Thanks to Drs Hawley and Gallagher for their helpful articles about opioid prescribing in the November 2021 issue of the BCMJ. They should be required study for primary care physicians, especially those reluctant to prescribe any form of opioid, including codeine compounds.
Their guest editorial acknowledges the reluctance, giving a background for such policy by the prescribing physician, including the concern of receiving a letter from the College. Despite their reassurance that this is a simple, necessary prescribing enquiry, the actuality may feel more like an inquisition. Thirty years ago, a College letter about my prescribing of liquid codeine as an antitussive resulted in a face-to-face interlocution, with the strong suggestion that such prescription was proscribed; use off-the-shelf preparations. The experience was very unpleasant; I became a nonprescriber. A different atmosphere is needed if primary care physicians are to continue to be opioid prescribers.
One of the articles also mentions that there have been calls to delist codeine, for a variety of reasons. However, for some migraine patients who do not respond to triptans and ergot, Tylenol #3 remains an effective rescue preparation when administered early in the attack. Even when migraine patients include classic aura in their range of symptoms, it is difficult enough to persuade a personal physician to prescribe a few Tylenol #3s in today’s opioid climate, let alone have to escalate that request to a stronger alternative if codeine preparations were to be no longer available. Delisting will predictably result in migraine sufferers ending up under the aggravating bright lights of the ER department for hours, awaiting IV metoclopramide or ondansetron to abort their attacks (personal experience).
—Anthony Walter, MD
This letter was submitted in response to “Guest editorial: Opioid prescribing: An essential skill for physicians and a collective knowledge we must not lose,” “Management of cancer pain with opioids,” and “Opioids for pain and shortness of breath in frail older adults: How to choose and use.”
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