Codeine use in over-the-counter (OTC) pain medication: a study of pharmacist knowledge and perception

Abstract

Codeine is an opioid widely available in South Africa’s community pharmacy sector in OTC analgesic combination preparations and cough mixtures in low doses. Its widespread availability has led to misconceptions of its therapeutic effect and safety. Pharmacists have primary contact with patients and are therefore able to influence patient perception and utilisation of over-the-counter (OTC) medications. The role of the community pharmacist, when treating general conditions such as pain, their perception of the role of codeine in these available OTC analgesic preparations, as well as their awareness of its misuse and abuse potential in the community, are not available in literature and need to be explored further. Aim: To investigate the utilisation of codeine-containing analgesic OTC preparations in Gauteng’s private healthcare market. Objectives: To analyse the patterns of utilisation of codeine-containing products in Gauteng’s private healthcare market using a national ordering database, as well as to gain an understanding of pharmacist and qualified post-basic pharmacist assistant (QPBPA) perceptions of analgesics. Study design: A mixed-method approach comprising of both quantitative and qualitative data collection methods. Data source and participants: Retrospective sales data was extracted from Orderwise for a six-month period from 1 January 2016 to 30 June 2016. There were 219 survey respondents comprising of pharmacists and QPBPAs based in Gauteng. In-DepthInterviews (IDIs) were conducted with eight pharmacists based in Gauteng. Method: The surveys were distributed to 513 pharmacists in Gauteng. Data from the surveys as well as the Orderwise data were transferred to SAS Enterprise 7.1 Software. The questionnaire was designed to illicit information based on the following broad categories: treatment preferences when it comes to OTC pain management; knowledge relating to codeine use; and perception and awareness of codeine dependence, misuse and abuse. The interviews were transcribed verbatim. Upon completion of the interviews, emerging themes were gathered via thematic analysis including open and axial coding by hand. Themes were divided into two broad categories: general pain management and management of OTC codeine use. The three themes that emerged from the data were OTC treatment of non-complicated pain, codeine used for the treatment of pain and codeine misuse and abuse. Results: Orderwise data showed that Gauteng has the second highest codeine-containing product sales distribution in South Africa. A majority (67.2%) of the codeine-containing products sold in Gauteng are indicated for pain. The drug class which includes any product containing paracetamol, the sedative H1 antihistamine doxylamine, and codeine and caffeine, accounts for the majority (59%) of all OTC pain products delivered. Survey and IDI results showed that an overwhelming majority of QPBPAs took drug-marketing into account when treating patients OTC. Patient-request had the second highest level of agreement by pharmacists after evidence-based-medicine. Most respondents said that an 8mg to 10mg dose of codeine is most effective for the analgesic enhancement of both NSAIDs and paracetamol. All interview participants and a majority of all survey respondents found codeine abuse, misuse and dependence to be a significant problem in their community. Half of the participants felt that a challenge in controlling the use and abuse of codeine, was due to the close proximity, and ease of accessibility to different pharmacies without a method of tracking patient use between these pharmacies. Pharmacists and QPBPAs felt that there should be an alternative strategy implemented to prevent OTC codeine abuse. Conclusion: This study highlights that in Gauteng, there is a huge demand for codeine-containing analgesic medication, especially those in combination with sedative antihistamines. This is met by a large pharmaceutical supply across the province’s private community healthcare sector. Codeine’s widespread availability OTC has made controlling its use by pharmacists and pharmacy assistants almost impossible and there is a callout for stricter and more proactive control measures placed on codeine-containing product use in South Africa.