This recent experience I had with a patient illustrates some of the holes within our current system...
At the pharmacy, we try to be diligent regarding sales of Tylenol #1 with codeine. Besides screening questions, we also have consistent staffing who work from store opening to closing and no part-time pharmacy assistants/technicians. Monitoring of the sale of Tylenol #1 is a bit easier since any of the staff may recognize the customer and when he/she last purchased this medication.
It's a system that is far from perfect and here's a story to show you why.
Back in late 2016, I met a new customer, Mr.S who purchased a bottle of 30 Tylenol#1 with codeine. He was not a regular patient nor a regular customer of ours. The exact details are a bit fuzzy (I am recalling a situation almost a year ago) but nothing was particularly odd about the first encounter. However, when he came by the pharmacy again for another 30 T#1 within the same week, I asked him more questions such as his current dosage and past history of use.
The patient was very open about his high acetaminophen and codeine usage and entire medical history. He even informed me of which pharmacy he got all his prescriptions from!
I called his pharmacy. This is not something I normally do and I had never called any pharmacy to discuss a T#1 purchase before, but I felt it was the appropriate action based on my conversation with the patient. I also had suspicions about why the patient would come to our pharmacy when he had a regular pharmacy from which he filled regular medications. Was he potentially going to all the local pharmacies for this medication?
The other pharmacy was not aware of his usage, and informed me that they would contact the patient's primary care provider. It was a local prescriber, so I also faxed over my documentation. The result was that the prescriber re-assessed the patient, advised him to lower the T#1 usage and try an alternative. I was also asked not to sell this patient any more Tylenol #1 with codeine.
I saw the patient maybe once or twice after that over the next few weeks, but I was never asked to sell him any T#1.
Almost a year had passed since then, and I completely forgot about the patient.
Then he showed up earlier this week.
Unfortunately, it appears he forgot about me at least as much as I forgot about him. However, after speaking to him for a minute I realized who he was, and brought up our last encounter from almost a year ago. He did not remember and seemed to get impatient as I tried to re-engage him on the topic of his usage. Ultimately he got upset that I would not sell him T#1 and he left.
Who knows when I'll ever see him again?
As I think about the proposal for moving T#1 from non-prescription to prescription status, I grapple with two fundamental questions:
1) Is T#1 effective?
2) Assuming T#1 has a therapeutic benefit, to what extent should it be monitored?
The answer to question #1 is "it depends". As one of my pharmacist friends has said to me, "You're basically giving someone a bottle of morphine, but you don't know the dose." Codeine converts to morphine to provide pain relief, but some individuals will receive more morphine or less depending on their own body's metabolism. Besides the pain killing attributes, the medication is well known for side effects like drowsiness and constipation.
If you're a pharmacist who sees a bottle of Tylenol #1 with codeine as a bottle of morphine whose dose is unknown, then your response to question #2 would be obvious; you would want monitoring as strictly as any other narcotic such as morphine, hydromorphone, oxycodone, fentanyl, etc.
I will tackle the other potential answers to question #2 in a future blog post, but I wanted to end off this blog post by highlighting some of the holes within our current system that can lead to misinformation and misuse:
The current discussions around T#1 are also framed within the context of the overall opioid crisis that we are facing. In a future blog post I will try to tackle some of the finer details of the question "Assuming T#1 has a therapeutic benefit, to what extent should it be monitored?"
If you have a story or feedback you'd like to share, please click the link below and let me know (anonymously).
The sequel to this article can be found here: