The case for cracking down on codeine
Long considered a relatively safe narcotic, codeine has recently come under more scrutiny
Everyone knows Coca-cola used to contain cocaine. That was in the days of opium dens and travelling tonic salesmen, before drugs were widely regulated.
It seems unthinkable today that a brand name beverage like this would actually contain narcotics, but there is one such opioid that remained readily available on store shelves until very recently. Codeine is considered a mild pain-reliever that can be sold over the counter as a painkiller — usually combined with a non-steroidal antiinflammatory drug (NSAID) like acetaminophen — or as an additive in cough syrup.
The current opioid crisis has helped shine a light on this drug that, like other modern opioids, was previously thought to be relatively harmless.
While a prescription is not necessary for low-dose codeine in Newfoundland and Labrador, you have to ask the pharmacist for it, and the pharmacist is required to consult you to determine whether it’s the right fit.
Some pharmacies won’t dispense codeine at all without a prescription.
Yet it was only a year ago that Health Canada advised that children under the age of 18 should not be given the drug in any form.
“When analyzing Canada’s opioid epidemic, (over-thecounter) codeine should not be ignored,” wrote Jesse Mackinnon in the November 2016 issue of the Canadian Pharmacists Journal.
Mackinnon cited a 1997 Canadian survey of regular codeine users that found 37 per cent were dependent on codeine, while four per cent abused it. Half of them obtained it over the counter.
By 2014, 514 Ontarians had begun methadone treatment for addiction to over-thecounter codeine, something usually reserved for weaning off much harder drugs.
Most provinces have since implemented stricter controls, and Mackinnon says that’s a good thing.
“In the midst of Canada’s fight against opioid abuse, the case for tighter (over-thecounter) codeine regulations should be considered,” he wrote. “There is little benefit to Canadians in having a minimally effective yet addictive product available without prescription, especially when there are other less risky options available.”
SOLD ON THE STREET
One problem with prescribing any opioid is the possibility of diversion — the patient selling it on the street.
Lisa Bishop, a pharmacy professor at Memorial University in St. John’s, says limiting the amount prescribed to only a few days or a week at a time has helped stem that flow.
Under the Prescription Monitoring Act in 2018, pharmacists in Newfoundland and Labrador also have to check their patient’s medication profile using provincial electronic health records.
The modern opioid crisis took off in the 1990s, Bishop said, when pharmaceutical companies really pushed the drugs and said they work really well for chronic pain and were not addictive.
“That, obviously, we know now is not true,” Bishop told Saltwire Network.
“Prescribers are being more careful and selective in terms of what they’re giving out,” she said, while admitting the system is not perfect.
MUST BE METABOLIZED
Codeine has unique properties that make it both useful as a mild analgesic (painkiller) and frustratingly unpredictable.
“The challenge with codeine is it needs to be metabolized in order to be effective,” said Bishop. “Codeine in the body, when you take it, is metabolized into morphine. And the morphine is the actual active drug that causes the analgesic effect.”
Some people don’t have enough of this enzyme, so codeine doesn’t work as well for them, she said.
“And other people have too much of the enzyme, so they’re actually metabolizing more of the codeine than they need and it can have too much of an effect.”
The results can be tragic. “A number of years back, there have been babies who have died because moms, after they’ve delivered, have been given codeine,” she said. “And then if they happen to metabolize too much of that codeine into morphine and it passes through the breast milk, then the baby can get too much of the morphine.”
NSAIDS OFTEN BETTER
With all the pitfalls, one might wonder why codeine is being used at all.
A review of past research published last week in the Canadian Medical Association Journal found that for mild post-operative pain, NSAIDS without codeine seemed to work better for patients than those with codeine.
Bishop pointed out the studies cited mostly focused on dental procedures, for which NSAIDS are already known to work better.
When Australia banned over-the-counter codeine in 2018, some pharmacy advocates feared addicts would just switch to harder narcotics.
Research subsequently found sales of the drug and overdoses both dropped by 50 per cent, with no detected uptake in stronger opioids.
But Bishop said codeine still has its uses.
“If someone has milder pain that an NSAID is not working for or there’s a reason that they can’t take an NSAID … then a small amount of codeine is probably not a bad thing to use,” she said.
“I prefer, as a pharmacist, to use a small dose of morphine, because the morphine is a pure drug and you don’t have to worry about metabolism for it to be effective.”