Nurse and midwife fact sheet: Talking to people about the changes in codeine access

This TGA behind-the-news article was published on 23 January 2018. Behind-the-news articles are published in response to issues that are of interest to the community at a point in time, for example, subjects that have been in the media.

On this page: About the change in codeine access | Support your clinical decisions | Treatment options | Masking an underlying health condition | Excessive use | Prescribing by registered nurses and midwives

About the change in codeine access

Research shows that current over-the-counter low-dose (<30 mg) codeine-containing products offer little additional pain relief when compared to similar medicines without codeine.

Codeine can be harmful. Health risks include tolerance, dependence, addiction, poisoning and, in high doses, even death. In addition, side effects of long term use of combination codeine medicines containing paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), are also potentially life threatening.

Treatment options

If someone asks you for advice about pain management, they are not always looking for medicines. You may want to suggest they discuss the use of alternative non-drug options or products that are available over-the-counter, with a pharmacist; discuss options such as a TENS machine, physiotherapy, complementary medicine (massage, acupuncture), exercise or lifestyle changes; or advise the person to discuss their pain and cough, cold and flu management options with a GP or other appropriate health practitioner.

There are also online self-management resources that may assist the person. See 'Chronic pain management' and 'National support services' under 'How and where to get advice' at https://www.tga.gov.au/codeine-info-hub.

Cough, cold and flu symptoms

There are numerous over-the-counter medicines available for treating cough, cold and flu symptoms which do not contain codeine.

Acute pain

Acute pain generally resolves within three months. The cause is usually known and the pain disappears when the injury or illness heals/resolves. In general, management of acute pain involves pain relief medication in conjunction with non-medicine approaches. If this does not resolve the person’s pain, you could recommend other self-management strategies (see the Treatment Options section) or refer them to a GP or other appropriate health practitioner for further diagnosis and treatment. In the case of acute pain with no obvious cause, investigation by a GP or other appropriate health practitioner should be recommended in the first instance.

Persistent/chronic pain

Chronic pain lasts longer than three months and continues even when the injury or illness has resolved. It can also be present without an obvious cause. Codeine-containing medicines should not be used for chronic pain. Discuss alternative pain relief options with the person which are consistent with the quality use of medicines principles as outlined in the National Medicines Policy document (search for “Department of Health National Medicines Policy Document”).

Chronic pain that persists should be referred to a GP or other appropriate health practitioner. This will allow for optimal management with consideration for multidisciplinary care models and non-drug or self-management approaches (see the Treatment Options section).

Masking an underlying health condition

Using over-the-counter pain medicines on an ongoing basis without a thorough investigation by an appropriate health practitioner could mask an underlying health condition which is causing the pain. The underlying health condition may require specific treatment. If the person has not undergone a thorough clinical assessment and appropriate examinations, refer them to a GP or other appropriate health practitioner.

Excessive use

Excessive use of codeine can lead to substance use disorder (SUD). Even when doses do not exceed the recommended maximum, tolerance and/or dependence can develop, and withdrawal symptoms can emerge on cessation. Symptoms of withdrawal may appear as the worsening of a pain condition (for example re‑emergence of headaches, muscle pain, and symptoms of cold and flu). If there is a possibility of SUD, such as tolerance or dependence, referral to a GP or other authorised prescriber is necessary for management.

Prescribing by registered nurses and midwives

People will be able to access prescription medicines if and when they need them by consulting with a health practitioner with prescribing authority. Nurse practitioners and midwives with scheduled medicines endorsement are authorised prescribers and can prescribe codeine-containing medicines when appropriate, consistent with their scope of practice. In some jurisdictions, registered nurses in rural and remote areas can supply codeine-containing medicines in specific circumstances, under protocol.