Tips for talking about codeine: Guidance for pharmacy assistants

8 September 2017

Working as a pharmacy assistant, you are in an important position to support customers requesting medicines for pain relief and cough, cold and flu. As of 1 February 2018, all medicines containing codeine will become a Prescription Only Medicine (Schedule 4). Therefore, it is important that you understand the options available for pain relief and cough, cold and flu for your customers and when to refer them to the pharmacist.

Cough, cold and flu

There are numerous over-the-counter medicines available for treating cough, cold and flu symptoms which do not contain codeine. Familiarise yourself with these medicines. If you are unsure of what medicine is best for your customer, refer them to the pharmacist.

Pain

Pain is one of the most common reasons for a person to visit a pharmacy.

Pain is usually caused by an injury or damage to the body. Pain can be classified differently by different people including ongoing/chronic pain or rapid onset/acute pain that can be mild, moderate or severe. People who experience pain may also experience emotional and/or behavioural issues. This is why pain is often described as multidimensional and why individuals with similar levels of pain (such as a twisted ankle or a sore throat) may present very differently. As a reuslt, a medicine that may help one person with their pain may not help another.

Types of pain (Acute and Chronic)

Acute pain is pain of 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 a cold or flu. 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-drug or self-management approaches recommended by the pharmacist.

Chronic pain is usually defined as pain that has been present for three months or more. However, not all cases of chronic pain 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, 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 In some cases, the originating process is no longer active but pain persists because of lasting changes within the nervous system; and in other cases the cause of the pain is unclear and continues without any readily recognised cause.

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 skilled and comprehensive assessment and a multimodal approach to treatment that does not rely on medicines alone.

People presenting with chronic pain should be referred to the pharmacist or their general medical practitioner.

It is important to familiarise yourself with the wide variety of over-the-counter (OTC) treatments available to treat pain (see OTC pain relievers). OTC medicines can have a range of benefits and disadvantages for each and every patient. It is also important to understand when to refer customers to the pharmacist to discuss their condition and for a more detailed consultation (see examples of referrals).

Medicines are not the only way to treat pain, and customers may also like to try some non‑medicinal approaches to their pain relief. Customers may also wish to speak with the pharmacist to discuss these in more detail. Some examples include: exercise, massage, yoga, hot/cold packs.

Some examples of when to refer to a pharmacist

  • When pain is not managed by current pain relief
  • Customers that require pain relief all the time
  • Customers who request codeine-containing medicines
  • Customers who request Schedule 3 medicines, also known as Pharmacist Only Medicines
  • Customers who are pregnant or breastfeeding
  • Customers who are taking any additional medicines
  • Customers with recurring headaches

Over-the-counter medicines for relief of mild-to-moderate pain

There are a number of OTC pain relievers available, and each has a role in treating different types of pain. The first step in choosing the most appropriate medicine is to find out what type of pain (chronic or acute) the person is experiencing, and how strong the pain is.

New products containing paracetamol and ibuprofen combined in a single dosage form have been shown to provide superior relief from mild-to-moderate pain when compared with OTC combination pain medicines containing codeine. They also have a longer duration of action when compared with standard paracetamol or ibuprofen alone.

OTC pain relievers

Non-steroidal anti-inflammatory drugs (NSAIDs)

Examples:

Ibuprofen (Nurofen)

Diclofenac (Voltaren)

Aspirin (Disprin)

Naproxen (Naprogesic)

Refer to the pharmacist if the customer:

  • is sensitive to aspirin
  • is pregnant or breastfeeding
  • has asthma, high blood pressure, or heart, kidney, liver or gastrointestinal conditions
  • takes any other medicines, including prescription, otc or complementary
  • is elderly or adolescent
Paracetamol

Example:

Panadol

Refer to the pharmacist if the customer:

  • has liver disease
  • takes any other medicines, including prescription, OTC or complementary
Ibuprofen and paracetamol combined analgesics

Examples:

Nuromol

Maxigesic

Refer to the pharmacist if the customer:

  • Has liver disease
  • Is pregnant or breastfeeding
  • Has asthma, high blood pressure, or heart, kidney, liver or gastrointestinal conditions
  • Takes any other medicines, including prescription, OTC or complementary
  • Is elderly or adolescent

This document has been developed by the Nationally Coordinated Codeine Implementation Working Group (NCCIWG). NCCIWG was established to assist with providing consistent communications to inform and educate the public and health professionals about the changes to the availability of codeine-containing medicines in Australia. NCCIWG includes representatives from state and territory health departments and peak professional bodies representing consumers and health professionals.