Longer-term treatment with buprenorphine–naloxone should be considered when there is a clear diagnosis of opioid dependence, including difficulty controlling use, continued codeine use despite harm, clear tolerance and withdrawal symptoms on cessation. For some people with codeine dependence, ongoing treatment with buprenorphine–naloxone or methadone has been lifesaving.
Over the next few months, as patients present to their GPs requesting codeine or reporting previous OTC codeine use, careful assessment may identify unmanaged tolerance or opioid dependence. The change in codeine availability may provide an opportunity for better management of chronic pain conditions. Depending on the pattern of codeine use, different management strategies may be appropriate. For most patients who report infrequent codeine use, alternative nonopioid analgesia will be appropriate. Where patterns of high-dose use are identified, medication-assisted treatment in consultation with drug and alcohol experts may be required. Where the level of opioid tolerance and dependence is unclear, supporting the patient to cease codeine in the short term is recommended in the first instance. MT
COMPETING INTERESTS: Dr Nielsen has been an investigator on projects supported by untied educational grants from Indivior, and has received travel expenses and/or received honoraria to speak on codeine dependence or related topics from Indivior, Pharmaceutical Society of Australia, TGA, Pharmacy Guild of Australia, Royal Australian College of General Practitioners, Primary Health Networks and Drug and Alcohol Networks around Australia. She is currently the recipient of an NHMRC Fellowship (#1132433). Dr Wilson has been paid honoraria by Indivior to present educational activities. Associate Professor Clark and Dr Reynolds: None.
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