New rules will restrict access to some codeine-based cough syrups because their narcotic ingredient makes them addictive and subject to robberies and abuse.
Cough syrups like Dimetapp-C, Robitussin AC and acetaminophen with codeine are sedating pain relievers that have been marketed for many decades.
But Canadian research has shown adolescents often take them in greater amounts than prescribed in order to get high.
The College of Pharmacists of B.C. said there have been growing concerns about forged prescriptions and pharmacy robberies targeting the codeine formulations. There have also been cases in which such medications have been diverted by health professionals for personal use or to be sold on the street.
The College of Physicians and Surgeons of B.C. says the liquid cough preparations have been too easy to get.
As of Jan. 2, 2020, medications with higher potencies will be reclassified as controlled medications that require special, duplicate prescriptions. Preparations with very low concentrations of codeine will still be available from behind the pharmacy counter.
Dr. Heidi Oetter, the registrar of the College of Physicians and Surgeons, said that apart from being potentially dangerous, codeine cough medications have not been proven effective for anything other than some pain relief.
“The risk is simply too high for something that has no demonstrated benefits,” she said.
Under the new rules, doctors will have to fill out prescriptions on a duplicate pad to help prevent forgeries. Oetter said this should also prompt physicians to “give more deliberate thought” when they are writing such prescriptions. And pharmacies must also store cough syrups with codeine in time-delayed safes along with their other narcotics.
Chris Chiew, general manager of western Canadian pharmacy operations for London Drugs, said that “grab and go” thieves are far less likely to steal from stores with such vaults because they don’t want to wait around for them to unlock.
Chiew said the time delay safes, security cameras and guards in the London Drugs stores are all excellent deterrents. But he agrees with the colleges that other measures to prevent abuse and addiction may also be helpful.
He said that lozenges, drinking water or other fluids, and humid air are all good alternatives to cough syrup.
Because of the opioid epidemic, Health Canada followed the lead of the U.S. Food and Drug Administration and did a safety review of cough and cold products containing opioids like codeine and hydrocodone. It found “limited evidence” linking codeine cough syrups to opioid disorders and other harms in children. It also found, however, that there is little evidence showing any medical effectiveness of the products and so, as a precautionary measure, it advised against the use of such products in those under 18.
Chiew said he understands Health Canada has also been doing consultations on codeine products that do not require a prescription. It is possible those discussions could end up with a new standard that requires every medication containing codeine — in any format including pills and liquid — to require a prescription. Currently, for example, pharmacists can use their professional judgment to sell, without a prescription, acetaminophen with eight mg of codeine and some caffeine to offset the sedative effect.
A 2018 review of the effectiveness and safety of non-prescription medications containing codeine by the Canadian Agency for Drugs and Technologies in Health found there is evidence that low-dose codeine is effective for pain control or chronic cough when compared with placebo or non-opioid analgesics.
“However, the use of codeine can sometimes be less or similarly effective as non-opioid analgesics, while introducing the adverse effects, such as drowsiness, nausea, and constipation.”
PRODUCTS AFFECTED BY THE NEW RULES:
Acetaminophen elixir with 8 mg codeine phosphate syrup
PMS-acetaminophen with codeine elixir
Dimetane expectorant C