Managing acute pain: the codeine problem

When you’ve got acute physical pain, it’s difficult to think about much else — all you want is relief as you reach for a painkiller to take it away. This has been happening ever since The Rolling Stones sang about Mother’s Little Helper in the 1960s.

Since the 1980s, some of the “helpers” we’ve reached for more often are codeine-based painkillers available at the chemist. From now on, though, these products will only be available if you see a doctor and get a prescription.

If you suffer from migraines, arthritis, back pain, a pinched nerve, or anything that causes you serious discomfort, you may not be happy to hear that your Panadeine Forte or Nurofen Plus is no longer at the pharmacy.

So why the over the counter codeine ban?

“The world has been in the grips of an opioid epidemic and that includes Australia," says Dr Tony Bartone, Vice President of the Australian Medical Association (AMA). In fact, codeine-based opiates kill more Australians than so-called “hard” drugs such as heroin.

The Alcohol and Drug Foundation says that between 2001-2012, opioid overdose resulted in the death of nearly 8,600 Australians. Nearly 60 per cent of these deaths were due to pharmaceutical opioids (of which codeine is the most popular), while fewer than 34 per cent were due to heroin.

This and other statistics has resulted in the regulatory body, the Therapeutic Goods Administration (TGA), changing the rules in a bid to stop codeine addiction, misuse, and deaths.

According to recent research, the potential for misuse is high: Around 35 per cent of Australians (or one in three) have bought a codeine-based painkiller in the last year, with many stockpiling them before the TGA change. But is there any real need to do this?

Not at all, says Dr Bartone. He says we’re catching up with the rest of the world — including the US, Japan, and Europe — in making codeine harder to obtain.
“[Classifying codeine as a Schedule 4 prescription-only drug] is international best practice. Codeine needs to be treated with respect — it is a narcotic. Not only that, research has found that it’s actually not that effective in managing long-term acute pain.”

This is backed up by research which found one in four Australians who’ve taken codeine in the past year admitted their pain is still not under control.

He says the fact that there has been a lot of talk about codeine in recent months is a good thing, for both doctors and the community, as the issue of implementing better long-term pain management strategies for patients is coming into sharper focus.

“Part of this involves educating the community. The TGA’s decision reflects our need as doctors to keep society safe,” he says.

“We have to have a conversation with patients about the nature of their pain and how to manage it effectively. And we already have better over-the-counter products for short-term acute pain at the chemist. For long-term pain, what’s needed is consultation to implement a pain management plan.”

He says he is in favour of a national real-time monitoring system to guard against “doctor shopping” by patients showing signs of codeine dependence. Tasmania has such a system in place and Victoria has one on trial. Dr Bartone says there’s impetus now for all states to jump on the bandwagon.

Finding the real cause of chronic pain
Chronic pain specialist Dr Chris Hayes also believes the TGA’s decision is a good one. “As a society, we tend to go for the easy fix but from where I sit medically, we spend a lot of our time nudging people away from that,” he says.

He believes patient pain management needs to be dealt with far more holistically than it often is by doctors currently, including offering patients with chronic pain a reassessment of their lifestyle choices.

“Pain management needs to cover psychological, physical, nutritional, and social aspects. When it comes to chronic pain, these are often all contributing causes,” he says. “It’s often about the need to change thought processes: retraining the brain and the nervous system."

“Something that is not talked about much is the need to give people hope, rather than focusing on the drug. This occurs through giving people encouragement, but also looking at their core beliefs, and at what else is happening in their life. What was going on, for example, when the physical pain first began?”

“Factors such as a person’s cardiovascular health, their diet, their ability to relax or be mindful — all this can have a huge influence on their relationship with chronic pain,” he says.

He adds that social isolation can also be a big factor as these individuals are often anxious, with their nervous system in constant “alert mode” — something which only exacerbates chronic pain.

Have you been using codeine to alleviate regular pain? What are your thoughts on the ban?

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