In recent years, the increasing accessibility of over-the-counter (OTC) medications containing low-dose codeine has ignited a growing public health concern across many European Union countries. Croatia, one such nation, permits the sale of these medications through community pharmacies without requiring a medical prescription. This regulatory environment places pharmacists at the frontlines, making them critical observers and gatekeepers in identifying and addressing codeine misuse and potential addiction. A newly published cross-sectional study sheds light on Croatian pharmacists’ direct experiences with patients suspected of codeine dependence, alongside their attitudes towards possible strategies to mitigate this emerging public health challenge.
The study, conducted during the last quarter of 2021, surveyed pharmacists across community settings in Croatia to gain insights into their encounters with patients who regularly obtain high quantities of OTC codeine-containing medicines. Pharmacists are uniquely positioned as healthcare professionals who not only dispense these potentially addictive drugs but also engage with patients about their usage patterns. This dual role renders them vital contributors to early detection and intervention efforts, yet until now, comprehensive data regarding their experiences and perspectives on codeine misuse have been scarce.
Out of approximately 2,800 active community pharmacists registered with the Croatian Chamber of Pharmacists, 594 responded to the online survey, representing a 21% response rate. A remarkable 92% of these participants reported recognizing patients who habitually purchase large amounts of OTC codeine products, often triggering suspicion of addiction. This high prevalence underlines both the widespread availability of such medications and the potential scale of codeine-related misuse within the country. Pharmacists’ encounters with these at-risk patients offer a critical window into the misuse trends that may otherwise remain obscured from broader healthcare surveillance.
Despite their frontline position, however, the survey revealed significant gaps in pharmacists’ engagement with formal remedial actions. While many pharmacists admitted to occasionally discussing the risks of codeine dependency with patients, proactive communication appeared to be somewhat limited. Even more strikingly, two-thirds of pharmacists refrained from reporting suspected adverse reactions associated with codeine use to Croatia’s national pharmacovigilance system. This reluctance has considerable implications for public health monitoring, as underreporting restricts the ability of authorities to detect patterns of misuse, addiction, and related complications on a population level.
The pharmacists surveyed also voiced substantial support for regulatory reforms. Over half endorsed the idea that codeine-containing medicines should be transitioned from OTC availability to prescription-only status. Such a policy change would align Croatia with many other EU countries that have enacted stricter controls on codeine sales to curb misuse and its dangerous consequences. The pharmacists’ strong advocacy for this shift underscores their recognition of the risks inherent in unfettered access to codeine and reflects the perceived need for systemic interventions beyond individual pharmacist efforts.
The growing concern over OTC codeine misuse in Croatia echoes global patterns where opioid-containing preparations, even at low doses, have demonstrated dependency potential. Codeine’s psychoactive properties, metabolized into morphine within the body, provide temporary relief from pain and cough but can foster tolerance and addiction when misused. The availability of such compounds without prescription oversight raises ethical and practical questions about balancing easy access for legitimate therapeutic use against the risks of abuse.
Pharmacists’ pivotal role in harm reduction is further complicated by insufficient national guidelines and educational resources focused on identifying and managing codeine misuse. The study’s findings highlight an urgent need to equip pharmacists with more precise protocols, training, and support systems. Enhanced education would empower pharmacists to confidently initiate conversations about addiction risks, recognize warning signs earlier, and engage in effective intervention strategies, thereby improving patient outcomes and public health.
Croatia’s current pharmacovigilance reporting mechanisms appear underutilized, as the majority of pharmacists hesitate to report suspected adverse events linked to OTC codeine use. Addressing the barriers to reporting—whether due to a lack of awareness, perceived complexity, or time constraints—could strengthen surveillance of codeine-related harms. Streamlining these systems and raising awareness about their importance might encourage pharmacists to contribute more actively to national safety databases.
In addition to pharmacovigilance enhancements, multidisciplinary collaboration between healthcare professionals, policymakers, and patient advocacy groups will be essential to developing comprehensive approaches to OTC codeine misuse. Pharmacists, by virtue of their direct interface with patients and medication dispensing responsibilities, are essential stakeholders in these efforts. Their insights and frontline experiences can guide the design of pragmatic policies that balance access and safety.
Moreover, the Croatian study underscores a broader implication: reliance on pharmacists as informal monitors alone is insufficient to stem the tide of codeine misuse. Structural reforms, including rescheduling codeine products to require prescriptions, must be considered seriously. Such control has been shown in other jurisdictions to reduce availability for misuse while preserving access for patients with legitimate medical needs.
This evolving landscape places pharmacists at a crossroads, requiring a balance between patient advocacy, regulatory compliance, and public health responsibilities. Empowering pharmacists with tools, clearer guidelines, and legislative support is paramount to turning their frequent encounters with potentially addicted patients into opportunities for early intervention and harm reduction.
Ultimately, this comprehensive examination of Croatian pharmacists’ experiences with OTC codeine abuse provides a compelling call to action. It exposes critical gaps in the current system and offers a roadmap for enhancing pharmacists’ roles through education, reporting, and regulatory change. The study not only contributes valuable data to the global conversation on codeine misuse but also exemplifies the need for multifaceted, evidence-driven strategies in addressing over-the-counter opioid addiction risks.
As codeine misuse continues to present challenges worldwide, the Croatian case emphasizes that pharmacy professionals must be recognized and integrated as key actors in addiction prevention frameworks. Their firsthand observations and patient interactions provide invaluable intelligence that, if leveraged strategically, can inform policies and practices designed to safeguard public health without unduly restricting access to essential medicines.
The findings present an urgent opportunity to reevaluate OTC codeine management policies, enhance pharmacist education programs, improve adverse event reporting systems, and ultimately implement regulatory reforms that reduce misuse while supporting responsible patient care. Addressing these issues now will be crucial in preventing the escalation of codeine dependence and its associated health, social, and economic burdens in Croatia and beyond.
Subject of Research: Pharmacists’ experiences with suspected addiction to over-the-counter codeine-containing medications and their attitudes towards remediation strategies in Croatia.
Article Title: Pharmacists’ experience with patients suspected to be addicted to over-the-counter codeine and their attitudes towards potential remediation strategies: a cross-sectional study.
Article References:
Margan Koletić, Ž., Pavličić, B., Ključević, Ž. et al. Pharmacists’ experience with patients suspected to be addicted to over-the-counter codeine and their attitudes towards potential remediation strategies: a cross-sectional study. BMC Psychiatry 25, 442 (2025). https://doi.org/10.1186/s12888-025-06881-6
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