Over-the-counter codeine should be limited in wake of 'opioid epidemic', says Sask. pharmacist

Pharmacists say it's time for Canada to restrict access to over-the-counter codeine as the country grapples with an opioid crisis.

There have been renewed calls to limit access of low-dose codeine products — including Tylenol 1 and their generic counterparts — since a pharmacy in Saskatchewan was disciplined for failing to understand how the drug can be abused.

Codeine is an opiate used as a painkiller and to treat coughs but can be misused.

In most of Canada, codeine comes in eight-milligram pills, mixed with two other ingredients, that can be purchased without a prescription.

Saskatchewan's College of Pharmacy Professionals recently released details of 15 charges against Dewdney Drugs, a store in Regina's North Central neighbourhood. The pharmacy has since closed.

An inspection revealed that between April 2017 and January 2018, the pharmacy purchased 1.6 million Tylenol 1 tablets. There was no report of what happened to 1.1 million of them.

Matthew Manz manages a nearby pharmacy and complained about Dewdney Drugs after the store sold a patient he was treating for opioid dependency three bottles of tablets containing codeine in less than a month.

Saskatchewan's pharmacy watchdog determined codeine was that patient's drug of choice.

Choosing not to stock codeine-containing drugs

Manz and some other pharmacists choose not to stock Tylenol 1.

"We're in the middle of this opioid epidemic," said Manz. "We have to be more conscious of what's going on.

"You're doing a harm reduction program within the pharmacy. You're getting people off opioids, but then at the same time you're offering over-the-counter opioids.

"In my head, it didn't make sense."

The Canadian Pharmacists Association supports the move to prescription status. It's also calling for Health Canada to review why low-dose codeine products are used in the first place, since evidence suggests there are better alternatives to manage pain.

Barry Power, the association's director of therapeutic content, said Canada is one of the world's top codeine consumers.

Health Canada says in 2015 more than 600 types of low-dose codeine tablets were sold. The agency is reviewing whether low-dose codeine products should be restricted to prescriptions only. Manitoba made the move in 2016.

Pharmacy college considering approach

Saskatchewan's pharmacy college, citing health risks and the drug's effectiveness compared to non-opioid drugs, said last year that it was considering a ban on the sale of low-dose codeine,

The college's registrar says no decision has been made yet. Jeana Wendel said in an email that it's considering a model similar to Manitoba's, as well as better monitoring of pharmacies and harm reduction education.

"Council is looking at a different approach versus an all-out ban," she wrote.

David Juurlink, a drug safety researcher in Ontario, said making the drugs available only by prescription is a no-brainer, because it would decrease access to a group of products that "causes more trouble than it solves."

He calls the recent case in Regina "clearly suspicious" and said low-dose codeine products are prone to misuse. People can get a buzz if they take enough of them, he said.

"I remember very vividly in small town Nova Scotia where I used to work, people would go from drugstore to drugstore and they'd buy 100 tablets every couple of days."

Juurlink and other medical experts say people who binge on over-the-counter codeine pills are at risk of liver poisoning from excessive levels of acetaminophen in their bodies.

Rand Teed, an addictions counsellor near Regina, said cough syrup containing codeine is mixed into drinks to induce euphoria, but with it comes a high risk of overdosing.