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GPs not prepared for switch to prescription-only codeine, expert warns

Kate Aubusson
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Julia Proud cried when she was told she needed to stop taking her opioids.

"You feel invincible when you're taking them. The thought of feeling the pain again was too confronting," Ms Proud, 45, said.

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When the cure becomes the problem, the rise of prescription opioids.

The avid cyclist was first prescribed oxycodone and fentaynl​ after she was hit by a car in October 2012 and surgeons fused together her damaged vertebrae with titanium rods and a bone graft.

As months passed, Ms Proud found she could not cope without her painkillers. She had been given no step-down plan. She just kept collecting her opioid prescriptions.

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"You start to get twitchy as the drugs wear off. You just want to keep popping them," she said.

"It was like I'd had a lobotomy. I felt numb all the time and very depressed. I used to be a very active person with lots of energy," she said.

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GPs will be bracing for an influx of patients pleading for opioid painkillers when, in February next year, codeine products - including Panadeine and Nurofen Plus - will become prescription-only drugs.

But overstretched doctors are ill-equipped to cope with patients desperate for painkillers without more resources, warned addiction specialist Dr Simon Holliday, a strong advocate for the rescheduling.

The rural GP recalls a time when he wanted nothing to do with patients hooked on opioids

"I thought they were drug addicts who would nick my needles, manipulate me into writing prescriptions, threaten me and upset my other patients," he said.

When he became a grudging methadone prescriber, he thought so-called addicts would scare off his other patients and spell the end for his practice.

It never happened.

"I've been treating some of these patients for 20 years. They're like good mates," Dr Holliday said.

But a lack of support for time-poor GPs - reluctant to treat opioid "addicts" - will have them reaching for their prescription pads rather than search for alternatives ways to manage their patients' chronic pain and opioid dependence, he said.

"We need to recognise that this is a real dilemma for doctors, their patients and regulators," Dr Holliday said ahead of the Australian Pain Society conference next week, where he will run a session on pain and opioid management.

"We are going to find that an awful lot of people are going to present with an awful lot of pain," he said.

The Therapeutics Goods Administration's rescheduling decision came after reports of codeine addicts swallowing up to 100 tablets a day, and people "pharmacist shopping" to stock up on the drugs.

A small percentage of people will find it easier to buy opiates on the black market, but most will turn up in GP waiting rooms, Dr Holliday said.

"GPs will be put in a very difficult position. People who have been using opioids for a long time – sometimes 20 years or so – will come in saying they have extraordinary levels of pain. They'll say they're not addicts, they just need their opioids.

"I think GPs will feel very uncomfortable and ill-prepared. They'll be reluctant to hand out opiates, but won't know what else to do,"  Dr Holliday said.

"Opiates are dangerous because they're so fantastic. You so feel better initially, but you very quickly develop a tolerance"

Taking opioids for more than a week doubles the chances that patients will still be taking them a year later.

"It's like installing malware into the hard drive of your mind. It colours your priorities," Dr Holliday said.

Instead of feeding opioid dependence, GPs needed to be empowered to help patients taper off and use alternative pain coping strategies, he said.

But the current Medicare structure rewarded fast throughput, six minute-medicine, Dr Holliday said.

"Writing prescriptions is often the fastest and easiest way to do this.

"We need a system that supports doctors who take on these patients and take the time to understand them," he said.

Patients needed a multi-pronged approach including methadone programs, surveillance, non-pharmacological chronic pain management, psychological support and practical lifestyle changes.

"We need to think about what our patients eat, how often they exercise, how they sleep. We need them to take the focus off their pain and back onto their lives," Dr Holliday said.

A spokesperson for the Department of Health said the TGA is developing a strategy to help inform the community and healthcare professionals about the rescheduling changes.

Federal Health Minister Greg Hunt has requested the TGA launch its information campaign in April, ahead of schedule, work with pharmacies to alert the public to the problems of codeine misuse and dependency, and help customers transition to alternative products, the spokesperson said.

For Ms Proud, a combination of her pain management physician, opioid replacement drugs, physiotherapy, psychological support and lifestyle changes emboldened her to taper off opioids and manage her pain without drugs.

"It was hard and frustrating, but eventually, over the weeks, I started to see little improvements.

"The pain is never going to be completely gone. I had to grieve for who I used to be, but I have more control over my life," she said.

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