HSE memo warns of ‘high usage’ of low-dose codeine products

There is ongoing evidence of high usage of low-dose codeine products, and associated harms, a HSE memo to services has warned.

The memo from Prof Eamon Keenan, Chair of the HSE’s codeine working group, was issued to HSE and HSE-funded services in January. The products being referenced are low-dose codeine products available over the counter in pharmacies, such as codeine with paracetamol (with or without other active ingredients), codeine with ibuprofen, and codeine oral solution. Some of these products may also be prescribed.

There was evidence of harm – including serious harms – associated with excessive or prolonged use of low-dose codeine-containing products. This included psychological and physical dependence. Serious harms could also occur from overexposure to the paracetamol or ibuprofen component of these products when used in excessive doses.

Healthcare professionals and services are required to raise awareness of the issue and review all care processes and guidelines to identify if there is routine use of these products in their service, among other actions.

The memo stated that low-dose codeine-containing products should “not be stocked routinely in clinical areas in any HSE or HSE-funded service”.

“For individuals who have been taking low-dose codeine-containing products regularly, assess the appropriateness of continuing this medication at their next scheduled medication review. Consider advising the use of alternative analgesia where suitable, eg, paracetamol or ibuprofen.”

According to the memo, the available evidence indicated that combination products with low-dose codeine and paracetamol or ibuprofen were no more effective than paracetamol or ibuprofen alone for management of pain.

A HSE spokesperson told the Medical Independent: “The memo highlighted the risks as outlined in the HSE National Patient Safety Alert (NPSA) of 2022 and the availability of equally effective and safer alternatives. It asked services to cease routine prescribing, administration, or recommendation of these products to new patients.”

While the option of issuing another NPSA was considered, it was felt an internal memo was “the most appropriate mechanism at this time”.

The HSE codeine working group was established on the request of the Chief Clinical Officer.

“The purpose was to consider HSE actions that might be needed upon notification that the Health Products Regulatory Agency (HPRA) had commenced a formal procedure to consider the regulatory status of low-dose codeine products currently available over the counter in pharmacies.

“As the HPRA regulatory procedure is ongoing and has not concluded, the codeine working group considered and prioritised actions to inform current HSE clinical recommendations to HSE services, including the memo to staff and reviewing public-facing information on the HSE website.”

The HPRA initiated its review in late 2022. A spokesperson for the Authority said: “The ongoing assessment of this matter, and any data received and reviewed by the HPRA, remains confidential. Once the review is completed, the HPRA will communicate the outcome.”