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We Need to Talk About Codeine: an Implementation Study to reduce the number of Emergency Department patients discharged on high-strength co-codamol using the Behaviour Change Wheel
  1. Rajendra Raman,
  2. Laura Fleming
  1. Accident and Emergency, Victoria Hospital, Kirkcaldy, UK
  1. Correspondence to Dr Rajendra Raman, Accident and Emergency, Victoria Hospital, Kirkcaldy KY2 5AH, UK; rajendra.raman{at}


Background The crisis of prescription opioid addiction in the USA is well-documented. Though opioid consumption per capita is lower in the UK, prescribing has increased dramatically in recent decades with an associated increase in deaths from prescription opioid overdose. At one Scottish Emergency Department high rates of prescribing of take-home co-codamol (30/500 mg) were observed, including for conditions where opioids are not recommended by national guidelines. An Implementation Science approach was adopted to investigate this.

Methods A Behaviour Change Wheel analysis suggested several factors contributing to high opioid prescribing: poor awareness of codeine addiction risk, poor knowledge of NICE (National Institute for Health and Care Excellence) guidelines on common painful conditions, mistaken assumptions about patient expectations and ready access to a large stock of take-home co-codamol. Based on this analysis a combined Education/Persuasion intervention was implemented over a 1-month period (January 2019) reaching 93% of prescribers. An Environmental Restructuring intervention was introduced at 4 months, and co-codamol prescriptions were monitored over a 12-month follow-up period. Unplanned re-attendances and complaints related to analgesia were monitored as balancing measures.

Results The Education/Persuasion intervention was associated with a 59% reduction in co-codamol prescribing that was maintained over 12 months. The Environmental Restructuring intervention was not associated with any further reduction in prescribing. No increase in unplanned re-attendances occurred during the study period and no complaints were received relating to pain control.

Conclusions The increasing incidence of prescription opioid addiction in the UK suggests the need for all clinicians who write opioid prescriptions to re-evaluate their practice. This study suggests that knowledge of addiction risk and prescribing guidelines is poor among Emergency Department prescribers. We show that a rapid and sustained reduction in prescribing of take-home opioids is feasible in a UK Emergency Department, and that this reduction was not associated with any increase in unplanned re-attendances or complaints related to analgesia.

  • analgesia/pain control
  • quality improvement
  • drug abuse

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  • Handling editor Simon Smith

  • Contributors Both authors contributed in equal measure to the conception and design of this Implementation Study. Both authors collected the relevant audit and survey data and contributed equally to the educational interventions described. RR drafted the manuscript, which was then edited and approved by LF.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.