Community pharmacies in South Africa (SA) can be either independent or form part of pharmacy chains. They are predominantly located in urban areas, where they serve the private healthcare sector, where many patients have medical insurance. However, pharmacists, as well as qualified post-basic pharmacist assistants (QPBPA) (under the supervision of a pharmacist), working in this environment, frequently provide pharmacist-initiated therapy and sell over-the-counter (OTC) medicine to the insured and uninsured patients.¹ This often includes pain medicine containing codeine. As per SA regulations, codeine is scheduled as S2 medicine, which should be stored behind a counter in a pharmacy and may only be supplied by a pharmacist or QPBPA under the supervision of a pharmacist.

Codeine is an opioid commonly used in the treatment of mild to moderately severe acute and chronic pain, dry cough and diarrhoea.² The ease of availability, largely because of the reduced regulations of codeine in most countries, including SA, has greatly increased its potential for abuse and misuse.³ Codeine-containing combination medicines can be a relatively safe form of treatment.⁴ However, the lack of public awareness of its habit-forming potential⁵ and the ease of access to OTC medicine have resulted in the perception that codeine-containing products are harmless.⁶ However, excessive or long-term use of these products risks the development of tolerance with related health harms like gastro-intestinal ulcers and haemorrhage. Immediate side effects of codeine include constipation and drowsiness, which poses risk when driving and performing daily tasks.^4,5 Furthermore, it poses a major public health, social and individual problem. It can contribute to deliberately or otherwise harmful effects in physical, mental, emotional or social impairment, which can be considered an aggravating factor for economic crises.

According to the World Health Organization (WHO) pain ladder, the treatment of mild pain includes paracetamol and non-steroidal anti-inflammatory agents (NSAIDs) and does not include opioids. Weak opioids like codeine, dihydrocodeine and tramadol, with or without paracetamol and/or NSAIDs, can be used to manage moderate pain for a short duration.⁷ Despite the WHO pain management guidelines, there is an increased tendency to use codeine-containing pain medication as first-line treatment.⁸ In many parts of the world, substantial numbers of patients are purchasing and consuming codeine in OTC products. Increased public health measures are required to improve the safe use of such products. There are no known validated screening tools for identifying pharmacy customers who are at risk of codeine misuse. Efforts to tackle the misuse of codeine may require serious consideration of up-scheduling and strict adherence to the regulations pertaining to restricted supply,⁹ advertising of codeine-containing products and providing information upon dispensing these products to communities.⁵ Additional regulatory measures such as record keeping and direct pharmacist intervention at point of sale may contribute positively to public deterrence of codeine misuse.³

Pharmacists play an important role in pain management by providing such services as medication reconciliation, drug monitoring and assessment, patient and healthcare provider education and counselling.¹⁰ Various studies highlight pharmacists’ opinions and experiences when dealing with the dispensing of codeine products and the difficulties experienced in attempting to improve patient awareness and knowledge of codeine misuse and dependence.^11,12 Limitations in communication between pharmacists and customers have been highlighted as a serious concern.¹¹ Pharmacists describe pharmacy hopping (using different pharmacies to obtain OTC medication) and difficulty in the relationships between the pharmacist and prescriber, as barriers to identifying customers potentially misusing codeine.³ Limited literature on the strategies followed by pharmacists to improve the management of codeine misuse and dependence in SA is available. Therefore, this study aims to examine the perceptions and behaviours of qualified pharmacy professionals (pharmacists and QPBPA) on the misuse of codeine-containing medicines in community pharmacies of Johannesburg, South Africa.

The study received 89 responses with an overall response rate of 26.6%. The response rate is in line with response rates from other web-based studies conducted among pharmacists in Malaysia, which showed response rates of 31% and 29.2%.¹⁶ In a study conducted on SA medical practitioners by Foley et al., 2018, a final response rate of 4.7% was achieved. Lower response rates have been documented for electronic studies (33.7%) as opposed to paper-based surveys (43.4%).¹⁷

Most of the participants were female and employed within the private community pharmacy sector. This is depictive of the SAPC 2018 gender distribution of female to male pharmacists in South Africa (62% female)¹⁸ and the SAPC 2015 data on area of practice illustrating that 68.3% of all pharmacists work within the community pharmacy private sector.¹

Pharmacy professionals agree that the risk of dependence and adverse health consequences associated with excessive use of codeine preparations is not fully understood by patients. This is corroborated by Dada et al.,¹⁹ where the vast majority of patients do not view themselves as needing help or as experiencing addiction. Pharmacy professionals further indicated that this could be because of insufficient information being provided to patients. Most participants in this study have less than 4 years’ experience, which could have had an impact on the ability to provide sufficient information to patients (p = 0.006). According to Hoppe et al.¹² scoping review, the years of experience is directly related to fewer perceived barriers to the provision of opioid interventions. Pharmacists with longer practice experience (3–10 years) were more likely to discuss misuse with patients as they may have a better understanding of the pharmacotherapy and management of chronic pain. Carney et al.²⁰ highlighted the ineffectiveness of information provision models that currently exist for patients at the point of dispensing. The study further highlighted that the patients’ lack of interest in utilising current sources of information (patient information leaflets) is likely to reflect a general patient perception that these products are safe.

The study findings indicate that just over half of the pharmacy personnel routinely ask patients about their use of OTC codeine. Good dispensing practices are followed by most respondents, whereby they avoid dispensing OTC codeine products as an initial treatment. Most participants agree that they would only dispense codeine preparations following unsuccessful treatment with non-opioids. Despite this, 42.7% still agree that OTC codeine-containing medicines are a better choice for the treatment of mild to moderate pain. High levels of agreement were exhibited by the respondents showing great concerns about the increased patient demand for OTC codeine-containing products.

South African legislation published in the Government Gazette 40869, dated 26 May 2017, restricts dosage units of 10 mg codeine per tablet or capsule and 10 mg per 5 mL of codeine syrup,⁹ and the regulatory requirement dictates that sales be recorded in a S2 register.³ Despite regulations, purchase from multiple pharmacies, as well as the ease of availability over the internet, are a growing concern expressed by the pharmacy professionals. Similar concerns were voiced among pharmacists in the United Kingdom and Ireland²⁰ as well as medical practitioners in South Africa.²¹

A level of caution appears to be exercised when patients request a product specifically by brand name. This was seen as the most frequent trigger experienced by the respondents for suspecting codeine misuse. According to Hamer et al.,²² most pharmacists will intervene on codeine overuse by asking the person to seek the doctor’s advice. Contrary to this, respondents of the present study indicated the use of referral system as the second least strategy applied. A study conducted in South Africa showed similar results with only 27% of the health professionals opting for referral in situations of suspected codeine misuse.¹⁹ Sub-optimal referral is linked to the lack of awareness of referral structures and appropriate addiction centres.²⁰

A study conducted in Ireland, United Kingdom and South Africa²⁰ showed that pharmacist intervention attempts centred on offering alternative first line pain management prior to supplying the codeine product or offering a product with similar packaging. In line with this, the present study found that after restricted supply (the most used intervention), the pharmacy professionals opt for substitution of codeine-containing medicines with non-opioid products. Hoppe et al.¹² reported that 40% of the pharmacists counselled patients on the risks of taking excessive codeine-containing products. The result of the current study is in concordance with the reported literature. In addition to these most frequently used strategies, few participants reported using slow or gradual withdrawal of the codeine-containing products as an intervention.

The results showed growing concern regarding the availability and accessibility of codeine-containing medicines within the community pharmacy sector and through other sources, such as the internet. Pharmacy professionals feel that the adverse health consequences of codeine misuse and dependence are not fully understood by customers, and the ineffectiveness of information provision by pharmacy personnel has been highlighted as a major concern. Currently, the referral structures are not utilised optimally by pharmacy professionals, who rather employ strategies such as refusal and substitution, which were not proved to be effective.

The continued availability of OTC codeine as a useful medicine is desirable. However, enforcement of strict regulations is needed to ensure appropriate use of codeine-containing medicines. The merits of up-scheduling codeine-containing medicines versus the need for the OTC availability of these medicines to the general public should be debated.