Discussing the effects of codeine up-scheduling in general practice

Amanda Lyons

22/02/2018 2:47:43 PM

Dr Evan Ackermann, GP and key author of the RACGP’s Prescribing drugs of dependence in general practice: Part C, talks with newsGP about his initial experiences following the up-scheduling of codeine.

Dr Ackermann believes GPs have handled the process of codeine up-scheduling well before and after the recent changes.
Dr Ackermann believes GPs have handled the process of codeine up-scheduling well before and after the recent changes.

In the lead-up to the planned up-scheduling of codeine to a Schedule 4 drug, which took effect on 1 February, there were concerns within the healthcare community about so-called ‘armies’ of codeine-dependent patients who would descend upon GPs looking for prescriptions.
However, according to the experiences of Dr Evan Ackermann, GP and leading contributor to the RACGP’s Prescribing drugs of dependence in general practice: Part C, the up-scheduling has so far proven to be a relatively smooth process.
‘I’ve been surprised that there’s been very little impact with the up-scheduling, to be honest,’ he told newsGP. ‘Our practices have continued as usual. We haven’t seen the demand for extra codeine or extra alternatives to codeine.’
Dr Ackermann has found that patient queries about codeine have largely arisen during routine consultations.
‘It’s often been a simple, “How can I replace my Nurofen Plus? What can I take for alternatives?”’ he said. ‘So there hasn’t been the expected increased demand at all.’
Another surprise to Dr Ackermann has been the lack of negative feedback from his patients, who have mostly been seeking advice and reassurance. Conversations about codeine have also provided an opportunity to reassess patient issues with pain.
‘Most of the time it’s about the explanation that the alternatives [to codeine] are just as good,’ he said. ‘Sometimes it’s a matter of going through their pain, finding out the cause and then going through the options, including whether they really need medications at all.’
The process of pain assessment differs for each patient, but usually involves identifying their medications, whether their pain requires further investigation, and putting a management plan in place.
‘It’s a very standard approach and I haven’t seen too many patients unhappy with it,’ Dr Ackermann said. ‘In fact, what I have experienced is people who are happy to come along and talk about their pain, what’s causing it and what they can do about it.’
Anecdotally, Dr Ackermann believes the experience of codeine up-scheduling in general practice has been a good one.
‘I think GPs are handling this process quite well and providing good outcomes for patients,’ he said. ‘It has offered an opportunity to assess patients’ pain and provide a good plan, so I think there will be some good health outcomes from it.
‘I’m very positive about the change, I’m very positive about GPs handling it, and I think it will be seen in the long term as the right thing to do.’

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Mai Maddisson   23/02/2018 5:17:02 PM

Well, you are meeting the ones who want to talk and feel that they will be heard. Maybe you have more sophisticated consultation skills.
Perhaps we have yet to see the long term outcomes: We keep asking why the illicit drug use is increasing. Perhaps we should be watching the trends over the next few years in the usage of those.
The very people who are using its side effect as a calmative are the ones who have problems with gastritis, IBS, etc. By resorting to those will we see an upsurge of these symptoms as those patients will probably use larger quantities because unlike muscle strains the symptoms are not transient. Are we risking major GIT hemorrhage? And perhaps these patients have already done their own clinical trials and found the substance to be ineffective for their needs. The mind boggles at what they might reach out for.
Much has been written about renal issues with the use of panadeine: If used as a calmative let us not forget that BP rises with angst, especially frustration. Could the true issue be a complication of unresolved angst which will become more florid as we remove every accessible calmative from the market. Are the complications of hypertension any less desirable. I would think an CVA or MIA would be more devastating.
Maybe we need to use a wider panorama approach than focusing on single areas without looking at the broader picture.

Dr Pietas Nyamayaro   24/02/2018 12:36:08 PM

I think its a bit of an assumption to assume that if its not happening in your practice then its not happening anywhere else. Demographics differ and patient's reponse to certain GPs are very different to those they think they can walk over. I am seeing at least 3 requests of nurofen plus or mersyndol daily and mostly its for 'my migraine' which has never been really diagnosed by anyone other than the patient. Similarly my colleagues have been having the same experience. It is an issue and I think they should have been free services organised for all those that are addicted and cannot come off the codeine by themselves instead of leaving it to the GP. Addictions should be managed by people who deal with it daily and know what to do to help people come off these medications safely. Most GPs are just giving in or they flatly refuse to prescribe, rightly so but without offering any kind of support which is really beyond general practice scope for those truely addicted. This thing was not thought through at all. Always leaving everything to the GPs and throw in a few resources on this and that website and hope for the best. To add insult to injury, they give funding to the pharmacists who were majorly involved with creation of this problem so they can 'manage chronic pain' now, even though they are no longer going to be dealing with these patients anymore, and no funding for GPs who are now managing this problem the legislation helped create. I think its a very shabby move by the government.

Dr Evan Ackermann   2/03/2018 10:52:02 AM

Thanks for the feedback. Dr Pietas Nyamayaro I agree with the migraine presentation - I have commented about this before. Many have not had their migraine evaluated, and some are on the OCP as well. Hence it has been a positive health experience these patients getting a total re-evaluation of their pain and health. This is well within a GP routine practice.

Also agree that its problematic allowing a profession who contributed to an issue being given funding to fix "pain" which is outside their scope of practice. It needs to be exposed.

Mai Maddisson - I agree about the problem of addiction and that long term consequences are unknown. That's why Quality Committee is trying to implement ongoing surveillance of PBS prescribing, hospital presentations and mortality. Its a wait and see for now.

Mai Maddisson   11/03/2018 3:49:33 PM

'Its a wait and see for now.'

Dr Ackermann, sadly that is the truth. You (symbolically) have inadvertently cornered possibly the most vulnerable of the people who chose to resort to their use.

Australia is a very heterogeneous country with many people who have derived from overseas, at times with fudged documents mostly enacted by their parents. Given Australia's diverse demographics there is no way each doctor can to even begin to guess at what belies the inner angst of a given person in context of their origin and its history. Most doctors don't even know the local history all that well because, to get into medical school they need to join the scientific rat race. And even locals can have skeletons in their cupboards.

Out there are many people (a number which cannot be estimated) for whom solitude is their only minimally comfortable way of life. Belonging in any group depends on shareable life narrative. That which is not shared by commission becomes shared by omission. It does not take others long to arrive at the conclusion that a person's narrative has a glitch.
Our newscasts continue to blare the untoward of life's realities. For such people, to socialize they would be cast to offer some kind of opinion. Their escape becomes solitude: Too much solitude becomes desolation: Desolation is relieved by transient removal of a person from their world: SEDATION. Its need cannot be predicted by making a timely appointment, and the available doctor may be a total stranger with whom they have no wish to share that particular need.
I would put it to you that those people have nowhere to go except even more toxic chemicals.
As is emphatically written, panadeine is indeed a poor analgesic, but it is a very effective sporadic sedative/hypnotic. Unfortunately what is received between the ears has no way of being controlled short of turning off all the accessible means of news and not answering the telephone. Such people use the word pain relief as a decoy!

COULD I SUGGEST THAT WHEN A COLLEAGUE CHALLENGES WITH A VERY OUTFIELD SUGGESTION THE RELEVANT AUTHORITY CONTACTS THAT PERSON PRIVATELY- NOT pooh-pooh them : The latter may with gradual trust disclose more than they would disclose on an open forum.
I know that the hoards need to be protected from the side effects of OTC medications, but at times the failure to allow such medications to be obtained with anonymity may produce even more serious/debilitating side effects. Other minorities are respected: Why are that group not privy to the same respect!
The publishing authority does have an orthodox system for effecting contact between two clinicians in such settings.

Perhaps you and your colleagues might ponder on that.

Do remember that patients, via the grapevine, will gravitate to the doctors who perhaps have by chance discovered some anomaly.