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Out of Stocks, Misperceptions Hit Patients

Pharmacists and consumers are frustrated at the gap between supply and demand for low-dose codeine – and consumers are still confused

Advantage Pharmacy CEO Steven Kastrinakis told the AJP that discussions he has had with the group’s pharmacies since the first of the month have centred on out of stock frustration and misunderstandings among patients.

He said that the feedback he’s had indicates that a significant group of consumers believed that all analgesics were being upscheduled on February 1, not just those containing low doses of codeine.

“We had pharmacists having to tell people that paracetamol is still available, and people were surprised and said, ‘oh, that’s great’,” he said.

“There’s another group of people who are more educated and who’ve tried to do the right thing by going to the doctor post-1 February, to get their codeine-related product. But it comes with the price rise.

“We’ve got them coming in still expecting to pay $9 or $10 but they’re now being asked to pay $18 or above. There has been an almost doubling of the price to pharmacy, and that’s where consumers are getting frustrated.

“They believe it’s a grab for cash and pharmacists being opportunistic.

“But we were making more margin in the past than we are now.

“Where they get angered is when they say that they wish they’d known the price would be so high, because they would’ve asked for a PBS prescription.

“Some patients have the notion that if something is on prescription, it’s available on the PBS automatically.”

Some of these patients had supported the upschedule as they mistakenly believed that prescription codeine would help them reach their Safety Net.

The other issue upsetting customers is one pharmacists know all about: the difficulty sourcing stock.

“We’ve had patients come into our rural pharmacies, they’ve gone to their doctor in a country town, had an appointment, had to wait, paid $30 or $40 out of pocket to get a prescription – only to find the medication’s not available because Panadeine is no longer available, or the actual price now is so high that they’re saying they’ve got to go back and see what alternatives are available. And that’s another $30 or $40 out of pocket.

“There’s confusion and anger being caused by people going to their doctor only to find their item has been discontinued.”

Consumers have spoken out about their difficulty sourcing prescription low-dose codeine, including in an article by News Corp writer Katy Hall, who wrote, “I made my way to the local chemist with my freshly printed prescription for the low-dose codeine products that help me claw my way out of my pain spiral in hand, only to be told that following the February 1 codeine ban, a number of products were now out of stock due to package reprinting requirements — the one I needed included,” she writes.

A number of commenters said they were having similar difficulties.

Mr Kastrinakis said Advantage Pharmacy had warehoused generic paracetamol/codeine and ibuprofen/codeine combinations before 1 February, “but if people want branded products, they’re not available”.

“From the manufacturer point of view, because of the unease and misinformation before February, supplies have run down because of the new packaging,” he said.

“Now, if someone wants Panadeine, I can give them paracetamol/codeine from our warehouse, but I can’t give them Panadeine because it’s not available.”

Patients are generally glad just to be able to access the medicine, he said, and doctors aren’t putting pressure on by ticking the no brand substitution box on scripts.

But “the surge in demand for these product equivalents is not met with the supply component of the equation”.

“Pharmacies have not been able to order any stock from wholesalers of the newly packaged product-equivalents, despite seeing the need from patients presenting with prescriptions.

“But not all pharmacies are able to access stock or had ample stock of some of the generic supplies or even the Panadeine brand.

“From the manufacturers’ perspective, this is perhaps a time to assess the aggregate demand. As prices are not yet stabilised, consumers’ willingness to pay must first be assessed.

“Prescribing patterns may also change over time, and the spike in demand may only be short-lived.”

How are patients treating pain?

Mr Kastrinakis said there has been an increase in patients presenting with scripts for Panadeine Forte, unscheduled medicine sales are climbing and that low-dose codeine sales have plummeted.

Codeine sales in the average Advantage Pharmacy represent about 0.6 to 0.7% of their annual turnover, he said.

“We’ve found that since the 1st of February, we’ve lost 20% of our margin in the pain category. If you look at all codeine sales across a cohort of my stores, codeine sales are down 83% from February 2017 to February 2018, for the same time period of the first three weeks of the month.”

One large pharmacy said that they would normally sell 10 to 12 OTC codeine products a day; in the last three weeks this pharmacy has dispensed eight items that were formerly OTC.

He has heard anecdotal reports that doctors are instructing patients to take 1.5 paracetamol tablets and a Panadeine Forte to get the same amount of pain relief formerly offered by Panadeine Extra.

Reader Steven Julius echoed these concerns, commenting on another recent AJP article that: “Pharmacist phones Dr: ‘We have none of the 15mg codeine containing panadeine or equivalent. Is it OK to give Panadeine Forte today and the pt. can take 1 tablet of 500mg/30mg and 1 tablet of 500mg Panamax?’

“Dr: ‘Yeah, sounds good’.”

“What we’re also finding now is that we’re selling more of the unscheduled items as well – the paracetamol and ibuprofen and combinations, including those available in supermarkets,” Mr Kastrinakis says.

Mr Kastrinakis says he is concerned that all this means patients are being left with untreated pain.

“You would hope they would visit their doctor or emergency department, but the upschedule has limited pharmacists’ choices in dealing with pain and some of these minor ailments.

“There were patients in the past that we could treat, now we can’t treat and in a country town situation where there’s no bulk billing, some can’t afford or get in to see the doctor.

“People in the country are saying they now have to plan more around their pain.”

Mr Kastrinakis reminded pharmacies that they can still dispense old stock with a script for now – something he feels not all pharmacists were aware of.

“Everyone was so scared,” he said. “There was probably a lack of understanding from pharmacists that even if they had stock left over, they could dispense it till October. With no credit policy in place, they didn’t want to over-order.

“It’s a commercial decision – if I get stuck with stock post-1 Feb, nobody’s going to help me deal with that, so they were trying to manage stock levels appropriately even though there was some extra demand in the last weeks of January.”

Pharmacies with remaining stock of the ‘pharmacist only medicine’ codeine-containing products can dispense and supply the product, provided there is a valid prescription for the named item, he said.

This arrangement stands for a maximum period of nine months (until 31st October 2018) according to the Therapeutic Goods Administration.

Published on 26 February 2018 on the Australian Journal of Pharmacy: https://ajp.com.au/news/stocks-misperceptions-hit-patients/