Monday, September 18, 2017

Painfully Common – Codeine Crisis?

Pain management can be complicated since there is no objective test to assess pain like in hypertension, and pain can be difficult to clearly articulate.  It’s also common for patients to ask for codeine containing products (schedule 2 in Ontario), to manage their pain.  Codeine is metabolized by the CYP2D6 enzyme into morphine, which then exerts its painkilling effects.  Patients metabolize codeine into morphine at different rates, therefore some patients may have a lot of pain relief and others may not experience anything at all.  To complicate things even further, codeine is an opioid that can cause addiction.

These factors contribute to why Health Canada is considering banning all non-prescription codeine1.  Health Canada is most concerned about the addictive potential of codeine, as they’ve noticed a significant number of patients entering rehab programs for non-prescription codeine substance abuse alone1.  From a pharmacist perspective, there are two predominant viewpoints:
  1. Schedule 2 codeine products have an important role in therapy and with the appropriate tools, they can be effectively monitored for abuse.
  2. Schedule 2 codeine products are too unsafe, due to their abuse potential, to be sold without a prescription.
Whether pharmacists can effectively monitor non-prescription codeine depends on the electronic tools available to them in each province.   For example, Alberta pharmacists have access to the patient’s electronic medical record (EMR) called NETCARE. They can use the software to identify when the patient last picked up codeine.  In this situation, schedule 2 codeine products can have an effective role in therapy and may not need to be prescription, since pharmacists are capable of monitoring for abuse.

However, Ontario pharmacists do not have access to an EMR and thus are unable to assess if the medication is being abused.  This can be dangerous since it is impossible to know how much codeine the patient is using.  In this instance, banning the sale of the non-prescription codeine products may be appropriate.

Health Canada should encourage provinces to make the appropriate regulatory changes based on their pharmacy infrastructure.  If the appropriate mechanisms are in place to monitor for abuse, the provinces should trust pharmacists to make the correct judgement to dispense codeine.

In either case, pharmacists must be competent to counsel patients on effective pain management strategies.  RxBriefCase offers an excellent program discussing mild to moderate pain management in primary care:
It will be interesting to see how Health Canada decides to regulate non-prescription codeine and how changes to the legislation will impact patients.

- Ajay Chahal

References
  1. Beeby, D. (2017, September 11). Health Canada aims for prescription-only codeine pills, syrups. Retrieved September 15, 2017, from http://www.cbc.ca/news/politics/codeine-opiate-prescription-health-canada-juurlink-pharmacists-ban-sales-1.4284013


Friday, September 8, 2017

The Elephant in the Room – Obesity Management

Obesity is a tough topic to discuss with patients and many pharmacists may not feel they are adequately prepared to initiate the conversation.  It’s a daunting task because if it is not approached correctly, we risk alienating the patient and possibly making things worse.
  
There are many wrong ways to start the conversation: using scare tactics, generic advice, or guilt. However these approaches have shown not to be effective.1  Instead, start the conversation with an open question, something like “I’m sure you’re aware of how weight can affect your health. Do you have any concerns about your weight and health that you’d like to talk about?1.  This allows the patient to take control of the conversation and voice their concerns at the beginning of the interaction.

Once you’ve spent some time with the patient discussing their concerns, motivation and goals, it’s time to develop a plan.  Too often clinicians will give generic advice like “eat less and exercise more”, which is ineffective advice for a patient who may have already heard that a dozen times. Specific simple interventions are effective ways to help patients get started towards healthier living.   

Here are 10 simple tips that you can suggest to your patients:2
  1. Keep a meal routine - Eat at roughly the same times each day, whether this is two or five times a day.
  2. Go reduced fat - Choose reduced fat version of foods such as dairy products, spreads and salad dressings where you can. Use them sparingly as some can still be high in fat.
  3. Remember to Walk - Walk 10,000 steps (equivalent to 60-90 minutes moderate activity) each day. You can use a pedometer to help count the steps throughout the day.
  4. Pack a healthy snack - If you snack, choose a healthy option such as fresh fruits or low calorie yogurts.
  5. Look at the labels - Be careful about food claims. Check the fat and sugar content on food labels when shopping and preparing food. “Eat Right Ontario” has a great patient resource to help read nutrition labels.
  6. Caution with your portionsDon’t heap food on your plate (except vegetables).
  7. Up on your feet - Break up your sitting time. Stand up for ten minutes out of every hour.
  8. Think about your drinks - Choose water or sugar-free drinks. Unsweetened fruit juice is high in natural sugar so limit it to 1 glass per day (200mL). Alcohol is high in calories so try to limit the amount you drink.
  9. Focus on your food - Slow down. Don’t eat on the go or while watching TV. Eat at a table if possible.
  10. Don’t forget your 5 a day - Eat at least 5 portions of fruit and vegetables a day (400g in total).
If you are interested in learning more on obesity management, stay tuned for my eNewsletter, “Uncomfortably Common – Obesity Management”, which will be sent to rxBriefCase members early next year.  Advancing Practice also offers continuing education, and a Certified Bariatric Educator Exam:

- Ajay Chahal

References
1. Freedhoff, Y., & Sharma, A. M. (2010). Best weight: a practical guide to office-based obesity management. Canada: Canadian Obesity Network.
2. Beeken, R. J., Leurent, B., Vickerstaff, V., Wilson, R., Croker, H., Morris, S., . . . Wardle, J. (2016). A brief intervention for weight control based on habit-formation theory delivered through primary care: results from a randomised controlled trial. International Journal of Obesity, 41(2), 246-254. doi:10.1038/ijo.2016.206