Published on Insights+ with MJA on 19 February 2018
This is the second article in a monthly series from members of the GPs Down Under (GPDU) Facebook group, a not-for-profit GP community-led group that is based on GP-led learning, peer support and GP advocacy.
UNLESS you’ve been asleep under the proverbial rock, you will be aware that the Therapeutic Goods Administration (TGA) rescheduled all previously Schedule 2 and 3 codeine-containing products to Schedule 4 (prescription-only) of the national Poisons Standard from 1 February 2018.
The lay and medical media have had a field day during the period surrounding this rescheduling change. In parallel, the number and range of discussions on GPDU’s Facebook page also increased over this period. This article will outline some of the main concerns arising from these discussions, including the problems that GPs had identified, along with the many solutions that have been shared.
Awareness and advocacy
While much of the discussion regarding changes in codeine occurred in January and February 2018, the discourse related to the rescheduling had begun in 2015, during the period when the TGA was accepting submissions for its rescheduling decision. GPs were discussing de-identified cases of over-the-counter codeine-dependent patients they were seeing and debating how such a change to prescription-only may affect clinical practice, in terms of potentially seeing more dependent patients and knowing how to clinically manage them.
Other members were incorporating the diverse GP viewpoints into TGA submissions, advocating for the important role of general practice-based assessment and management of both pain syndromes and opioid dependence.
It is clear from recent posts on the page that many GPs had only become aware of the changes relatively late.
One of the key areas of concern for GPs is how this change may alter their relationship with patients. For many, it was seen as an opportunity to engage a relatively “hidden” population in better managing their pain. For others, the issue of safety within the consultation room was raised, with some GPs worried about a potential increase in angry or dependent patients contributing to challenging patient–doctor dynamics. The responses provided advice on how to defuse anger, refocus a consultation’s clinical attention and reframe this “challenge” into “a clinical opportunity”.
Much of this discussion then focused on the best management of pain and of the potential addiction from codeine misuse in some patients. Media-promoted pharmacy and community concerns about lack of access to codeine-containing analgesia for migraines, menstrual, dental and musculoskeletal pains triggered GP discussions and sharing of resources on first-line (non-opioid) pain management approaches for these common conditions.
With a greater focus on the more limited role of opioids, including codeine, in pain management and the potential adverse effects of opioid therapy, discussions then turned to how to deal with patients presenting with, or assessed to have, codeine dependence or addiction. Conversations explored the criteria for opioid use disorder, and the role and variable access of medication-assisted treatment of opioid dependence around our nation. GPDU members, through the Royal Australian College of General Practitioners (RACGP) Victoria Faculty, put together a webinar dealing with these concerns, which generated further GPDU activity about treating dependent patients with medications such as buprenorphine/naloxone in the community.
Some GPs took the opportunity to reach out with their own personal concerns about this change contributing toward the stigma of chronic pain and the use of opioids. Other colleagues disclosed their own difficulties with living with chronic pain and shared their fears, echoing the sentiments of many of our patients. Within the forum, there were many examples of peer support for these colleagues, expressing thanks for their bravery in sharing their accounts, validating their experiences, and many advising their colleague to ensure they see their own GP to explore the treatment options for their pain conditions.
The majority of codeine-related posts on the page focused on seeking access to resources relating directly to the changes, as well as resources regarding pain management. In this way, the GP community was introduced to a number of web-based resources to assist them and their patients. These included the TGA’s own portal, information from the National Prescribing Service (NPS), and the not-for-profit Scriptwise (an organisation primarily focusing on preventing opioid overdose deaths). An individual doctor’s call-out for help with multilingual patients led to a link to the NPS’ patient factsheet page, which included many languages other than English – all within an hour of the initial query.
Especially in the second half of 2017, when the media and other organisations had started campaigns around the (then) scheduled changes, GPs were scrambling to find any helpful information directly from GP organisations. The amount of interest in this topic, in addition to the increasing collation of resources, led to some members advocating directly to the GP colleges, which helped ensure GPs had support and access to assistance from their own colleges, the RACGP and the Australian College of Rural and Remote Medicine.
More recent discussions on GPDU have focused on the relatively difficult access to pain consultation services, especially for rural and for financially disadvantaged patients. GPs are now taking these concerns to policy decision makers, further advocating for their communities.
What has the experience taught us?
The TGA’s decision to reschedule codeine-containing analgesics to prescription-only (Schedule 4) has taken GPs on a diverse journey. The discussion has evolved and matured with time, from the initial “what’s happening with codeine?” posts through to “how can I best approach this to help and not harm my patients?” enquiries.
The speed and efficiency of information, resource and advice provision, within a group-moderated environment, has been quite impressive and shows the power of social media to provide GP-learning, peer support and advocacy, principles on which the group is based.
Dr Paul Grinzi is a GP in rural central Victoria and inner urban Melbourne. He is a medical educator with Murray City Country Coast GP Training.
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