It’s time to talk to patients about protecting them from opioid-related harms, writes Debbie Rigby
From 1 February 2018 all codeine-based medications will become prescription-only.
Low-dose codeine is currently used in a number of over-the-counter combination products for cough and pain relief. These medicines are being up-scheduled to protect the broader public from the risks of codeine, and to support problem users to adopt a safer treatment regimen.
Studies have shown that, for most patients, the addition of codeine carries significant risks but little benefit. The risks include addiction, withdrawal symptoms when ceasing use, and paracetamol or ibuprofen poisoning when large doses of these codeine-containing combination products are taken.
For around 20%–30% of people, codeine is associated with side effects such as constipation, nausea, dizziness, sleepiness and sleep apnoea.
Paracetamol/ibuprofen combinations are an alternative to codeine combination medications for short-term pain relief.
Studies of the efficacy of the combination medicines have looked at the treatment of pain from a range of sources including dental pain, postoperative pain, dysmenorrhoea and musculoskeletal pain.
It was found that paracetamol/ibuprofen combinations offer acute pain relief similar to that provided by codeine-based analgesics, with generally improved tolerability.
For short-term use, the combination of paracetamol and ibuprofen does not pose any further safety concerns above the known risks for the individual components. For longer term use, the combination may increase the risk of bleeding over and above that associated with the individual drugs.
Talking with patients about codeine
For pharmacists approached by patients concerned about the changes to the availability of codeine, a good strategy is to remember that patients respond best when conversations are framed as protecting them from opioid-related harms and when they recognise you have their best interests in mind.
The Therapeutic Goods Administration has prepared tips and suggestions for pharmacists about these changes, including how to talk about pain management, and how to address possible substance use disorders.
For GPs approached by patients, this is an opportunity to re-evaluate the reasons a patient is using codeine, and possibly address the patient’s conditions in a more effective way. Non-pharmaceutical treatments, such as physiotherapy, occupational therapy, massage and acupuncture, should also be considered in the treatment of pain.
Debbie Rigby is an Advanced Practice Pharmacist and consultant pharmacist. In 2016 she was named AJP top Woman of Influence in Pharmacy.
See NPS MedicineWise’s resources on codeine here.