Tips for talking about codeine: Guidance for pharmacists
All codeine-containing medicines will become Prescription Only Medicines from 1 February 2018. This includes combination analgesics and codeine-containing cough, cold and flu products.
You may want to suggest the use of alternative products that are available over the counter (OTC) and do not contain codeine, or advise the person to discuss their pain and cough, cold and flu management options with their health professional with prescribing authority1 (known as an authorised prescriber).
Some consumers may seek to stockpile codeine-containing medicines prior to 1 February 2018. These medicines are not indicated for chronic pain and can cause dependence. Therefore, you need to ensure supply is consistent with quality use of medicines principles.
Discussing pain management and negotiating treatment can be challenging
- Use empathy and validation combined with a setting of clear boundaries to try to contain difficult behaviour and to motivate positive change. Boundaries prevent situations where the person dominates the interaction and the outcome. Examples of this include inappropriate analgesic provision.
- Evidence suggests that validation of the person's pain is associated with increased satisfaction and reduced anger and frustration.
- See the following 'Suggested talking points' for examples of questions to ask, when to consider referral to a general practitioner or other suitably skilled authorised prescriber, and suggested approaches for explaining the referral process.
People who are prescribed opioids respond best when conversations are framed around protecting them from opioid-related harms and when they recognise you have their best interests in mind. See the Pharmaceutical Society of Australia's (PSA) Pain management webpage for further information.
- General practitioner, specialist, clinician, nurse practitioner, midwife, nurse prescriber, dentist
Suggested talking points
Asking open ended questions about pain will help with your diagnosis.
It is important to establish whether the pain is a symptom or a specific condition. This will help with your recommendation of treatment and/or referral.
Don't assume that if someone asks you to assist them with pain that they are looking for medicine. You may want to discuss other pain management strategies (non‑medicine) include physiotherapy, mind-body techniques, psychological techniques, occupational therapy, massage, acupuncture, exercise, lifestyle changes, and active self-care management.
What have you tried for your pain in the past?
Sometimes long-term pain may indicate an underlying problem. Tell me more about your pain. How long have you had it? Please describe the type of pain you are experiencing (dull, sharp, tingling etc.)?
Do you know the cause of your pain? Is your pain associated with a known diagnosed condition, injury or disease (e.g. arthritis)?
Yes, there are other pain management strategies available. (Discuss the different options)
Manage expectations. Inform the person what your scope of practice is and to what extent you can/cannot help them.
What outcome would you like today?
There is evidence that low dose codeine (<30 mg/dose) does not have a therapeutic effect on pain and does not provide any more symptomatic relief than other OTC products without codeine (for example paracetamol, ibuprofen or a combination of both).
Codeine (> 30mg/dose) is indicated for acute pain relief when the pain is mild to moderate. It is not indicated for the treatment of chronic pain; however OTC low dose codeine is currently being used for the self-treatment of chronic pain. Long term low dose codeine use 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.
Inform the person to whom you are giving advice that there are other options available for them within the pharmacy, and additional pain management strategies are also available after an assessment by their authorised prescriber.
What are you most worried about with the changes?
Did you know codeine...? (Inform about the risks of long term codeine-containing medicine use)
Codeine might not be the best option for you. I'd like to ask you a few questions to determine what level of pain you have and how I can help you.
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 or self-management approaches recommended by you, the pharmacist.
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 (also known as complex chronic pain).
If OTC medicines do not adequately treat the person's acute pain, you should refer them to a general practitioner or other suitably skilled authorised prescriber for further assessment.
It sounds like you have acute pain. Many types of acute pain can be adequately treated by OTC medicines without codeine that are available in this pharmacy. I'd like to ask you a few more questions to establish what treatment is going to be best for you. If these options don't suit, then seeing your authorised prescriber is the next step.
Chronic pain is usually defined as pain that is present after the initial healing time has elapsed, typically for three months or more, 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.
Chronic pain not treated adequately in the pharmacy should be referred to a general practitioner.
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 requires a skilled and comprehensive assessment and a multimodal approach to treatment that does not rely on medicines alone. Referral to a pain specialist may also be required.
It sounds like your pain is chronic, as it has been present for three months or more. Combination codeine medicines are not appropriate in this situation. I would like to ask you some questions, so that I can better advise you on what your options might be.
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.
Refer them to appropriate websites for self-treatment, for example Pain Bytes
Yes, there are other pain management strategies available. (Discuss the different options)
You may wish to discuss these options with your general practitioner.
Asking open ended questions will help you understand how people are using codeine.
As a pharmacist, a complete diagnosis of substance use disorder (SUD) is outside of your scope of practice and referral to an authorised prescriber is necessary for assessment and treatment planning, which may include detox or initiation of opioid pharmacotherapy. However, you will be able to establish if there is a possibility of SUD, such as tolerance or dependence. Even when therapeutic doses are taken (i.e. no more than the maximum dose every day), dependence can develop, and withdrawal symptoms can emerge on cessation. Symptoms of withdrawal may appear as a worsening of a pain condition (e.g. re-emergence of headaches (such as analgesic medication overuse headache), muscle pain, cold and flu symptoms).
Give written information on SUD if appropriate.
What happens when you stop taking codeine? Can you tell me about the symptoms you experience?
Tell me about how you have been using codeine? What do you find effective? Do you ever need to take more than two tablets at a time? Do you ever use codeine for sleep or to feel better?
I am very concerned about your health. From what you have told me, your body may be used to having codeine regularly and might benefit from some support to stop taking codeine. Ongoing use of codeine in combination with [ibuprofen or paracetamol] in the manner you have described may result in long-term harm for you and your health. The level of care needed to properly manage your pain, and/or help you stop taking codeine is outside my area of expertise. However, I am happy to refer you to your authorised prescriber to ensure you get the care you need. I am also happy to continue to provide care that is not in relation to these medicines. Are you interested in that?
You may wish to ask the person to whom you have provided advice for a brief summary of your discussion to see if they understand the outcomes.
If required, give them written information on the topics you have discussed.
Do you have any questions about the recommendations we've discussed?
Are you still concerned about the codeine changes?
Do you understand that as your pain has been going on for more than three months, a different treatment approach might be more effective? It may be best to be seen by your authorised prescriber.
Do you understand that dependence on codeine is a medical condition? Effective treatments are available by your general practitioner or alternative.
- Hunter New England Local Health District NSW Government. Pain Matters: Managing conflict in clinical interactions 2005.
- Edmond SN, Keefe FJ. Validating pain communication: current state of the science. Pain 2015;156:215-9.
- Krebs EE, Bergman AA, Coffing JM, et al. Barriers to Guideline-Concordant Opioid Management in Primary Care - A Qualitative Study. The Journal of Pain 15:1148-55.
- Robinson M. Effective pain management in the OTC setting. Australian Pharmacist 2015.
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- Nielson S, Lintzeris N, Mackie K, et al. Preventing pharmaceutical opioid misuse: pharmacists have a role to play. Australian Pharmacist 2010 29:107-11.
- Spark J and Wood P. Getting the combination right for OTC codeine Pharmacy news; May 2014.
- Philpott L. The battle against pain. Australian Journal of Pharmacy 2014;94:44-46.
- Pharmaceutical Society of Australia. Ethical issues in declining to supply. 2003 (accessed 25 May 2015).