A unique opportunity: codeine has been rescheduled
As you are already aware, from February 2018 medications containing codeine have become prescription-only.
The Therapeutic Goods Administration’s decision to reschedule codeine has been well-documented and can be found on the TGA website: Scheduling delegate’s final decision: codeine, December 2016.
The rescheduling of codeine is an ideal opportunity to:
+ Discuss alternative pain management options which evidence suggests are more effective (both pharmaceutical and non-pharmaceutical)
+ Speak with patients and explain the risks associated with using codeine-based products such as dependence and addiction
+ Develop a treatment plan with patients who appear to be experiencing chronic pain or dependency issues
Talking alternative options with your patient
People who request codeine containing medications as a result of codeine becoming prescription only in February are likely to need relief from acute or chronic pain. It is important to first understand why the patient requires pain relief and understand the history of their pain. Some questions you might ask are:
+ “Do you know what caused the pain?”
+ “How long have you had the pain for?”
+ “How often do you use this medication?”
+ “How much do you take?”
+ “Do you feel sick when you try to stop taking them? Can you describe it for me?”
+ “What’s the longest time you’ve gone without taking them?”
If your patient has had pain for less than 3 months, you can talk to them about about the many other treatment options available – both non-pharmaceutical and pharmaceutical.
It is important to let your patient know that effective pain management can involve the use of non-pharmaceutical therapies. These non-medication based treatments may include:
+ Heat and inflammatory rubs
+ Heat packs or ice packs
+ TENS machines
It might also be beneficial to explain to your patient that seeing allied health professionals such as physiotherapists may be an effective way of managing their pain.
Medication options if your patient’s pain is not treated by non-pharmaceutical options may include:
+ Combination ibuprofen and paracetamol
Managing Chronic Pain
Helping patients to manage chronic pain can be complex and require a joint effort from your patient and yourself as their GP.
It’s important to ensure that your patient has realistic expectations about chronic pain management. As you know, in many cases treatment plans might focus on getting your patient to enjoy their everyday life, even if some pain remains.
Working with your patient to create a comprehensive, multi-modal pain management plan is very beneficial. This may involve a referral to a pain specialist or working together with your patient to try different ways – both non-pharmaceutical and pharmaceutical – to treat their pain.
If you require assistance in helping manage your patient’s chronic pain, there are a number of resources available to download below.
Training resources available
NPS free accredited CPD activities such as:
Chronic Pain Resources for your patient
There are many different online resources available to help your patient self-manage their pain while you work together.
It may be helpful to show your patient some of the resources provided by other organisations which seek to help Australians better manage their pain, such as this PainBytes website developed by Pain Management Network.
Other relevant information is available to download below
Pain Management Referral
Specialists in pain management may include:
+Allied health professionals such as physiotherapists, psychologists and/or occupational therapists
+ Pain specialists or pain management treatment centres
It is important to note that when codeine is rescheduled, it is possible that pain specialists may become more heavily used which could increase wait times for your patients.
Dependence or Addiction Referral
It is possible that your patient may also present with dependence or addiction to codeine-based medications. As we know, tolerance can mean that your patient may not be aware that they have become dependent on these medications.
Sometimes patients may have misconceptions about AOD services, and it can be helpful to let them know that drug and alcohol treatment centres and addiction specialists commonly see patients with codeine dependency and addiction.
Referrals may be made to:
+ Addiction specialists
+ Drug and alcohol treatment centres
Referral to these services is likely only necessary in more complex cases. It is likely you will be able to help treat your patient’s health condition through your practice.
If you require more information on treatment options or have any questions, there are support services available. A great place to start is the DACAS website which hosts a range of information and also a helpline for health professionals.
Mental Health Referral
You might therefore need to prepare a mental health plan with your patient to achieve the best health outcomes.
Understanding dependence and addiction
Do not hesitate to start a conversation (with empathy and sensitivity) about dependence and its treatment if needed.
Codeine dependence is a medical condition and just like any other health condition such as diabetes or asthma, can be managed well in general practice. Support is available for GPs who require more training or information about treatment in this area (see below).
There are many effective treatments available for codeine dependency and addiction, which include:
+ Medication-assisted treatment
+ In-patient or residential treatment programs
Support for GPs
There are many organisations which can provide support for GPs seeking to provide potentially lifesaving treatment for their patients.
DACAS provide a 24-hr help line for health professionals to ask questions of addiction medicine specialists and professional drug and alcohol counsellors.
DACAS (VIC): 1800 812 804
DACAS (TAS): 1800 630 093
DACAS (NT): 1800 111 092
DACAS have also produced a series of factsheets for physicians seeking to treat drug-related presentations in a general practice setting, which you can access here: http://www.dacas.org.au/Clinical_Resources/For_GPs.aspx.
This includes a guide for prescribing .
+ Motivational interviewing
+ Relapse prevention
+ Controlled drug use interventions
+ Prescribing for drug withdrawal
+ Managing difficult and complex behaviours
Tips for discussing dependence and addiction
Starting a conversation with your patient can be difficult, but has the potential to be life-saving.
Here is some advice on how to start a positive conversation with your patient about dependence and/or addiction:
+ Maintain a non-judgmental and empathetic approach which places dependency and its treatment in the context of improving health outcomes. For example, explain that dependence is a long-term health condition which requires a treatment plan, just as diabetes or asthma do.
+ Explain the risks associated with codeine use and that there are effective treatment options available
+ Use ‘I’ statements such as ‘I am very concerned about your health…’, ‘As your doctor, I believe there are more effective ways we can…’
There are a number of resources which can also help prescribers understand their patients’ symptoms including:
+ the Subjective Opiate Withdrawal Scale, and
Here are some examples of how you can start this conversation:
+ Your response to my questions suggest you might be physically dependent on these medicines. What do you think?”
+ “Codeine dependence is a common consequence of being prescribed or buying and using these medications over an extended period of time”
+ “Dependency is a medical condition which requires treatment, just like diabetes or asthma”
+ “People sometimes have a lot of misconceptions about addiction and dependence, but this is something that can happen to everyone and doesn’t say anything negative about a person’s character or moral fibre”
+ “There are many effective treatments available to manage and overcome codeine dependency”
It can also be helpful to explain the alternatives to using codeine, and the lack of scientific evidence around its effectiveness. Examples of how to start these conversations are provided in the previous section.
How codeine rescheduling will operate
According to the TGA, some codeine-containing medications are currently listed on the PBS for severe pain conditions; however these medicines contain high doses of codeine. The currently available over-the-counter analgesics have low doses of codeine and are not currently on the PBS.
A full list of codeine containing products which have been rescheduled can be found on the TGA’s codeine hub here.
Why was codeine rescheduled?
Research has demonstrated that codeine-related deaths more than doubled in Australia between 2000 and 2009 with approximately 40% of these deaths involving over-the-counter medications.
The rise in codeine-related deaths is part of the worldwide opioid crisis which has seen countries such as the United States and most of Europe adopt strategies to prevent prescription medication overdose deaths.
The Therapeutic Goods Administration’s decision to reschedule codeine has been well-documented and can be found on the TGA website: Scheduling delegate’s final decision: codeine, December 2016. You can also read Chief Medical Officer, Professor Brendon Murphy’s media statement here.
Benefits of this decision by the TGA include:
+ Prevention of accidental deaths linked to codeine-containing medications
+ Exploration of alternative and more effective treatment options for pain management
+ Prevention of adverse events related to unintentional overdose of paracetamol or ibuprofen, and
+ Reduced dependency and reduced risk of dependency.
At the heart of this decision is the fact that many Australians are not aware of the harms associated with using codeine and the potentially more effective alternatives available for pain management.
Want to know more?
The TGA has provided the evidence underpinning the rescheduling decision and related documentation on its website: