Collaborate to manage pain

woman with headache

Collaboration and communication with patients is key to helping legitimate pain patients, with real-time monitoring useful for catching misusers of codeine only.

Most people who become dependent on over-the-counter codeine do so in the process of treating chronic pain – and so the real-time system monitoring its sale will only address part of a significant problem, say pain management stakeholders.

Pharmacists may be able to use the increased scrutiny on codeine sales as a gambit in talking to chronic pain sufferers about ways to address their condition.

“Real-time monitoring is going to be effective at catching misusers of codeine, but it has no answers to managing a legitimate pain patient who is calling for help,” says Joyce McSwan, clinical pharmacist, pain educator and Persistent Pain Program manager at the Gold Coast Primary Health Network.

“What’s necessary is to understand the complexity of the problem, and to want to work in this space that requires you to be more interactive with your patient and more collaborative. This has to come from where the patient is looking at the problem, and not be something we try and force on them,” she told the AJP.


The accidental addict

Long-term use of opioids – whether via prescription or over the counter – is not appropriate for the management of non-cancer chronic pain, says Lesley Brydon, CEO of Painaustralia, which alongside other organisations has worked with the Pharmacy Guild on creating its real-time management program for OTC codeine sale.

But it frequently happens because access to the multidisciplinary approach needed by patients varies wildly.

“The highest prescription of opioids is amongst lower socio-economic groups and in rural and remote areas; one of the issues for these patients is lack of access to services,” she told the AJP.

She cited the Australian Atlas of Healthcare Variation, which showed that the number of prescriptions for opioids was more than 10 times higher in the area with the highest rate compared to the area with the lowest rate.

For example, residents in parts of western New South Wales, western Victoria, rural areas of South Australia, some coastal regions of Queensland and the central highlands of Tasmania, were being prescribed opioids at rates of between 78,731 to 110,172 per 100,000 people.

In contrast, prescribing rates in areas of higher socioeconomic status and in major cities, including Sydney’s north shore and Melbourne’s eastern suburbs, were much lower at 10,945 to 34,416 per 100,000 people.

At the time of the Atlas’ release, Painaustralia said the data highlighted the need for the Federal Government to implement the National Pain Strategy, which calls for all Australians to have access to multidisciplinary pain management.

“We think there’s altogether too much reliance on medicines for management of chronic pain,” Brydon says.

“But in these areas where there’s no access to multi-disciplinary services, the only thing a GP can really do is write a script.”

McSwan says that despite measures to educate patients about the possibility of codeine addiction – such as on-pack stickers advising of the risk – many not only remain unaware of the dangers, but may not have ever been spoken to by a health professional about them.

“These people who are inadvertently using a lot of codeine – it’s not that they want to,” she says. “Some have never been asked about a better way. So if you’re picking up on them, you still need the skills to address the ongoing issue that the real-time monitoring system is picking up.

“Real-time monitoring is not a pain management tool. Some pharmacists might look at it that way, but it’s not.

“It will invalidate genuine persistent pain sufferers who had no other option. It’s often assumed that they go down that road because they want to, but few do.

“You can’t change OTC codeine into ice or anything like that; yes, it can cause euphoria, but seeking that usually starts with pain. Sub-acute pain turns into chronic, they’ve felt they have no other option and then when it provides relief, they think it’s the bee’s knees and keep using it. In most cases the patient just had no idea there was a problem.

“When you provide these patients with support and real options, I’m confident in saying that 100% of the time the patient will take on the new opportunities to manage their pain that you have given them.”

She says that when issues such as rebound pain and withdrawal symptoms are explained, it becomes clear that few patients had any understanding that they were harming themselves.

“When they realise how ineffective codeine really is for chronic pain, patients are usually very interested in the idea that they’d rather do better.”


For more, see the March 2016 edition of the AJP.

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  1. Milly Malone

    Just stumbled across your website and have wanted to vent my feelings on OTC tablets for a while.

    I’ve suffered from chronic headaches for as long as I can remember. When I was a child that meant rolling in bed and moaning in pain, and taking an asprin, which sometimes helped. I’ve learnt to live with my headaches and have tried most medications or preventative medications available. A lot had no effect and the best thing to relieve my bad headaches (eventually diagnosed as migraine) is/was something called ergotamine, which was taken off the market in Australia in the 1970s until I found Cafergot which worked for me. Also now unavailable. However in my later years my headaches have mostly reduced in intensity, although I still get a bad one when I’m not expecting it, and I take OTC paracetamol and codeine tablets for the pain. I strictly adhere to the no more than 8 in 24 hours, and my headaches often go to 48 hrs, so much time still in pain. I know what usually triggers the worst headaches, but still find taking 2 headache tablets at the start of any headache can ‘stop’ it going on so long. I also feel really wrung out the following day. These headaches run in the family, so feel sure there is a big genetic component. What I want to say is that when you’re in pain there is no euphoric feeling with taking the amount of codeine in OTC tablets, just a reduction in pain. It’s only the codeine that works as I could throw paracetamol tablets over my shoulder for all the good they do a headache, if taken without codeine. I buy the tablets with paracetamol because I had a stomach ulcer a few years ago from taking a lot of asprin (only took the prescribed amount over the time allowed) on an empty stomach. The tablets I take usually have more paracetamol than codeine, and I have found out that paracetamol can kill people when taken in excess, so how is it possible for people to be taking more than the required amount? They would end up sick or dead eventually surely. I can’t understand all the fuss over codeine taken OTC. It just makes my life more difficult as I’ll have to get a script to buy headache tablets, because I would use more than most people, even though I use them properly I now feel like a drug user.

  2. Felicity Stewart

    It’s disgusting though I love how they act as if they will stop being OTC when no decision has been made and the majority see it as a stupid idea that will make no difference in helping those who abuse drugs as they will just seek and get them elsewhere, I too suffer from severe migraines and back pain, I also have agoraphobia so going to the GP all the time isn’t an option for me, so essentially what they would achieve is ruining people’s lives or making people’s lives harder than they already are just because a few abuse these pills it doesn’t mean that the majority does and IF, that’s a big if by the way, they somehow managed to convince enough pencil pushing morons who have no idea what their talking about that there’s enough support to make these prescription (which I doubt) I’d just get repeat scripts for panadean fort, I suggest the have a good hard think about how many they would be harming rather than helping, I have enough stress and anxiety in my life already without the needed stress of extra DR visits which by the way, my Dr has already clearly stated many times I’m allowed to take these pills — Again, don’t punish the majority of us by making pathetic and un-needed changes not when there’s clearly other ways such as monitoring.

  3. Felicity Stewart

    On another note,

    We are adults, thought that needed to be cleared up and as adults we don’t need people deciding what we can or can’t take or -gasp- that there’s too much people taking medication for pain, in case you haven’t realised pain medication was created for pain, hence the name. If you personally wish to use other means to manage yours then by all means go ahead but don’t tell me how I should manage mine.

  4. Minnie Bannister

    I am another chronic pain sufferer who wishes to comment on the above article.

    1. I’ve never experienced euphoria from codeine. I take aspalgin when my pain levels interfere too badly with my work, and still manage to work effectively. If I don’t take it at these times, I am unable to work. This has many follow-on problems that are obvious.

    2. My mother died from liver failure after taking to much panadeine forte for chronic pain over many years – killed by the paracetamol component, not the codeine. If you look at the death rates from codeine, and compare them with those associated with paracetamol, it is blindingly obvious that many, many more lives would be saved by taking paracetamol off the market.

    3. From my personal experience, paracetamol has no effect whatsoever on my pain. Recent research indicates I am far from alone in this.

    4. I know what works for me. Why waste my GP’s and pharmacist’s time with all this bureaucratic nonsense?

    5. The aim appears to be to remove an effective pain medication, and replace it with nothing. There is a massive waiting list to get into any public pain clinic, and the limited number of pain clinics that currently exist are geographically out of the reach of a very large proportion of the population.

    6. In relation to this…

    “when it provides relief, they think it’s the bee’s knees and keep using it. In most cases the patient just had no idea there was a problem. When you provide these patients with support and real options, I’m confident in saying that 100% of the time the patient will take on the new opportunities to manage their pain that you have given them.”

    …all I can say is “balderdash”.

    Medication IS a real option. Frankly, I think that closer to 100% of chronic pain sufferers would be happier to have their pain “relieved” than “managed.”

    7. Lesley Brydon lacks the knowledge to be the CEO of an organisation purporting to represent people with chronic pain. I suggest she do some very basic research into the differences between tolerance, dependence and addiction.

  5. Jan Rees

    I too suffer from chronic pain. I have never experienced euphoria from codeine, maybe relief that something works. Panadol does nothing for the pain, so I have to wait in pain for hours before I can take some panadeine.

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