Today I am having a conversation with a patient about acetaminophen with codeine. This patient has chronic pain – her pain is high-impact pain. This means that her chronic pain has impacted her life in many ways. It affects her mood, her relationships with other people, her ability to work and to enjoy activities and life in general.
She came to me as a consult pain and she was taking acetaminophen and the highest dose of codeine but she was still experiencing very high pain levels. Codeine is a opioid that is different to others. The body has to change the codeine into morphine. This requires an enzyme called CYP2D6. There are genetic differences in how the body changes codeine to morphine.
This patient was very keen to go off opioids. I suspected that she may be one of these people not converting codeine to morphine. Buprenorphine and naloxone was used to taper her off opioids and her reaction proved that she was actually almost opioid naive. Which meant she was hardly converting any codeine into morphine. Which means she was not really on opioids at all.
This difference in patients and how they metabolize codeine makes it a dangerous drug. Some people convert the codeine so well it can then lead to breathing difficulties and even death. This is why I try to stop patients from using codeine.
This patient is now off opioids entirely and we are embarking on a journey of pain management without using opioids. This is a much safer strategy and if done correctly will give equal results to those patients using opioids without pain strategies. To prove this point, I will discuss another patient who had pain for over 40 years and is now pain free except for usual pain – as when she is climbing a mountain.
This patient had back pain for 40 years. Working on my pain program and the pain education, she is now pain free.
Below is the pain program which you can try. I will add steps as I go along.