CODEINE CRACKDOWN COMING?

The federal government is proposing to end what one pharmacist has called the “dirty little secret” of Canadian drug policy, requiring a prescription for codeine-containing drugs that are now available over the counter.

The suggested change would put a damper on products with sales of 600 million pills a year, and a nonprescription status virtually unique in the industrialized world.

In a notice of the possible new rules, the government cites the surprising addiction toll exacted by the low doses of codeine in medicines that combine the opioid with acetaminophen or other painkillers.

About 500 people a year are admitted just to publicly funded addiction-treatment centres because they’re hooked on non-prescription codeine alone, and another 800 because of addiction to low-dose codeine plus other drugs, the department says.

A leading Canadian expert on drug policy says the pills are almost as dangerous for another reason, too: people who pop them for the high are consuming large amounts of acetaminophen or ASA, both drugs that can be highly toxic in bulk.

Pharmacists and other experts have called for this change since long before the current opioid-addiction epidemic — to little effect until now, said Dr. David Juurlink, a physician and toxicologist at Toronto’s Sunnybrook Health Sciences Centre.

“It’s a no-brainer, and it should have been done years ago,” he said. “It’s a distinctly unwise and inadvisable thing to allow.”

Juurlink is blunt in assessing why the department has taken so long to act: “Inertia and bureaucratic ineptitude, the two things Health Canada does best.”

The proposal is open to a 60-day comment period, after which time the government will decide whether to pass a regulation implementing the change.

The most common of the targeted products are generic versions of Tylenol 1 — codeine and acetaminophen — and “222s” — codeine and aspirin.

Canada is close to the world leader in codeine use, its consumption several times higher than most other Western countries.

Health Canada says making the low-dose codeine drugs prescription-only might lead to more use of the health-care system as patients wanting them would have to see a doctor. It could also drive abusers to more dangerous alternatives.

But it would also ensure that Canadians carefully consider with their doctor the best drug for their needs, said the notice. It noted, in fact, that over-the-counter codeine pills are of questionable effectiveness, with one 2010 review finding non-opioid alternatives worked better than codeine.

In fact, the dose in those tablets is virtually non-therapeutic, said Juurlink. While it is derived from opium, codeine has to be converted to morphine by the liver, so the resulting concentration also differs from person to person, he said.

Benedikt Fischer, an addictions scientist at Torontobased Centre for Addictions and Mental Health, warned that the risk of “displacement” — users moving to a more potent alternative — is real and has a recent precedent. When OxyContin was essentially taken off the market in Canada, many prescribers, patients and abusers switched to the much more powerful and perilous Fentanyl, he said.