16 Oct “It became a dirty little secret”: 5 questions to ask your doctor about codeine
16 October 2018
“It became a dirty little secret”:
5 questions to ask your doctor about codeine
With the use of opioid-based pain relief such as codeine quadrupling in the last decade, experts say it’s important to ask your GP the right questions.
After the birth of her son, Deniz Okutgen was given codeine for pain relief for when she returned home. With no family support to help with looking after her child, she relied on her medication to just ‘get on with things’. Never would she have anticipated that it would lead to dependency, serious health issues, isolation and a battle to withdraw off the very drugs she thought were helping her.
“I started taking about fifty tablets a month to manage my pain, but I kept needing more and more because the medication had stopped working as well as it first did. Being dependent on something is like quicksand. I was at my GP once a week because of health issues I didn’t know was related to my use of codeine. I thought I had diabetes, I was experiencing panic attacks, plus I was waking up and passing out. It was really scary.”
Risk vs benefit
Bee Mohamed, chief executive of ScriptWise, a non-profit organisation dedicated to preventing prescription medication harms, says that Deniz’s story is sadly all too common.
“About three quarters of opioid overdose deaths in Australia are due to prescription opioids like oxycodone and codeine.To give you some perspective, more people in Australia die due to prescription opioid and sedative medication (benzodiazepine) use than road accidents. It’s a national crisis.”
GP and Addiction Specialist, Dr Hester Wilson agrees and adds that many people don’t understand why certain drugs require a visit to the doctor. This was particularly evident earlier this year when over-the-counter codeine became a scheduled drug requiring a prescription from a GP.
“Many people don’t understand why certain drugs, such as codeine, require a prescription. Perhaps they think we are a ‘nanny state’ or that doctors are trying to make things difficult. However, as we learn more about certain drugs it may be discovered that they have more side effects than previously thought and it is time to re-evaluate how easily they should be available. It is all about the drug’s risk versus benefit profile and ultimately the patient’s safety.”
Codeine is an opioid drug closely related to morphine and is derived from opium poppies. It is often prescribed to a person for acute pain, perhaps due to an accident, migraines, back pain or when leaving hospital after having a baby. However, it is highly addictive if taken repeatedly. For some people, once they start taking codeine they can’t stop and, if they try to, they experience withdrawal symptoms such as nausea, insomnia and vomiting.
25-year-old Joeleen Koszyk was given prescription opioids (including an over-the-counter product containing codeine) after back surgery that was related to the birth of her child. She thought she had everything under control.
“The doctors I was seeing just kept writing me scripts whenever I requested it, despite taking around 300 pills a month. I couldn’t go anywhere without my medication. After my family became concerned I decided to stop cold turkey one Friday night, but by Sunday I had turned the house upside down searching for a script. It was devastating. Codeine became part of the problem.”
Deniz had a similar experience, saying “I started to feel guilt and shame about the amount of medication I was taking, but when I took the medication those feelings would go away. That’s when the alarm bells started to go off in my head. It became a dirty little secret.”
Alternatives to codeine
Despite the reasons for making codeine prescription only, there are concerns that doctors continue to prescribe codeine rather than work with patients to find alternatives. A recent survey showed that 80% of people who have gone to the doctor for a prescription for codeine have not been recommended an alternative.
“I am concerned that there may be some doctors who are writing scripts for codeine without undertaking a comprehensive assessment of the individual patient’s risks. Some people are really struggling, and experiencing significant withdrawal symptoms. Codeine is a sedative and can add to the risk of overdose if used with other sedatives, including alcohol. The more you use the higher the risk,” continued Dr Wilson.
“In some cases, codeine may be totally appropriate. However, there are often other, non-pharmaceutical options that can be very effective. This may be a combination of modalities, depending on the issue, such as psychology, podiatry, physiotherapy exercise and other options. You may need to get a referral to see a specific specialist, for migraines as an example, or a pain specialist.
“Unfortunately, pain management can be complex, and doctors may feel they don’t have the time, skills or support needed to address the root cause of a person’s pain. It is really important for patients to be informed and ask their GP the right questions, for their own sake.”
Find a GP that is right for you and ask the right questions
“It’s hard when you go to a medical professional for advice and you aren’t told the full story, you just do what they say because they are the ‘expert’. I wasn’t even told about addiction and withdrawals. I was worried about taking the painkillers, and even advised my GP that I have an addictive personality, but my GP said not to worry if I was using the painkillers correctly,” said Joeleen.
Dr Wilson says that the relationship between patients and their GP is critical and needs to be based on honest conversations.
“There needs to be a level of respect and engagement between patient and practitioner. People can feel scared or judged. Anyone can become dependent on codeine if they use it regularly or long-term. Patients need to feel comfortable with their doctor to honestly talk about their challenges, particularly when it comes to prescription medication and dependency. If you don’t feel that way or are concerned that your GP is not listening to you, it may be best to look for a different doctor..”
In terms of pain management, Dr Wilson suggests a good step in the right direction is asking your doctor a few simple questions if given a script for a pain medication.
What are the issues or side effects of this drug?
What are the risks for me as an individual?
Do we really know what is going on with my pain?
Can we reassess or rethink my treatment? Or, what is the best combination of treatment?
Can I work out a pain management plan with you, or does it require a specialist?
Dr Wilson says there can also be an emotional element in relation to pain that should be considered.
“There can be a lot of different reasons why people don’t tell their GP what is really going on in relation to dependence. For those already using codeine long-term, it is important to ask yourself if you are using it for pain, or how are you finding it when you try to stop. Is it being used to manage emotional pain, difficulties in life or physical pain? If you have had a headache for a long time you should ask if the medication you are on could be making your headaches worse.”
Deniz agrees, saying “Looking back on everything I went through, I feel like being on pain relief made the pain worse in some ways. It makes you more susceptible to feeling pain. I was taking it for five different issues, but after I went off the medications I didn’t have any pain anymore.”
Help and support exist
“Many people who have been using codeine for a long time can be afraid to stop. They should ask how their GP can support them. It is ok to take it slowly. It can be helpful to get some psychological support. Those that have a willingness to try different things are often the most successful in managing pain. Patients need to work collaboratively with their health professional and have really honest conversations,” says Dr Wilson. “For chronic pain, it’s also important for consumers to get educated and look for information themselves. Understanding how the brain works in relation to pain can be a real breakthrough.”
Both Deniz and Joeleen are thankful they have seen light at the end of the tunnel.
“It took me a year to be ready to go off codeine. I was really scared about what the withdrawals would be like. Finding a good psychologist really helped. I am so glad to now be off codeine. I feel like a different person. I wish I had done it earlier,” says Deniz.
“I now have a GP who avoids prescribing painkillers and encourages me to try alternatives. After five years I finally have a pain management plan to allow me to manage my pain without painkillers. As my GP says, ‘Pills don’t equal skills’! I want the skills to manage my pain long-term. It wasn’t until I got off the painkillers that my pain became much more manageable. I didn’t realise that the painkillers had become part of the problem,” finished Joeleen.
Where to seek help
Speak with your GP, health professional or someone you trust if you’re concerned about your medication use. There are also a number of free and confidential helplines you can call. Find out more at www.scriptwise.org.au/get-support
Statistics about prescription opioid use in Australia.
Use of opioid-based painkillers has quadrupled in the last decade
Levels of prescription overdose are at record levels
Codeine-related deaths in Australia more than doubled between 2000 and 2009
Prescription opioids such as oxycodone account for over three-quarters (76%) of opioid overdoses in Australia 
In 2015-16, about 1 million Australians aged 14 years or older misused a pharmaceutical drug in the previous 12 months 
More than three quarters of people who develop dependence on codeine do not seek help despite highly effective treatments being available.
Pharmaceutical opioids account for more drug-related deaths than any other drug category
Dr Hester Wilson
A Fellow of the Royal Australian College of General Practitioners, Dr Hester Wilson is also a Fellow of the Chapter of Addiction Medicine in the RACP. She completed her Masters in Mental Health in 2013. She has worked in primary health care settings for the last 25 years. She currently works at the Langton Centre as a Staff Specialist in Addiction and in general practice in Newtown, Sydney. Dr Wilson is the chair of the NSW branch of the RACGP GPSI in addiction. She has a particular interest in improving health outcomes for patients with chronic complex illnesses in the primary care setting. She has facilitated training for doctors and other health care workers since 2001.
ScriptWise is a not-for-profit organisation dedicated to preventing the harms associated with prescription medication use. ScriptWise formed in 2014 to amplify the voices of the alarming number of families and individuals affected by prescription medication overdose. ScriptWise works with partners and those personally affected to address the root causes of this complex and multifaceted issue. To find out more visit: www.scriptwise.org.au
 Online survey of 215 Australian residents who had purchased OTC codeine products in the 6 months prior to February 2018. Research conducted by Futurescape Global Limited.
 International Narcotics Board, 2016. Accessed 4 Oct 2016: https://ndarc.med.unsw.edu.au/news/use-opioid-painkillers-increases-fourfold-australia-10-years-while-most-world-lacks-access
 Australian Bureau of Statistics, ‘3303.0 – Causes of Death, Australia, 2016’. Accessed 4 July 2016: http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0~2016~Main%20Features~Drug%20Induced%20Deaths%20in%20Australia~6
 Amanda Roxburgh, et al, Med J Aust 2015; 203 (7): 299. Accessed 4 October: https://www.mja.com.au/journal/2015/203/7/trends-and-characteristics-accidental-and-intentional-codeine-overdose-deaths
 Roxburgh, A., Dobbins, T., Degenhardt, L and Peacock, A. (2018). Opioid-, amphetamine-, and cocaine-induced deaths in Australia: August 2018. Sydney: National Drug and Alcohol Research Centre.
 Australian Institute of Health and Welfare, ‘Non-medical use of pharmaceuticals: trends, harms and treatment 2006-7 to 2015-16. Accessed 4 July 2016: https://www.aihw.gov.au/reports/illicit-use-of-drugs/non-medical-use-pharmaceuticals/contents/summary
 Darren Roberts and Suzanne Nielsen, Changes for Codeine, Aust Prescr 2018; 41:2-31. Accessed 4 October https://www.nps.org.au/australian-prescriber/articles/changes-for-codeine
 Australia‘s Annual Overdose Report 2018, Penington Institute. http://www.penington.org.au/australias-annual-overdose-report-2018/