A unique opportunity: codeine is being rescheduled
As you are aware, from February 2018 medications containing codeine will become prescription only.
The Therapeutic Goods Administration’s decision to reschedule codeine has been well-documented. You can find our more and view the full list of codeine-containing products which have been made prescription-only on the TGA’s codeine information hub here.
The alarming increase in codeine-related morbidity and mortality in Australia is part of a worldwide opioid crisis which has seen countries such as the United States, and most of Europe adopt strategies to prevent prescription medication overdose deaths.
Codeine rescheduling is therefore an important opportunity to:
+ Discuss alternative chronic pain management options which evidence suggests are more effective (both pharmaceutical and non-pharmaceutical)
+ Encourage patients who appear to be experiencing chronic pain or dependency issues to see their GP and/or another relevant specialist
+ Speak with patients and explain the risks associated with using codeine-based products such as dependence and addiction
Discuss alternative options with your patient
People who come in to the pharmacy to request codeine-containing medications likely 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 may 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?”
If your patient has had pain for less than 3 months, you can talk to them about the many other OTC medications and other therapies available to treat their pain.
It is important to let your patient know that effective pain management often involves the use of non-pharmaceutical therapies. This may involve seeing allied health professionals such as a physiotherapist or psychologist. Non-medication based treatments may include:
+ Heat and inflammatory rubs
+ Heat packs or ice packs
+ Exercise therapy
+ Complementary medicine (massage, acupuncture)
Other medications, which are proven to be effective than codeine-based medications, are also great alternatives:
+ Combination ibuprofen and paracetamol
Training resources available
+ NPS free accredited CPD activities such as:
Tips for discussing alternative options
Codeine rescheduling offers a unique opportunity to explain to your patient why codeine-containing medications are often not the best pain management option due to the associated risks and lack of evidence for effectiveness.
Below are two simulations of how to speak with patients seeking over-the-counter codeine for acute or chronic pain.
Around the risks of using codeine:
+ “Codeine-containing medications can have very serious side-effects such as tolerance, dependence and addiction. I can provide you with other medications which do not have the same risks but are more likely to be effective in managing your pain.”
+ “Codeine analgesics available in pharmacies are combined with paracetamol, ibuprofen or aspirin. Using these medications in high doses over long periods of time may lead to serious health problems such as liver damage, kidney failure and heart attack”
Conversation starters around effectiveness:
+ “Scientific evidence has found that low dose codeine which you can buy over the counter does not provide more pain relief than other products without codeine”
+ “Codeine is metabolised differently in different people, and it is therefore hard to determine whether it will provide effective pain relief for you.”
+ “Over-the-counter codeine is most effective when used for a short time, usually only three days at a time, because of the risks of becoming dependent on this medication.”
Training resources available
Resources available to provide at your pharmacy
It can be helpful to provide patients with easy-to-understand information they can read and take with them if needed.
ScriptWise has developed this codeine factsheet you are welcome to print and provide to patients at your pharmacy. Please contact: firstname.lastname@example.org
Knowing When to Refer
Knowing when to refer your patient to a general or nurse practitioner for pain management or dependence issues is essential.
If your patient’s acute pain does not appear to be managed by the alternatives you’ve suggested, you’ll need to refer them to their GP to develop a pain management plan.
If after your initial conversation, it appears that your patient has experienced pain for longer than 3 months, it’s time to advise them to see their GP for a more effective, long-term pain management plan.
It is possible that your patient may also present with dependence on codeine-based medications. This is therefore an important opportunity to encourage your patient to visit their GP to discuss this issue.
Read more about codeine referrals here.
Tips for explaining the referral to your patient
A simple way to begin this conversation may be to say:
+ “I’d really like you to see your GP about your pain. As your pharmacist, I’m concerned about your health due to the common problems associated with using codeine medications. I am happy to provide other care outside of these medications. How does that sound?”
+ “I really encourage you to see your GP to discuss a more comprehensive management plan for your pain. Are you interested in that?”
+ “Helping you with the pain you’ve described is outside my area of expertise, however I am happy to refer you to [INSERT RELEVANT PRACTITIONER] to help you get looked after.”
Start the conversation
Do not hesitate to start a conversation about the risks of using codeine and dependence, if you think it’s necessary. While starting a conversation with your patient can be difficult, it has the potential to be life-saving.
Stigma around dependence and addiction is often a barrier which makes it more difficult for your patient to seek help. Sometimes patients hold mistaken and harmful misconceptions around addiction; including, for example, that addiction is a result of a lack of willpower or internal strength, or that treatment is not effective. As a pharmacist, you are uniquely placed to sensitively and empathetically correct these assumptions and help ensure your patient receives the care they need.
Here are some examples of how you can start this conversation:
+ “Codeine dependence is a common consequence of being prescribed or buying and using these medications over an extended period of time”
+ “Dependence 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”
Training resources available
Tips for discussing dependence and addiction
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 dependence 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.
+ Remain calm and collected even if your patient becomes frustrated or angry with your discussion
+ 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 pharmacist, I believe there are more effective ways we can…’
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: