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Presentation: Alternative options to codeine in the pharmacy

Codeine up-scheduling workshop, Melbourne, 28 November 2017

16 January 2018

For further information about changes to medicines containing codeine, see the Codeine information hub.


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  • Presented by: Pene Wood, Opioid Management Team lead
  • Presented at: TGA workshop: Codeine up-scheduling, 28 November 2017
  • Presentation summary: This presentation provides an overview of alternative options to codeine in pain management.


Alternative options to codeine in the pharmacy

Dr Pene Wood
Opioid Management Team lead
Primary Health Network (PHN), Western Victora

TGA workshop: Codeine up-scheduling, 28 November 2017

I'm now delighted, speaking about pharmacists, I'm now delighted to introduce Pene Wood. Now Pene is both the practitioner of pharmacy and electro pharmacy and lectures at Latrobe Bendigo, and is working in the western Victoria PHN, which I guess goes from Geelong, Lara. Where does it start? Geelongish to the borderish.

Mildura or not?  So a fair chunk of this big state of Victoria, so kind of very useful to have Pene, here apart from the fact that she's driven a lot of work with the PHN and has also got a broader interest in opioid management undertaking a PhD in it, and that includes both OTC and prescription opioids. So, your schedule 4s and your Schedule 8s. And I guess can see it from both the pharmacist point of view, the Public Health Network point of view, but also elements, and we'll come back to this later on, from rural and remote point of view. So, absolutely delighted to have Pene here.

So, I was asked today to present on alternatives to codeine in the pharmacy. So, other options we have when patients have previously used codeine or requesting codeine. So, this has mostly already being covered but just as a bit of an overview.

Codeine is a weak short-acting opioid which achieves its analgesic action through conversion to morphine in the liver. As John mentioned, a lot of people aren't aware of this and are surprised when you actually mention this to them. Some people don't realize codeine is even an opioid or that things like Nurofen Plus actually have codeine in them. So, there's a lot of misinformation and lack of health literacy out there in the community.

Also as John mentioned, there's lots of variability with the conversion to morphine. So, only about 5 to 15% of a dose of codeine is actually metabolized to morphine, and then the variability with the different groups of being able to do that. And despite the huge concern out there in society with the scheduling changes, codeine is rarely if at all first-line therapy for a lot of conditions. It's actually recommended to try single ingredient preparations first, so your single paracetamol aspirin, NSAIDs and of course, all non-drug therapies for pain or pain touch should also be explored.

I think it's also important to be starting to have this conversation now, as pharmacists with your patients about the unavailability of codeine, just because patients still can have that security blanket of having the codeine available as a backup. So, it's a really good time to say, hey have you thought about trying this? I'll still give you your Panadeine maybe as a backup, but how about we try this first? And then, if this doesn't work, we can use another option, and I think that's a good way of getting patients to perhaps change their thinking and willing to try other things.

 So this, I stole off Malcolm Dobbin. It's a little chart he created. So, Malcolm Dobbin works for the Department of Health here in Victoria, and it's a little chart he created from a summary of Cochrane reviews about the numbers needed to treat to get benefit from different medications. And as you can see, combination ibuprofen and paracetamol is quite good. Ibuprofen and codeine is less effective, and ibuprofen by itself is quite similar to the ibuprofen and codeine showing that the ibuprofen… I mean the codeine probably doesn't have a lot more benefit over the top of plain ibuprofen.

I think as pharmacists also, it's important for us to remember when someone comes in requesting medications or with painful conditions, to remember our appropriate questioning, especially if it's a direct product request. We tend to, have you had it before? What's the pain? Here you go. And it's important to delve into what actually more information about the pain to find something that's probably more appropriate. So, we need to make sure we're asking where the pain is. Is it severe, moderate, mild? Scale one to ten, the nature. So, is that throbbing? Is it burning? Is it stabbing? How long has it happened for? When is it occurring? Is it occurring all the time? Only when you do certain things? Are there other symptoms that go along with the pain? So, shortness of breath, swelling, any other symptoms. What things make it worse? What relieves it? What aggravates it? What other medications and medical conditions? And could that be a source of the pain? Such as medication withdrawal headaches and things like that. And is there any alarming symptoms or anything that indicates that we need to refer straight away?

So, I've just gone over a few of the conditions that I believe most often we get requests for combination analgesics containing codeine for in the pharmacy. So, one of these is migraine and I think it's really important in migraine that we're treating at the first sign of symptoms. One of the issues with migraine is that the stomach actually shuts down, so then any medication we're taking is not going to be absorbed as well, and that's why a good option, I guess, is aspirin. Soluble aspirin because it is absorbed a lot quicker and more readily, So, aspirin 900 milligrams is an option that we can offer in the pharmacy as a first-line for migraine. And then of course, your other anti-inflammatories and paracetamol, and again a soluble option is a good option.

I had an example of this with a patient recently. Came into the pharmacy, had travelled down from Ballarat to Geelong, had a migraine because of the light in the car, left their tablets at home, came in to talk to me about can I have some Panadeine? That's what I usually take for my migraine, and I spoke to her about the codeine changes and suggested that maybe she like might like to try aspirin because of the stomach shutting down and it would be more easily absorbed. And she said to me, no one's ever actually suggested that to me before. No one's ever recommended. I've suffered from migraines 10 plus years and no one's actually ever recommended that to me before. And she was more than happy to take it and try. I'll give that a try. She actually asked me, I didn't even have to offer. Can I try that?  Sure.

So, I think as pharmacists, we need to be mindful of this again with that direct request. When someone requests a product, they don't necessarily know about other options and we forget about that. I had another example where a patient came in. I was looking in my brother's pharmacy up in Yarrawonga and they requested Nurofen Plus and I said to them, so have you used this before? No. So why are you particularly requesting this? My daughter uses it and she told me to come and get it. So, there was no reason for him to be actually trying Nurofen Plus. So, we actually started off with ibuprofen by itself he was quite happy with that. Came back in the next day, checked with him how it was going and it was fine. It helped.

So, I think we need to remember we're the health professionals and they're the patients. They're just coming off potentially what someone else has used what their family and friends have used so it's up to us to have that professional role and actually decide what's best and what other options they might be available. And again, they may not realize that there are other options available.

Also in the pharmacy if they're not getting a good response from that medication, we can actually offer them anti-emetic drugs to help that gastric motility and help with the absorption. So, Metoclopramide is available with paracetamol for use for migraine as an S3 so that's an option that we can give. And also, we've got Prochlorperazine available in the pharmacy for migraine as well, so that's another option that we can give. And again, if it's an online headache, I think it's really important to actually explore the underlying cause of the headache, whether it's dehydration, injuries, stress, eyestrain, alcohol. No one here's ever had a headache from alcohol. Medication overuse, might be cough, it could be hormonal, so it's really important to explore that underlying reason and perhaps treat that rather than be just be treating the headache.

And then of course, if it's an ongoing thing, then it should be referred. It shouldn't be managed in the pharmacy, it should be referred further. And I remember when I was a young intern pharmacist, we had a patient with single chronic use of Mersyndol. Coming in all the time. We tried to get her to go to the doctor all the time; she wouldn't, she wouldn't, she wouldn't. And in the end, she ended up having eyesight trouble. So, we said right, you really need to go to the doctor, and she had a brain tumour, and by that stage it was too late. So, it's really important that if it's that ongoing use, then we really need to refer.

So, another thing that's commonly requested, Nurofen Plus is commonly requested for  primary dysmenorrhea. So NSAIDs are a really good option here because it's the prostaglandins released by the endometrial cells at the start of menstruation that causes the  vasoconstriction, muscle contraction and compression of the spiral arteries, and that leads to that that cramping and pain. So, if we inhibit the prostaglandins which is what NSAIDs do, that can help with the pain, so NSAIDs best given 48 hours before menstruation is expected if they're on a regular cycle, or as soon as the onset of the pain starts. Treatment continues for 48 to 72 hours when the prostaglandin release is maximal and there's insufficient evidence to favour one NSAID over another, even though marketing tends to do so. So, with your Ponstans and things like that, there's actually no evidence that one's better than the other.

And of course, if it's secondary dysmenorrhea, then it actually should be referred for further investigation. I work with someone that works in yeast drug and alcohol, and she said they have a lot of young women actually come in for detox withdrawal who've become addicted to Nurofen plus because of menstruation issues, because they've started it off when they're young in their early teens. Someone's recommended it; a family friend, pharmacist, whoever and then what's happened is at that time, young women are also going through a lot of potential anxiety issues, trying to find their way in the world, and the codeine has actually helped with that as well. So, then they've become dependent on it so they're not just taking small amounts. They end up taking more and more can be problematic. So, codeine is not indicated at all in primary or dysmenorrhea.

From my own experience, I had severe period pain when I was younger and I was prescribed Mersyndol Night for my period pain. That become a big problem when I was in high school.  I'd get my Mersyndol Night during the day and be trying to study for exams as well, and it was just knocking me out. When Nurofen Plus came on the scene later when I was a bit older, I was using that as well and that seemed to help, a bit of a dry mouth, but that helped as well, and then I mean when you have it at home, I will admit some nights, I didn't sleep very well when I had a Nurofen Plus. I'm an educated pharmacist and I'm doing that so I wonder what people who perhaps don't have that health literacy but feel like, it helps me sleep I might take that as well, could be doing as well.

There are other options for primary dysmenorrhea, non-medical options. So, heat, TENS, acupuncture, acupressure, spinal manipulation, herbal and dietary preparations, and the gynaecologist in Geelong speaks highly of magnesium for girls be the primary dysmenorrhea as an option. So, some randomized control trials have actually shown pain reduction with these methods but the studies were limited in size and quality. So, more research needs to be done, and again, Chinese herbal medication, exercise and psychological, behavioural interventions have shown benefit in small trials, but more work needs to be done.

Alright, so musculoskeletal injury. So, acute injury. We need to remember our RICER. Everyone can remember that, I'm assuming. Rest, ice compression, elevation, referral if required. First-line analgesia is paracetamol. NSAIDs have a theoretical risk of inhibiting muscle repair by the negative effects they have on the satellite cell population, so this is the muscle stem cell responsible for repair and maintenance of skeletal muscles. So, there's that theoretical risk that it might impede repair, especially in younger groups. They shouldn't be used for longer than 48 hours, and again no one NSAID is better than the other.

But non pharmalogical methods need to be really taken into account and considered here. So, physiotherapy. Exercise is really important for rehabilitation as long as it's not done too soon. Ice, all those types of things, heat and massage are contraindicated in the first 48 hours though, because they can do more harm than good. So, when I was working full-time in pharmacy, one of the most common requests for combined analgesics containing codeine was for dental pain, legitimate and non-legitimate. I think it was used quite often as an excuse. We used to record down, we'd say to him when you're off to see your dentist? I've got this hole in my tooth. I need  the codeine from Nurofen plus. When are you off to see your dentist? Oh, next week. We'd record that down. They'd come in next week. How did you go at the dentist? Oh, whoops, I'd forgotten I said that's when I was going. So….

Obviously, you need to avoid foods that provoke pain. So, it's really sweet foods, hot and cold foods, avoid them. Advise about analgesia, so quite often dental pain there's inflammation, so NSAIDs are suitable if they're not contraindicated. Of course, with other medications, it's important to cover any obvious cavities with an inert material, so chewing gum can be used. There's also this thing called dentist in a box. I think you can still get that so you can cover over.  Topical anaesthetics could be appropriate but referral to a dentist ASAP is the most important factor. So, these are just measures to get them through until they can get into a dentist.
Cold and flu. I think too much in pharmacy, we get requests for combination and cold and flu tablets. You know, I want a cold and flu table, I want a day a night formulation. When you talk about their symptoms, what are your symptoms? They say I've only got a blocked nose but they still want the day-night formulation. So, there's a lot of medications in there that they're getting unnecessarily and not to treat any symptoms. So I think it's important to think about what the actual symptoms are and supply medications to treat the symptoms rather than a combination product. So often people didn't have aches or pains or headaches but they're requesting a day-night formulation that had paracetamol and codeine in it and using it inappropriately.

Chronic pain. I'm not going to talk too much about that because Malcolm's here to talk about chronic pain, but just with respect to pharmacy, the role of opioids in chronic pain, a non-cancer pain management is really limited, and as I said, Malcolm will talk more about that. But experience suggests that opioids work in one in three patients and that they reduce pain intensity by 30 to 50 percent at best. And in patients taking opioids for chronic non-malignant pain, about 80% have at least one adverse effect. So, sometimes we need to think about are we doing more harm than good?

From a pharmacist perspective, it's really important to educate a patient about the role of medications and chronic non-cancer pain. The fact that they only have a small a small role and a small part of a big pie I suppose of treatment. We should be discussing lifestyle modifications, including diet and exercise, so research has shown that processed sugary foods can cause inflammation, and that alcohol can actually be neurotoxic as well so it can worsen your empathic pain. And so, we need to be discussing non-pharmalogical options, so including heat massage, psychotherapy, physiotherapy, osteotherapy, osteopathy, all those other things.

So, it might be worth the pharmacist talking to the patient about developing a pain management plan. There's a link to that. That goes to the MPS pain management plan but it's something that a pharmacist can sit down and start the process with a patient and then they can continue that on with their GP. They can take that on to their GP and discuss what more appropriate options, and perhaps discuss about their prescribed medications as well.

In pharmacy too, we have professional services that can be used to help aid with pain management. So, meds checks. We can be offering meds checks to help with pain management, home medication reviews and there's also some pharmacy pain management programs, eg Pain Wise which I don't know if people are aware of, is run by Joyce McSwan, a Queensland pharmacist which is up in the Gold Coast, PHN. So, there's different options that we can offer with regard to professional services in pharmacy as well.

And of course, trying to link in and being aware of support groups and patient information for your area. So, MOVE Australia, the national prescribing source of service has lots of good patient resources. Pain Australia, I'm sure there's plenty of others that I've missed. And it's important to know about your local pain service as well and what's available, and how patients can access that too.

Complementary medicines for pain. So, fish oil has some evidence in arthritis but we need to be making sure we're getting the right dose. So, often a lot of the products are really under dosed or you need to take nine capsules to get the right dose, so for inflammation, it's recommended by arthritis groups that you need at least 2.7 grams of total omega-3. So, the EPA and DHA, so you really needed those concentrated fish oils. Some people can't tolerate the side effects. I don't know if people here have tried it, I've had the liquid one, disgusting and fishy aftertaste. You do need to be mindful, there's a theoretical risk of increased risk of bleeding, and you do need to take it for at least three months to get the full effect.

Turmeric has some limited evidence but anecdotally, some people find that it has good effect as an anti-inflammatory. There is limited good quality studies so watch this space perhaps for more better conducted studies to show more evidence. It has a reasonable safe profile so it might be worth trialling if people can't tolerate or are contraindicated for NSAIDs. You do need to be careful with Warfarin still as with everything. And you need to be aware that turmeric has different bioavailability with different formulations. So, some are actually better than others.

Glucosamine and chondroitin, quite limited evidence and mainly for osteoarthritis of the knee. I think the take home message here is do your research perhaps before recommending any complementary medicines to make sure of evidence, risks, benefits, and costs sometimes can be a factor.

So, I guess my key message is make sure you validate the pain with the person, even if you think it's mild. Sometimes, it can have a big effect on their life so be empathetic, remember non-pharmacological options and lifestyle factors. Make sure you educate and give realistic expectations as to what to expect from pain management, especially with medication. So, how long it's going to take to work, how long it's going to work for, what kind of level of their relief they can expect. I think in society at the moment, we expect to be pain-free, and that's actually not really realistic I suppose. And it's important to remember that pain is there for a reason; it's a protective factor so sometimes it's good to have a little bit of pain. And make sure you get them to come back to see you or go to the GP if they don't get adequate relief from their medication.

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