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. 2025 Apr 30;25(1):442.
doi: 10.1186/s12888-025-06881-6.

Pharmacists' experience with patients suspected to be addicted to over-the-counter codeine and their attitudes towards potential remediation strategies: a cross-sectional study

Željana Margan Koletić  1 , Blaženka Pavličić  2 , Željko Ključević  3 , Ana Soldo  4 , Livia Puljak  5
Affiliations

Pharmacists' experience with patients suspected to be addicted to over-the-counter codeine and their attitudes towards potential remediation strategies: a cross-sectional study

Željana Margan Koletić et al. BMC Psychiatry. .

Abstract

Background: Croatia is one of the European Union (EU) countries where low-dose codeine products (LDCP) can be purchased over the counter (OTC) directly from community pharmacists without a prescription. The misuse and dependence potential of OTC LDCP have raised growing public health concerns. As the first point of contact for patients seeking these medications, pharmacists play a critical role in identifying misuse and implementing harm-reduction strategies. However, little is known about the experiences and perspectives of pharmacists in Croatia regarding codeine addiction. This study aimed to examine the experience of pharmacists in Croatia with patients addicted to over-the-counter codeine and their attitudes toward potential remediation strategies.

Methods: A cross-sectional study was conducted between October 18, 2021, and December 23, 2021. Eligible participants were pharmacists, members of the Croatian Chamber of Pharmacists, employed in community pharmacies in Croatia. The data were collected via an online questionnaire that examined the attitudes and experiences of pharmacists in Croatia regarding OTC medicines containing codeine and the demographic characteristics of pharmacists.

Results: Out of 2800 active pharmacists in Croatia, 594 participated in the study (21% response rate). The majority (92%) saw patients who regularly purchased high quantities of OTC products containing codeine and for whom pharmacists suspected they could be addicted to this medicine. Most participants occasionally talked to patients about possible codeine abuse and addiction. Two-thirds of participants did not report suspected adverse reactions associated with OTC codeine use to the national pharmacovigilance system, despite patients indicating a potential link. More than half of the participants noted that codeine-containing medicines should be switched from OTC to prescription-only status.

Conclusions: This study showed that 92% of pharmacists in Croatia encountered patients who may be misusing or are dependent on OTC codeine products. However, they indicated limited engagement in formal reporting or intervention. The findings highlight the need for more precise guidelines, enhanced pharmacist education, and consideration of regulatory changes, such as reclassifying codeine-containing medicines to prescription-only status, to support pharmacists in mitigating risks associated with codeine misuse.

Keywords: Codeine; Croatia; Opioids; Over-the-counter; Pharmacists; Prescribing policies.

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Conflict of interest statement

Declarations. Ethical approval and consent to participate: The study protocol was approved by the Ethics Committee of the Catholic University of Croatia on February 9, 2021 (Classification no. 641-03/21 − 01/02; Registration no. 498-03-02-06-02/1-21-02) and the Croatian Chamber of Pharmacists’ management board. The study was conducted in accordance with the institutional Codes of Ethics. All methods were performed in accordance with the relevant guidelines and regulations. Informed consent was obtained from all study participants in the online survey system. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests. Disclaimer: The views expressed in this article are the personal views of the author(s) and may not be understood or quoted as being made on behalf of or reflecting the position of the regulatory agency/agencies or organisations with which the author(s) is/are employed/affiliated. Clinical trial registration: Not applicable. This study was not a clinical trial.

References

    1. Foley M, Harris R, Rich E, Rapca A, Bergin M, Norman I, Van Hout MC. The availability of over-the-counter Codeine medicines across the European union. Public Health. 2015;129(11):1465–70. - PubMed
    1. Wells JS, Bergin M, Van Hout MC, McGuinness P, De Pleissisc J, Rich E, Dada S, Wells R, Gooney MA. Purchasing over the counter (OTC) medicinal products containing Codeine - Easy access, advertising, misuse and perceptions of medicinal risk. J Pharm Pharm Sci. 2018;21(1):30049. - PubMed
    1. Nielsen S, Van Hout MC. Over-the-Counter Codeine-from therapeutic use to dependence, and the grey areas in between. Curr Top Behav Neurosci. 2017;34:59–75. - PubMed
    1. McAvoy BR, Dobbin MD, Tobin CL. Over-the-counter Codeine analgesic misuse and harm: characteristics of cases in Australia and new Zealand. N Z Med J. 2011;124(1346):29–33. - PubMed
    1. Nielsen S, Murnion B, Dunlop A, Degenhardt L, Demirkol A, Muhleisen P, Lintzeris N. Comparing treatment-seeking Codeine users and strong opioid users: findings from a novel case series. Drug Alcohol Rev. 2015;34(3):304–11. - PubMed