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A Comparative Exploration of Community Pharmacists’ Views on the Nature and Management of Over-the-Counter (OTC) and Prescription Codeine Misuse in Three Regulatory Regimes: Ireland, South Africa and the United Kingdom

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Abstract

Misuse of codeine containing preparations is a public health concern given the potential for associated harms and dependence. This study explores the perspectives of community pharmacists in three regulatory regimes on issues of customer misuse of over-the-counter (OTC) and prescribed codeine. A qualitative design comprising six focus groups (n = 45) was conducted in Ireland, United Kingdom, South Africa. Transcripts were analysed using the constant comparative method of content analysis. Pharmacists described popular codeine-containing products and the need for improved medicine information and warning labels. Issues around legitimate availability of codeine and regulatory status; presence of therapeutic need; difficulties in customer–pharmacist communication; business environments and retail focus were raised. Participants also discussed how they identified customers potentially misusing codeine and difficulties in relationships between pharmacists and prescribers. A number of recommendations were put forward as ways to manage the issues. The study highlights the difficulties encountered by community pharmacists operating under various regulatory regimes when supplying codeine containing preparations in negotiating patient awareness and compliance and potential ways to deal with misuse and dependence.

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Notes

  1. www.codemisused.org

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Acknowledgments

The research leading to these results has received funding from the European Community’s Seventh Framework Programme FP7/2007-2013 under grant agreement no 611736. The authors wish to acknowledge Mariam Deldar, Christine Pyke and Jillian Glynn for their role in transcribing the interviews, as well as the pharmacists that participated in the focus groups.

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Authors and Affiliations

  1. Alcohol, Tobacco and Other Drug Research Unit, South African Medical Research Council, Francie van Zyl Drive, Cape Town, South Africa

    Tara Carney, Siphokazi Dada & Eileen Rich

  2. Department of Psychiatry and Mental Health, University of Cape Town, Rondebosch, South Africa

    Tara Carney

  3. School of Health Sciences, Waterford Institute of Technology, Waterford, Ireland

    John Wells, Michael Bergin, Michelle Foley & Marie Claire Van Hout

  4. Cara Pharmacy Ltd, Ballyshannon, Ireland

    Padraig McGuiness

  5. Weldricks Pharmacy Ltd, Sheffield, UK

    Anna Rapca

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  1. Tara Carney
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  3. Michael Bergin
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Correspondence to Tara Carney.

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Appendix. Initial Interview Guide

Appendix. Initial Interview Guide

  1. 1.

    Tell us what it is like to be a pharmacist in Ireland?

    1. a.

      Let’s discuss the general policies around pharmacists in this context

    2. b.

      What are some of the challenges that pharmacists face?

    3. c.

      What are some of the strengths of the pharmacy industry in Ireland?

  2. 2.

    Let us discuss the products that you provide to customers as a pharmacist that contain codeine?

    1. a.

      Are these products usually over-the-counter products or prescribed/dispensed?

    2. b.

      What are the most common products that contain codeine that you sell?

    3. c.

      What, in your opinion, are the most harmful aspects of codeine use for customers that use codeine products?

    4. d.

      How do you keep records of customers that buy products containing codeine?

    5. e.

      Do you think codeine misuse is a problem for customers that visit the pharmacy that you work in, and why?

  3. 3.

    What is your relationship with medical professionals that prescribe codeine products?

    1. a.

      What would you do if you received a prescription containing codeine that was clearly problematic (i.e. much more than the expected amount)?

    2. b.

      How do you respond to repeat prescriptions?

    3. c.

      Describe some of the difficulties in working with medical professionals when codeine has been prescribed.

  4. 4.

    What would lead you to suspect that someone is misusing codeine products?

    1. a.

      Can you describe the patterns of behaviour that customers that may have a problem with codeine use display?

    2. b.

      Discuss the kind of consequences that as a pharmacist, you have seen codeine misusers face?

    3. c.

      Are there any alternatives to products containing codeine that you offer to customers?

    4. d.

      Have you ever refused to provide a customer with a product containing codeine? If so, tell us what happened and how you dealt with it.

    5. e.

      Does your pharmacy have a monitoring system for those suspected of codeine misuse?

  5. 5.

    Alternative Methods to obtain Codeine Products

    1. a.

      What do you understand by double-doctoring, and have you ever come across it either in the pharmacy where you work or other pharmacies?

    2. b.

      What are your views on web-based pharmacies?

    3. c.

      Have you had any experiences of suspected codeine misusers using their family or friends to buy products for them? Tell us about these instances.

  6. 6.

    Management and Referral

    1. a.

      If you suspect that a customer has a problem with codeine use, what would the procedures be that you follow to try and help them?

    2. b.

      Do you know of places that you could refer customers to for treatment for codeine and/or other drug misuse?

  7. 7.

    Training

    1. a.

      What kind of training have you received (if any) for what to do if customers may need help with their codeine use?

    2. b.

      Would you like more training on codeine prescription, monitoring and referral?

    3. c.

      If so, what kind of training do you think would be helpful?

  8. 8.

    Finally, if you could change only one thing (either within the pharmacy or in the wider healthcare system more generally) to reduce the frequency of codeine misuse what would it be?’

    1. a.

      What changes might be possible for the future?

    2. b.

      What resources would be needed for these (human or other)?

    3. c.

      What would be the facilitators and barriers to implementation of these changes that you envisage?

    4. d.

      Do you think that the current legislation or regulation of codeine is helping to reduce codeine misuse?

    5. e.

      What could be put into place to protect patients more?

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Carney, T., Wells, J., Bergin, M. et al. A Comparative Exploration of Community Pharmacists’ Views on the Nature and Management of Over-the-Counter (OTC) and Prescription Codeine Misuse in Three Regulatory Regimes: Ireland, South Africa and the United Kingdom. Int J Ment Health Addiction 14, 351–369 (2016). https://doi.org/10.1007/s11469-016-9640-z

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