Tips for talking about codeine: Guidance for health professionals with prescribing authority
As a health professional with prescribing authority1, you may see more people requesting codeine for pain management when codeine becomes a Prescription Only Medicine on 1 February 2018.
It is important to:
- develop your practice policies for prescribing medicines for pain
- know how to manage pain without reliance on opioids
- know when to refer to an allied health professional for other therapies, to a pain specialist or clinic for assessment and management, and/or to drug and alcohol services.
- General practitioner, specialist, clinician, nurse practitioner, midwife, nurse prescriber, dentist
Suggested talking points
Asking open ended questions about pain will help with your assessment.
You will need to perform a comprehensive clinical assessment of the person's pain rather than just treating the pain as a symptom.
Don't assume that if someone asks you to assist them with pain that they are looking for pain tablets. Explore other options such as physiotherapy, massage, acupuncture, exercise, lifestyle changes and active selfcare management.
Manage expectations of the person to whom you are providing care. Inform them that sometimes pain management is a long-term process and requires more than medicines.
Discuss all of the person's concerns and needs as they arise. Schedule another appointment for further discussions if required.
What have you tried for your pain in the past?
Over-the-counter (OTC) codeine-containing medicines have been used in the past for the self-treatment of chronic pain problems. However, we know these are not effective at the OTC dose, can have serious and potentially life threatening side effects and are not first-line in treating chronic pain so we don't always prescribe them.
Sometimes long-term pain may indicate an underlying problem. Can you tell me more about your pain? How long have you had the pain for? Can you describe the pain you are experiencing (dull, sharp, tingling etc.)?
What would you like to achieve with your pain management? (For example, a higher level of functioning. However, pain free may not be achievable)
There is evidence that low dose codeine (<30 mg/dose) does not provide any more symptomatic relief from pain than OTC products without codeine (for example paracetamol, ibuprofen or a combination of both).
Codeine (>30 mg/dose) is indicated for acute, mild to moderate pain. It is not indicated for the treatment of chronic pain; however low dose OTC codeine is currently being used for the self-treatment of chronic pain. Incorrect long term use of low dose codeine for chronic pain is associated with health risks, specifically developing tolerance and dependence, and associated side effects from long term consumption of paracetamol and ibuprofen which are potentially life threatening.
What are you most worried about with the changes?
Did you know codeine...? (Inform about risks of long term codeine-containing medicine use)
Acute pain is pain of recent and sudden onset that in most cases is a symptom of injury or tissue damage (such as a broken bone or sprained joint), an infection in the skin/internal organ (such as appendicitis or tonsillitis), or blocking of blood supply to a limb or the heart. It is important, and usually possible, to identify the cause of the pain, direct treatment to that cause, and to try and reduce the pain itself. This might involve medicines available through the pharmacy and/or non-medicinal options or self-management approaches.
The term acute pain is also often used by people who have long‑standing pain to describe the worsening of that pain. Here the word acute refers more to severity than to duration.
It sounds like you have acute pain. Acute pain can sometimes be adequately treated by OTC medicines without codeine that are available in the pharmacy. In your case it was great that you were referred to me to discuss whether you need additional pain relief. Let me ask you a few more questions to establish what treatment options are going to be best for you.
Chronic pain is usually defined as pain that is present after a normal time of healing (typically more than 3 months, but not always). Not all cases of chronic pain however start with an episode of acute tissue damage. Although most episodes of acute pain resolve when the underlying injury or disease process heals, some conditions, such as inflammatory arthritis or peripheral neuropathy, are characterised by ongoing disease processes that may cause persistent pain. In some cases, the originating process is no longer active but pain persists because of lasting changes within the nervous system; and in other cases the cause of the pain is unclear and develops without any readily recognised pathology.
Many cases of chronic pain are complex, as they involve not only what may be happening in the person's body, but also what is happening in their lives. Just as acute pain can be accompanied by anxiety, chronic pain can be associated with major changes in mood and how the person functions at home, work, with family or in society. This multidimensional aspect of pain means that the person may require a skilled and comprehensive assessment and a multimodal approach to treatment that does not rely on medicines alone.
Ensure your practice has policies on how to prescribe opioids and other strong pain medicines if/when they are appropriate. Referral to pain specialists may be required for cases unresolved in the practice. Consider non‑pharmacological therapies first if there is not an immediate need for drug therapies.
It sounds like you have chronic pain.
Chronic pain is when the pain has been present for more than three months. In order for me to treat you correctly, we need to do a comprehensive clinical assessment of your pain and its cause.
Other pain management strategies (non-drug) include physiotherapy, mind‑body techniques, psychological techniques, occupational therapy, massage, acupuncture, exercise, lifestyle changes, and active self-care management.
Yes, there are other pain management strategies available. (Discuss the different options)
Specialist pain medicine physicians (pain specialists) have expertise in both the physical and psychological aspects associated with patients experiencing chronic pain. They are skilled in multidisciplinary assessment and management and in tailoring a treatment program to the individual. Such programs may use medicines but this is usually in combination with a variety of non-pharmacological approaches. Specialist pain medicine physicians should be consulted early, especially when you and the person to whom you are providing care feel that adequate progress is not being made.
Although we have tried many things to help with your pain, both drug and non-drug therapies, we do not seem to be making progress. I would like you to be seen by a specialist pain medicine physician, someone who has more expertise in dealing with complex situations such as yours.
Substance use disorder (SUD) is a medical condition where a person loses control over the amount of medicine they use and can continue to use medicines despite experiencing harm. It is important to remember that these people are presenting symptoms of a condition, and the medical and social circumstances of these people can often be complex.
People with potential SUD may present to your practice, including those that have been using OTC low dose codeine to self-manage pain.
Ensure your practice has a 'drugs of dependence therapy agreement' policy to inform people about the risks of the drug and expectations for ongoing care using drugs of dependence.
Symptoms of opioid SUD can include a strong desire for opioids, inability to control or reduce use, continued use despite interference with major obligations or social functioning, use of larger amounts over time, development of tolerance, spending a great deal of time to obtain and use opioids, and withdrawal symptoms that occur after stopping or reducing use, such as negative mood, nausea or vomiting, muscle aches, diarrhoea, fever, and insomnia.
A SUD presentation will provide the opportunity to organise proper care for these people. As a health professional, you need to be non-judgemental, use a neutral matter of fact tone of voice and be empathetic. Don't be afraid to explore the issues around SUD. Once SUD is identified and discussed, you may have an opportunity to provide treatment within your practice with practice policies and support from drug and alcohol specialists, or refer these people to the local drug and alcohol services to ensure they get the care they need. You may want to refer to Alcohol and Drug Information Service (ADIS) for counselling and referral.
If the person does not accept your advice and continues to pressure you, you can ask them to leave, but provide them an option to return for further help with their SUD when they are ready.
How long have you used this medicine? Did you get it from the pharmacy, was it prescribed or did someone else give it to you?
I am concerned about that and your health. A request like this can sometimes be a sign of dependence on the medicine. How much you are taking?
Pain medicines with codeine only provide a short-term benefit. If your pain is worse when you don't take them, it may be because you have become dependent on them. Using other medicines or non-drug methods have been shown to have better long-term benefits.
I am concerned that providing ongoing medicine is not good for your overall health. I suggest that we trial a graduated withdrawal program, or I can refer you to a specialist?
Thank you for coming to see me. I am unable to prescribe the medicines that you requested today, because I don't believe it is in your best interest in terms of your overall health. I have mentioned alternative methods of exploring and treating your pain. We can begin to trial an alternative option today, or you can give some further thought to my advice and we can make another appointment to trial other options.
I believe you. You do have pain. You do believe codeine (opioids) are necessary and this is of overwhelming importance to you. You can see your pain levels improve every time you take codeine (opioids). However, short term results do not mean that codeine (opioids) are effective or safe. We can assess your pain and work together to determine what is safe and effective for your type and level of pain.
I understand that you are experiencing pain, and I would like to fully assess you to determine how best to care for you in terms of your pain and your request for codeine (opioids). Please understand that this is complex. For this reason I will do what I can to help you today, and we will get the ball rolling at your next visit regarding your pain management.
You can only legally prescribe medicines for their intended use in the treatment of a person under your care. You must take all the reasonable steps to ensure a therapeutic need exists.
You can't legally prescribe drugs merely to support a person's drug dependence.
We don't just prescribe strong pain-relieving drugs to people who ask for them. We need to have another look to establish what treatment options are best for you. (Discuss other options.) It may be best if you take into consideration what we have discussed today about alternative treatments.
As your doctor, I would like to make a diagnosis first to determine what options are available to you that are safe and effective. I hope that we can work together to get best health outcome for you.
You may wish to ask the person to whom you are providing care to briefly summarise your discussion to see if they understand the outcomes.
If required, give them written information on the topics you have discussed.
If you are referring them to a specialist, write down the details for their reference.
If you are helping them with gradually tapering off a medicine, write down the expected outcome and timeline.
Is there something that you were hoping to discuss that we haven't yet?
Do you have any questions about the recommendations we've discussed?
Do you have any other concerns about how we might work together to manage your pain?
Do you understand that as your pain has been present for more than three months, a different treatment approach might be more effective, including assessment by a pain specialist?
Do you understand that dependence on codeine is a medical condition? Effective treatments are available and we need to treat it properly.