Upscheduling codeine could have migraine silver lining


woman with headache

There’s been a lot of debate on upscheduling codeine, writes Phil Spyrou, but if it happens, pharmacists will have an opportunity to help migraine sufferers

The final decision on whether codeine will be upscheduled or not will be made tomorrow, on the 19th of November 2015, by the Therapeutic Goods Administration.

There has been heated debate about the positives and negatives of upscheduling codeine.

Some pharmacists have expressed that they would be relieved to no longer play the role of the “medicine police”. Filtering between legitimate users and people misusing codeine is very difficult without access to a real time reporting tool such as Project STOP for pseudoephedine.

Others are concerned about increased health care costs for consumers and the Government.

Conservative estimates, produced by Cadence Economics, are an increased cost to government of $316m annually on the Medicare Benefits Schedule alone.

There are some positives which would result from codeine being upscheduled that haven’t yet been discussed.

It is highly likely that less people will be taking codeine for migraines if it was up-scheduled. Here are three benefits that migraine sufferers could experience if codeine is to be up-scheduled this week.

 

More effective relief of migraine pain

Patients experiencing migraine pain usually present to pharmacy with the question: “What’s the strongest thing you have for a migraine?”.

Currently, the most likely response to this question from almost all pharmacy assistants and pharmacists is to recommend Panadeine Extra (as it contains the highest amount of codeine available over-the-counter) or Nurofen Plus (as it contains an anti-inflammatory, which is known to be effective for migraines, and codeine).

If codeine is upscheduled, these patients are likely to be offered the new paracetamol/ibuprofen combination products, such as Maxigesic or Nuromol, as these would be the only pain relief available other than paracetamol, aspirin or NSAIDs on their own.

Migraine sufferers would then be receiving both first and second line treatments for migraine pain. With codeine available over-the-counter, they would have received only one medicine recommended for migraine and another which is not actually recommended.

Without the overhanging cloud of codeine availability, pharmacists may get more chances to discuss other treatment options with their migraine patients. For example, recommending a high dose of soluble aspirin for those needing fast relief and suggesting prochlorperazine or metoclopramide for those experiencing nausea.

Oral rehydration salts can also be very useful as many sufferers are likely to be dehydrated, especially over summer.

Patients who have already used codeine for migraines may refuse to believe that anything less would be effective for them.

Other patients who regularly use codeine for migraines would definitely not benefit from the upschedule of codeine in the short term. They are likely to be somewhat dependent on codeine and also may be suffering from medication overuse headache.

 

Fewer side effects

Codeine is not recommended in the Therapeutic Guidelines to treat migraine pain as there is limited evidence to suggest that it is more effective than simple analgesics. The other reason it is not recommended though is the higher risk of side effects.

If codeine is upscheduled, migraine sufferers will not have their nausea worsened and will not experience constipation as a side effect.

 

Lower rates of medication overuse headache (rebound headaches)

Codeine is much more likely than paracetamol or ibuprofen to cause medication overuse headache.

Studies show that taking codeine on more than 10 days per month for longer than three months can result in rebound headaches.

Experts believe, though, that paracetamol and ibuprofen need to be taken on more than 15 days per month for longer than three months to cause medication overuse headache.

With less people taking codeine for migraines, it is likely that the prevalence of medication overuse headache will drop over time.

 

Phil Spyrou is a community pharmacist, member of the International Headache Society and author of the Headache Freedom blog.

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5 Comments

  1. Drugby
    18/11/2015

    Thank you Phil for this rational evidence-based discussion. It’s the first patient-centred words I’ve read on this hot topic! Other commentators have focused on the loss of income for community pharmacies and the need for real time monitoring. Regardless of whether codeine is upscheduled, we should realize we should always provide the best advice to our patients. And remember too, many people with chronic migraines will benefit from triptans and therefore need to go the GP anyway. Also is it really a migraine??

  2. Nicholas Logan
    18/11/2015

    No one doubts codeine’s limitations but unfortunately evidence suggests that up-scheduling will mean that pain suffers will be prescribed a higher dose in larger quantities and stock pile them at home. It’s anti-QUM.

    • Phil Spyrou
      18/11/2015

      Thanks for your comment Nicholas. Please share which evidence shows this.
      Kind regards,
      Phil

  3. Phil Spyrou
    20/11/2015

    The decision to up-schedule codeine has been deferred for one year. Whatever the outcome, pharmacists should tailor their recommendations to migraine sufferers.

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