A prospective cohort study evaluating the impact of upscheduling codeine in Australia among frequent users of codeine

Development and validation of a brief screening tool for over-the-counter codeine dependence

BACKGROUND

Low-dose codeine is sold without a prescription in countries like the UK, Ireland, and South Africa. Due to misuse concerns, exploring pharmacy screening tools to identify those at risk and needing additional support is vital.

OBJECTIVES

The study aims to develop and validate a brief screening tool that assesses the risk of codeine dependence with language appropriate for routine use in community pharmacies.

METHOD

Scale development and validation occurred over two studies. In Study 1, scale item generation was based on structured analyses of psychosocial and pharmacy variables from frequent over-the-counter codeine consumers (N = 795). CFA was used to assess the cohesiveness of the resultant four-item Codeine Dependence Scale (CDS). ROC analyses were used to assess the performance of the CDS against risk cases identified by the Severity of Dependence Scale; identifying an optimal cut-off value of ≥2 as representing individuals at risk of codeine dependence. In Study 2, this CDS threshold was assessed against positive DSM-5 Opioid Use Disorder (OUD) cases related to codeine use assessed using the AUDADIS-IV.

RESULTS

With a cut-off score of ≥2, the CDS has sensitivity and specificity of 76% and 48%, respectively, against a DSM-5 codeine-related OUD diagnosis using the AUDADIS-IV. For identification of any codeine-related OUD (as measured by the AUDADIS-IV) 15 months after baseline, the CDS achieved an overall correct classification rate of 52%; 72% for positive cases.

CONCLUSIONS

The CDS exhibits reasonable cross-sectional and longitudinal sensitivity but low specificity, partly due to its brevity. However, the inclusive nature of the CDS is not a negative for application as a screening tool in a pharmacy setting as individual CDS items represent critical conversation points with a pharmacist, regardless of the screening outcome. The non-confronting nature of CDS items make the scale a viable option for pharmacy-based SBI in countries where codeine remains OTC.

Opioid prescribing in general practice: an Australian cross-sectional survey

BACKGROUND

Prescribed opioid doses > 100 mg oral morphine equivalent (OME) and/or co-prescribing of sedating psychoactive medications increase the risk of unintentional fatal overdose. We describe general practice encounters where opioids are prescribed and examine high-risk opioid prescribing.

METHODS

The 2006-2016 BEACH study data, a rolling national cross-sectional survey of randomly selected GPs, was analysed.

RESULTS

Opioid prescribing increased 2006-2007 to 2015-2016, however, this plateaued across the latter half-decade. From 2012-2016 3,897 GPs recorded 389,700 encounters and at least one opioid was prescribed at 5.2%. Opioid encounters more likely involved males, those 45-64 years, concession card holders and the socioeconomically disadvantaged. GPs more likely to prescribe opioids were 55 years or older, male, Australian graduates, and in regional and remote areas. The most common problems managed with opioids involved chronic non-cancer pain. One-in-ten opioid prescribing episodes involved high-risk doses and 11% involved co-prescription of sedating psychoactive medications. Over one-third of GPs provided other (non-pharmacological) interventions at encounters with opioid prescriptions.

CONCLUSIONS

Only 5% of GP encounters involved an opioid prescription. Of concern, were: prescribing for chronic non-cancer pain, potentially high-risk opioid encounters where > 100 OME daily dose was prescribed, and/or there was co-prescription of sedating psychoactive medication. However, approximately one-in-three opioid prescribing encounters involved non-pharmacological interventions.