Medical professionals’ perspectiveson prescribed and over-the-countermedicines containing codeine:a cross-sectional study

Michelle Foley,1 Tara Carney,2 Eileen Rich,2 Charles Parry,2

Marie-Claire Van Hout,1 Paolo Deluca3

To cite: Foley M, Carney T,Rich E, et al. Medicalprofessionals’ perspectiveson prescribed and over-the-counter medicines containingcodeine: a cross-sectionalstudy. BMJ Open 2016;6:e011725. doi:10.1136/bmjopen-2016-011725

▸ Prepublication history andadditional material isavailable. To view please visitthe journal (http://dx.doi.org/10.1136/bmjopen-2016-011725).

Received 29 February 2016Revised 21 June 2016Accepted 23 June 2016

1School of Health Sciences,Waterford Institute ofTechnology, Waterford,Ireland2Alcohol, Tobacco and OtherDrug Research Unit, SouthAfrican Medical ResearchCouncil, Cape Town, SouthAfrica3Institute of Psychiatry,Psychology andNeuroscience, King’s CollegeLondon, London, UK

Correspondence toDr Michelle Foley;mfoley@wit.ie

ABSTRACTObjectives: To explore prescribing practitioners’perspectives on prescribed codeine use, their ability toidentify dependence and their options for treatment inthe UK.Design: Cross-sectional design using a questionnairecontaining closed-ended and open-ended items.Setting: A nationally representative sample ofprescribing professionals working in the UK.Participants: 300 prescribing professionals workingin primary care and pain settings.Results: Participants stated that they regularlyreviewed patients prescribed codeine, understood therisks of dependence and recognised the potential forcodeine to be used recreationally. Over half theparticipants felt patients were unaware of the adversehealth consequences of high doses of combinationcodeine medicines. One-quarter of participantsexperienced patient resentment when asking aboutmedicines containing codeine. Just under 40% ofparticipants agreed that it was difficult to identifyproblematic use of codeine without being informed bythe patient and did not feel confident in identificationof codeine dependence. Less than 45% of allparticipants agreed that codeine dependence could bemanaged effectively in general practice. Slow orgradual withdrawal was the most popular suggestedtreatment in managing dependence. Education andcounselling was also emphasised in managingcodeine-dependent patients in primary care.Conclusions: Communication with patients shouldinvolve assessment of patient understanding of theirmedication, including the risk of dependence. There isa need to develop extra supports for professionalsincluding patient screening tools for identifying codeinedependence. The support structure for managingcodeine-dependent patients in primary care requiresfurther examination.

INTRODUCTIONPain is a common reason for accessing primarycare services. It is estimated that 14 millionpeople in the UK suffer from long-term pain,1

with patients presenting with headaches

thought to account for 1 in 25 of primary careconsultations,2 and musculoskeletal painaccounting for 1 in 7.3 Opioids are widely usedin pain management with codeine being thesecond most widely prescribed opioid medi-cine in general practice.4 In 2012, it was esti-mated that 640 codeine prescriptions per 1000patients were dispensed in the UK.5

Additionally, medicines containing codeinecan be purchased over the counter (OTC) inpharmacies, albeit with restrictions.6

Medicines containing codeine (up to 12.8 mgper unit dose) may only be sold in the UKunder the supervision of a qualified pharma-cist. There are restrictions on the quantity oftablets permitted for sale in a single transac-tion and the product is not available for self-selection, although advertising of codeine-containing medicines is permitted in the phar-macy and on national media. A sale may berefused if there is suspicion that the buyer ismisusing codeine. Currently, the nature andextent of OTC codeine use and misuse in theUK is not widely reported.

Strengths and limitations of this study

▪ This is the first study examining medical profes-sionals’ perceptions of medicines containingcodeine across the UK.

▪ The study used a questionnaire design withclosed-ended and open-ended items relating toprescribed and over-the-counter medicines con-taining codeine and included questions ondependence and treatment options in practice.

▪ Professionals involved in the prescribing ofcodeine were accessed across the UK using theprinciples of stratified random sampling.

▪ Response rates were lower than expected andthe study was unable to access the full popula-tion of nurse prescribers.

▪ This study is cross-sectional and therefore doesnot describe how the situation might changeover time.

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Treatment with opioid medication is thought to beeffective in the treatment of moderate pain for acuteand short periods of <6 months.7 Current scientific evi-dence measuring the efficacy of codeine over otheralternative medications for chronic and longer termpain remains inconclusive.8 There are limited studiesexamining the efficacy of low doses of codeine found inmany prescribed and OTC medicines (<12.8 mg perunit dose). While several Cochrane reviews have evalu-ated the efficacy of codeine, these are principally con-fined to acute postoperative pain at high doses (60 mg).Some studies show codeine as clinically useful in somepatients. A Cochrane review using 14 studies comprising926 participants compared the use of single-dose oralparacetamol plus codeine with the same dose of para-cetamol alone for postoperative pain in adults.The review concluded that the addition of codeineprovided effective pain relief to ∼10% more participantsthan the same dose of paracetamol alone. The use ofcodeine in combination with paracetamol was found toextend the duration of analgesia by ∼1 hour.9 A recentCochrane review found that the combination of ibupro-fen 400 mg plus codeine 25.6–60 mg demonstratedeffective analgesic efficacy in postoperative pain;however, very limited data suggest that the combinationis better than the same dose of either drug alone.10

Equally, the use of codeine-containing syrups in supres-sing cough appears to lack positive scientific basis and isnot widely discussed in the current literature.While codeine is considered a weak opiate, it carries

an identified abuse potential. Development of toleranceon regular or excessive use appears within a short timeframe.11 Literature reports increasing trends in themisuse of codeine, including OTC preparations, whichappears to incur significant negative epidemiological,social and economic consequences.12–16 Related harmsin terms of morbidity and mortality are documented,12

along with monetary costs associated with indirecteffects on healthcare, prevention and treatment.17

Treatment of codeine dependence is varied and doesnot appear to be well documented in the literature.Guidance on options for opioid dependence is evidentbut appears non-specific to weak opioids such ascodeine. Summary statistics for codeine dependenceobtained from treatment providers in the UK suggestthat codeine as the primary and secondary substance ofmisuse is extremely low at 2.2% (4248 individuals) of allthose entering addiction treatment services in theperiod 2013–2014.18 These statistics may give an impres-sion that codeine dependence is not an issue warrantingattention compared with other substances of misuse;however, treatment for codeine dependence conductedin primary care does not appear in national treatmentsurveillance systems. What is of particular concern is thatcodeine-dependent patients appear to function wellwithin the range of perceived normality, carrying out thefunctions of normal daily living.19 Evaluating as towhether medical professionals are equipped to detect

and manage patients presenting with codeine depend-ence is therefore an area of considerable importance.Studies have called for further research on the experi-

ences and concerns of medical professionals around useof medicines containing codeine, with particular focuson their experiences, challenges, perspectives and prac-tices.20 The aim of the study was to garner informationregarding prescribing practitioners’ perspectives on pre-scribed and OTC codeine use, their ability to identifydependence and options for treatment in the UK. Thisstudy was part of a larger study examining OTC and pre-scribed misuse of codeine medicines in the Republic ofIreland, UK and South Africa and was funded by theEuropean Commission (http://www.codemisused.org).

METHODRecruitment of participants and study proceduresThe study involved a cross-sectional design and tookplace between May 2014 and April 2015 using anonline questionnaire (see figure 1). A nationally rep-resentative sample of medical practitioners in the UKwas facilitated through Specialist Info, a medical direc-tory specialist. A random list of 1000 practice man-agers was generated by strata using proportionatenumbers of general practitioners (GPs) present ineach country (Wales n=48, Northern Ireland n=36,Scotland n=98, England n=818). Each practicemanager was asked to recruit at least one GP fromtheir respective practice to participate in the study.Each practice manager was sent a reminder ∼2–4 weeks later. A total of 150 pain specialist physicians’email records were also retrieved from Specialist Infoand these were subsequently sent the link to thesurvey. In order to have representation from nurseprescribers, a previous distribution list of 98 pain spe-cialist nurses was used.21 These participants wereasked to indicate their agreement to be added to theemail distribution list. In total, 54 agreed to partici-pate and the link to the survey was then provided. Intotal, this process resulted in 136 participants com-pleting the online questionnaire. A further 65 GPswere recruited through GP target sessions. A secondrandom sample of 1000 practice managers was gener-ated, checked for duplicates and emailed as previouslydescribed. A follow-up reminder was distributed 4–6 weeks later. This resulted in the completion of afurther 98 questionnaires. The indicated time to com-plete the questionnaire was ∼10 min, and this was spe-cified in the email correspondence and prior toproceeding with the questionnaire. Information onthe study was provided and informed consent wasobtained prior to proceeding online. Participantswere advised to complete the questionnaire only once.Dissemination activities, including circulars and news-letters, were used to encourage participation in thestudy. Ethical approval was granted by King’s CollegeLondon Ethics Committee (PNM/13/14-75).

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Data collection methodsWe collected the data using an online questionnaireusing the survey tool http://www.onlinesurveys.ac.uk.Questions were developed to bridge gaps in knowledgefollowing a comprehensive search of the literature.4

Eight questions were added to collect demographicinformation in order to establish the representativenessof the respondents. The questionnaire comprised a com-bination of closed-ended and open-ended items, on pre-scribed and OTC medicines containing codeine, andincluded questions on triggers for suspecting codeinemisuse, managing codeine-dependent patients andreasons for referral. Participants were provided with anopportunity to add additional comments at the end ofthe questionnaire and knowledge of innovations on pre-venting medicine misuse (see online supplementary

information for full details of questionnaire). A paperedition of the questionnaire was made available at GPtarget sessions in two separate locations (continuing pro-fessional development). GPs had the option to completethe questionnaire online via the survey link or completethe paper copy and return to the researcher at the endof the target session. GPs were also informed that theycould return by post and were provide with a returnenvelope on request.

Data analysisData were downloaded directly from the online datacapture page to SPSS V.21. Data captured in paperformat were entered manually and combined with thedata captured online. Data were screened and checkedfor errors. Data were then examined descriptively using

Figure 1 Recruitment of participants to the study. GP, general practitioner.

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frequencies and percentage. The data were summarisedto create two categories by combining levels of agree-ment and disagreement for reporting purposes. Theoccurrence of codeine dependence was estimated usingthe approximate numbers of patients suspected ofhaving codeine dependence as indicated in the ques-tionnaire divided by the number of consultations indi-cated by professionals in an average month. Referralswere estimated using the numbers indicated by partici-pants in the questionnaire, and this figure was presentedas an overall percentage of the total number of partici-pants’ referrals to secondary care for codeinedependence.The open-ended questions were downloaded into a

separate Excel sheet for content analysis. These datawere examined and individual categories were created

for each of the open-ended questions based on commonfeatures and dominant subjects identified in the text.The categories were discussed by two senior members ofthe research team and agreed. Three researchers inde-pendently coded the data (two academic researchersand one pharmacist). This was achieved by labellingeach field where the content matched the associatedthematic category. Intercoder reliability of the data wasconducted by dialogue between three members of theresearch team. Each item was checked for agreementand non-agreement with the thematic categories. Wherediscrepancies were identified or disagreement with thecategory placing occurred, the researchers discussed theillustrated content. This was then resolved when two ormore researchers were in agreement. Data were pre-sented as an overall percentage of those who respondedto the open-ended questions.

RESULTSThree hundred medical professionals involved in pre-scribing codeine were recruited to the study, giving anoverall response rate of ∼12.5%. Table 1 details thedemographic information. The mean age of participantswas 47 years (range 25–68 years). The average numberof years of practice was 19.52 years (range 1–48 years).

Prescribed codeineFigure 2 illustrates statement items examining medicalprofessionals’ experiences of prescribing codeine.Percentage agreement and disagreement were used todescribe the results. In total, 50% of participantsshowed some level of agreement that the requests forprescribed codeine were increasing. In relation to pre-scribing practices, 54% of participants implied thatthey avoided the prescribing of codeine with otherdepressant drugs. In total, 82% of participants agreedto some extent that they prescribed codeine followingunsuccessful treatment with non-opioid analgesics.Only 12.6% of participants agreed to prescribe codeinecough linctus following unsuccessful treatment ofcough with non-codeine-based medicine. Less than20% of participants agreed that low doses of codeine,<30 mg, are not very effective in treatingmild-to-moderate pain. In total, 80% of professionalsagreed to routinely reviewing patients who are pre-scribed codeine. In total, 27% of those respondingbelieved that patients resented them for asking abouttheir use of medicines containing codeine. However,most professionals disagreed with the statement inrespect to ‘feeling awkward’ around questioningpatients about their codeine use (76.6%).Furthermore, over half showed a level of disagreement(53.7%) with the statement ‘patients are aware of theadverse health consequences of high dose of combin-ation codeine medicines’. Participants recognised thepotential for codeine to be used recreationally(81.7%).

Table 1 Demographic details and information pertaining

to profession, location and specialist training

N=300Frequency(f)

Percent

Gender

Male 140 46.7

Female 160 53.3

Age Median 48 years,

range 25–68 years

Profession

General practitioner 238 79.3

Independent/supplementary/

nurse prescriberi23 7.7

Specialist in family medicine 31 10.3

Specialist in pain management 0 0

Other 8 2.7

Number of years as a qualified

practitioner

Median 20 years,

range 1–48 years

Number of consultations in an

average week

Median 100, range

7–500

Country

England 253 84.6

Wales 15 5.0

Scotland 23 7.7

Northern Ireland 9 2.7

Location

Urban 166 55.3

Rural 40 13.3

Mix of both 94 31.3

Specialist training in substance misuse

Yes 89 29.7

No 208 69.3

Did not indicate 3 1.0

Type of substance misuse training

Certificate in substance misuse 42 47.2

Postgraduate qualification in

substance misuse

13 14.6

Continuing professional

development (CPD)

12 13.4

Other 5 6.3

Did not indicate 17 19.1

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OTC codeineFigure 3 shows statement items examining medical pro-fessionals’ experiences of OTC codeine. Percentageagreement and disagreement were used to describe theresults. A total of 76% of those responding to the ques-tionnaire were found to routinely ask about patients’ useof OTC codeine medicine, and 71% indicated that theydocumented the use of OTC medicines in the patients’medical notes. Concern about availability of OTCcodeine in pharmacies was recorded at 45.8%. Concernabout the availability of OTC codeine on the internetwas slightly higher at 64%. However, the vast majority ofpractitioners agreed to some extent that the potential tobuy codeine from multiple sources added significantlyto the potential for misuse (86.9%). A total of 35%showed some level of agreement that medicines contain-ing codeine should be regulated to a prescription-onlymedicine, while a similar percentage (36%) did not orhad no opinion (28%). A total of 16% of participantsfelt that patients were given sufficient information andthere was agreement that patients were not fully awareof the risks of dependence with consumption of OTCcodeine medicines (83.8%) and believed them to besafe (86.3%). Only 23% of practitioners agreed (orstrongly agreed) that codeine was more effective thannon-opioid analgesics. The potential to extract codeinefrom compounded formulation showed mixed levels ofagreement.

Dependence, screening and treatmentFigure 4 shows responses to the various statementitems examining codeine dependence. Only 8% of

participants agreed that patients were not at risk ofcodeine dependence when they took their codeinemedicine as prescribed. The majority agreed to someextent that patients did not fully understand the risk ofdependence when taking prescribed medicine contain-ing codeine (82%). Over 40% agreed the difficulty inidentification of problematic use of codeine withoutbeing informed by the patient. This corresponded withrelatively high percentages of those who did not feelconfident in identification of codeine dependence(41%). When asked if women were at higher risk ofdevelopment of codeine dependence, only 20.8%agreed, while 16% showed a level of disagreement. Atotal of 45% of all participants agreed that codeinedependence could be managed effectively in generalpractice.A total 21% of participants agreed to have suitable

screening methods to identify if codeine was being usedinappropriately. A total of 27% of participants agreedthat adequate services were in place to manage codeine-dependent patients, while only 28% agreed to be fullyaware of best practice in managing codeine misuse anddependence. A high proportion of participants (70.3%)would like more instruction on the prescribing of poten-tially addictive medicines.

Managing codeine dependenceA total of 86% of the total participants had suspectedcases of codeine dependence in practice. The mediannumber of patients suspected of being codeine depend-ent was calculated as being three patients per 100 con-sultations. When asked if they had referred a patient to

Figure 2 The level of agreement (agree strongly, agree) and disagreement (disagree strongly, disagree) and neutral responses

with statements related to prescribed codeine medicine.

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Figure 4 The level of agreement (strongly agree, agree) and disagreement (strongly disagree, disagree) and neutral responses

with statement items related to codeine dependence and treatment. OTC, over the counter.

Figure 3 Percentages of agreement (strongly agree, agree) and disagreement (strongly disagree, disagree) and neutral

responses with each of the statements related to over-the-counter codeine.

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specialist care for codeine dependence in the pastmonth, 27% of participants indicated referrals to sec-ondary/specialist care. Where referrals were indicated,the median number was one patient in a monthlyperiod.

Patient behaviours, treatment options and referral reasonsPractitioners were asked to describe the typical patientbehaviours triggering their suspicion of codeine misuse.Table 2 shows thematic categories of results displayed asa frequency and as a percentage of the total responses.Patient behaviours that triggered suspicion of codeinemisuse and dependency included requesting codeinespecifically by name, early requests and refills andcalling the surgery at inappropriate times to requestcodeine medicines. The potential to obtaining codeinefrom multiple sources was expressed. Additional

comments reflected the difficulties in managingpatients’ codeine use.

It is very difficult to control patients’ codeine use as theymay use multiple pharmacies, buy from friends or online.I don’t think we have fully woken up to the scale of theproblem of opiate dependence. Especially when opiatesare prescribed by pain clinics for chronic, non-cancerpain. (GP participant)

Have advised colleagues many times that this is a time-bomb (not wishing to be melodramatic!) If evidence ispromoted or the Daily Mail decides to champion acodeine scare we will be on the back-foot managing thefall-out and patient distress. (GP participant)

Lost prescriptions or medicines were also perceived tobe an indicator of dependence, and practitioners usedanecdotes to describe patient situations such as ‘the dogate my script’, ‘I lost my medication on the bus’ or ‘onholiday’. Unresolved pain was indicated as a furthertrigger in suspicion of dependence, and situations ofhypersensitivity to pain were described in terms of head-ache, inadequate pain relief and indications of chronicpain not being helped by the current medicationregime. Aberrant behaviours were described andincluded aggression, demanding codeine, reluctance tochange medication and becoming very keen to obtain ascript. Physical signs of misuse included restrictedpupils, anxiety, constipation, gastric disturbances andirritability. Other indicators included history ofcomorbidity and history of addiction. Some professionalsalso mentioned social and economic factors includingtaking excessive sick leave and unemployment.Various treatments for codeine dependence were

described by practitioners (see table 2). A large propor-tion of respondents mentioned slow or gradual with-drawal as the suggested treatment in managingdependence. Education and counselling was alsoemphasised and was more often suggested with gradualwithdrawal and restricted prescriptions. Additional com-ments were also made about the area of practitionertraining in managing misuse and the requirement toimprove patient knowledge on codeine consumption.

It would be helpful to have some teaching on misuse ofOTC products and management there of. (GPparticipant)

I am very concerned about the number of people I seewho take products containing a combination of codeineand paracetamol at levels that put them at high risk ofliver damage as they often do not realise that taking largeamounts for the psychoactive effects of the codeinemeans that they are likely to be unintentionally overdos-ing on the paracetamol. (GP participant)

Restricted prescriptions were described in terms ofgiving limited amounts of codeine in doses of up to3 days or a 1-week supply. One GP spoke of the role of

Table 2 Main thematic categories and frequency of

responses

N=300Frequency ofresponses (%)

Can you describe the patient behaviours that trigger your

suspicion of codeine misuse?

Requesting prescriptions for codeine 212 (71)

Aberrant behaviour 89 (30)

Unresolved pain/cough 78 (19)

Lost prescriptions or medications 52 (17)

Physical or psychological symptoms 41 (14)

History of addiction 38 (13)

Doctor/pharmacy shopping for codeine

medicines

28 (9)

History of comorbidity 14 (5)

Socioeconomic status 14 (5)

Sex 3 (1)

Can you describe the types of treatments that you use for

patients with codeine dependence?

Slow or gradual withdrawal 153 (51)

Education/counselling 87 (29)

Referral to secondary or specialist

care

87 (29)

Restricted prescriptions 60 (20)

Substitution with another drug (drug

not specified)

30 (10)

Substitution using methadone/

buprenorphine/other opiate drug

27 (9)

Substitution with non-opioid

medication

15 (5)

Substitution using benzodiazepines/

other antipsychotics/other

15 (5)

Cold turkey 9 (3)

What were the main reasons for referring patients to

specialist treatment?ii

Failure to manage patient effectively in

practice

150 (50)

Complex case requiring specialist care 186 (62)

Patient request for referral 63 (21)

Lack of resources 45 (15)

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advertising and efforts to control repeat prescribing,while another also spoke of the problems of monitoringof repeat prescriptions.

We worry about codeine abuse, etc., yet Solpadeine isvery heavily advertised, but it does serve a purpose in self-medication for moderate pain. In my experience patientsare started too early on high strength codeine painkillersand simply parked there via repeat prescriptions. Littleeffort seems to be given to follow up and monitoringusage before the patient becomes addicted to thecodeine as opposed to suffering pain. (GP participant)

Big problem. We struggle to monitor repeat prescriptionsclosely enough. Hospitals hand out codeine and trama-dol like smarties. Difficult to know how best to tackleOTC access as primary care does not have the capacity topick up seeing all those people who self-treat appropri-ately with OTC meds. (GP participant)

Other suggested treatments include substitution usingnon-opioid analgesics, substitution with other drugsincluding amitriptyline and benzodiazepines, otheropiates, methadone and buprenorphine. Some respon-dents indicated that the main treatment they used was‘cold turkey’. Referral to specialist care was also indi-cated, including drug and alcohol services, rehabilitationcentres, psychologists, psychiatrists and pain specialists.The primary reasons for referrals are reported in table 2

and were indicated as the inability to manage the patienteffectively in primary care or that the patient was acomplex case requiring specialist care. Complex cases weredescribed as those with multiple issues, including otherdrugs and alcohol misuse, pregnant patients and othercomorbidities, usually related to mental health. Some senti-ment was also expressed about other drugs of misuse.

Whilst codeine is misused, I am more concerned withheroin and cocaine misuse. (GP participant)

We also have big problems with dihydrocodeine, oxy-codone, tramadol, pregabalin and gabapentin. (GPparticipant)

Patient’s request to be referred for specialist treatmentwas also a common response. Indications were also thatreferrals to specialist care were as a result of the lack ofresources, or time during the consultation and lack ofknowledge with regard to the best practice.Some additional comments were made related to the

lack of resources available to manage the problem ofcodeine dependence.

There is a gap between practicing perfect medicinewhere patients’ drug use is explored in depth and thepracticalities of managing time and workload. I feel thatto a certain extent, exploring drug misuse in patientswho are pre-contemplative is not necessarily the mosteffective use of time (although of course would be donein an ideal world). (GP participant)

DISCUSSIONThe current study exhibited high levels of agreementthat patients prescribed codeine were routinely reviewedby their medical professional and included questioningaround OTC codeine use. Half of all those whoresponded felt that the request for codeine medicineswas increasing and is substantial in raising someconcern. The increasing requests for codeine may bedirectly as a result of newer restrictions imposed onOTC supply, forcing patients to obtain a steady sourceon prescription.21 Other factors contributing to the per-ceived increase in codeine requests may relate tochanges in scheduling of other prescription opioidssuch as tramadol.22 In the UK, tramadol must only besupplied in quantities that do not exceed 30 days andmust not be dispended on ‘batch’ repeat prescriptions,making refills more difficult to obtain. Codeine is cur-rently not bound by these restrictions. While there is nospecific evidence to verify that codeine consumption isincreasing, a level of caution should be exercised by theprescriber when a medicine is requested specifically byname. Content analysis of the open-ended questionsshowed that one of the most common triggers for sus-pecting misuse was when codeine was requested specific-ally by its name or brand name.Views regarding the effectiveness of 30 mg of codeine

showed some notable variation. The efficacy of lowdoses of codeine is not well documented in the litera-ture and a greater evidence base is required to furtherdevelop indications for codeine use.23 Prescribing ofcodeine was indicated following unsuccessful treatmentwith non-opioid analgesics. However, the complexity ofpain management has drawn significant attention overrecent years with limited options for prescribers to avoidunpleasant side effects.24 25 Newer drugs acting at theγ-aminobutyric acid (GABA) receptors have gatheredsome momentum in the treatment of chronic neuro-pathic pain; however, they also carry significant sideeffects and serious risk of misuse.26 The difficulty for anyprescriber is to balance the benefits and risks of opioiduse and it is feasible that codeine is considered to havelower abuse liability due to it weak opioid status.27

There is concern regarding patients’ use of OTCcodeine-containing medicine, and a large number ofrespondents in the current study believe that patientswere unaware of the health consequences associatedwith high doses of combination codeine preparations.Equally, the respondents were of the view that patientsdo not understand the risk of dependence when takingprescribed medicines containing codeine. This concurswith evidence reported in the literature.28 29 Furtherresearch should identify the level and type of informa-tion patients require to make informed decisions sur-rounding their medicine use, both prescribed and OTC.Rescheduling of codeine has drawn significant debateand some suggestion was made in the current study toremove sales of OTC codeine altogether.24 However,without actual prevalence rates of misuse and harm, it is

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difficult to draw definitive conclusions. Equally, otherprescription opioids, including codeine, are alsomisused, so removal of OTC codeine is unlikely to elim-inate the problem entirely. Additionally, several coun-tries across the European Union (EU) do not permitthe sale of OTC codeine,25 and there is little evidencethat restricting this provision has any impact on harmsassociated with its use. The rescheduling to aprescription-only medicine is likely to place additionalpressure on GPs for self-limiting conditions and shiftdiversionary patterns. This may explain differencesobserved in the current study regarding rescheduling ofcodeine to a prescription-only medicine.Risk of development of a codeine dependence in spite

of taking codeine as prescribed was identified by themajority of professionals in the UK and shows that pre-scribers are aware of potential risks associated with itsuse. Detection of codeine dependence in patientsappears to be problematic, with low levels of confidenceexpressed in detection of codeine dependence, high-lighting the need for specific screening tools.30 Equally,adequate screening tools for identification of patient atrisk appear lacking in practice, and practitioners indi-cated the desire for further training activities on pre-scribing potentially addictive medicines. Education ofprofessionals on the abuse potential of codeine and theability for individuals to extract paracetamol from com-pounded formulations is also warranted to enhanceexisting knowledge.Currently, there are no specific clinical guidelines on

managing codeine detoxification, although clinical guid-ance does exist under the broad umbrella of opioiddetoxification.31 In the current study, an overwhelmingmajority of respondents indicated that they used theprocess of gradual withdrawal including tapering of thedose, restricting and reducing patients’ prescriptionscoupled with education and counselling techniques asstrategies to address misuse of and dependence oncodeine. A minority of participants mentioned that theywould prescribe benzodiazepines and other medicinesto manage codeine-dependent patients. The basis of thisdecision should be investigated further in light thatsome of the drugs mentioned come with a high abusepotential. The methods offered by respondents may wellbe the foundation on which to build some guidance forprescribers and pharmacists in managing detoxification,however, taking into consideration that each patient willhave their own individual needs. Owing to the fact thatseveral of the prescribers mentioned the toxicity asso-ciated with paracetamol and ibuprofen, initial treatmentto reduce this risk should be the first consideration.11

The education and counselling offered and expressedby professionals in the open-ended questions could befurther evaluated for its content, applicability and effec-tiveness in the treatment process.Levels of referral to secondary care appear low and

reflect the levels of patients entering addiction treatmentindicated by the National Drug Treatment Monitoring

Service,18 and may indicate that a high proportion ofpatients are being effectively managed in primary care,or more seriously, not being detected at all. If this is thecase, then actual prevalence rates of misuse are under-reported in the national figures. The reporting ofcodeine misuse by general practice outside of secondarycare may actually help in the estimation and prevalenceof codeine and other substances of misuse in populationswho remain outside of addiction services. Professionals inthe current study identified a lack of support services forthose identified with problems related to their codeineuse. The acknowledgement of poor support requiresfurther investigation in the context of the developmentof adequate services for patients within primary care,community and inpatient settings.

LIMITATIONSThere are several limitations with respect to this study.The recruitment of participants to this online survey waschallenging and therefore resulted in a lower thanexpected response rate. The targeting of GP practicemanagers rather than GPs directly may have impactedon the response rate. However, due to the level of emailcorrespondence GPs receive, filtering it in this mannermay have been beneficial. There may be some criticismof the methods used to boost response; however, as aprofessional group, it is unlikely that participantsanswered the questionnaire more than once. The studyis cross-sectional in nature and therefore cannotdescribe how the situation might change over time. It isalso possible that those experiencing problem withcodeine dependence in their practice may have beenmore likely to participate in the study. It is possible thatthe term misuse and dependence may have differentmeanings to specific responders, and while specific defi-nitions were provided, these were contained within anadditional information drop-down menu. However, oneof the major strengths of the study is the fact that itresponds to the increasing demand for greater informa-tion regarding codeine misuse and dependence foundin the UK and provides information that can be used infuture studies.

IMPLICATIONS FOR PRACTICEGreater sources of information are required to developpolicy on codeine use, misuse and treatment options inthe interest of public health. This study has shed lighton medical professionals’ experiences in the UK andhas highlighted areas of concern regarding medicinescontaining codeine and the need to develop specificpatient screening tools. It is important to note that med-icines containing codeine have utility when used appro-priately; however, greater research is required toexamine its indications for use in longer term pain man-agement. Further education and training is required inthe area of prescribing addictive medicines at all levelsof practice. Similarly, specialist training on recognition

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of the signs and symptoms drawn from the responses ofprofessionals in this study could help with early detec-tion of codeine dependence. The reporting of cases ofcodeine dependency outside of addiction services intonational registers should be considered. It is importantto identify as accurately as possible the prevalence ofcodeine misuse and dependence in the population sothat services can be adequately provided and needsaddressed appropriately.

Acknowledgements The authors would like to acknowledge theCODEMISUSED project secondees who assisted with this study during theirsecondment periods.

Contributors All the authors contributed substantially to the study conceptionand design. MF, ER and CP conducted the analysis and interpretation of data.MF and PD recruited the participants. MF drafted the work and TC, M-CVHand PD revised it critically for important intellectual content. All authors gavefinal approval of the version to be published and agreed to be accountable forall aspects of the work in ensuring that questions related to the accuracy orintegrity of any part of the work are appropriately investigated and resolved.

Funding The research leading to these results has received funding from theEuropean Community’s Seventh Framework Programme FP7/2007-2013under grant agreement no 611736.

Competing interests None declared.

Ethics approval Ethical approval by King’s College London Research EthicsCommittee prior to recruitment of participants (8 April 2014).

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement No additional data are available.

Open Access This is an Open Access article distributed in accordance withthe Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, providedthe original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

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