Pain pointers: How to prepare your pharmacy for codeine change

Preparing now for the up‑scheduling of codeine‑containing medicines to prescription-only will mean pharmacists are in a better position to inform and educate their customers.

February 1, 2018 will mark the end of over-the-counter (OTC) codeine-containing medicines and unsurprisingly for some, it’s a tough pill to swallow.

‘Consumers are really seeing it as their right to pain relief being taken away without anything else being put in its place,’ said CEO of Australian Pain Management Association (APMA), Elizabeth Carrigan.

APMA’s recent survey on codeine rescheduling found only 19 per cent of respondents believed they would not be disadvantaged by the changes.

‘About 75 per cent of respondents believe they will be disadvantaged by the changes and that’s because of the increased cost, difficulty in getting in to see a doctor or because they live rurally or regionally,’ said Ms Carrigan.

While the change may be hard for some, there are things pharmacists can start doing now to minimise the pain for themselves, their staff and their patients.

Not only that, but the change presents opportunities you should prepare to capitalise on.

PSA has been working to support members through the transition to Prescription-Only. PSA National President Dr Shane Jackson said, ‘We remain committed to supporting pharmacists to manage the planned change.

‘Community pharmacists have the skills, knowledge and expertise to advise patients regarding the effective and safe use of over-the-counter (OTC) analgesics for the treatment of acute, short-term pain. We also believe mandatory real-time recording of opioids including codeine is fundamental to addressing the issues we have with opioid misuse in Australia.

‘PSA’s position has always been that we support consumers continuing to have appropriate access to codeine containing OTC products with the advice of a pharmacist, while minimising harm from intentional or unintentional misuse by using a realtime recording system.’

Explaining the change

Whether you’re explaining the change to your staff or patients, pharmacists should stick to the public safety message behind the Therapeutic Goods Administration’s decision, said Clinical Pharmacist, Pain Educator and Pain Program Developer, Joyce McSwan.

‘Everyone will have an opinion on the decision but pharmacists have to be very clear on the facts to avoid confusion,’ said the Managing Director of PainWISE Pharmacy Professional Service program.

Those facts are that TGA has decided combination medicines containing codeine, which were previously available as S2 or S3 medicines, will be up-scheduled to S4 from 1 February 2018.

The official message from TGA is: ‘Research shows that current OTC low-dose (<30 mg) codeine-containing products offer little additional pain relief when compared to similar medicines without codeine.’

‘Codeine can be harmful. Health risks include tolerance, dependence, addiction, poisoning and, in high doses, even death.

‘In addition, the side effects of long term use of combination codeine medicines containing paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs), are also potentially life threatening.’

Ms McSwan added that it’s important to ensure patients understand the changes aim to protect them from opioid-related harms.

‘Otherwise they might feel invalidated, like they’re classified as some sort of addict or you’re simply being difficult and policing them,’ she said.

At the same time, TGA said it’s important that discussions around the impending changes don’t induce fear, distress or panic buying.

Preparing yourself and your staff

An extensive range of tools has been developed to help you prepare for the change.

PSA’s centralised codeine hub (www.psa.org.au/codeine) provides members with a suite of CPD, resources and information on PSA’s advocacy work related to codeine.

PSA and the Pharmacy Guild of Australia have also developed a series of online learning modules to help pharmacists and pharmacy assistants navigate the change.

The five-part series starts with an overview of the changes and likely impacts. It proceeds with modules on identifying acute versus chronic pain, transforming your business, exploring the principles of pain management and pain management in practice.

Pharmacists can expect additional content from PSA in the new year and following the scheduling change.

TGA has also produced a codeine information hub with numerous factsheets and guidance materials.

Preparing consumers

With three in four APMA survey respondents saying they believe the up-scheduling of codeine-containing medicines will disadvantage them, it’s important for pharmacists to start discussing the changes early, said Ms Carrigan.

‘This is especially the case for consumers who may not be able to access a GP easily because of location, cost or language barriers,’ she said.

‘Pharmacists are in a great position to educate consumers around the fact that probably low dose codeine may not have been that effective as a pain reliever anyway. And encourage them to try other pain relievers or topical preparations.’

Ms Carrigan added that those who are concerned about the changes should be allowed to talk to the pharmacist in a private area. TGA recommends using empathy and validation, while setting clear boundaries to help contain difficult behaviour and motivate positive change.

‘Evidence suggests that validation of the person’s pain is associated with increased satisfaction and reduced anger and frustration,’ TGA states.

After explaining the public safety reasoning behind the change and listening to a patient’s concerns, pharmacists should inquire as to the nature of their pain in order to determine an appropriate pain management pathway.

TGA’s Tips for talking about codeine resource has a list of common questions and sample responses to get you started.

You can also refer to PSA and the Pharmacy Guild of Australia’s decision-making tree for assessing and referring patients who present with pain.

Preparing your pharmacy

Helping patients navigate pain management pathways may require a range of changes to your pharmacy.

Neil Petrie, winner of the 2016 Pharmaceutical Society of Australia Award for Quality Use of Medicines in Pain Management, says firstly you need to ensure you’re accessible.

‘A pharmacist’s greatest asset is their knowledge and the consumer needs to have access to that,’ said Mr Petrie, Consultant Pharmacist with PRN Consulting.

‘One way is to look at your setup in the dispensary – maybe having a forward pharmacy setup.

‘Get out from behind the dispensing bench and into the pharmacy itself, sit down with clients to dispense their scripts and have a technician to do more of the technical role.’

Ms McSwan added that you may need to make changes to your workflow and rostering.

‘From a very basic level, make sure you build in service time because you need time to assess, then you need time to recommend,’ she said.

‘Have a look at your own workflow, what professional services your business is already offering, look at it on a support level, staffing level and rostering level and decide what sort of service you can deliver.’

Ms McSwan adds it will be important to have materials and stock on hand to streamline the process too. That could include organising your shelves so pain relief products aren’t literally all over the shop.

‘If you cannot run a case fast enough, that’s going to start costing you,’ she said. PSA has a counter card to encourage consumers to talk to their pharmacists about pain management and Self Care Fact Cards for pharmacists to use with patients.

There are also templates for letters of referral.

Navigating pain management pathways

With evidence suggesting that codeine-containing medicines are not effective for chronic pain, CEO of Painaustralia, Carol Bennett, said pharmacists need to play a critical role in a multi-disciplinary approach to pain management.

‘Pain is complex and sufferers are often in situations where they want to approach a trusted health professional and they need help to be expedient because they have work and lives to get on with, so it makes pharmacists very accessible,’ she said.

‘But it also means that the complexity of pain, in all its forms, is something that pharmacists really need to be across if they’re going to provide effective options.’

To that end, consider completing CPD-accredited courses such as PSA’s online learning modules on identifying acute versus chronic pain, and pain management principles and practice.

Ms Bennett also encourages pharmacists to visit Painaustralia’s resource hub which includes a vast collection of factsheets, reports and books, tools and apps, plus provider information and guidelines.

‘It’s absolutely essential to have a good understanding of the medication and non-medication options that are available, because for many pain sufferers medication has an important, but a limited, role to play,’ Ms Bennett said.

TGA advises that in addition to considering alternative OTC products, pharmacists should discuss non-drug options, such as a Tmachine, physiotherapy, complementary medicine (massage, acupuncture), exercise or lifestyle changes.

Ms McSwan added: ‘One of the biggest mistakes pharmacists make is being too quick to err on the side of caution and refer the patient on when in reality they have a huge role to play.’

Referrals

In many cases, following your assessment of the nature of pain, other factors and using your clinical judgement you will conclude that referring a patient is the best course of action.

Or for some pharmacies it may seem easier and less time and resource-intensive to simply refer those who present with pain.

But there are sustainable public health imperatives when it comes to playing an active role in pain management, said Ms McSwan.

‘If we don’t engage, the patient will not differentiate you from the next pharmacist,’ she said.

‘We need to make sure that if we’re referring out, there’s a way for that business to boomerang back.

‘That comes through good communication with allied health and engaging with services in our community.’

TGA and PSA recommend meeting with, calling or writing to local professionals and services – including doctors, physiotherapists, psychologists and pain management program providers – ahead of the changes.

Ms McSwan added that pharmacies should look at implementing a system where pharmacy students or assistants make follow-up calls to patients.

‘I don’t mean everybody but some prioritised cases need to be followed up, otherwise we’re missing out on engaging with a patient a second time,’ she said.

Public health

Ms McSwan said pharmacists have an ethical responsibility to play an active role in pain management, but it can also have remuneration benefits, as patients will return to a health professional actively engaged and interested in their care.‘

If we remove ourselves from the equation and every pharmacist goes ‘you know what, it’s too hard, I don’t have time, I’ll make my money out of something else’ there will be a missing portion in the health pathway,’ she said.

‘We need to acknowledge that we are an important part of the health pathway, remunerated or not. And for the sake of public safety we do need to play a role.’

Risks around suggesting NSAIDs

With OTC codeine-containing drugs off the table, there may well be greater demand for nonsteroidal anti-inflammatory drugs.

But of course NSAIDs are not without their risks – from gastrointestinal to cardiovascular and renal risks, among others.

It’s therefore critical that pharmacists gain a full understanding of the medication history of any customer seeking NSAIDs, said PRN Consulting’s Neil Petrie.

‘Pharmacists are in an ideal position to have an understanding of medical conditions and other medications that a customer is on. And we know about drug interactions,’ he said.

PainWISE’s Joyce McSwan added that it’s important pharmacists assess risks on an individual basis, rather than making a “conservative call” that stops patients accessing pain relief.

‘We’re more than capable of targeting that sort of evaluation from patient to patient. If we can’t do that, then what can we do?’ she asked.

‘The big thing is asking yourself: what is the clinical significance given that there are all these contraindications? Do they apply to that patient or not? If they don’t, great – supply the NSAID,’ she said.

‘If they do apply, at what level? Are NSAIDs okay for a couple of days? As a stat dose? Or are they not appropriate full stop?’

Finally, it’s important that patients know that anti-inflammatories are generally only for short-term use, Mr Petrie noted.

‘Make sure they understand the side effects they should be looking out for, give them some sort of expectation of when they should see some improvement in their condition, and what to do if no improvement occurs,’ he said.

Affected medicines

• Paracetamol
  500mg + codeine ≤15mg
  (e.g. Panadeine, Panadeine Extra, Mersyndol DayStrength)
• Ibuprofen
  200mg + codeine ≤15mg
  (e.g. Nurofen Plus, Panafen Plus)
• Paracetamol
  500mg + codeine ≤15mg + Doxylamine ≤5.1mg
  (e.g. Mersyndol, Dolased)
• Aspirin
  ≤500mg + codeine ≤15mg
  (e.g. Aspalgin, Dispirin Forte, Codis)
• Cough and cold medicines
  (e.g. Codral Original Cold & Flu, Demazin Day & Night Cold & Flu)

Timeline

1.  Staff awareness, training and protocols

Ensure pharmacists and staff are trained to advise on pain management options, handle patient queries and stock management. Complete PSA’s online training modules on managing the transition. Get familiar with PSA’s support resources, including referral letter templates and advice flowcharts (see PSA website).

2.  Stock management

Calculate projected sales and ensure stock until Feb 2018. Confirm supply arrangements and take steps to minimise excess stock. Consider a ‘Pain Power Wall’ stocked with pain medicines and other relief products.

3.  Consumer awareness

Display materials such as PSA’s pain management counter card and Self Care Fact Cards (see PSA website). Counsel patients and carers seeking combination analgesics containing codeine.

4.  Contact local health professionals

Call or write to local health professionals to inform them of the change (see PSA website for template).

5.  Offer additional professional services

Offer MedsChecks and medication reviews if clinically appropriate. Consider professional services to support patients, such as pain management and opioid replacement therapy.

6.  Research pain management support and information services

• Australian Pain Management Association
• Pain Management Network
• Painaustralia
• Department of Health Drug Help