Friday, December 1, 2017

Tramadol: A Case of Misclassification?

Although tramadol was being considered for classification as a controlled drug back in 2007, it remained an uncontrolled drug.1 A decade later, Health Canada is reconsidering the decision and may re-categorize tramadol as an opioid.1

Tramadol is a painkiller that increases serotonin levels in the body like antidepressants do, leading to some analgesia.1 In addition, CYP2D6 in the liver then converts tramadol to a compound called M1, which is an opioid that provides pain relief similarly to morphine.1 One thing to remember is the pharmacogenomics involved with the conversion of tramadol to M1.1 Some individuals have weak CYP2D6 activity and do not receive the opioid effect, whereas, others may have rapid conversion and acquire a large opioid effect.1

The classification of Tramadol as an opioid is being contemplated due to multiple health care professionals voicing concerns as well as a report on opioid trends from the Canadian Institute for Health Information (CIHI) released last week.2 According to the report, tramadol prescriptions have increased 30% and daily doses have increased by 23% between 2012 and 2016.3 Despite the Canadian non-opioid classification, CIHI included tramadol in their report on opioids because the World Health Organization classifies it as an opioid, as does the United States’ Drug Enforcement Administration and the manufacturers' scientific description.2

Tramadol has the potential to be abused, misused, and can cause dependence especially at higher doses.2,4 Its classification as a non-opioid makes for minimal reporting requirements resulting in a lack of data to help us measure the extent of its abuse and misuse in Canada.2

The opioid crisis does not look like it will resolve any time soon as there is no simple solution for the problem. Therefore, making even the smallest of changes, such as modifying the classification of tramadol to an opioid and the resulting alterations in reporting requirements, could prove crucial.

Now we wait and see if Health Canada will make this change.

1. Juurlink, D. (2017, November 27). Why Health Canada must reclassify tramadol as an opioid. The Globe and Mail. Retrieved from

2. Howlett, K. (2017, November 22). Health Canada eyes opioid restrictions for popular painkiller. The Globe and Mail. Retrieved from

3. Canadian Institute for Health Information. (2017). Pan-Canadian Trends in the Prescribing of Opioids. Ontario: Canadian Institute for Health Information. Retrieved from

4Purdue Pharma. (2016). PRODUCT MONOGRAPH INCLUDING PATIENT MEDICATION INFORMATION : Zytram XL®. Pickering. Retrieved from

Thursday, November 23, 2017

Being a Wise Pharmacist

The Canadian Pharmacist Association (CPhA) just released a campaign called Choosing Wisely Canada for pharmacists.1 This campaign was created to help pharmacists have discussions with patients to identify if treatments are warranted, have evidence to support use, and/or can cause harm to patients.1 The recommendations were made by asking Canadian pharmacists and pharmacy researchers to provide their input, which were then reviewed by an expert committee.The final list was created considering the relevance to pharmacy practice, possible impact and supporting evidence.1 The six evidence-based recommendations were made for pharmacists to help optimize patient care and safety.1

1.   Don’t use a medication to treat the side effects of another medication unless absolutely necessary.2

It is important to clarify if a symptom is part of a medical condition or a side effect to a medication.2 You do not want to initiate a prescribing cascade, as it can lead to polypharmacy.2 The polypharmacy can then generate to more side effects, drug interactions, impact adherence and patient’s quality of life.2

For more information read: The prescribing cascade revisited.

2.   Don’t recommend the use of over-the-counter medications containing codeine for the management of acute or chronic pain.2 Counsel patients against their use and recommend safe alternatives.2

According to evidence, use of over-the-counter pain medication containing codeine is not supported over non-opioid options.2 Codeine has the potential to be abused and cause dependence.2 Furthermore, the codeine containing medications tend to have high doses of the simple analgesics (acetaminophen, aspirin or ibuprofen) which can cause adverse effects with misuse (i.e. liver toxicity, peptic ulcers and renal damage).2 
3.   Don’t start or renew drug therapy unless there is an appropriate indication and reasonable expectation of benefit in the individual patient. 2

About 66% of Canadians over the age of 65 take five or more drugs.2 Polypharmacy increases risk of adverse drug reactions and can lead to hospitalization.2 Pharmacists should clarify the therapeutic indication for all medications and only renew prescriptions if benefits of therapy are known to be greater than the risks.2

A tool to help with this task: Check up on “checking”

4.   Don’t renew long-term proton pump inhibitor (PPI) therapy for gastrointestinal symptoms without an attempt to stop or reduce (taper) therapy at least once per year for most patients.2

PPIs are safe and well-tolerated for short term use in of gastroesophageal reflux disease, but can cause adverse effects if used long term, such as: increased risk of fracture, C. difficile infection and diarrhea, community-acquired pneumonia (CAP), hypocobalaminemia and hypomagnesemia.2 Recommend H2-receptor antagonists or lifestyle changes for patients that have used PPIs for 4 weeks and are no longer symptomatic.2 Note: This recommendation does not apply for Barrett esophagus, severe esophagitis grade C or D, or known history of bleeding gastrointestinal ulcers.2

Tools to help with this task: Bye-Bye PPI and PPI Deprescribing Algorithm

5.   Question the use of antipsychotics as a first-line intervention to treat primary insomnia in any age group.2

Many people have been using antipsychotics for an off-label indication of insomnia.However, there is no evidence to support first-line use in guidelines and there are side effects to consider (i.e. weight gain and metabolic disorders).2

6.   Don’t prescribe or dispense benzodiazepines without building a discontinuation strategy into the patient’s treatment plan (except for patients who have a valid indication for long-term use).2

Benzodiazepines are often prescribed for anxiety disorders and insomnia.2 Long term use in elderly patients can lead to tolerance, dependence, adverse effects (i.e. sedation, impaired memory, falls) and hospitalization.2 Guidelines recommend using other options before benzodiazepines.2 If prescribed they should not be used long term and a treatment plan should be developed (i.e. taper schedule).2

A tool to help with this task: Benzodiazepine and Z-drug Deprescribing Algorithm

These six changes have the potential to make a large impact on patient care and safety. What do you think about these new recommendations? Email me to share your success stories.

A video of the recommendations available as well: 6 Things Pharmacists & Patients Should Question - Choosing Wisely Canada


     1. Canadian Pharmacists Association. (2017, November 21). Choosing Wisely Canada. Retrieved from

     2. Canadian Pharmacists Association. (2017, November). Six Things Pharmacists and Patients Should Question. Retrieved from

Friday, November 17, 2017

Medical Marijuana in Pharmacies - Will it Happen?

Hello rxBriefCase,

Marijuana has been in the news continuously for the past few months, with emphasis on the recreational marijuana deadline in July 2018. A couple weeks ago, the Liquor Control Board Ontario (LCBO) announced the first 14 cities to have shops that will be selling legalized recreational marijuana. Now that the recreational marijuana framework and dispensaries have been established, people have moved on to the next big thing - medicinal cannabis.
Shoppers Drug Mart just posted a job for a medical marijuana brand manager position, despite pharmacies not yet having the role of dispensing medical marijuana.1 Handling medicinal cannabis dispensing has been a goal for Loblaw Companies Ltd., the company which also owns Shoppers Drug Mart, since they applied for a Health Canada license last year.1 Other pharmacy companies are also looking to dispense  medicinal cannabis under the belief that pharmacies are ideal distribution locations, just like for any other prescription medication.1
Based on a recent study, it appears it's not just the pharmacy companies who think this is a promising idea - so does the public.2 The data from the new study done by the Ontario Pharmacist Association (OPA) shows that more than 7 out of 10 adult Ontario residents trust pharmacists to dispense medical marijuana.2 Furthermore, 56% of the survey participants indicated preferring medicinal cannabis being dispensed at pharmacies, compared to other alternatives.2

This is not the way the medical marijuana dispensary framework is currently set up, and not using pharmacists in this process could create safety risks for patients.2 This may be a missed opportunity for patients, as they forgo access to advice and information that could benefit their overall health. Pharmacists are the drug experts and can monitor for treatment effectiveness, side effects and identify potential risks (i.e. drug interactions or contraindications).2

Pharmacists are experts at reviewing prescriptions, dispensing medications, identifying drug interactions and counselling patients. We have a lot of practice with these activities, however, this may not be true when it comes to medical marijuana. Some pharmacists may see this new role as an opportunity to expand on our skill set and apply our drug expertise further. Others may feel uncomfortable dispensing medical marijuana as it will require developing new skills and obtaining new knowledge to provide patients the best care possible. 

With medicinal cannabis potentially being dispensed from pharmacies, it is very important that pharmacists receive education and training to help them prepare for a potential role in medical marijuana dispensing.

What are your thoughts? Do you feel prepared?

Note: There are medical marijuana continuing education options available for pharmacists and other healthcare professionals.

Ontario pharmacists can have their continuing education costs subsidized with the help of allied health professional development funds from HealthForceOntario ($1,500 per year). 


1. The Canadian Press. (2017, November 13). Shoppers Drug Mart posts job for medical marijuana brand manager. CBC News. Retrieved from

2. Baker, J. (2017, November 12). OPINION: Ontarians trust pharmacists to dispense medicinal cannabis, data shows. Toronto Sun. Retrieved from

Friday, November 10, 2017

Installing Virus Protection Software

Hello rxBriefCase,

No, I am not referring to the software you install to protect your computer from a virus, but rather the influenza vaccination you provide patients to protect them from the flu. This blog post will provide an overview of important guideline recommendations and answers to common questions.

Recommendations to Remember
  • Two Doses for Children to Start: Any child getting vaccinated for the first time between the ages of 6-months through-8 years-old, will requires two doses, at least four weeks apart.1,2,3 It is recommended that children get their first dose as soon as the vaccine is available for the season.1
  • FluMist Recommendation Change: FluMist, the intranasal vaccine (LAIV4), is no longer the preferred vaccine for children.1,2,3 This means that either the injection or the intranasal vaccination can be used for children, without preference.2,3 Though more child friendly, the intranasal formulation is not considered to have superior effectiveness.2 Alberta and Saskatchewan have stopped covering this intranasal option under their immunization program.9 Read more: Flu shot or nasal spray?
  • Preferred Vaccine in Children: Children under the age of 18 are recommended to receive the quadrivalent vaccine.2,3 The trivalent vaccine provides protection against three different flu viruses (2A, 1B), compared to the quadrivalent which protects from four strains (2A, 2B). The quadrivalent vaccine is recommended for kids under the age of 18 because the morbidity and mortality resulting from B strains is higher in that age group versus the adult population.2,3
  • Pregnancy and Flu Shots: Pregnant women may receive any licensed and recommended (consider age) influenza vaccine.3,4 Data shows the influenza vaccination does not lead to any pregnancy complications or birth defects.4 Note: LAIV should not be used in pregnancy.3
  • Egg Allergy and Flu Shots: An allergy to eggs is no longer a contraindication for flu shots. 2,3 Studies have shown that the use of chicken embryos in the production of the vaccine do not create any issues for patients with egg allergies.5 Patients with an allergy to eggs, like all other patients, should be observed for 15 minutes after receiving the flu shot.1,5 Read more: Algorithm for patients with egg allergies
  • New Vaccine Available for Seniors: There is a new high dose trivalent vaccine (Fluzone High Dose) available for seniors (65+). This vaccine is currently not covered by any province, but it was just announced that it will be covered in Ontario next year.2,3,6 The high dose vaccine is four times as potent. It is suggested for the elderly due to the high disease burden of influenza and their declining immune response.3 The high dose vaccine is predicted to help create a stronger immune response and be more effective for seniors.2,3 Canadian Association of Retired Persons (CARP) supports the high dose vaccine: There’s a new flu vaccine available this year, just for Canadians 65+ (Video)

Common Questions from Patients
When is the best time for me to get the flu shot?
It is recommended to get the vaccine before the onset of influenza cases in the community or by the end of October.1,3 However, getting the vaccine later in the flu season can still be beneficial.1,3

Will the flu shot give me the flu?
No, it will not. You may experience a low-grade fever, aches, or some injection site soreness, redness and swelling.7 

Why did I get the flu even though I got the flu shot?
The flu shot does not guarantee 100% protection, but it is the best way to try and protect yourself and others.8 There are a few possible reasons why you may have gotten the flu despite getting vaccinated. You may have been exposed to the flu virus before you got the flu shot or during the two weeks it takes your body to create antibodies which help provide the protection.8 Also, the virus you may have been exposed to might not have been included in the vaccine for that season.8 The vaccine provides protection for the most common circulating strains, but not all strains.8 Furthermore, the protection one gets depends on their overall health and age. 8

Helpful Links to Help Update Your Influenza Knowledge:

  1. Grohskopf LA, Sokolow LZ, Broder KR, et al. Prevention and control of seasonal influenza with vaccines: Recommendations of the Advisory Committee on Immunization Practices — United States, 2017–18 Influenza Season. MMWR Recomm Rep 2017;66 (No. RR-2):1–20. DOI:
  2. Bhaidani, S. [Hey Pharmacist]. (2017, October 4). Giving the Flu Shot? Here's 5 Things to Know
  3. [Video File]. Retrieved from
  4. National Advisory Committee on Immunization. Advisory Committee Review: Canadian Immunization Guide Chapter on Influenza and Statement on Seasonal Influenza Vaccine for 2017-2018:
  5. Centre for Disease Control and Prevention. (2017, September 19). Flu Vaccine Safety and Pregnancy. Retrieved from
  6. Centre for Disease Control and Prevention. (2016, September 2). Flu Vaccine and People with Egg Allergies. Retrieved from
  7. Ministry of Senior Affairs. (2017, November 7). Aging with Confidence: Ontario’s Action Plan for Seniors. Retrieved from
  8. Centre for Disease Control and Prevention. (2016, August 25). Seasonal Flu Shot Question and Answers. Retrieved from
  9. Centre for Disease Control and Prevention. (2017, October 26). Frequently Asked Flu Questions 2017-2018 Influenza Season. Retrieved from
  10. Mulholland, A. (2017, October 16). Flu shot or nasal spray? Conflicting studies lead to confusion. Retrieved from

Friday, November 3, 2017

Who Am I and What Am I Doing Here?

Hello rxBriefCase,

My name is Puja Modi and I am a final year student at the University of Toronto - Leslie Dan Faculty of Pharmacy. Like many students that preceded me, I am here completing a 5-week rotation as part of my Advanced Pharmacy Practice Experience (APPE) placements. These APPE rotations have offered me opportunities to apply my knowledge and gain experience that will help me with my future pharmacy career.

With graduation looming, everyone keeps asking me the same big question – where do you see yourself working? Currently, my answer is that I have not yet decided. The uncertainty stems from the fact that I have enjoyed all my past pharmacy placements and learned something valuable from each opportunity. My previous experiences include community pharmacy, hospital pharmacy, public health and safety research. This rotation at rxBriefCase is different from my former experiences and will allow me to expand my skill sets into the world of continuing education (CE).

No matter where I end up, I know that continuing education will always be a part of my career, as it is very important to stay up to date. This rotation will allow me to understand the landscape of CE in Canada, accreditation standards of the Canadian Council on Continuing Education in Pharmacy (CCCEP), and the role of pharmacists in CE development. I will also have the opportunity to refine my critical analysis and medical writing skills. I will be improving these skills by completing a critical appraisal of a CE program, writing an eNewsletter, developing a module for MedSchoolForYou and continuing to blog on my experiences and trending topics in the pharmacy world.

Some random facts about me:
  • I love to travel - my most memorable trips were to India (3 months) and Europe (3 weeks)
  • Hobbies of mine include dancing, photography and NETFLIX (next show: Stranger Things)
  • I am a big foodie who is constantly eating – I am always open to suggestions for the best places to dine in Toronto

Keep an eye out for my next post!

- Puja Modi 

Thursday, September 21, 2017

I See the Light! – Canadian e-Prescribing Platform on the Horizon

A national e-prescribing system, removing the need to transcribe (and sometimes translate) written prescriptions?

Sounds too good to be true, but Canada HealthInfoway is working hard to make this a reality.

An e-prescribing system works by having the prescription electronically transfer from the physician’s office software, directly into the pharmacy software.  This isn’t a novel idea, with several pharmacies and doctor’s offices already having their own systems in place.  However, Canada Health Infoway is looking to create one national system, called PrescribeIT, to redefine the standard across all pharmacies and clinics.

PrescribeIT has one feature that other e-prescribing systems lack, the ability to communicate to the physician if the prescription has been filled1.  This may seem like a small feature, but doctors have generally been left in the dark, not knowing if their prescriptions are being filled.  Prescribers can become frustrated if they’re unsure the patient’s condition isn’t responding due to inadequate therapy or if the patient is non-adherent. PrescribeIT is a step forward to solving this problem and improving pharmacist-doctor communication.

E-prescribing can be a blessing and a curse to pharmacists.  On one hand, they no longer have to interpret (sometimes poor) doctor handwriting; this job will already be completed by e-prescribing. In a St. Johns study, e-prescriptions had an error rate of 0.66%, and hand written prescriptions 1.33%2.  The caveat is that errors will be far more difficult to catch.   If a doctor accidently inputs the wrong drug or patient into the e-prescribing tool, through a wrong click, it may be impossible to determine if it’s in error.  Therefore, it will be crucial that pharmacists communicate with patients to determine if the medication is appropriate.  This is a practice that pharmacists are already doing, but will now become even more important.

Don’t get too excited yet, as PrescribeIT is only just being trialed at Algonquin Family Health Team and the Muskoka Medical Pharmacy in Ontario1.  It will likely be a few years until we see it rolling out to other Canadian pharmacies.  This is an exciting new technology that will hopefully improve the standard of care in pharmacies.

- Ajay Chahal

  1. (n.d.). Retrieved September 20, 2017, from
  2. Phillips, J. L., Shea, J. M., Leung, V., & MacDonald, D. (2015). Impact of Early Electronic Prescribing on Pharmacists’ Clarification Calls in Four Community Pharmacies Located in St John’s, Newfoundland. JMIR Medical Informatics3(1), e2.

Monday, September 18, 2017

Painfully Common – Codeine Crisis?

Pain management can be complicated since there is no objective test to assess pain like in hypertension, and pain can be difficult to clearly articulate.  It’s also common for patients to ask for codeine containing products (schedule 2 in Ontario), to manage their pain.  Codeine is metabolized by the CYP2D6 enzyme into morphine, which then exerts its painkilling effects.  Patients metabolize codeine into morphine at different rates, therefore some patients may have a lot of pain relief and others may not experience anything at all.  To complicate things even further, codeine is an opioid that can cause addiction.

These factors contribute to why Health Canada is considering banning all non-prescription codeine1.  Health Canada is most concerned about the addictive potential of codeine, as they’ve noticed a significant number of patients entering rehab programs for non-prescription codeine substance abuse alone1.  From a pharmacist perspective, there are two predominant viewpoints:
  1. Schedule 2 codeine products have an important role in therapy and with the appropriate tools, they can be effectively monitored for abuse.
  2. Schedule 2 codeine products are too unsafe, due to their abuse potential, to be sold without a prescription.
Whether pharmacists can effectively monitor non-prescription codeine depends on the electronic tools available to them in each province.   For example, Alberta pharmacists have access to the patient’s electronic medical record (EMR) called NETCARE. They can use the software to identify when the patient last picked up codeine.  In this situation, schedule 2 codeine products can have an effective role in therapy and may not need to be prescription, since pharmacists are capable of monitoring for abuse.

However, Ontario pharmacists do not have access to an EMR and thus are unable to assess if the medication is being abused.  This can be dangerous since it is impossible to know how much codeine the patient is using.  In this instance, banning the sale of the non-prescription codeine products may be appropriate.

Health Canada should encourage provinces to make the appropriate regulatory changes based on their pharmacy infrastructure.  If the appropriate mechanisms are in place to monitor for abuse, the provinces should trust pharmacists to make the correct judgement to dispense codeine.

In either case, pharmacists must be competent to counsel patients on effective pain management strategies.  RxBriefCase offers an excellent program discussing mild to moderate pain management in primary care:
It will be interesting to see how Health Canada decides to regulate non-prescription codeine and how changes to the legislation will impact patients.

- Ajay Chahal

  1. Beeby, D. (2017, September 11). Health Canada aims for prescription-only codeine pills, syrups. Retrieved September 15, 2017, from