicts’ turning to black markets for their needs.

“This would lead to them being exposed to drug dealers who would lead them along different addiction pathways,” he suggested.

“Without significant investment by the government, the switch from P to POM would be an utter disaster.”

Solution to harassment issues

Meanwhile, a dispenser, who asked to remain anonymous, told C+D that they had a recent negative experience of declining to sell codeine linctus: “We had a patient trying to buy it a few weeks ago who got quite aggressive because we refused the sale.”

This was echoed by another pharmacist, who said: “I am fed up of the conversations with addicted people who try and repeatedly buy!”

6 Comments
Question: 
Does your pharmacy provide addiction support services?

Ranj Locum, Locum pharmacist

Ok, long rant, but very important. I don’t ever post here, but this is something that really gets me and I struggle to deal with the relaxed nature of codeine sales. ALL codiene products should be POM!

One of the benefits of being a locum is that I get to operate in lots of different areas. If you honestly believe there's no problem with selling opioids otc, then you are either burying your head in the sand or you have only worked in those rare areas where there are very few sales.

I get phone calls once, sometimes twice a week in different areas, asking if we sell codeine linctus. "what it is man. I have this dry cough, yeah. And the dokta, says this is the best thing for me"

All of these articles also act like the problem is limited to codiene linctus. I’m finding more and more that College and University age students are trying to buy codeine and Phenergan products (which should also be taken off otc!) Educate yourselves here and ask yourself why they want these? I hear horror stories of youngsters these days, mixing this stuff to make the recreational drug "sizzurp" aka"purple drank" aka "lean" or whatever else they want to call it. Why is this not something we’re addressing?!

Every time I sell co-codamol otc, I ask all the correct questions. However, like a robot, most people answer the questions before I finish my sentence and end with "I've not used it in months though and know not to use it regularly." 

Now, this is where the problem of being a locum lies. I don’t see the same customers regularly, so can’t really track who’s buying more often than they should. I could refuse the sale, but an adult has met the criteria based on their response. If I say no, then I get a complaint about prejudice (this has happened several times). All I can do is remind the staff to take a mental note of who’s buying codeine proudcts and reiterate to the patient, the 3 day rule and that it is highly addictive. Occasionally I get lucky and the counter assistant remembers a repeat customer and informs me to refuse the sale (and I try call the local pharmacies to be vigilant and try to signpost the customer).

Customers all know the answers by this point and know they can go elsewhere. When a patient asks what the strongest painkiller is, I will always recommend Ibuprofen and or paracetamol (and a rub too) if suitable. I will tell them that codeine is in theory the strongest, but it is a highly addictive opioid and that there are lots of people addicted and they don't even realise it. This gives them the info, so they can make an informed decision. At this point, you’ll be surprised by how many people will say "oh no, I don't want that". When this happens, I feel like I have a small victory. Those who decide to proceed, I will stress the 3 day rule (while selling them a box of 32 which lasts up to 4 days at the max dose. Work that one out!) and the addiction potential.

I don’t think it’s helpful telling patients that at otc doses codeine isn’t even a good painkiller. This will just make them want to buy solpadeine max! Thank god, in over a decade, I’ve never met a single patient who’s clocked on that they can get higher than POM doses codeine, if they went to two pharmacies bought both solpadeine max and neurofen plus (not to mention linctus), but there are no doubt people out there that are aware of this.

Things that need doing:

Pharmacists being extra vigilant with otc sales and giving counter staff a refresher. Reiterate the importance of short term use and highly addictive nature (I even tell them why it’s addictive! If they are better informed they will think twice).

 

We seriously need to an otc sale of opioids product Audit. Yes clinical audits are annoying, but they’re all about patient safety. This may reveal some startling figures and may potentially reveal an opioid epidemic! Until we get data, nothing will happen.

 

Perhaps have leaflets/sign posting information for people we refuse sales to.  Over 99% will chuck these away and leave in huff, but if we get through to some people it’s worth it. Often people come to buy for their partners, so it may be easier to give the info to them and let them have the hard talk.

Tell GPs and dentists to not recommend otc co-codamol regularly (why does this still happen?!)

 

Stop advertising these products! If we are going to sell them make cigarette-style packaging a legal requirement (yes I’m serious here). White box, with a warning label, pack size 24 and factual information about codeine addiction.

Charles Beadle, Locum pharmacist

I can’t recall the last request I had for Codeine Linctus. Even with the need for vigilance regarding Codeine containing preparations, I think any call to reclassify Codeine Linctus to POM is not necessary 

PARESH shah, Community pharmacist

our sales are quite small in number as we strictly control how we sell these products. however i think it is an inportant product for otc and should be kept otc. we have to control how we sell these products. because soon the next product will be phenergan, nytol, senna, dulcolax etc, etc. anyway what guarantee is it that doctors will prescribe less . i see lots of prescriptions for co-codamol 30/500 on repeats

Mr CAUSTIC, Community pharmacist

If you do not keep codeine linctus on display it is easy to say sorry it is out of stock .  No problem and no confrontation .  I  think it should remain P. 

Naresh Rallmil, Community pharmacist

Unfortunately removing display isnt enough either.  We are hearing that customers are phoning pharmacies before hand to ask if the pharmacy has codeine in stock as they have a prescription for it before coming in and then asking to buy it over the counter instead.

Getting Shorter, Community pharmacist

Well that's just dodging the issue. Pholcodeine is a perfectly good alternative for an actual dry cough.

I've said it before and will keep on - codeine OTC provides limited benefit and massive abuse, make it all POM.

The point raised in the article about treating the addicts is quite valid. However, GPs would be warned in advance; I suspect few would turn the black market unless they are already iun touch with it; and the withdrawal symptoms may be unpleasant, but they would be tolterable for most people - and even acceptable once they have it properly explained that the headache "coming back" is not their original headache reccuring.

Job of the week

Support Pharmacist
Queen Elizabeth Hospital and Heartl
up to £47,500 dependent on hours (30-40 hours flexible)