By Radiha Khan, CONTACT: 18rkhan@wghs.org.uk
Key words: over-the-counter (OTC) medication/drug, prescription-only (PO) medication/drug, up-scheduling medication/drugs, self-medication, public health ethics
OTC medications are those that can be sold directly to people without a prescription. OTC medications treat a variety of illnesses and their symptoms including pain, coughs and colds, diarrhoea, constipation, acne, and others. Most of us right now will have some form of over-the-counter medicine in our house right now, most commonly ibuprofen or paracetamol. Simply, these are just some of the many examples of OTC medications available. We can access these medications, at a local pharmacy or supermarket, as a source to promote self-medication and reduce healthcare costs. The government has implemented policies to reduce the amount of money the NHS spends on prescriptions for treating minor conditions that usually get better on their own as before these policy changes, the NHS spent around £569 million (2018) a year on prescriptions for medicines that can be bought from a pharmacy or supermarket.
But is this scheme of self-medication truly as revolutionary as believed? While the active ingredients in OTC drugs may be effective in treating certain minor ailments, they may also have psycho stimulant effects. The misuse of such drugs for intoxication has long been observed. Some commonly abused OTC drugs include codeine-based drugs, cough products (such as dextromethorphan), sedative antihistamines (such as diphenhydramine), decongestants and laxatives.
Among these kinds of OTC medications, codeine, which is indicated for use as a cough suppressant and analgesic, is usually sold with laxity. It is evident that people sometimes may use large quantities of these medicines impulsively, and so restricting the availability of pain relief medicines for purchase and in the home is effective in reducing the number of hospital admissions and deaths from accidental or impulsive overdose. But these generic restrictions of sales on opioids, like codeine, are not sufficient to curve the impacts it is having. The average age of patients reported for acute poisoning or admission by OTC medications, such as codeine, is about 20 years old, affecting the health of young people in particular.
In a pharmacy practice, the ethical challenges of regulating the sale of OTC drugs, such as codeine, are complex. It requires individual pharmacists (and their assistants) to decide on the appropriateness of sales, even having to enquire about suspicious purchases and previous purchases at other pharmacies, which customers may refuse to answer to. Also, if a customer strongly insists on the necessity of the drug on some grounds, it is expected to be difficult to refuse to sell the drug even if suspicion prevails – there is no definitive evidence of intentions and actions, it is all dependent on word of mouth and trust.
In addition, there are challenges with the up scheduling of OTC medications, creating restriction to an individual’s right to health, which is unethical. This is that, up-scheduling will be restricting the rights of people to access self-care through the proper use of OTC medications. Codeine may be arguably necessary for the right to health when the quality of life is impaired by pain or cough. If codeine is up-scheduled, it will no longer be available at pharmacies without a doctor’s prescription. But, at times up-scheduling is necessary, especially in the case where it will improve public health, reducing the misuse of OTC medication, and the number of dependants on OTC medication. In Australia, after the 2018 up-schedule, there was a 50.8% decrease in poison centre calls and a 53% decrease in hospitalisations. Similar trends have been observed in Canada and Ireland as well. Such positive outcomes have made up-scheduling a popular public health intervention against OTC drug misuse. Therefore, the choice to up-schedule codeine linctus, from an OTC medication to a PO medication, in the UK is an understandable measure. This could help to improve and ensure the safety and well-being of patients. Since 2019, there have been increasing reports in the media of codeine linctus being misused as an ingredient in a recreational drink, commonly referred to as ‘Purple Drank’, and so it’s up-scheduling will hopefully help prevent its misuse and abuse, as it can have major health consequences when used incorrectly.
However, it is obvious that not all is resolved via up-scheduling. Firstly, a doctor’s prescription does not eliminate the misuse of the drug. This means that must rigorously evaluate the need for up-scheduled medications in each case and prescribe only the necessary doses. Secondly, there is a possibility that codeine-dependent patients might suffer collateral harm from sudden withdrawal once the drug is up-scheduled, forcing pharmacists to violate the principle of non-maleficence.
However, it is obvious that not all is resolved via up-scheduling. Firstly, a doctor’s prescription does not eliminate the misuse of the drug. This means that must rigorously evaluate the need for up-scheduled medications in each case and prescribe only the necessary doses. Secondly, there is a possibility that codeine-dependent patients might suffer collateral harm from sudden withdrawal once the drug is up-scheduled, forcing pharmacists to violate the principle of non-maleficence. This means that addiction treatment facilities must be prepared to handle new entrants into their detoxification programs and mental healthcare needs to be strengthened, especially for young people who are already engaged in or vulnerable to OTC drug misuse.
While OTC medications promote self-medication, and release the burden on healthcare services, by allowing access to medical resources for minor issues, their increasing misuse has created a public health crisis, that many governments are attempting to crack down for the better of their countries. Considering the situation from the perspective of public health ethics, these OTC medications need to be up-scheduled as long as self-medication can be achieved through other less addictive alternatives. This ensures that the right to health is preserved but the safety and well-being of individuals is maintained.
References
1 – National Institute on Drug Abuse (2017). Over-the-Counter Medicines DrugFacts. [online] National Institute on Drug Abuse. Available at: https://nida.nih.gov/publications/drugfacts/over-counter-medicines. Accessed on: 24 March 2024
2 – Ino, H. and Nakazawa, E. (2022). Over-the-Counter Drug Misuse and Dependence: Public Health Ethics’ Foray into Fight against the Codeine Crisis. Pharmacy, [online] 10(6), p.155. Available at: https://doi.org/10.3390/pharmacy10060155. Accessed on: 24 March 2024.
3 – NHS (2018). Why can’t I get a prescription for an over the counter medicine? [online] nhs.uk. Available at: https://www.nhs.uk/common-health-questions/medicines/why-cant-i-get-prescription-over-counter-medicine/. Accessed on: 24 March 2024.
4 – GOV.UK. (2024). Codeine linctus to be reclassified to a prescription-only medicine because of risk of abuse and addiction. [online] Available at: https://www.gov.uk/government/news/codeine-linctus-to-be-reclassified-to-a-prescription-only-medicine-because-of-risk-of-abuse-and-addiction. Accessed on: 24 March 2024.
5 – GOV.UK. (2012). Best practice guidance on the sale of medicines for pain relief. (n.d.). Available at: https://assets.publishing.service.gov.uk/media/6012d8a1d3bf7f05be4d1e87/Appendix_4.pdf. Accessed on: 24 March 2024
