Here's My Proposal For Over The Counter Codeine

Here's how we might find common ground on codeine over the counter

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Kenny

This post is a sequel to a previous one titled "Tylenol #1 With Codeine Debate - Here's A Story". You can read it here but it's not necessary:
http://www.behindthecounter.ca/stories/tylenol-1-with-codeine-debate-heres-a-story

First of all, I want to acknowledge the important perspectives to consider as 8mg codeine products may be removed from "over the counter" status:

• Patients do not want their access to 8mg codeine products to be unreasonably restricted
• Acetaminophen (Tylenol) overdose and toxicity is a concern to everyone
• Side effects of codeine are a concern to everyone
• Pharmacists want to do more for pain management but have limited time and funding
• Pharmacy organizations have been pushing for greater recognition of pharmacists' opportunity to help patients with pain management:
  www.cbc.ca/news/canada/toronto/opioid-medication-pharmacy-consultation-1.4310435
• Low dose codeine has questionable efficacy, but some patients do find relief from using it 
• Restricting 8mg codeine to only doctor or nurse practitioner prescription may produce extra stress and costs on the health care system and patient waiting times
• Healthcare providers generally do not know if their patients are using over the counter codeine products 
• Pharmacists are the gatekeepers of low dose codeine products and are in the optimal position to properly counsel patients
• Any individual's ability to obtain 8mg codeine products appears restricted only to the amount of money they have, the number of local pharmacies and any red flags they may set off to the pharmacist selling it

I am not sure if this has already been suggested, but here's what I would consider doing:

1. Remove 8mg codeine products from over the counter status
2. Add these products to prescription only and require identification on pick-up just like all the other opioids and controlled medications. Before some readers jump to conclusions, please read to the end...
3. Allow Pharmacists to prescribe 8mg codeine products. Pharmacists are already formally recognized as capable quit smoking coaches and we can prescribe Champix and Zyban. Note: I recognize that it's easier to suggest that 8mg codeine products should be prescription-only and leave it to the current prescribers such as doctors and nurse practitioners to manage it, but this post is about an idea to advance the profession.
4. Introduce a new government-sponsored minor pain management service (similar to the already existing pharmacy smoking cessation program that is paid for by the Ministry of Health)
5. Pharmacists who wish to participate in the minor pain management program must complete a continuing education course (similar to how pharmacists complete a course to be able to bill the government for smoking cessation services).
6. The prescriptive authority of the pharmacist is not dependent on obtaining the additional pain management education (I am currently still on the fence about this)
7. Pharmacists who enrol patients into the minor pain management program have regular follow-ups with the patient and regular communication with the patient's doctor or NP
8. The payment will come out of the Ministry of Health's existing professional services budget (preferably with an expansion of the budget)
9. The Ministry can better track which patients received these codeine products, if they have enrolled in the pharmacist-led program, and what kind of effects this program might have on patient outcomes. It is important to measure outcomes to maintain or improve future funding.  
10. I would also support keeping 8mg codeine products  as over the counter or Rx-only without pharmacist prescriptive authority, but still adding a new minor pain management service

 Here are some considerations I made:

• We are not replacing or even trying to replace the valuable role of doctors, NP's or pain specialists. Pharmacists are already counselling patients every single day on minor pain (using products such as acetaminophen, ibuprofen and various topical medications). Products with 8mg of codeine per dose can be reasonably classified for minor pain only. Pharmacists refer for more moderate to severe pain (as we are already doing daily).
• Pharmacists can already dispense 8mg codeine products without a prescription and without recording identification but if the product was 15mg codeine, they would have to receive a prescription and would document the identification of the person picking it up.
• I am not a fan of pharmacists just scanning a health card to retrieve past usage of 8mg codeine products. It minimizes an important role we can have in helping manage a patient's minor pain.
• There will be some immediate backlash and disappointment from patients. Pharmacists should be prepared for a lot of difficult conversations (I had someone recently tell me they alternate Tylenol #1's with 2-2-2's). However, I believe better oversight of codeine products has long-term benefits for patients.
• I am aware this does not fully resolve drug-seeking behaviour of certain patients. If one pharmacist does not want to prescribe 8mg of codeine, the patient may just simply go elsewhere
• The proposal works best with a more robust and detailed Ontario Narcotic Monitoring System (ONNMS)
• A minor pain management service is a great start to a minor ailments service

If you agree or disagree with me, you should voice your concerns to the following pharmacists. These two individuals have a seat at the Ontario Opioid Emergency Task Force:

• Allan Malek, Executive Vice President and Chief Pharmacy Officer, Ontario Pharmacist Association. His email is publicly available: amalek@opatoday.com
• Tina Perlman, Manager, Pharmacy Practice, Ontario College of Pharmacists. Her email is not publicly available

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