The most recent Choosing Wisely recommendations come from the Canadian Pharmacists Association. As to be expected from the far ranging groups that contribute to Choosing Wisely Canada, there is often some overlap in the advice we review. It is worth emphasizing, in the current realm of prescribing opiates, that the pharmacists and the Canadian Headache Society both agree to be cautious in using opiates in treating headache, as well as acute or chronic pain. We've covered a couple of these recommendations below; check out our Quick Links section for more recommendations and more information!
Don’t prescribe opioid analgesics or combination analgesics containing opioids or barbiturates as first line therapy for the treatment of migraine.
Non-steroidal anti-inflammatory drugs and triptans are recommended first line treatments for acute migraine therapy. Opioids may produce increased sensitivity to pain and increase the risk that intermittent headache attacks will become more frequent and escalate to a chronic daily headache syndrome (medication overuse headache), particularly when opioids are used on 10 days a month or more. Opioids may impair alertness and produce dependence or addiction syndromes.
Don’t recommend the use of over-the-counter (OTC) medications containing codeine for the management of acute or chronic pain. Counsel patients against their use and recommend safe alternatives.
There is no evidence to support the use of low-dose codeine pain medication over non-opioid analgesics. Codeine is an addictive opioid with potential for abuse and dependence. OTC codeine products are often supplied in combination with non-opioid analgesics (i.e., NSAIDs and acetaminophen). In addition to concerns regarding codeine abuse and dependence, misuse of these codeine-containing combination analgesics may also result in serious adverse effects due to high doses of the simple analgesics (ibuprofen, acetaminophen or aspirin). Effects of high doses of simple analgesics may include liver toxicity, gastric perforation, haemorrhage and peptic ulcer, renal failure, chronic blood loss anaemia and low blood potassium (with potential fatal heart and neurological complications).
To further convince you of the concerns related to OTC codeine products,the Canadian Medical Association (CMA) recently submitted a statement to Health Canada outlining the limited benefits of codeine and the risks of availability in OTC products. The CMA is recommending that Health Canada follow suit of many European countries and make codeine available by prescription-only to improve the benefits and minimize the risks of using this product.