According to State Agency of Medicines figures, painkillers containing codeine have been a popular pharmacy product for years already, and behind that popularity are substance abuse and the misuse of the drugs.

Codeine, an opiate derived from the sap of the opium poppy (Papaver somniferum), is metabolized by the body to morphine.

"The State Agency of Medicines was also contacted by the loved ones of people with substance abuse issues as well as users themselves seeking help," said Maia Uusküla, director of the agency's Department of Post-Authorization Safety.

A joint decision was reached by pharmacists, doctors and the State Agency of Medicines to switch such drugs to prescription only.

Estonian Chamber of Pharmacists (EPK) board chair Karin Alamaa-Aas told ERR that this issue is all too familiar to pharmacists, which is why the change is necessary and one that has been long awaited.

"There are people who come into the pharmacy every morning and buy one pack of the original Solpadeine — that's 12 tablets — and they run out of it every day too," Alamaa-Aas said. "That's very heavy misuse, and this issue has been talked about for a long time already."

She added that a pharmacist can advise their clients, but cannot refuse to sell the drug to them.

The EPK board chair recalled that cough syrups containing codeine were once available OTC as well, and were eventually restricted to prescription only for the same reason.

The people to most commonly misuse painkillers containing codeine are those with headaches, she said; they buy a painkiller and end up continuing to take it. Unfortunately, the long-term use of paracetamol (acetaminophen) or ibuprofen can end up inducing headaches when you stop taking the painkiller.

"If this includes codeine too, then that's addictive," she explained. "That's why it's becoming a prescription-only drug — its use is justified for certain diagnoses, but only in the short term."

Among those to misuse codeine-containing drugs are people of all ages, with complaints ranging from joint pain to pain caused by age-specific conditions that do in fact require pain management. Starting next year, such customers will be directed to see their family doctor, which Alamaa-Aas considers a good thing, as some of them likely have yet to even be seen by a doctor for their pain.

The doctor, in turn, can then determine what issue caused them to start using the painkillers to begin with, and can provide different treatment options for the management of chronic pain. For those experiencing severe pain, doctors can also refer them to specialized pain treatment offices as well.'

Pharmacists recommend paracetamol

For those used to taking Solpadeine or paracetamol with codeine for regular headaches, pharmacists recommend taking just regular paracetamol instead.

"It is being increasingly used as a painkiller and is precisely what is recommended because it has the fewest side effects and [drug] interactions," said Alamaa-Aas. "But with every drug, what's crucial is the correct use — at not too high, but also not too low of a dose." Overuse of paracetamol, for example, makes it hepatotoxic, or damaging to the liver.

It is due to the latter risk that some countries who authorized the sale of paracetamol in supermarkets later reversed their decision, as the number of overdoses grew.

"If a patient truly needs a drug to contain codeine as well and hasn't misused it — only needing two tablets once a month — they can talk to their doctor and have it prescribed," the EPK board chair said.

When planning the change, the State Agency of Medicines took other countries' experiences into consideration

Estonia's State Agency of Medicines took other countries' experiences into consideration as well in planning the change. Australia, for example, designated all drugs containing codeine prescription-only in 2016 already, following which the number of cases of opiate- or codeine-related poisonings fell by half.

Based on the reports of drug wholesalers, the State Agency of Medicines estimates that some 15,500 people a day used paracetamol within the maximum daily dose in Estonia last year.

The number of people taking a combination of paracetamol and codeine daily, meanwhile, totaled below 2,800. As the estimate was based on maximum daily dose, the true number of people possibly misusing it at higher doses was lower.

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