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.”
Branching out with allied health
“My discussions with the Guild have made it clear that they know pharmacy has to take a responsible attitude to this,” says Brydon.
“Whilst sale of product might be a major source of revenue for pharmacists, they have a role as community-based health care professionals who need to give people good, common-sense advice about managing their health.
“But you can’t just take people off medicine. You’ve got to offer them some other advice – and pharmacists need to be aware of the need for access to multidisciplinary services and be able to refer people appropriately.”
Karalyn Huxhagen, 2010 PSA Pharmacist of the Year and winner of the 2015 PSA Award for Quality Use of Medicines in Pain Management, is group facilitator of the Mackay Pain Support Group. She says that since rules about referrals to physiotherapists were relaxed, it has been easier for her to direct persistent pain patients to local practitioners.
“Now, when I’ve got a patient taking ibuprofen/codeine, I can make a suggestion: ‘I know, why don’t you go and have this physio assess what you need?’ she says.
“It’s less money for the patient than seeing a GP, they’re easy to get in to see and I’m sending them to a professional who’s specifically going to look at their problem.”
Huxhagen says that she has forged links with physiotherapists in her local area and directed pain patients to them, with good results.
“After talking with physios one weekend, I worked the next Sunday in the pharmacy and saw a couple of the patients who were continuously taking ibuprofen/codeine,” she says.
“I’d been on their case already, but this time I said, ‘No way, I’m not giving you any more unless you go next door [to the physiotherapists] and get an assessment done’.
“After an hour and a half one came back and said, ‘I feel so relaxed, I haven’t felt this good for ages’.
“People with chronic pain need to get into a plan with their physiotherapist and other allied health professionals. Pharmacists can produce a pain management plan with their patients – I really believe that pain should be treated like any other chronic disease that needs a plan, as with asthma, so that they know what to do when things exacerbate and they know where to go for help.”
Mind your management
Brydon says that people suffering from chronic pain may also suffer from mental health issues, particularly depression. This does not mean chronic pain should be dismissed as a mental health issue, which it all too often is.
She cited a recent University of Sydney study published in Arthritis Care and Research, which showed that people with depression are 60% more likely to experience low back pain at some time in their lives.
“Chronic pain and mental health really go hand in hand,” she says. “People living with chronic pain are usually depressed, and people who are depressed will often go on to have pain.”
These patients may also be angry; they may have seen multiple health professionals or waited a long time to access a pain clinic, and may have experienced discrimination and stigma from friends, family, colleagues or health professionals who decide their pain is “just a sign of weakness”.
She encouraged pharmacists to talk with chronic pain patients – whether they’re being prescribed analgesics or are buying them over the counter – about holistic ways to manage pain.
“Many of these patients usually don’t get the exercise they need, for example,” she says. “And often people who don’t have a healthy diet can go on to develop these problems.
“Have a dialogue with the patient and make an assessment about the most helpful practitioner to send them to. It’ll usually be a GP, because through the GP they can get access to care plans under Medicare which will enable a limited number of visits to allied health practitioners who may be able to help.
“Ask gentle questions about lifestyle and diet – I know many already do, but it’s so important that pharmacists get out from behind the dispensary and talk to their customers to develop an understanding of what lifestyle habits may be contributing to chronic pain.”
HMRs are another good way to start tackling the chronic pain problem, says Huxhagen, but even a quick discussion in the pharmacy can help if it’s done well.
“Take the time to explain this stuff, whether you’re in an HMR or not. I’m a fan of drawing a diagram and showing lots of pictures to show why codeine will give you constipation, or why, if you keep taking ibuprofen and codeine, this will happen or that will happen. I don’t know if they pin it on the fridge like I ask them to, but it’s a start.
“Codeine combinations are the quick fix,” she says. “It’s because they won’t make the time to address the pain properly, they’ve been down the doctor route and they didn’t feel the doctor engaged with them, so they flop back to the quick fix.
“If we want our car serviced or our pain managed, we want it quick, we want it done yesterday and we don’t want to pay a lot of money for it. That can happen with your car, but it just can’t happen with pain management.”
McSwan says that ultimately, repeat codeine purchasers are calling for help, and pharmacists need to give it.
“The key point is that real-time monitoring is not a persistent pain management tool,” she says. “Really get that straight.
“Don’t think, ‘I’ve logged this sale into the system so I’ve done my job’. Because what’s that going to do for the patient?”
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.
Pharmacists can produce a pain management plan with their patients – I really believe that pain should be treated like any other chronic disease that needs a plan, as with asthma, so that they know what to do when things exacerbate and they know where to go for help.
People living with chronic pain are usually depressed, and people who are depressed will often go on to have pain.
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.