What do codeine shoppers really need?

codeine shoppers: sad woman examines a white tablet

There has been a lot of discussion by pharmacists in recent times about surveillance of codeine shoppers, writes 2010 PSA Pharmacist of the Year Karalyn Huxhagen.

Codeine seeking behaviour is different to pseudoephedrine (PSE) seeking behaviour.

With PSE there is the issue of diverting the medication to manufacture methyl amphetamines and the impact this has on society.

With codeine seeking behaviour, the majority of the product is for personal use to feed the addiction that the person has developed in the management of their pain.

The need to identify patients who are “pharmacy” shopping is realistic but the final outcome is the same, whether they are regular consumers at your pharmacy or whether they visit multiple pharmacies. They need education and support to improve the management of their pain condition.

We have been taught that effective management of disease states is based on a firm diagnosis, selection of appropriate medication, effective communication and monitoring of outcomes.

Pain may be a symptom for a myriad of disease states and medical conditions but the management of pain is complex and relies on a whole-of-patient regime to improve the patient outcomes.

The pharmacist is a key part of the pain management team. Our role is to support, monitor, intervene and give acceptable, evidence based advice.

We are not police or drug surveillance officers.

Patients with complex pain needs who I see as a consultant pharmacist often require more than a home medicine review every two years. They need regular support, a person to discuss their medications questions with and a person that they can trust.

The pharmacist needs to open up the discussion on effective management of medical conditions that cause pain.

While you may feel that you are a rote machine in asking the questions as per the WHAT STOP GO or CARER protocol the fact that you ask the questions gives you the opportunity to open the communication to a level where you can demonstrate that you are able to provide informed care to these patients.

These same principles apply to all requests for pain relief medicine, such as basic analgesics, analgesic rubs and spray and even requests for tape and bracing.

I am an advocate of developing and formulating a pain management pathway with patients. This can be as simple as a plan written on the back of a repeat folder or a formalised medication review with a personalised patient management plan.

A pharmacist has the skills and tools to do be the interventionist and communicator and support person who works collaboratively with the patient and medical practitioners to effectively manage the patient’s pain.

How do you manage requests for pain relief in your workplace?

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  1. John

    Hi Karalyn.

    What about the consumer who is not simply needing support to better manage their pain, but rather is taking codeine because they are unconditionally addicted. Codeine is addictive. I know of one such person who would attend multiple pharmacies, use false names, know the right answers to get through pharmacist questioning… all to feed his addiction. So well trained at this deception, he would buy and consume a packed of ibuprofen/codeine each day.

    If this is not a clear example for either real-time monitoring or rescheduling of codeine products, I don’t know what is. What is particularly concerning, this is not an isolated case. There is growing evidence reported in the literature that codeine is a problem in Australia. For example published in the Medical Journal of Australia last year.

    John – Consultant Pharmacist

    • kvs

      I agree. I believe community pharmacists are all too happy to help a consumer who is suffering with chronic pain, but after working in a fairly small city as a locum, I do not believe that the people I’ve seen in every pharmacy I work in coming in every couple of days for “period pain” or “toothache” are doing anything but feeding an addiction. Of course, that is also an issue that requires management and sensitivity. However, it is far more difficult to deal with in a community setting and sometimes difficult to identify when shoppers are savvy about switching up pharmacies, names or explanations.

      People who are suffering from pain are far more open to advice and suggestions regarding management. They will often present at the same pharmacy where they fill their prescriptions. Their use is easier to monitor and often you will know which GP is handling their care. Obviously this doesn’t apply to every case, but generally deception isn’t involved that complicates the problem with an abuser.

      Codeine is an opioid, and causes euphoria, so I think a frank discussion on how to handle those abusing it in absence of pain is an important conversation to have. When I used to administer the opioid substitution program, a large slice of the patient population started by abusing OTC codeine products, so I think it’s vital that we, as front line providers, learn to identify and manage that issue as well.

      • Karalyn Huxhagen

        Hi thank you for the comments. I agree that there are customers who are truly addicted and need addiction support. This is not easy to do. You need to find what services are available in your area to assist e.g addiction clinics; ATODS units; private addiction clinics etc. Kowledge and understanding of the services that are available and how to refer patients into these services is one major component. The real time monitoring will assist the pharmacist to identify the customers with a significant issue and give the pharmacist more support to challenge the patient. My point is that monitoring and identifying that there is a problem is the tip of the problem when dealing with opioid addiction.. Monitoring does not rectify the addiction. Pharmacy needs more than a monitoring system- we need access to education about how to access services for these customers and how to work with the customer to develop a plan to manage their addiction and maybe also to manage the original pain issue. Monitoring and taking on a survelliance personna is not the ultimate solution. The ram raids, increased burglaries and crafty methods of bribing and paying Pseuoepehdrine mules for obtaining Pseudoephedrine have already demonstrated that survelliance pushed some of the more inventive addicts to other extremes to obtain product. My point is that we need more than a real time monitoring system. How to handle and support customers with addictions is just as important as Mental Health First Aid in my opinion.

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