Understanding codeine addiction – Dr Adrian Reynolds

Understanding codeine addiction – Dr Adrian Reynolds


My name is Adrian Reynolds. I am the Clinical Director of Tasmania’s Alcohol
and Drug Services and I’m the President of the Royal Australasian College of Physicians
chapter of addiction medicine. As of the 1st of February 2018 all compound
analgesics containing codeine will no longer be available over the counter and they now
require a doctor’s prescription. I’m here today to talk to GPs about how to
manage patients who present or are referred to them as a result of recent up-scheduling
of codeine containing medicines. As a doctor specialising in addiction medicine
I see and am very aware of the wide ranging harms associated with these medicines and
they include an alarming increase in the number of over dose related deaths and a range of
other medical harms. I therefore strongly support the recent up-scheduling
of these medicines. This is a rich opportunity for GPs to provide
high quality care to their patients who are finding themselves in difficulty as a result
of using these medicines. In diagnosing opioid dependence the key indicators
are a loss of control, patients describing a craving and compulsion to use, continuing
to use despite a range of harms including medical harms and also obtaining and using
these medicines becomes more important than other life priorities. If this is the case the GP should remain non-judgemental
but have a clear and honest discussion with the patient about what is going on in their
lives, the problems that these medicines may have contributed to and work through how the
GP can assist the patient to arrive at a better treatment plan that is safer and that is going
to be more effective for them. In assessing the patients who present with
problems related to these medicines the first thing is for the GP to assess whether there
is evidence of sedation or intoxication or opioid withdrawal signs and symptoms. That gives the GP a very good head start in
determining whether they can treat the patient safely and with confidence or whether they
may need to consider a referral to an addiction medicines specialist. There are a range of tools that are also available
to GPs and these tools will be made available on the website. They include a codeine screening tool, there
is a clinical opioid withdrawal scale that doctors can access and that gives them objective
signs to examine for in the patient and there’s a scoring regiment that goes with the COWS
and that gives them some indication of the presence and the level of dependence and
there are a range of other drug and alcohol related assessment tools. For example, the audit tool that patients can
actually self administer in the waiting room to assess whether there are other drug and
alcohol problems, in this case an alcohol dependence and then there are further tools
such as the ASSIST, which is a WHO tool, to assist the presence of other drug problems
in the patients. That assessment allows the GP to have more
global assessment of whether this patient has and the extent of their drug problem and
also informs them whether they can they can treat the patients themselves or once again
whether they need the advice or direct support of more specialised drug and alcohol services. If a GP is waiting for their patient to be
seen by an addiction medicine specialist the first key consideration is patient safety. Patient safety really depends on what medicines
the patient’s actually been taking, how much, for how long and related harms that may have
already arisen. Also, of course other medical and mental health
issues need to be assessed and considered. It’s really important that the doctor not
jump to prescribing other psychotropic medicine that alter the way people or their patients
think, feel or behave. What we don’t want doctors to do is jump to
prescribing other medicines that are low value and high risk. The reason these medicines were up-scheduled
was to address that very problem. Once your patient starts seeing an addiction
medicines specialist it will be important for you to remain involved in their care. Not only the treatment of their other medical
conditions but the treatment and management of their opioid problem that has been identified. It will be really important for you to continue
working in parallel with the addiction medicines specialist and to be providing coordinated
care with the patient’s best outcomes. With the states and territories there are
specialist drug and alcohol services and doctors who specialise in addiction medicine and GPs
should be forthcoming in contacting those specialists services and health professionals
for advice and indeed what GPs will find is those specialists services are very keen to
up-skill GPs to provide training and support to them. There aren’t enough addiction medicine specialists
in the country to see every patient who presents with an alcohol or other drug problem so it
really is vital that GPs do up-skill and develop their confidence to assess and manage patients
presenting with codeine problems and other drug and alcohol problems. This is really a rich opportunity for doctors
to help patients whose lives may being dominated by their addiction. It’s an opportunity for doctors to free patients
from the chains of addiction and help them to get on with their lives. It’s a chance for doctors to help patients
achieve better health outcomes today and into the future. To learn more about the codeine rescheduling
decision visit nps.org.au/otc-codeine

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