From February 2018 medicines containing codeine will no longer be available OTC, meaning pharmacists will need to provide alternative medicines and methods of managing pain. Leanne Philpott reports.
The TGAs decision to reschedule medicines containing codeine to prescription-only, due to risks associated with misuse, dependence and adverse events, has created a lot of talk in the pharmacy industry.
“This is not the complete answer,” says Karalyn Huxhagen, consultant pharmacist and winner of the 2015 PSA Award for Quality Use of Medicines in Pain Management.
“There will be a negative impact unless these patients have someone to turn to who can reinforce the alternatives available. Yet sadly, most of the other options I have available cost money, time and effort and patients who have been codeine seeking for some time have been on the easy road of paying $7.95 every three days for their codeine fix.”
The Australian Pain Management Association (APMA) opposed the initial decision by the TGA to upschedule codeine and it is still against the current ruling for two reasons. Head of the APMA Elizabeth Carrigan explains, “Firstly, on cost grounds it becomes expensive for consumers to have to see their GP for a headache or sprained ankle. Often people have to take time out of work to have a doctor’s appointment for a simple short-acting problem.
“Secondly, it is unlikely to be successful in curbing drug-seeking behaviour. Not long ago oxycontin was being prescribed in large quantities resulting in significant harms including deaths from accidental overdoses, unintended addiction, as well as misuse by drug seekers. It wasn’t until the manufacturers changed the formulation that misuse was significantly reduced.
“The upregulation is designed to curb the supply of codeine products thus preventing misuse. However, it is likely to be difficult for prescribers in limiting the misuse of codeine given the oxycontin experience.
“There needs to be a good relationship between the GP and the pharmacist to manage patients with pain well. If a patient can’t get in to see their GP then being able to visit their local pharmacist for advice and treatment is essential.”
Pharmacist Alex Page from Outback Pharmacies, NSW, says he has mixed feelings on the codeine verdict. “I don’t particularly like codeine as an analgesic due to its low efficacy, short duration of effect, high addictive potential and the fact that a significant proportion of the population cannot metabolise codeine into an active metabolite. That being said, it can still have a role in acute management of pain. However, I believe it’s even overused for that purpose.
“The main reason for the upscheduling was to curb the misuse and abuse of codeine yet this move does nothing to achieve this and, if anything, may worsen the issue due to their being no real-time recording system for prescribers, along the lines of MedsAssist. While I’m in favour of any move to limit codeine use in the community, the move must be well thought through. I sincerely hope there will be a number of caveats attached to the TGA’s decision before it is rolled out on Feb 1 next year, as it could be a horrid transition for patients, pharmacists and GPs.”
“I believe in certain circumstances [not having codeine as an option] will make it difficult to treat pain. A patient may present with an acute pain issue and if an anti-inflammatory is contraindicated and paracetamol alone is ineffective then there is little other option than a referral to the GP. I rarely suggest codeine to a patient so this isn’t a particularly common occurrence, but it will still be frustrating for the patient and pharmacist,” says Page.
Possible substitutes for the treatment of pain include paracetamol and NSAIDs, in particular combination paracetamol and ibuprofen medications such as Maxigesic or Nuromol.
Joyce McSwan, Persistent Pain Program clinical director—Gold Coast Primary Health Network, explains, “Combination ibuprofen-paracetamol medications are for mild to moderate acute pain and should be used early in detection of acute pain (with inflammatory and nociceptive pain symptom presentations) and at the recommended dose per the individual commercial products.
“The synergistic combination of ibuprofen and paracetamol can be helpful in addressing the pathology of the acute pain condition and generally, if the doses are taken as indicated, evidence suggests that it can address mild to moderate acute pain reasonably well, provided it is taken at early onset. If the pain escalates then the expectation on the pain reliever may be unrealistic and it may be deemed to be ineffective. However, we must start out with reasonable expectations on what we are expecting to assist with, for example just mild to moderate pain.”
McSwan points out that the doses recommended on the packaging can be quite different. “This can be a confusing point for pharmacists as each product has a different dosing schedule and slightly different efficacy claims. Whilst the claims are evidence based, the pharmacist needs to be familiar with what exactly these are. It’s important to read the directions and be sure of the frequency of use for the different brands. Overall, usage should not be for longer than 3-5 days, no matter which product is chosen.”
She adds that the use of simple combination analgesics such as ibuprofen/paracetamol must not be automatically assumed. “Even in acute pain states, the diagnosis or symptoms have to be understood well. While most acute pain has an inflammatory and nociceptive component, in some patients with chronic pain who are experiencing an acute pain flare up, it may be more neuropathic in nature or related to muscular spasms, in which case an acute use of an anti-inflammatory may not be effective or indicated.”
Carrigan adds, “Pain is an emotional experience as much as it is a sensory one. It is unlikely that a ‘wonder drug’ will be discovered in the near future for pain relief… it is simply too complicated. The biopsychosocial emphasis to improve mood, physical fitness and rehabilitation, getting back to doing what is important in life will remain an important part of pain reduction. Pain management programs are able to harness pain experts in the one setting and then target and tailor biopsychosocial therapies to individuals with chronic pain.”
A multi-pronged approach to pain
Experts in the field of pain management have long declared that there’s the need for a multi-disciplinary approach to pain. Huxhagen explains, “GPs are in general overwhelmed with requests for pain management medications, The GPs who develop a proper pain management program with patients are faced with the patient’s lack of adherence to programs such as rehab and advanced plans involving drugs such as Lyrica, tricyclic antidepressants (TCAs) and exercise. Pain needs to become a recognised major health priority and there needs to be wider access to pain clinics and rehab centres that involve specialised practitioners who can manage these patients.
“Pain should be an Australian health priority. We need to start developing a pathway within the faculty of medicine and the appropriate support divisions that develops pain specialist registration in the same way that we now have the ‘rural generalist program’. This needs to be a cross faculty program, involving physiotherapists, pharmacists and occupational therapists, so that these allied healthcare professionals can graduate with advanced training in pain management.
“Fostering a network of people who know each other and respect each other’s ability is vital to providing services such as pain management. The culture of thinking that GPs do not want support from allied healthcare professionals is old and needs to be put to the grave. We now have programs that see undergraduates doing advanced learning programs together as whole teams; in hospital practice everyone works as a team. Why suddenly in community practice should a GP be left to sink and swim by themselves? Cross professional education programs are vital if we want to make a difference in pain management. A GP cannot manage these patients by themselves and they need to know who is the best contact and who will provide ongoing care and report back.”
Page says, “One of the positives of the codeine decision and the publicity around it is that it presents a terrific opportunity to discuss pain management with patients and educate them that medications are indeed a small aspect of pain management. There is still the wide perception that so called ‘pain killers’ are silver bullets to treat pain, so shifting patients mindsets on this is one of greatest challenges in improving their pain management.
“Pharmacy should be considered as the interconnector of health professions and first port of call for advice due to our ease of access. We are highly trained on medication and how it affects the body but we also have currently under-utilised knowledge and skills in being a part of the multidisciplinary team to help treat and identify conditions. Currently we are hamstrung by the fact we can only refer on to a GP if we feel the patient requires the skills and services of another health professional and the patient then has to see a GP before they can be referred to a physiotherapist or psychologist, for example (to be eligible for Medicare subsidised appointments). This delay in introducing key stakeholders of the multidisciplinary team could be a factor in the overuse and misuse of codeine in the community.”