A report by Stephen Janz MPH, Clinic Director – Kenmore Centre for Health
The news that painkillers containing codeine will be restricted to prescription only from 1 February 2018 should not mean bad news to chronic pain sufferers. Codeine is one of a class of medications called ‘opioids’, which are originally based on the opium poppy. Medications which contain codeine such as Panadeine or Nurofen Plus have become a common self-treatment for many painful conditions. Stronger prescription-based opioids are also often used in the management of pain. The problem is that while these medications may give temporary relief, they do nothing for the underlying cause of the pain. Further they become less effective over time, requiring higher doses, often leading to other health problems, dependence and addiction (1). The widespread misuse of opioids is so extensive in the US that 100 people a day are estimated to die from it. The US has declared this ‘opioid crisis’ a public health emergency (2).
The new codeine restriction has placed the focus on non-drug pain management strategies, and in particular complementary and alternative medicines (CAM) (3-4). Many chronic painful conditions can respond to manual therapy, exercise and relaxation techniques – often reducing and sometimes eliminating the need for medication (3-4). The American College of Physicians recently updated their guidelines on treating low back pain (5). Based on the evidence the guidelines now recommend physicians offer CAM treatments such as acupuncture, massage, and spinal manipulation ahead of painkillers for acute and chronic low back pain, as well as yoga and tai chi for chronic low back pain (5). Other evidence-based guidelines recommend exercise therapy and acupuncture for shoulder pain (6), and the UK National Institutes of Health recommend acupuncture for migraine and tension headaches (7). A recent UK review identified that about 10 acupuncture treatments were effective in reducing several types of chronic pain, with some effects persisting for up to a year in some cases (8). Even the Australian government department of health has recommended that doctors, nurses and pharmacists direct patients to consider options such as massage, acupuncture, relaxation and exercise as an alternative to pain medication now that codeine is restricted to prescription only (9-11).
From 1 January new pain management standards require US hospitals to offer non-drug treatments for pain including acupuncture, massage therapy and chiropractic, or educate patients about them (12). Australia on the other hand has given no such mandate, despite the evidence. Australia was the first county in the western world to register Acupuncturists in its health system, yet the Health Minister continues to block improving access to qualified acupuncture treatment by refusing to incorporate Registered Acupuncturists into Medicare’s Chronic Disease Management Scheme. Fortunately, recent changes to private health insurance do not affect acupuncture or massage therapy, and people will continue to receive rebates from their private health funds for these treatments.
Changes are coming to pain management for some people, and your doctor remains best placed to advise on alternatives to painkillers in general and codeine based medications in particular. These changes shift the focus to strategies that address the source of the pain and quality of life rather than the symptom of pain in isolation. A comprehensive approach to chronic painful conditions and a renewed understanding of the role of manual therapy, CAM and exercise should leave many people better off with a safer longer-term solution.
- Chou R. The effectiveness and risks of long-term opioid treatment of chronic pain. Executive Summary. Rockville, MD: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services; 2014. Available from: http://www.ncbi.nlm.nih.gov/books/NBK258809/.
- Washington Post. News. https://www.washingtonpost.com/news/post-politics/wp/2017/10/26/trump-plans-to-declare-the-opioid-crisis-a-public-health-emergency/?utm_term=.30c373f0c3e5
- Heather Tick A N, Kenneth R. Pelletier, Robert Bonakdar, Samantha Simmons, Ronald Glick, Emily Ratner, Russell L. Lemmon, Peter Wayne, Veronica Zador. Evidence-Based Nonpharmacologic Strategies for Comprehensive Pain Care: The Consortium Pain Task Force White Paper: The Pain Task Force of the Academic Consortium for Integrative Medicine and Health. 2018.
- National Centre for Complimentary and Alternative Medicine (NCCAM). Chronic pain: in depth. Available from: http://nccam.nih.gov/.
- Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2017 Apr 04;166(7):514-30.
- Hopman K KL, Lukersmith S, McColl AR, & Vine K. Clinical Practice Guidelines for the Management of Rotator Cuff Syndrome in the Workplace. The University of New South Wales. 2013.
- National Institute for Health Care and Excellence. Management of migraine (with or without aura): NICE guideline CG150. In: National Institute for Health Care and Excellence, editor. 2012 (updated 2015).
- MacPherson H, Vertosick EA, Foster NE, Lewith G, Linde K, Sherman KJ, et al. The persistence of the effects of acupuncture after a course of treatment: a meta-analysis of patients with chronic pain. Pain. 2017 May;158(5):784-93.
- Therapeutic Goods Administration. Talking to your patients about the changes to codeine access: Information for pharmacists. Available from: https://www.tga.gov.au/sites/default/files/pharmacist-fact-sheet-talking-your-patients-about-changes-codeine-access.pdf.
- Therapeutic Goods Administration. Tips for talking about codeine: Guidance for health professionals with prescribing authority. Available from: https://www.tga.gov.au/tips-talking-about-codeine-guidance-health-professionals-prescribing-authority.
- Therapeutic Goods Administration. Codeine-containing medicines: Harms and changes to patient access. Available from: https://www.tga.gov.au/sites/default/files/consumer-fact-sheet-codeine-containing-medicines-harms-changes-patient-access.pdf
- The Joint Commission. Pain assessment and management standards for hospitals (2017). https://www.jointcommission.org/assets/1/18/R3_Report_Issue_11_Pain_Assessment_8_25_17_FINAL.pdf