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Editor's ChoiceMain Category: Pain / Anesthetics
Also Included In: Back Pain; Body Aches
Article Date: 02 Aug 2010 - 3:00 PDT window.fbAsyncInit = function() { FB.init({ appId: 'aa16a4bf93f23f07eb33109d5f1134d3', status: true, cookie: true, xfbml: true, channelUrl: 'http://www.medicalnewstoday.com/scripts/facebooklike.html'}); }; (function() { var e = document.createElement('script'); e.async = true; e.src = document.location.protocol + '//connect.facebook.net/en_US/all.js'; document.getElementById('fb-root').appendChild(e); }());
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Codeine is a weak opioid used in many combination pain relief products, but its role in managing acute pain is questioned in this month's edition of Australian Prescriber.
In the article Dr Bridin Murnion, from the Drug Health Service at Royal Prince Alfred Hospital Sydney, discusses the evidence around combinations of different painkillers in the same tablet (eg. ibuprofen or paracetamol with codeine). She argues that in many cases pain relief is not increased by using two different painkillers.
"Codeine is often an ingredient in combination painkillers, however there is not much evidence for its effectiveness and the role of codeine in managing acute pain is unclear," says Dr Murnion.
NPS's review of evidence shows that studies in acute pain suggest only modest additional pain relief is achieved when codeine is added to paracetamol, and the risk of side effects increases after repeated doses.
As an opioid, codeine can be addictive. When people take it in higher doses than recommended, they are also taking high doses of the other pain relief ingredients, paracetamol or ibuprofen, and it's these ingredients which, when misused, can cause serious adverse events such as stomach and liver damage.
A National Health and Medical Research Council review found insufficient evidence to recommend the use of paracetamol/codeine combinations in acute low back pain, acute neck pain, acute shoulder pain or acute knee pain.
"For dental pain, the most effective approach is to undertake appropriate dental treatment. After dental extraction, anti-inflammatory medications are better than combinations of paracetamol and codeine," Dr Murnion advises.
While there is a significant body of evidence identifying the efficacy of NSAIDs (e.g. ibuprofen, aspirin, diclofenac) in acute pain, there are limited data on combining them with opioids.
"Many anti-inflammatory drugs are more effective than combinations of codeine with paracetamol or aspirin," she writes.
Dr Murnion says the recent rescheduling of these products is unlikely to impact significantly on people's pain relief options but may reduce the harms from overuse.
These findings are in line with NPS reviews of evidence that show when treating acute pain, only modest additional pain relief is achieved when codeine is added to other analgesics.
"As a weak opioid, codeine can be addictive but because it can't be purchased without either paracetamol, aspirin or ibuprofen, people end up consuming more than they need of these products too," NPS acting CEO, Karen Kaye said.
"Taking more than the recommended maximum amount of these products can result in serious side effects. Overuse or misuse of products containing aspirin or ibuprofen can result in gastric ulcer perforation, or in products containing paracetmol, liver toxicity or death."
"The recent rescheduling of these products ensures people using these products will get the professional advice from a pharmacist and addictions will be identified."
To view the full article go to http://www.australianprescriber.com.
Source: Australian Prescriber
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posted by Mike Griffin on 2 Aug 2010 at 7:57 amI recently suffered a shoulder injury and took ibuprofen but I was experiencing considerable pain so upgraded to ibuprofen plus codeine. As a consequence I unwittingly contracted constipation causing a return of hemorrhoids that had been quiescent for a number of years. I was unaware of the side effect of codeine nor did the packaging warn me. The internet however said that everyone knows codeine causes constipation but I didn't.
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posted by Murgatroyd on 2 Aug 2010 at 3:39 pm
As someone who has suffered from chronic lower back pain for years I disagree strongly with the national prescriber's article. Once the doctors' decided that panadeine forte was 'useless' at relieving pain my pain increased greatly. Their opinions however did not change and I pity anyone who is going to be forced off their pain medications purely because some big pharmaceuticical companies are manipulating the attitudes of prescribers to create a demand for and then fill a 'void' created by the lack of codeine based medicines.
Fact 1:
If codeine was useless for pain relief then opioids would not have been used for thousands of years for pain relief.
Fact 2:
There are whole raft of newly designed synthetic pain relievers about to hit the market in the next two years that are all patented.
Fact 3:
You can't patent an opioid.
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posted by susan on 3 Aug 2010 at 12:38 am
i injured my back using a lap top in bed. I went to all sorts of health professionals. in the end the only thing that helped was codeine. i was in so much pain i couldn't lower myself onto the toilet. I couldn't drive. after one treatment with the physio i felt good and then went for coffee and then couldn't get up from the seat.
it isn't as bad now. but until you know that level of pain then you cannot realise what a relief it is to be able to take something to help. paracetamol, celebrex, ibuprofen, aspirin were tried and nothing really helped me until codeine was included in the cocktail.
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posted by Snickers on 3 Aug 2010 at 2:18 am
I agree with Murgatroyd , codeine has the historical track record, but alas can't be patented by the pharmaceutical industry. Furthermore, people react to medications in vastly different ways. I find I require far less paracetamol for acute pain if there is a small amount of codeine incorporated into the medication -- and the stuff actually gives some noticeable relief from pain. I personally think it's also a good thing to be able to minimize stress to the liver whenever possible. I've tried NSAID's such as Naproxen and Diclofenac, and although they may slowly reduce inflammation over time, they do not give me any noticeable relief of acute pain. And many of these drugs are far harder on the stomach.
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posted by kay peterson on 3 Aug 2010 at 4:10 am
I totally agree with Murgatroyd.
I've been able to tolerably manage pain with over the counter levels of codeine added to paracetamol interspersed with over the counter anti inflamitory products. For too much of the anti inflamotory tablets can irritate the stomach used alone.
The ridiculous process to go through at a pharmacy to go through getting these tablets means one can't get a friend to pick them up and the purposeful delay in providing them means it's not always possible to get them timewise ( no car-public transport or lift with busy friends) so running out of them . The result is in ending up in more pain that sets of a far worse cycle.
This then creates the need for my higher level of these meds to regain my equilibrium.
My doctors prefer not to move me up to the stage of seriously prescribed NSAIDS when generally the use of the over counter meds works. I've been personally reluctant to go to the higher level prescribed pain killers due to their real capacity to be addictive in needing to rely on them and potentialy needing ever increasing levels and negative sedating effects.
Non legal drugs aren't a great option due to possible legal consequences, far worse cognitive problems and addictions.
I realise now I am prepared to accept the need for the prescribed stronger pain killers to use in conjunction with over the counter inflamitory meds. The pharmacist says to see my doctor whenever I get these over counter meds. I have and I do. Except, as my Gp tells me, there is no curative treatment for my condition.
Being in pain increases muscular tension and increases sensitivity to the pain resulting in massive exhaustion and restrictions in movement for days. All this then brings on relapses in depression, that otherwise had abated.That's the other result, I will be going back on antidepresants.With all that maybe something from the benzodiazepam group could be added for muscle relaxing properties, The nasty problems they can cause, my normal detterent, wouldn't be noticed much in amongst the rest of the meds.
I will now get an accelerated passage to commencing an identity of having chronic level illnesses, becoming an invalid - or a celebrity familiar with detox or casuaulty depts -rather than one with some weak hereditary points emerging in aging. The need to be able to to remain mobile and carry out daily tasks overides everything & my GP would support that & hence prescribe whatever it takes to achieve that and not have days frozen in pain unable to much of anything. I'ts unfortunate it needs to be achieved at the compromise of being clear headed which was possible on over counter meds including codine.Imagine what more I'll need in the future starting a decade earlier on this course of action, well unless the alternative meds creates the mental unclarity of the dead celebrities' confusion coctails.
All this is good for the pharmaceutical industry and pharmacists. If those in goverment have investment shares in pharmaceutical companies it explains their illogical support of what will cost tax payers more.
Very few people are as stupid as to take these meds in the wrong quantity or are addicted to them.
Abusers of over the counter meds are invariably either very confused elderly persons requiring support or serious younger substance abusers.
They have addictions to other drugs, far more potent while the over counter meds are only to them the minor addition ( though ingestion quantity isn't).
..Oxycotin, Vicodin ES, Morphine, maybe but rarely have Pethidine or Dextropropoxyphene, adjuvnts now to follow...Diazepam, Midazolam, Lorazepam, Ketamine,
Antidepresants, and there are more and more options. For the daring desperate who end up needing more than scripts supply, there is the purchase of the above or similar acting substances via social networking.
Insufficient pain relief by weaker over the counter meds creates stress , elevates cortisol levels that potentialy can and often do raise every other pain mechanism.
This then raises the types and amounts of pain control drugs required, often coming from the list above - of more toxic options. A counter productive result for those who had safe effective use of the meds with minor levels of codine.
The confused elderly will still take too much paracetamol and substance abusers will do that as well ( it's often the thought that counts more) remaining on other serious drugs.
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posted by john lauren on 3 Aug 2010 at 6:20 am
Despite being remarkably healthy for my age (56) I occasionally get quite severe headaches. Several limited medical investigations have been unable to specify anything and have had me try some obscure medications - including some ergot derived substance. None of these had the slightest effect on reducing my headaches except off course panadeine forte or a codeine fortified product from the chemist.
From my limited investigations it would appear that codeine is by far one of the safest drugs in the entire pharmacological suite of medications. This fear that it is addictive is grossly over exaggerated. I have no inclination whatsoever to take any drug anymore than absolutely necessary.
If some druggies go codeine shopping that is likely to be exclusively their problem, moreover taking codeine for a high is quite likely to be far less harmful than the alternatives that drug addictive people will procure - just ask some and or investigate this with open eyes.
This matter is reminiscent of the ban on using other opiates such as heroin to give effective pain relief to the terminally ill - supposedly on the worry that they are likely to become a hopeless drug addict when they miraculously get better.
I do smoke, drink very little alcohol and generally resist taking antibiotics or any medication and I do not wish to promote the taking of any drugs, but this third degree interrogation when I want a bit of codeine in my pain relief medication is totally absurd. Get real
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