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Friday 19  January

Special Edition Newsletter

Codeine changes: Are you prepared?

As you know, after 1 February, codeine-containing medicines will only be available to consumers by prescription.

There is substantial evidence of harm from the misuse and abuse of low dose codeine-containing medicines1.

Research shows that current over-the-counter low-dose (< 30 mg) codeine-containing products offer little additional pain relief when compared to similar medicines without codeine.

 

Is the patient you're seeing dependent on codeine?

Dependence – The misconceptions

Discussing dependence with people who regularly use codeine can be difficult. Stigma around dependence and addiction is often a barrier which makes it more difficult for people to seek help.

Sometimes people hold mistaken and harmful misconceptions around dependence and addiction such as, addiction is a result of a lack of willpower or internal strength and that treatment is not effective.

You're uniquely placed to correct these assumptions sensitively and empathetically, and to help your patient receive the care they need.

Dependence affects people from all walks of life.

A 2010 Turning Point report identified that the majority of the group of codeine dependent users studied were employed, had completed at least 12 years of education (Year 11 equivalent) and most were treatment naive.

While almost all participants who were classified as codeine dependent felt their codeine use was a problem for them, only a quarter had sought treatment for codeine dependence. There was also an association between OTC codeine dependence, chronic pain and poorer psychological functioning2.

What does dependence look like?

Physical signs of dependence (withdrawal) may include:

  • Sweating
  • Agitation
  • Yawning
  • Aching muscles and bones
  • Stomach upset and cramps
  • Diarrhoea
  • Muscle cramps
  • Insomnia and sleep disturbances
  • Restlessness
  • Runny nose and eyes
  • Anxiety
  • Fatigue
  • Hot and cold flushes
  • Dilated pupils
  • Palpitations
  • Headache
  • Goosebumps

Behavioural signs of dependence include:

  • Inappropriate use of the medications
  • Non-indicated use i.e. use for sleep
  • Doses higher than recommended
  • Repeated reported loss of medication
  • Obtaining medications from multiple sources
  • Picking up medications for someone else or multiple people
  • Multiple dose escalation without health professional advice
  • Unwilling to try alternatives to the medication
  • Using an OTC medication in addition to a prescribed opioid and their doctor is unaware of this use
  • Resistant to changes in therapy despite evidence of detrimental physical or psychological effects
  • Exaggerates or feigns medical problems.
  • Provides a convincing, textbook-like description of symptoms but vague medical history.
  • Unwilling or unable to provide the name of their regular doctor, or states that the doctor is unavailable.
  • Shows unusual knowledge about opioid medications.
  • States that specific non-opioid medications do not work, or that they are allergic to them
  • Adds pressure by eliciting sympathy or guilt, or by direct threats
  • Seeks multiple packs for different reasons e.g., to keep one in the car, one at work.

Having a positive conversation with your patient...

Here are some tips that can help you talk with patients about codeine:

  • Maintain a non-judgmental and empathetic approach which puts dependency and its treatment in the context of improving health. For example, explain that dependence is a long-term health condition which requires a treatment plan, just as diabetes or asthma do.
  • Validate your patient’s pain - this is likely to help your interaction and reduce anger and frustration.
  • Explain the risks associated with codeine use and that there are effective treatment alternatives.
  • Use ‘I’ statements that take the focus away from the person and put it on you, such as ‘I am very concerned about your health …’, ‘I believe there are more effective ways we can help you with …’

For more suggestions on how to navigate these conversations, visit the TGA Codeine Hub to access documents such as Tips for talking about Codeine: Guidance for Pharmacists and Tips for talking about Codeine: Guidance for prescribers.

Treating dependence in primary care

Codeine dependence can be managed within the primary care setting. 

Patients may benefit from Medication Assisted Treatment of Opioid Dependence (MATOD), also known as Pharmacotherapy or Opioid Replacement Therapy (ORT). 

MATOD is evidence-based and effective for any type of opioid dependence, be it codeine, prescription opioids or illicit opioids. 

One component of MATOD is treatment with opioid replacement therapy such as buprenorphine/naloxone (Suboxone®) or methadone. Buprenorphine/naloxone and methadone are both long acting opioids used as a replacement to the patient’s usual opioid, in this case codeine. 

These treatments suppress the debilitating symptoms of cravings and withdrawal and enable the patient to cease their codeine and any associated dependence-driven behaviours.  They enable the patient to engage in recovery therapy and implement positive long-term changes. For this treatment to be effective, concurrent psychosocial supports are key.

All Victorian GPs can prescribe buprenorphine/naloxone (Suboxone®) for up to five patients without undertaking formal training. Buprenorphine is a partial agonist at the mu-opioid receptor, and has higher receptor affinity than other opioids, therefore displacing them if they are present. In addition, it has a ceiling effect on maximal opioid activity and therefore has a lower risk of respiratory depression and overdose when compared with methadone and other opioids such as oxycodone.

Caution is still required when buprenorphine/naloxone is combined with alcohol, benzodiazepines, other opioids or other medications that can cause respiratory depression.

Naloxone is an opioid antagonist and included in the formulation to reduce misuse or diversion of this medication.

To learn more:

DSM-V diagnostic criteria for Opioid Use Disorder

A diagnosis of opioid dependence, now formally referred to as Opioid Use Disorder, can be confirmed by using the DSM-V criteria3 as follows:

A problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  • Opioids are often taken in larger amounts or over a longer period than was intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
  • A great deal of time is spent in activities necessary to obtain the opioid, use the opioid or recover from its effects.
  • Craving, or a strong desire or urge to use opioids.
  • Recurrent opioid use resulting in a failure to fulfil major role obligations at work, school or home.
  • Continued opioid use despite having persistent or recurrent social or interpersonal problems cause or exacerbated by the effects of opioids.
  • Important social, occupational, or recreational activities are given up or reduced because of opioid use.
  • Recurrent opioid use in situations in which it is physically hazardous.
  • Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been cause or exacerbated by the substance.
  • Tolerance*, as defined by either of the following: A need for markedly increased amounts of opioids to achieve intoxication or desired effect OR a markedly diminished effect with continued use of the same amount of an opioid.
  • Withdrawal* as manifested by either of the following: The characteristic opioid withdrawal syndrome  (refer to Criteria A and B or the criteria set for opioid withdrawal, pp 547-548 of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) OR Opioids (or a closely related substance) are taken to relieve or avoid withdrawal symptoms.

*Note: this criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.

Useful websites and resources

How can I get clinical advice about codeine dependence?

The Drug and Alcohol Clinical Advisory Service (DACAS) is a free specialist telephone consultancy service for health professionals.

It offers professional advice from an Addiction Medicine Specialist and is available 24 hours, 7 days on ph: 1800 812 804. DACAS consultants try to respond to the call within one hour, or as soon as possible if the matter is urgent.

Your local pharmacotherapy network (A4PN) can provide support in managing patients with codeine dependence and offer services such as:

  • GP Mentoring
  • Addiction Medicine Specialist advice
  • Educational events
  • Support to access training
  • Practice support – e.g. MBS item numbers (see flyer for details). 

Contact the Area 4 Pharmacotherapy Network (A4PN) via email A4PN@semphn.org.au or phone: 0428 785 371.

References

1. Therapeutic Goods Administration. Codeine information hub. 2017  [cited 2017 October]; Available from: https://www.tga.gov.au/codeine-info-hub.
2. Nielsen, S., J. Cameron, and S. Pahoki, Over the counter codeine dependence. 2010, Turning Point Alcohol & Drug Centre: Melbourne, Australia. p. 79.
3. Association, A.P., Diagnostic and statistical manual of mental disorders (DSM-5®). 2013: American Psychiatric Pub.

EVENTS AND EDUCATION ABOUT CODEINE RE-SCHEDULING

23
Jan
  Victorian Opioid Pharmacotherapy Program- Part 2
Pharmacists
Webinar- attend via live streaming on mobile phone, tablet or computer.
Details and registration
 
6
Feb
  Codeine Rescheduling - Practical Tips for GP, Pharmacy & Practice Readiness
GPs, Pharmacists, Practice Staff and AOD Workers
Glen Waverley
Details and registration
 
11
Feb
  Victorian Opioid Pharmacotherapy Program- Part 1 &2
Pharmacists and Pharmacy Assistants
Cranbourne
Details and registration
 
18 Feb   Medication Assisted Treatment for Opioid Dependence (MATOD) - Module 2
GPs, Nurse Practitioners
Details and registration
 
6
March
  Managing codeine presentations and lessons learnt thus far
Doncaster
Details to follow - save the date!