Table 1

The codeine risk environment in the context of pain treatment: examples of environments producing and reducing harm

MicroenvironmentMacroenvironment
Risk Intervention Risk Intervention
Physical Prolonged codeine use.
Excessive codeine use.
Codeine dependence.		Increased education for peers on diversion of medications.Diversion of codeine containing medicines (obtaining codeine from friends and family).Review of regulation on prescription and monitoring.
Social Ineffective risk communication between GPs and patients to inform of codeine risks.
Disengagement from healthcare providers.
Limited engagement between patient and pharmacist.
Over-reliance on potentially inaccurate internet and peer information.		Increased information provision on codeine risk and alternative pain therapies in primary care.
GPs receptive to reviewing patient concerns.
Improving patient attitudes towards GP consultations and pain management.
Improving healthcare provider attitudes to pain management and codeine misuse. Clinician-led assertive engagement strategies in primary care.
Provision of social support via peer group and online.
Explore pharmacist–patient communication strategies.
Effective strategies targeting peer education and awareness of codeine misuse.		Codeine’s dominant role in contemporary pain treatment.
Stigmatisation of codeine dependence.
Anonymised information sourcing on the internet from unreliable sources.		Improved access to alternative non-pharmacological pain management therapies.
Increased awareness and opportunity for early intervention for codeine dependence across community, employment and health services.
Economic Lack of resources available for non-pharmacological pain treatment in primary care (eg, physical therapy).Funding and reform for NHS primary care and local drug addiction treatment services.
Policy Low utilisation of medicine review of repeat prescription of codeine.
Ineffective implementation of pharmacy OTC restrictions.
Ease of circumventing pharmacy restrictions.		Timely prescription monitoring and review of concerns.
GP instigated follow-up consultations and interventions.
Assertive and active review from primary care.
Continued provision of effective interventions in primary care such as tapering and pure codeine replacement.
Training of pharmacy staff to ensure consistent implementation of pharmacy OTC risk reduction policy.		Nature of GP appointments (long waiting times, short duration).
Ineffective laws and regulation governing OTC sales of codeine containing medicines.		More time to spend with codeine-dependent patients in GP surgeries. Increased availability and convenience in securing appointment and access to screening and brief intervention.
Review of legal and regulatory governance surrounding OTC codeine.

  • Factors may overlap physical, social, economic and policy environments and change place between environments over time.

  • GPs, general practitioners; NHS, National Health Service; OTC, over the counter.