Registrar’s message: reclassifying liquid codeine-based preparations to enhance public safety

There is mounting concern over prescription liquid cough preparations containing codeine. Such cough preparations are too readily available and too often abused by vulnerable youth, which is one of the reasons the College of Physicians and Surgeons of BC (the College) is working with the College of Pharmacists of BC (CPBC) to reclassify these preparations as Schedule 1A drugs.

This reclassification was approved by the College Board in May and the CPBC Board in September. It will take effect on January 2, 2020. The change will require physicians to adjust how they currently prescribe liquid codeine-based preparations to their patients. Most notably, these preparations will now fall under the Controlled Prescription Program, and physicians will have to prescribe such medication on a duplicate pad. While there are always inconveniences associated with a change like this, the evidence supporting this reclassification justifies the change.

These medications are easier to obtain than other opioid preparations, which can lead to the potential for addiction and widespread non-medical use. Here in BC, prescriptions written for cough medications containing codeine make up a small proportion of the total prescriptions written each year. However, the problems associated with these prescriptions are disproportionately high. They account for an excessively high number of thefts from pharmacies and an increasingly high number of prescription forgeries. 

Ontario data indicates that nine per cent of children in grades seven to 12 misused cough and cold medications in 2017, and it remains a significant drug of abuse in Canada. In the US, cough syrup containing codeine is commonly abused by young people, where it is popularly known in hip-hop culture as “purple drank.” It has been responsible for several high-profile deaths of performers and young people.

In addition to being dangerous if misused, research shows codeine cough medications are not even effective in their intended use. While codeine has been shown to have some limited utility as an opioid analgesic for acute pain, there is limited data on its effectiveness for chronic cough, and no evidence that cough medications containing it are useful for acute coughs associated with upper respiratory illness for children and young adults. The risk is simply too high for something that has no demonstrated benefits. 

The rescheduling of codeine-containing liquid preparations from Schedule 1 to Schedule 1A will require physicians to give more deliberate thought to writing these prescriptions, reduce forgeries and make it more difficult for pharmacy thefts as the preparations must be kept in a time-locked safe. While these may be inconveniences in the short term, they are far outweighed by the long-term gains in enhancing public safety.

The move to mandatory use of a duplicate prescription will be phased. For the next three months, both duplicate and non-duplicate prescription forms will be accepted for codeine-containing liquid preparations. As of January 2, 2020, only duplicate forms will be accepted. Physicians who continue to prescribe these preparations are urged to make arrangements by ensuring that they have an adequate supply of duplicate pads. For more information on the reclassification, registrants can email rxpads@cpsbc.ca or visit https://www.bcpharmacists.org/codeine

Heidi M. Oetter, MD
Registrar and CEO

DINProduct
2298708ACETAMINOPHEN ELIXIR WITH 8MG CODEINE PHOSPHATE SYRUP
816027PMS-ACETAMINOPHEN WITH CODEINE ELIXIR
2198630CALMYLIN ACE
2243063COVAN SYRUP
2244078DIMETAPP-C
1934740ROBITUSSIN AC
2169126TEVA-COTRIDIN
2244079DIMETANE EXPECTORANT C
2053403TEVA-COTRIDIN EXPECTORANT