Codeine Crisis in Pain Management
Many people know of someone who lives with some variety of pain or have been in a state that needs pain killers prescribed by a doctor.
For most of these people , in some way, shape or form an ‘Opioid’ (such as Codeine), may have come up in conversation with either a doctor, pharmacist, nurse or family member.
Opioids include drugs like oxycodone, methadone, morphine, pethidine and heroin.
These drugs have been used in western medicine for many years, but there is a relatively well-established (but sometimes misinformed) stigma around the use of opioids.
This has been driven particularly since the rise in opioid-drug related deaths in western countries - and further due to the establishment of the ‘War on Drugs’ in the USA (similarly in Australia).
Australia has hit record opioid overdose death numbers.
Reports from The Australian Bureau of Statistics, both in 2016 and 2017, identified that increasing opioid-related overdose deaths are of serious concern.
Every day in Australia - an average of 3 people die, 150 people are hospitalised and 14 people present to emergency departments because of harm from opioids.
What is Codeine?
Codeine is part of this group of drugs that interacts with opioid receptors in the brain and elicit a range of responses within the body, from feelings of pain relief, to relaxation, pleasure and contentment.
Usually prescribed for moderate pain (and in some cases, cough suppression) this medication is included in many pain relief products, some of which were previously available over the counter.
Common side effects of codeine include:
constipation
nausea and stomach cramps
mood changes
dizziness
drowsiness
feeling faint
inability to sleep and unusual dreams
While it is important for people to understand the risks of using Codeine based medication particularly in high doses or prolonged use - a large systematic review shows us there is no indication in the available literature which clearly links low doses of Codeine (alone or in combination) to substance use disorder issues in previously non-dependent subjects.
Healthcare System Changes
Strong evidence shows that medicines containing low-dose codeine combined with paracetamol or nonsteroidal anti- inflammatory drugs (NSAIDs) such as ibuprofen or aspirin, are generally no more effective than other non-codeine medicines.
In May 2010, over-the-counter (OTC) codeine products were up-scheduled from Schedule 2 (Pharmacy Medicine) to Schedule 3 (Pharmacist Only Medicine) but this change had no meaningful impact on codeine poisonings.
In 2016, the most common analgesics used for ‘non-medical’ purposes by Australians were OTC codeine products. Codeine was up-scheduled again in February 2018 to Schedule 4 (Prescription-only medicines) but we have still seen a 9% increase in Opiate overdose related deaths the past 5 years. Opioids continue to be the most commonly identified drug group in unintentional drug-induced deaths, and the number of unintentional drug-induced deaths involving opioids has nearly tripled in the last 12 years.
A large study from Saint Louis University School of Medicine compared the odds of new Schedule II opioid (codeine, hydrocodone, oxycodone) prescriptions versus Schedule IV opioid (tramadol) prescriptions in the 18-month periods before and after the CDC guidelines were released on March 15, 2016.
Basically - “Did opiate restrictions actually make a change to the amount of opiates prescribed by doctors ?”
The analysis included 279,435 U.S. adults identified through the Optum De-Identified Integrated Claims-clinical data set.
The researchers found that the prevalence of new prescriptions for each drug before vs after guideline publication was relatively similar:
7.1% vs 7.0% for Codeine,
47.4% vs 45.6% for Hydrocodone,
22.4% vs 24% for Oxycodone,
23% vs 23.4% for Tramadol.
In patients (both with and without benzodiazepine co-medication or psychiatric disorders), the odds of being prescribed a Schedule 2 opiate versus tramadol after versus before guideline changes were effectively the same.
While the intentions behind changing medication scheduling are clearly with the best interest of the public at heart, it doesn’t seem to be having effective positive changes on the key outcomes of concern, in the USA at least.
In Australia, rescheduling codeine was followed by market substitution seen with increased sales to pharmacies of over-the- counter analgesics with lower risks of dependence (such as single ingredient Paracetamol/Panadol and Ibuprofen/Neurofen), while there was no increase in the amount of prescription-only pain medications sold.
Clinically, it does seem as though some groups of people who have (prior to Codeine rescheduling) been able to effectively manage persistent pain using OTC medications responsibly are now being either less effectively managing their pain, or more frequently requiring higher dose opioid/more intensive intervention to manage their symptoms.
This is also a common problem seen in acute pain and injury that can usually (in the past) be self-managed safely and effectively without a GP review or new script for pain killers.
Especially in rural communities, where GP access for scripts is limited, this does present a barrier for many who are in need of short-term or regular analgesic pain relief that has previously been managed effectively with Codeine containing products. Another risk in this case (that is difficult to monitor) is the potential increase in ‘doctor-shopping’ behaviour in those seeking prescription pain relief.
Largely, the effect of restricting non-prescription access to Codeine should reduce the misuse of this medication as patients are required to consult with their GP before receiving a script - but without a clear alternative pathway or system to manage the resultant change in peoples’ self-efficacy, many are left in the dark and left in pain as well.
What can clinicians do for patients?
There are some systems that have been put in place for Opioid substitution in Australia and other Western countries from a medical perspective. High dose buprenorphine/buprenorphine-naloxone is proving a useful approach for patients with chronic pain and opioid use disorder. However only few Australian general practitioners – estimated at around 10% - prescribe methadone or buprenorphine/naloxone.
Greater availability of multidisciplinary pain services for people with chronic and persistent pain, and addiction treatment services for opioid dependent people are what’s really necessary to make meaningful change in this area.
We need systems in place to direct patients to more effective and safer treatment approaches instead of a reliance on opioid medications. A review of 57 pain management services in Australia, shows us that only 4 are offering a combined pain and addiction service.
This is a key fault in our healthcare system - overlooking the reciprocal relationship between pain, addiction and pharmaceutical use/mis-use.
The Royal Australian College of General Practitioners (RACGP) have encouraged general practitioners (GPs) to refer patients to physiotherapists as an alternative to prescribing Codeine - but it is still early to make a call on whether this is being implemented at it’s full capacity.
Should Pharmacists, Physiotherapists and other allied health professionals be granted greater responsibility and advanced rights to modify / manage medications (as has previously been successful in some countries health sectors)?
Maybe.
Should people in pain with a history of opioid misuse or resistance/tolerance be granted greater support (financially as well as psychologically) to access pain management allied health intervention from Physiotherapists and Exercise Physiologists?
Also maybe.
While there is uncertainty behind the how we can create the safest, most effective, holistic pain management systems for people experiencing persistent pain or chronic Codeine dependance/addiction to pharmaceuticals - we do know that there is an important role for physiotherapists and Exercise Physiologists in providing healthcare support to those with disability as a result of pain.
Physiotherapy and Exercise Physiology interventions have been proven in research, time and time again, to create positive, lasting improvements on peoples’ pain and quality of life.
Good rehabilitation and pain management involves empowerment and education around ways people can safely self - manage their symptoms, take accountability for their health and develop independence in looking after their body.
Understanding these changes and how they affect a person in pain helps Physiotherapists and Exercise Physiologists to offer the highest quality support and guidance needed to best control pain, disability and physical function.
Education is Key
There are many things about the reasoning behind changes to Codeine prescription regulations that people may not be aware of. A large part of gaining benefit from restriction to certain medications is understanding why changes have been made.
One of the most powerful tools in assisting those who have had previous experience with OTC Codeine for pain management or suffering from Codeine dependence, is providing quality advice and education to empower people to understand their pain.
Opioids are not very effective for chronic pain and can present substantial risk for harm.
Research shows that Codeine containing products products can offer modest pain relief in the short-term (1-3 hours) but offer little additional pain relief compared with other medicines without Codeine.
Severe pain is not necessarily a sign of severe damage. It is often possible for clinicians to detect serious problems through careful questioning.
Pain is an output of the brain and therefore will be influenced not only by nerve signals from the tissues, but also one’s thoughts, past experiences, beliefs, emotions and social environment.
Humans produce their own opioids after exercise, laughter and some physical treatments such as massage/manual therapy.
Pain systems sometimes become sensitive and can overestimate potential for tissue damage. This can lead to severe pain in the absence of any serious injury.
Pain system sensitivity can increase temporarily after stopping long-term use of opioids.
This means more pain initially, along with other withdrawal symptoms, including anxiety, nausea, restlessness, sweating, vomiting or abdominal pain
All we can be certain of at the moment - is that while movement is medicine…
For many people, our current medical and healthcare system still has some work to do in developing pain management pathways that effectively direct people towards moving better, moving more and moving with less pain.
If you’d like more information on any of the information above or would like a better understanding of how movement can be medicine for you, keep an eye out for more content like this or get in touch to book an appointment for a personalised plan of action today.
This page does not give you all the information about pain management, codeine, opioids or prescription medication use. Please read the Consumer Medicines Information (CMI) for the specific brand of medications you are taking, and if you have more detailed medication specific questions, ask your pharmacist or doctor.