For pharmacists - talking to your patients about changes in codeine access

• Analgesics  - codeine-containing combination medicines, available under brand names such as Panadeine, Nurofen Plus and Mersyndol, and pharmacy generic pain relief products.
  
• Cough, cold and flu products - codeine-containing  medicines, available under brand ranges such as Codral, Demazin and pharmacy generic cough, cold and flu medicines.
  

Patients respond best when conversations are framed as protecting them from opioid-related harms and when they recognise you have their best interests in mind. If a patient specifically requests codeine-containing products, it is important to establish whether the pain is a symptom or disease. This will help with your recommendation of treatment or referral process.

There are numerous over-the-counter medicines available for treating cough, cold and flu symptoms which do not contain codeine. Use your clinical knowledge to determine an appropriate alternative treatment.

Acute pain generally resolves within 3 months. The cause is usually known and the pain disappears when the injury or illness heals. If over-the-counter medicines do not adequately treat your patient's acute pain, you could recommend other self-management resources or refer them to their GP for further diagnosis and treatment.

Chronic pain lasts longer than 3 months and continues even when the injury or illness has healed. Codeine-containing medicines should not be used for chronic pain. Discuss alternative pain relief options with your patient which are consistent with the quality use of medicines principles. Chronic pain that cannot be adequately treated in the pharmacy should be referred to a GP. This will allow for optimal management with consideration for multidisciplinary care models and non-drug or self-management approaches (see the Know your options section below).

As a pharmacist, a complete diagnosis of substance use disorder (SUD) is outside of your scope of practice and referral to an authorised prescriber is necessary for detox/management. However, you will be able to establish if there is a possibility of SUD, such as tolerance or dependence. Even when doses do not exceed the maximum, dependence can develop, and withdrawal symptoms can emerge on cessation. Symptoms of withdrawal may appear as the worsening of a pain condition (e.g. re‑emergence of headaches, muscle pain, cold and flu symptoms).

Don't assume that if someone asks you to assist them with pain that they are looking for medications. You may want to suggest the use of alternative products that are available over-the-counter; discuss non-drug options such as a TENS machine, physiotherapy, complementary medicine (massage, acupuncture), exercise or lifestyle changes; or advise the patient to discuss their pain and cough, cold and flu management options with their GP.

There are also other online self-management resources that may assist your patient. See 'Chronic pain management' and 'National support services' under 'How and where to get advice' in the TGA codeine information hub.

Before 1 February 2018, some consumers may have 'stockpiled' codeine-containing products, currently available over-the-counter, fearing an inability to access these medications post 1 February 2018.

Medication stockpiling involves a person obtaining and storing an excessive amount of prescription or non-prescription medicine for later use

• After 1 February 2018 there are still pain relief options. Your patients can access prescription medicines if and when they need them by consulting with their GP or other health professional with prescribing authority.
  
• Storing excess quantities of medicine can be dangerous and the potency and effectiveness of a medicine that has been stored for an extended period of time cannot be guaranteed.