The looming upscheduling of codeine provides a reminder to consider how you handle chronic pain patients, writes Karalyn Huxhagen

Management of chronic pain in pharmacy is evolving as the removal of codeine from over the counter medications will force both consumers and pharmacists to have a reality check in respect to management options.

The OTC products containing codeine are sub optimal in efficacy when you consider the amount of codeine in each medication but that does not stop the chronic user from using these medications in an ineffective manner.

Management of chronic pain is not only about the pain itself as other regulatory mechanisms can begin to contribute to the overall health of the patient. Pharmacist intervention at the pain experience part of this model can assist the patient to move to the right hand side of the model with resolution and recovery being the preferred option.

At times full recovery may not be able to be achieved but the final outcome may be acceptance of the level of medical intervention that is achievable.

  • Anxiety
  • Fear and avoidance behaviour
  • Hypervigilance
  • Insomnia
  • Anger
  • Depression
  • Catastrophising
  • Tachycardia
  • Tachypnoea (respiratory alkalosis)
  • Sweating
  • Pupillary dilation
  • Pallor
  • Raised blood pressure
  • Increased stroke volume
  • Increased myocardial oxygen demand
  • Reduced myocardial oxygen supply
  • Reduced blood flow to viscera and skin (delayed wound healing)
  • Hypoxia
  • Atelectasis
  • Pneumonia
  • Increased catabolism
  • Decreased insulin production
  • Decreased testosterone production
  • Fluid retention
  • Immune suppression
  • Delayed gastric emptying
  • Nausea

The above list is some of the symptoms and outcomes that a patient living with chronic pain may endure. Some of these conditions are related to the pain itself but many can be caused by the medications and treatment that the patient will be exposed to.

The chronic pain patient is also exposed to the stressors of:

  • Loss of income.
  • Lack of tolerance to their condition by workplace, family and friends.
  • Inability to perform tasks.
  • Loss of libido and sexual performance.
  • Feeling of helplessness.
  • Judgement by medical profession and associated health providers as the escalation in use of opioids and benzodiazepines places them into a category requiring surveillance for doctor shopping and medication abuse.

Chronic pain patients have to be managed using the biopsychosocial model of health as their pain becomes part of their overall health management. These patients have to remodel their lives to ensure that their pain does not completely control their lives.

Acceptance of the level of intervention that is reasonable and acknowledgement that complete recovery cannot always be achieved is very important for chronic pain patients.

Pain Australia state the following key points about management of chronic pain:

  • Medicines alone are not the most effective way to treat chronic pain.
  • Chronic pain may never be completely cured, but can be managed.
  • People managing their pain on a daily basis get the best results.
  • There are many self-management strategies that can help.

Pain Australia,, produces many fact sheets that health professionals can give to patients to assist them to understand the physiology of their pain. These leaflets discuss the treatment options which are not just medication.

All patients living with chronic pain should have a Pain Management Plan that outlines what to do when exacerbations occur. When do they add in a NSAID/Steroid/increase their opioid dose? When should they return to the pain clinic?

As we move toward the loss of codeine containing medication from the OTC range of pharmaceuticals it is important to utilise the resources from the MedASSIST tool page and Pain Australia. These information leaflets discuss alternatives for managing all areas of pain whether it be chronic, acute, headache or persistent pain.

The chronic pain patient requires a management toolkit that contains much more than medication. We should be a small part of their support network.

We have a duty of care to provide advice and to give them a firm push when they start to take the easy road of ‘popping a pill or two’ rather than returning to physiotherapy or hydrotherapy or programs that require effort.

For further reading of where pharmacological management of pain needs to move to I commend a piece of literature to you. ‘Human Experimental Pain Models for Assessing the Therapeutic Efficacy of Analgesic Drugs’ Olesen Anne et al. The American Society for Pharmacology and Experimental Therapeutics. 64:722–779, 2012

Karalyn Huxhagen is a community pharmacist and was 2010 Pharmaceutical Society of Australia Pharmacist of the Year. She has been named winner of the 2015 PSA Award for Quality Use of Medicines in Pain Management and is group facilitator of the Mackay Pain Support Group.