I was reading an article recently about opioid prescribing in non-cancer pain and it got me thinking about the increase in codeine prescribing (for pain specifically) I have seen locally over the past 1-2 years. Personally, I have seen a rise in younger people requesting codeine first-line for pain relief and patients of all types over-requesting their repeat prescription of opioid medications in recent times.
This blog post is going to concentrate mostly on codeine phosphate prescribing but I will first explain what opioids drugs are. Prescription opioid drugs include the painkillers codeine phosphate, dihydrocodeine, tramadol, buprenorphine and oxycodone amongst others: these are ‘controlled’ drugs, which means their manufacture, supply and possession are monitored. Controlled drugs are separated in to different schedules depending on their safety/risk profile and codeine is ‘schedule 5’ which is the ‘mildest’ category more information is found on the BNF website (https://bnf.nice.org.uk/guidance/controlled-drugs-and-drug-dependence.html).
Here’s a bit more of the science…
Opioids are derived from the opium poppy but some are now purely man-made i.e. synthesized in a lab. This group of drugs act on the opioid receptors in the brain to produce morphine like effects: blocking pain signals and in some, giving a sense of euphoria, also known as a ‘high’ which can make this group of drugs potentially addictive.
Why prescribe these drugs in the first place?
I prescribe codeine phosphate because it is an effective painkiller for short-term acute pain. If NSAIDs are not advisable and the patient needs something stronger than paracetamol, there are limited options. Codeine can be a good drug if used appropriately, and I don’t want to worry the thousands of people taking it correctly under good medical advice. I, myself, had to resort to codeine on two occasions: I had pyelonephritis (kidney infection) in pregnancy and nothing else touched the pain and secondly I had a trapped nerve in my neck/shoulder (worse than childbirth pain!). My husband thought I was drunk after taking it on that occasion! Not something I would rush to take again but would consider it in the right circumstances.
A working example
Let’s use a case study to help show how it might work in practice:
A 33 year old patient comes in to the practice with a two week history of muscular low back pain, the is no radiation of pain in to the legs and no other concerning features. The patient has tried paracetamol for the pain.
I would generally advise:
- rest – i.e. avoid aggravating movements/exercise
- gentle exercises (usually give a leaflet or sign post to useful websites)
- non-steroidal anti-infammatory drugs (NSAIDs e.g. ibuprofen or naproxen)
- allow time (6-8 weeks) to heal
- If no better then self-refer to physio in 6-8 weeks
- reattend the surgery if new symptoms
NSAIDs, unfortunately, do not suit everyone; patients with asthma should avoid using them, those with stomach issues may not get on with them and they can interact with other drugs e.g. blood pressure medication such as rampiril or anticoagulants (blood thinners) like warfarin.
So what if we can’t advise stepping up from paracetamol to ibuprofen? The next step up would then be a codeine containing drug.
The how does addiction occur?
The issue with addiction arises when these opioid drugs are used long term as the body can become tolerant to their effects. In some patients, higher doses may be required to act on the pain, and hence dependence slowly creeps in.
Patients can access codeine in other ways apart from a GP prescription; mild (8/500mg) co-codamol (codeine phosphate and paracetamol) is available from pharmacies over the counter. Stronger doses (15/500mg or 30/500mg) are sometimes issued from online doctors/pharmacies and may also be prescribed by hospital doctors or out-of-hours GPs. On occasion, a patient will ask a relative or spouse to ask for a codeine prescription for their own benefit.
Addiction usually becomes apparent when a patient requests codeine too regularly or a pharmacy contacts us to inform us a patient is attending repeatedly.
How can we avoid addiction?
I have changed my discussion with patients around opioid prescriptions over the last year. I will make it clear codeine is for short term use only and to be used alongside other treatments such as physiotherapy or acupuncture.
If there is concern about over-use then adding the drug to the repeat list can actually make it much easier to monitor. We can set how many issues of a particular prescription can be done in a certain time scale and specify a GP or in-house pharmacist review at any point in the future. I will not issue extra medication if a prescription is lost. The system allows us to add alerts or ‘reminders’ to the patient’s notes if there are concerns and this will flag up to any prescribing clinician to be even more careful with prescriptions of opioid drugs.
It is important to discuss the potential side effects of codeine when first prescribing; constipation, nausea, dizziness and drowsiness are common. I now raise the potential for addiction in the circumstance that the medication is not used appropriately. I specify that the medication should only be used for a specific time period and at the prescribed dose.
I think it is important, as health professionals, that we inform patients of this risk of tolerance and dependence. I have concentrated mostly on codeine prescribing here as I think it is the first drug to tackle as it is easily bought over the counter and sometimes too quickly prescribed by medical professionals, not just in general practice. Yes, it has a place in our prescribing arsenal, but should we be reaching for the prescription pad so often? We really need to think about the indication (reason) for the pain relief and consider both short and long term consequences of a prescription.
I wonder if codeine should be promoted to a Schedule 3 controlled drug like its distant cousin tramadol? This means prescribing would need to be tighter – fixed quantities and more monitoring on collection of the prescription both from the surgery and at the pharmacy?
Addiction to prescription medication is a growing problem and will affect both primary and secondary health care systems. It is making the papers more and more…Ant McPartlin of Ant and Dec fame has been the most recent celebrity to admit to addiction to codeine and tramadol. We are just at the tip of the iceberg and I think it is important to increase awareness to both avoid opioid addiction in the first place and to encourage affected individuals to seek medical advice and support.
If you or a relative needs support regarding prescription opioid drug dependence then do speak to your GP or access further advice at:
- If you are local to me in York then we have access to support from Changing Lives https://www.changing-lives.org.uk/services/drug-alcohol/