The Society of Hospital Pharmacists of Australia

Recommendations from The Society of Hospital Pharmacists of Australia on end-of-life care, antibiotics, antipsychotic drugs, NSAIDs & codeine. The Society of Hospital Pharmacists of Australia (SHPA) is the national professional organisation for more than 3,000 pharmacists, pharmacists in training, pharmacy technicians and associates working across Australia’s health system.

Don't recommend the use of medicines with sub-therapeutic doses of codeine (<30mg for adults) for mild to moderate pain.

Date reviewed: 1 March 2016

Products containing low dose (<12mg) codeine per tablet combined with another analgesic medicine are available without a prescription and are commonly recommended for the treatment of mild to moderate pain.

Codeine is converted to morphine in the body to work. The extent of this metabolism depends on each individual’s pharmacogenetics, which are not readily known and highly variable between individuals.

There is evidence that doses of codeine less than 30 mg every 6 hours, are no more effective than paracetamol or an NSAID alone. Therefore, combination products that contain low dose codeine should not be recommended for mild to moderate pain. If used their effectiveness should be assessed within 48 hours. If symptoms persist the product should be ceased and the patient referred for further assessment.

Codeine can lead to constipation, nausea, vomiting, bloating and abdominal pain. Any of these symptoms can impact on quality of life.

Supporting evidence
  • Murnion BP. Combination analgesics in adults. Australian Prescriber 2010;32(4):113-115.
  • Ledema J. Cautions with codeine. Australian Prescriber. 2011;34(5):133-135.
  • Derry S, Moore RA, McQuay HJ. Single dose oral codeine, as a single agent, for acute postoperative pain in adults. Cochrane Database Syst Rev. 2010 Apr 14; (4): CD008099.
  • Signal Investigation Unit. Codeine use in children and ultra-rapid metabolisers: Pharmacovigilance and Special Access Branch Safety Review. Version 1.0. Canberra: Therapeutic Goods Administration; 2015.
  • Analgesics Expert Groups. Therapeutic guidelines: analgesic. Version 6. Melbourne: Therapeutic Guidelines Limited; 2012.
How this list was made How this list was made

A working party was formed and they sought suggestions from SHPA’s Committees of Specialty Practice, Reference Groups, State and Territory branches and Federal Council. More than 40 proposed statements were considered by the working party. A shortlist of 10 statements was identified for consideration by the SHPA’s membership through an online survey. All members were invited to comment on each proposed statement, specifically: whether it related to the practice of pharmacy, related to medicines that are frequently used, and if a significant cost. Members were also invited to rate the statements in order of preference. The survey results were used by the working party to identify the final six statements which were presented to SHPA’s Federal Council who ratified the choice of the five final statements.

Download SHPA Recommendations