Since the recent rescheduling of codeine, patients who have been taking over-the-counter products are increasingly presenting to their GPs. For this reason, we are highlighting this article, which featured in a recent Medicine Today supplement.
- If a patient requests a codeine prescription, first establish the reason they take codeine and their pattern of use.
- If a patient has been using codeine regularly over a relatively long period (e.g. more than a month), assess for likely dependence.
- A taper from codeine (e.g. with symptomatic medication or a medication such as buprenorphine–naloxone)is a reasonable approach in the first instance where a diagnosis of codeine dependence is not established.
- When a patient clearly meets criteria for opioid dependence, with a well-established pattern of daily high-dose use, and taper approaches have failed, consider medication-assisted treatment for opioid dependence (e.g. with buprenorphine–naloxone), with the support of alcohol and drug services for nonaccredited prescribers.
On 1 February 2018, codeine became a prescription-only medication in Australia. Many patients who take codeine are presenting to GPs and other healthcare providers asking for advice. Some patients may have been using codeine intermittently for acute pain in recommended doses, and others may have found themselves taking larger doses over a longer period (see the case of Julie in Box 1). This article outlines the recommended assessment and management strategies for patients who present with different levels of codeine use in general practice.
Why, how much, how often and how long?
The first step with patients presenting with over-the-counter (OTC) codeine use is to understand the underlying symptoms or conditions for which they are using codeine and to determine how likely they are to need help in stopping codeine. Are they taking codeine occasionally for acute pain or daily for chronic pain? Are they taking codeine for nonpain reasons, such as in response to stress, anxiety or insomnia?
The next step is to assess the pattern of codeine use and ask patients what happens when they do not take it. This information will help determine whether they have developed opioid tolerance and show signs of opioid withdrawal on cessation. These symptoms may be part of a pattern of opioid dependence. However, opioid dependence (as defined by the International Classification of Diseases [ICD-10]) goes beyond neuroadaptation to opioids (with tolerance and withdrawal) to include behavioural components such as craving, continued use despite ill health or other harm and loss of control over use.
Assessment of patients taking codeine should cover:
- current codeine use (reason, dose, route of administration, duration and symptoms on cessation)
- other medication and alcohol, nicotine and substance use
- mental health and physical comorbidities
- social circumstances
- physical examination (including signs of opioid toxicity and withdrawal; see Box 2)
- investigations (e.g. urine drug screen, liver function tests, full blood count)
- how difficult the patient thinks it may be to go without codeine and whether they experience opioid withdrawal symptoms when they go without codeine
- whether the patient is exceeding maximum doses, buying codeine from multiple pharmacies, obtaining prescriptions for codeine or other opioids or hiding their use from others.