Public consultation: adding non-exempted codeine products to the Manitoba Prescribing Practices Program (M3P)
CPSM requests feedback from registrants, stakeholders, and the general public regarding adding non-exempted codeine products to the Manitoba Prescribing Practices Program (M3P).
Codeine is an opioid analgesic used primarily for pain relief, cough suppression, etc. Codeine has similar side effects to other opioids (e.g., morphine), including dizziness, drowsiness/sedation, constipation, and “slowed” breathing, with the potential to contribute to death in overdose situations.
Codeine contributes to more overdose deaths than any other opioid in Manitoba.
In Manitoba, the prescribing of codeine remains more prevalent than any other opioid. Codeine contributes to more overdose deaths in Manitoba annually than any other opioid. The majority of these deaths are accidental in nature and involve a combination of codeine and other sedating medications.
View the data on prescribing and codeine use in Manitoba
Adding codeine to the M3P drug list was reviewed and discussed extensively by the Quality Prescribing Working Group, a group of representatives from several Manitoba regulatory colleges who reviewed prescribing-related legislation from 2022 to 2024.
There are several exempted codeine-containing medications; the most commonly prescribed is T1.
Proposed change
The working group recommended that all non-exempted codeine-containing products be included under the Manitoba Prescribing Practices Program (M3P) drug list.
This change requires approval from both the College of Pharmacists of Manitoba Council (CPhM) and CPSM. CPhM Council approved the addition in September of 2024. This CPSM public consultation is intended to collect feedback regarding adding non-exempted codeine products to the M3P drug list.
What would this change mean?
Non-exempted codeine-containing products would be added to the M3P drug list, including Tylenol #2 and Tylenol #3.
Several codeine products are already on the M3P drug list, including Codeine Contin, Codeine IR, and pure codeine syrup.
Exempted codeine products, including Tylenol #1 will remain excluded from the M3P drug list. This will help maintain patient access to low-dose codeine products that may also be prescribed by pharmacists.
This change would not impact over-the-counter Tylenol products.
Background information
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What is the Manitoba Prescribing Practices Program (M3P) and drug list?
About the Manitoba Prescribing Practices Program (M3P) and drug list
The M3P is a provincial prescription monitoring program adopted by CPSM Council and CPhM. M3P is specifically intended to minimize the risk of diversion for several high-risk drugs that fall under the federal Controlled Drugs and Substances Act.
A key component of the program is the M3P schedule that lists these drugs. Prescriptions for drugs listed on the M3P list must (in accordance with section 5.8(2) of the CPSM General Regulation) include:
(a) the patient's name, address, date of birth and personal health information number on the approved form;
(b) clearly and accurately set out the name and dosage form of the drug, the quantity to be dispensed and the directions for use, including the intervals at which the drug is to be taken and;
(c) be dated and signed by the prescribing registrant.
The Standard of Practice – Prescribing Requirements (sec 7) has the following requirements for prescribing M3P drugs:
7. Manitoba Prescribing Practices Program (M3P Drugs)
7.1. Physicians must prescribe the drugs listed on the M3P schedule in the manner prescribed in the Regulation and this Standard.
7.2. Section 7 of this Standard does not apply to:
7.2.1. prescriptions for drugs administered in a personal care home as described under the Manitoba Health Services Insurance Act;
7.2.2. prescriptions for drugs administered in a hospital or institutional, residential healthcare facility; and
7.2.3. the direct administration of a designated drug to a patient by a prescriber.
7.3. All prescription drugs on the M3P Schedule must be written on a prescription form as is approved by CPSM.
7.4. The treatment goal, and/or diagnosis, and/or clinical indication(s) must be included for all M3P prescriptions.
7.5. The prescription must contain only one drug per prescription form.
7.6. The prescription is only valid for three days after its issuance to the patient and the physician must so advise the patient.
7.7. Prescribers must prescribe in accordance with the Practice Direction for Prescribing Methadone or Buprenorphine/naloxone.
Adding non-exempted codeine such as Tylenol #2, Tylenol #3, and cotridin liquid to the M3P drug list will impact prescribing in the following ways:
1) Verbal prescriptions will no longer be permitted for these drugs.
2) Physician Assistants and Clinical Assistants will no longer be able to prescribe these codeine products to outpatients. Currently, PAs and ClAs require a co-signature from their supervising physician to prescribe codeine products.
3) Prescriptions will have to meet M3P requirements. This would require therapeutic indication, the total quantity of codeine to be dispensed written in numbers and words, and only one drug per prescription form (i.e., a codeine prescription will require a separate page/sheet).
4) The pharmacy must receive prescriptions within 3 days of issuance.
Codeine contributes to more overdose deaths than any other opioid in Manitoba.
It is our observation that when prescribers go through the steps required to prescribe M3P medications, they are reminded of the risks associated with prescribing the medication. Codeine is not a safer opioid. It carries all the associated risks of other opioids and, therefore, should be prescribed with the same caution and rigour as other opioids.
Other considerations include:
· This change is consistent with all other opioids (with exempted products excluded to maintain patient access).
· A balance between appropriate assessment and treatment of acute pain and public safety must be at the forefront.
· In most provinces, codeine is already treated similarly to M3P medications.
· Several codeine products are already on the M3P drug list, including Codeine Contin, Codeine IR, and pure codeine syrup.
1. Review the information provided in all the sections above (proposed changes, data, background information, impacts, rationale, and M3P drug list).
2. Submit your comments regarding the proposed changes through the following:
· By email to: CPSMconsultation@cpsm.mb.ca
· By mail to:
The College of Physicians & Surgeons of Manitoba
1000-1661 Portage Avenue
Winnipeg, MB R3J 3T7
The deadline for feedback is February 18, 2025.