Physiotherapist fact sheet: Talking to people about the changes to codeine access

Information for physiotherapists

Codeine became a Prescription Only Medicine on 1 February 2018. As a result, all codeine-containing medicines are no longer available without a prescription. The Royal Australian College of General Practitioners (RACGP) have encouraged general practitioners (GPs) to refer patients to physiotherapists as an alternative to prescribing codeine. Physiotherapists should be prepared to discuss the changes with patients who may desire, but can no longer access, codeine‑containing medicines.

About the change to codeine access

There is high-quality evidence from a systematic review (which includes 14 randomised controlled trials) that over-the-counter codeine-containing medicines offer modest pain relief (around 12 points on a 100-point pain scale) in the immediate term (three hours post ingestion) when compared to placebo. However, the same review also shows that these products offer little additional pain relief compared with other medicines without codeine. For full access to the review and evidence report, please see Review of the efficacy and safety of over-the-counter codeine combination medicines

Codeine can be harmful. Health risks include tolerance, dependence, addiction, poisoning and, in high doses, respiratory failure and death. Additionally, side effects of long-term use of combination codeine medicines containing paracetamol or nonsteroidal anti-inflammatory drugs (NSAIDs) are also potentially life threatening.

The balance of modest benefits and potential for severe harms and abuse led the Therapeutic Goods Administration to make codeine a Prescription Only Medicine.

For more information, please see Codine Information Hub.

Providing physiotherapy care as an alternative to opioids

1) Show Empathy

Some people may express feelings of frustration as a result of being referred to a physiotherapist. This may be due to past positive experiences with intermittent use of codeine. Other people may have never taken opioids before and were referred to physiotherapy due to their GP being reluctant to prescribe opioids.

People respond best when conversations are framed around protecting them from opioid-related harms and when they recognise you have their best interests in mind. This includes informing them on the physiotherapists role in pain treatment. The role of the physiotherapist is to assess pain thoroughly and to provide people with effective non-medicinal options for pain relief. People may be unaware that non-medicinal treatment options can provide equivalent pain relief to opioids, with fewer side effects (Dispelling the myth that chronic pain is unresponsive to treatment, BMJ Journals Volume 51, Issue 13).

2) Perform a focused and comprehensiveclinical assessment

As with most primary care assessments, a key role of the initial interview is to identify people who may have a serious cause for their pain. People with clinical features of serious pathology (red flags) require appropriate monitoring or referral. Ensure those exhibiting signs of a substance abuse disorder (e.g. reporting work or family problems related to opioid use) or who are withdrawing from long-term opioid use, have adequate medical, psychological, and social support.

In addition to the usual history and physical examination, some useful questions to gauge psychosocial influences on pain include:

• What concerns you the most about your pain?
• Have you been told what is causing the pain?
• Were there any major changes or stresses in your life when the pain started or increased? This is important as we now know that stress can sometimes increase or prolong pain related to a given injury.
• Can you tell me a bit about bout your usual sleep, diet and exercise regime?

Some of the psychosocial determinants of pain and related disability can be assessed formallyusing validated questionnaires such as the Pain Catastrophising Scale.

Clinical guidelines now suggest using validated prognostic screening tools, which combine information from a series of psychosocial questions for low back pain. These tools help guide discussions about recovery and the intensity of physiotherapy management required. Examples for low back pain include the STarT Back Screening Tool and the PICKUP Tool.

3) Provide reassurance

Briefly explaining a person’s symptoms can reduce fear and concern about pain (Effect of Primary Care–Based Education on Reassurance in Patients With Acute Low Back Pain, Systematic Review and Meta-analysis). Acute pain with a clear nociceptive origin, for example an ankle ligament injury, is straightforward to explain. However, pain without a clear origin can be more challenging, for example, non-specific low back pain, and many types of chronic pain cannot be explained using a specific pathoanatomical diagnosis. Consider explaining these non-specific pain conditions within the broader biopsychosocial context of pain. There are free resources available to help explain pain ‘in less than 5 minutes’.

Rather than providing diagnostic labels, which can increase concern and promote unnecessary tests and treatments, focus discussions about pain on the person. Which biopsychosocial factors from the history and examination appear to be contributing to this person’s pain? Discuss the results of prognostic screening. Are there any unhelpful beliefs that need to be addressed? Some people may not be aware of how complex and adaptive pain can be. For example, they may not know that:

• Opioids are not very effective for chronic pain and have substantial risk for harms.
• Severe pain is not necessarily a sign of severe damage. It is often possible for physiotherapists to detect serious problems through careful questioning.
• Pain is 100 per cent an output of the brain and therefore influenced not just by nerve signals from the tissues, but by one’s thoughts, beliefs, emotions and social environment.
• Humans produce their own opioids after exercise, laughter and some physical treatments such as massage.
• Pain systems sometimes become sensitive and can overestimate potential for tissue damage. This can lead to severe pain in the absence of any serious injury.
• Pain system sensitivity can increase temporarily after stopping long-term use of opioids. That means more pain initially, along with other withdrawal symptoms, including anxiety, nausea, restlessness, sweating, vomiting or abdominal pain (see The Conversation article in Useful resources for clinicians).

4) Discuss and implement a management plan

Not everyone needs complex care. Acute musculoskeletal pain often resolves over time with minimal intervention. People should be informed of this. Chronic pain can also resolve over time, but may require additional support. Consider using a prognostic screening questionnaire to help identify people at risk of long-term pain. There may be a number of beneficial evidence based physiotherapy interventions to choose from compared to no treatment. See the PEDro database for up-to-date evidence. Consider engaging in a shared decision making process to formulate a management plan. A two-hour, freely available shared decision making course is available via the: Australian Commission on Safety and Quality in Healthcare.

Present evidence-based physiotherapy options for pain relief alongside any potential harms. Always offer the option of self-care and watchful waiting.

5) Monitor outcomes

Use a combination of patient reported outcome measures to monitor progress and set goals, including pain intensity scales (e.g. 0-10 numeric rating scale measuring current and average pain over past week) and functional scales (e.g. patient specific functional scale, condition-specific disability questionnaires). You may need to refer to other health professionals if there is no progress with non-medicinal care, signs of substance abuse, difficulty tapering opioids (see Useful resources for clinicians), worsening clinical anxiety or depression, or family or work problems.

Useful resources for patients

• painHEALTH
• Pain Course
• MyBack

Useful resources for clinicians

• Codeine information hub
• Pocket Guide: Tapering Opioids for Chronic pain
• Thinking of taking opioids for low back pain? Here’s what you need to know