Upschedule codeine to reduce misuse: Canadian pharmacist


Making it prescription-only is likely the best way to address misuse and abuse in both Canada and Australia, he argues

Jesse MacKinnon, who has just published an article about OTC codeine in the Canadian Pharmacists Journal (Revue des Pharmaciens du Canada), told the AJP that despite assertions to the contrary from stakeholders, in his experience patients who present to pharmacy requesting codeine resist the offer of help with managing their pain.

In the article, “Tighter regulations needed for over-the-counter codeine in Canada“, MacKinnon calls for upscheduling of codeine-containing OTC medicines to be seriously considered.

“The national Narcotic Control Regulations suggests that every pharmacist should counsel on these drugs, but in my experience, this rarely happens,” MacKinnon wrote in the article.

“Most patients can easily buy 200 pills of these OTC narcotics as long as they simply tell the pharmacy cashier that they have ‘had it before’.

“A change is needed to ensure safer and more effective use of OTC codeine products in Canada.”

MacKinnon believes patients who misuse codeine often have “predetermined agendas”, know how to “work the system” and are not willing to accept advice offered in community pharmacy.

“Patients tell me that they have tried all other analgesics such as acetaminophen and NSAIDs and that their family physician knows they take OTC codeine.

“Most community pharmacists have limited access to a patient’s medical history or even a list of current medications. This makes for a difficult and frustrating clinical encounter in which pharmacists are trying to decipher legitimate versus illegitimate use of codeine based on counselling alone.”

MacKinnon told the AJP that his experience in community pharmacy is that “almost no one purchasing OTC codeine wants me to give them advice on their pain”.

“I find it hard to believe that Australia would be different. ‘Codeine tantrums’ as described in The Age newspaper article in Australia happen in my pharmacy as well.”

These occur when MacKinnon attempts to give advice on pain and recommend analgesic alternatives to codeine, he says.

“If patients purchasing OTC codeine were willing to accept my advice, then most patients would be refused the sale of codeine and given a trial of acetaminophen, NSAIDs (topical or oral) or capsaicin.

“That unfortunately is not the case, so I disagree with Australian stakeholders in that patients purchasing OTC codeine are willing to accept the advice of pharmacists.”

MacKinnon writes that more research is needed into the effectiveness of prescription monitoring programs in reducing abuse and addiction of OTC medications, though there is evidence that these programs can help reduce inappropriate prescribing and dispensing of prescription opioids and other controlled drugs.

Most Canadian provinces have a system in which OTC codeine sales can be uploaded to a database, but these databases are imperfect, MacKinnon writes, sometimes recording OTC codeine sales only as an “FYI”.

As yet there is no research on the effectiveness of these programs, he says.

“Implementing a PMP (prescription monitoring program) is not the ultimate solution and may not be sufficient in curbing OTC codeine misuse. A PMP could tell pharmacists that, for example, a patient had purchased 200 pills of OTC codeine 60 days ago,” he says.

“But under what clinical circumstances, if any, would it be appropriate for a pharmacist to sell this patient another bottle? Even with a PMP, pharmacists in many provinces would still not have access to medical and medication histories.

“Pharmacists are still left making clinical decisions about these narcotics with an incomplete clinical picture.”

MacKinnon told the AJP that he has been monitoring the Australian situation and has read the Australian Cadence Economics, Fiscal Impact of Codeine Changes report, but “I think after considering all angles of the argument, changing codeine to prescription only is better than implementing a monitoring system like MedsASSIST.

“Is it worth the time and money to implement something like MedsASSIST, in order to maintain public access to a medication that has minimal place in therapy?

“In my opinion the answer is no. I think community pharmacists can be helpful in many situations, but when it comes to opioids, one of the most risky class of drugs (in terms of overdose deaths and addictions) – looking at it from a logical and sober perspective – pharmacists should not be independently assessing and treating patients with any opioid.”

This may increase physician visits, he says, but there is a prescription schedule for a reason.

“If morphine was OTC, then yes, moving it to prescription only would ‘increase physician visits’.

“But that’s only a small part of the picture.

“When Health Canada looks at classifying drugs as ‘prescription only’, they first and foremost look at: whether the drug should require practitioner monitoring (one part: addiction and dependence potential), is there uncertainty with the drug, and could it cause public harm (one part: potential for diversion or abuse).

“Not whether a certain drug will ‘increase physician visits’, or even ‘cause an inconvenience to the patient by not having it freely available OTC’.”

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