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Rural and remote health practitioners are being primed to offer alternative treatments to opiate codeine to consumers after the drug became prescription-only earlier this year.

Since February, codeine-containing medicines became unavailable over the counter in pharmacies across Australia without a prescription.

The rescheduling created unique considerations for rural and remote health practitioners and their consumers accustomed to using codeine to manage pain for a variety of conditions.

Responding to changes, the Australian College of Rural and Remote Medicine (ACRM) held a series of webinars earlier this year aiming to prepare rural GPs and other health practitioners, including nurses and nurse practitioners, for the transition period by educating them on the most appropriate form of treatment for their consumers moving forward.

The webinar series, funded by the Commonwealth Government via the Therapeutic Goods Administration (TGA), included backing from CRANAplus, the National Rural Health Alliance and Rural Doctors Association of Australia.

Addressing the webinar, addiction medicine specialist Dr James Finn pointed to widespread evidence showing significant misuse of codeine in Australia plus how it is no better for relieving chronic pain than other over the counter medicines such as paracetamol and ibuprofen.

He said codeine was the most widely used opioid in Australia, with more than 15 million packets of over the counter codeine containing drugs sold annually, prior to its rescheduling.

Codeine is a prodrug that converts into morphine and commonly causes physiological and psychological dependence, he added.

Dr Finn said users of codeine, ranging from occasional to regular, would now likely present to GPs seeking prescriptions.

He said it was important health practitioners learn to spot red flags indicating drug-seeking behaviour and use resources like opioid risk assessment tools to screen patients.

He said health practitioners should encourage their patients to use non-pharmacological methods of pain management and steer them through any associated withdrawal period.

“We have to prepare the patient for withdrawal. We have to educate and reassure the patient regarding the possible symptoms of withdrawal, including the expected severity and duration,” Dr Finn said.

Also speaking during the webinar, pain specialist Dr Suyin Tan highlighted pain management as a significant problem.

Dr Tan argued rural areas tend to experience higher rates of opioid prescription, which becomes a default management strategy, due to the lack of access to alternative approaches to managing pain.

She said our societies were “awash with opioids” but evidence does not support their efficacy in treating chronic non-cancer pain.

Dr Tan encouraged health practitioners to look beyond turning to opioids and instead address possible underlying contributors to pain such as psychological factors that trigger depression and anxiety and improving social support and physical activity.

“You have to engage with them and that means having a conversation with the patient where you explain that opioids are not a long term strategy and that there is a very high risk of harm and as time progresses they’re more likely to suffer harm than benefit.

“[It’s great] if you’ve got nurses in your practice who can do some form of counselling and just help to change the conversation away from drugs and medication onto managing people’s distress in non-pharmacological ways.”

In the second webinar, Alice Springs based pharmacist Tobias Speare, who facilitates education for Remote Area Nurses (RANs) and Remote Area Nurse Practitioners, said a holistic multi-disciplinary approach including nurses, GPs, specialists and Aboriginal health workers, could synergise pain management strategies and improve patient outcomes.

Mr Speare said about 20-30% of patients prescribed opioids for chronic pain misusd them and that hospitalisations for prescription opioids poisoning doubled from 1998 to 2009, exceeding hospitalisations for heroin.

“Opioid analgesics are associated with substantial risks and there are effective alternatives. The pharmacology of codeine is variable, which adds an additional risk to the use of codeine on patients and it should be avoided in high-risk groups.”