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.