OTC spotlight: painkillers containing codeine

Why this matters

Painkillers that combine codeine with paracetamol or ibuprofen are among the most closely controlled medicines sold over the counter. Codeine is an opioid. It can cause dependence, and regular use can itself cause headaches. Most pharmacies ask for every request to be referred to the pharmacist.

What support staff need to know

• These are Pharmacy (P) medicines. Follow your sales of medicines protocol. In many pharmacies that means every sale goes through the pharmacist.
• They are only for the short term treatment of acute, moderate pain that has not been relieved by paracetamol, ibuprofen or aspirin alone. They are not for coughs, colds or minor aches.
• They should be used for no more than three days. The front of every pack carries the warning 'Can cause addiction. For three days use only'.
• Packs sold over the counter contain no more than 32 tablets or capsules. Larger packs need a prescription.
• They are not for children under 12. For 12 to 18 year olds there are further restrictions, so always refer.
• Codeine should not be used by breastfeeding mothers.
• Codeine linctus, a cough medicine, was reclassified to prescription only in 2024 because of the risk of abuse and addiction. It can no longer be sold over the counter.

WWHAM in practice

Who is it for, and how old are they? What is the pain and how bad is it? How long have they had it? Action already taken: have they tried paracetamol or ibuprofen alone, at the right dose? Medicines: what else do they take, and have they used a codeine product recently?

The last question is the important one. Someone who has already used a codeine product for three days needs to speak to the pharmacist, not buy another pack.

Signs that someone may need help

• Asking for a codeine product by name, often the strongest or largest pack
• Buying frequently, or visiting different pharmacies
• Saying they need it every day, or that the pain comes back when they stop
• Becoming anxious or irritable when questioned or refused
• Headaches that have become daily while using painkillers

None of these proves a problem, and people in pain deserve respect. Your job is to notice and refer quietly to the pharmacist, who can have a private, supportive conversation.

When to refer to the pharmacist

• Every request, if that is your pharmacy's protocol
• Pain lasting more than three days, or pain that keeps coming back
• Anyone under 18, pregnant or breastfeeding
• Anyone taking other medicines, especially other painkillers, sedating medicines or alcohol in quantity
• Repeat requests or any of the signs above
• Any request you feel uneasy about

PPets learning connection

This spotlight supports the OTC consultation, WWHAM and red flags learning in the Level 2 Certificate. Our free OTC red flags guide is a useful counter reference.

Record this as CPD

Registered pharmacy technicians can use this article towards GPhC revalidation, as an unplanned CPD entry or as the starting point for a reflective account. Pharmacy assistants and trainees can use it as evidence of reflective practice. Note down three things:

1. What you learned from this article
2. How you have applied it, or will apply it, in your own role
3. The benefit to the people who use your pharmacy's services

Sources and further reading

• MHRA Drug Safety Update: over-the-counter painkillers containing codeine or dihydrocodeine
• MHRA Drug Safety Update: codeine for analgesia, restricted use in children
• GOV.UK: codeine linctus to be reclassified to a prescription-only medicine

Related from PPets

• OTC consultation training
• Community pharmacy red flags
• WWHAM training

This article is for general educational purposes only. It is not legal advice, professional regulatory advice or clinical advice about an individual patient. Always follow your pharmacy's SOPs and check current official guidance and product information.

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