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Codeine Addiction Explained

Codeine is one of the most commonly prescribed painkillers in the UK, found in medicine cabinets across the country. Unfortunately, codeine is habit-forming, and many people now struggle with codeine addiction, with potentially severe implications for their physical and mental health and life circumstances.

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What Is Codeine?

Codeine is an opiate, as well as an opioid with various medical uses including as a treatment for pain, as a cough medicine, and as an anti-diarrhoeal medication. It is frequently provided in combination with paracetamol (acetaminophen) or non-steroidal anti-inflammatory drugs (NSAIDs) including ibuprofen and aspirin.

Although codeine is provided in the UK as a prescription medication and is found in various pharmacy medicines, like all opioids, codeine is addictive, with a medium dependence liability [1].

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Legal Status (UK)

In the UK, codeine is a class-B controlled substance (class-A if prepared for injection)[3] with serious penalties, including imprisonment for unlawful possession and supply. However, it is legal to possess codeine in certain circumstances: neat codeine and higher-strength formulations are prescription-only medicines, while lower-strength formulations and combinations with paracetamol, ibuprofen or aspirin can be sold over-the-counter.

As a rule of thumb, it is legal to possess codeine in the UK with a prescription, and without a prescription if it is mixed with at least one other ingredient and the dosage of codeine in each tablet, capsule or lozenge does not exceed 100 mg, or a concentration of 2.5% in the case of liquid products such as linctuses.

Codeine Brand and Street Names

Codeine as a stand-alone medication is supplied by numerous manufacturers, with various brand names, though in those circumstances it is typically known simply as codeine. [2]

Some brand names of popular medicines containing codeine include Nurofen Plus, Panalgesic, Aspalgin, Panadeine Forte, Co-Codamol, Panamax Co, Mersyndol, Solpadiene (Plus, Max and Migraine varieties) and Codral.

Because codeine is commonly used recreationally, it is also known by various street names including Schoolboy, Coties, T-Threes, Lean, Sizzurp, Purple Drank and Cs.

Routes of Administration

Codeine is typically taken orally, either in tablet form or as a syrup. It is also available in suppositories for rectal administration, and in some circumstances is provided via either intravenous or intramuscular injection.

Types of Codeine

Provided on the NHS, codeine usually comes in tablet form, with each tablet containing either 15 mg, 30 mg or 60 mg of codeine; or as a liquid to be swallowed (containing 25 mg of codeine in each 5 ml dose). Codeine can also be given in cough syrup form, typically containing 15 mg per 5 ml dose. It can also be administered as an injection.

Outside the confines of the NHS, codeine is often combined with paracetamol, and sold as co-codamol; with aspirin (co-codaprin); and ibuprofen (brands including Nurofen Plus). Codeine linctus is provided as a cough syrup.

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Illicit codeine is usually found in tablet or syrup form, though some users may also obtain liquid codeine, or codeine powder, which may then be injected.

Pharmacological Actions of Codeine

Codeine is an agonist (a chemical which binds to a receptor in the brain or body and activates it to produce a response) of the µ (mu) opioid receptor (MOR). Typically, rather than acting directly upon that receptor, codeine is metabolised in the liver to produce morphine, which is ten times more potent in terms of its impact on the MOR. Codeine acts upon the central nervous system to produce an analgesic and sedative effect due to the reduced excitability of neurons caused by the inhibition of release of key neurotransmitters.

Chemical formula

Codeine has the chemical formula C18H21NO3, and the chemical synonym 3-Methoxymorphine.

Codeine Addiction and How It Develops

Addiction is a disorder of the brain’s reward system, in which an individual feels the compulsion to engage in certain rewarding behaviours despite an awareness of the adverse consequences of doing so. The repeated exposure to an addictive stimulus – in this case, to the consumption of codeine and the experience of its effects – causes an adjustment in the level of certain chemicals in parts of the brain including the nucleus accumbens and the ventral tegmental area.

The positive sensations and emotions resulting from higher levels of chemicals, like dopamine, drive the affected individual to continue to engage in addictive behaviour, causing a further adjustment in the function of the reward system. If you are in this position, then you will feel compelled to repeat the addictive behaviour over and over to experience the sensations of well-being and pleasure which the substance has produced. You will actually feel an increasingly strong need to repeat the behaviour to stave off any negative sensations. They may manifest as a result of a sharp decrease in dopamine levels if the behaviour is not engaged in.

Codeine consumption poses a risk of the development of physical dependence. Dependence is frequently confused with and mistaken for addiction, but although the two phenomena are similar and often closely related, they can occur independently of each other.

Dependence is a phenomenon whereby the system of an individual consuming a certain substance repeatedly over a period of time becomes used to the presence of certain levels of that substance and subsequently becomes reliant upon it for normal functioning. When the substance is suddenly withdrawn from the system, the brain and body can begin to function abnormally, with various unpleasant and potentially dangerous symptoms manifesting. They are collectively known as withdrawal syndrome.

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Why Is Codeine So Addictive?

Codeine is addictive for two main reasons. Firstly, taking codeine can produce a pleasant euphoric and sedative “high” in the user, which can drive repeated consumption as the user seeks to replicate that pleasurable experience. Repeated codeine consumption constitutes an addictive, rewarding stimulus, with the reward centres of the user adapting to the repeated experience of that behaviour and driving further instances of consumption. Secondly, codeine is also physically addictive[4]: taking codeine repeatedly over a period of time can give rise to dependence, and a dependent user will need to continue to take codeine to stave off withdrawal symptoms.

Causes & Risk Factors of Codeine Addiction

Although much is known about the phenomenon of addiction, science has still not fully established why one person will develop an addiction while another in similar circumstances may not; the factors are too case-specific to come up with a rule. It is known that both genetics and the environment play a role in the development of codeine addiction.

A number of factors have been identified which are known significantly to increase the likelihood that an individual will go on to develop a codeine addiction.

Genetics

A person’s genetics are known to influence very strongly their susceptibility to addiction, and a family history of substance abuse and addiction, and/or of other mental health disorders, is a leading risk factor for codeine addiction.

Brain chemistry

The role of the brain in the development of addiction is an area of very significant study and research. Irregularities – potentially, but by no means necessarily, resulting from illness or injury – in the brain’s reward centres and other parts of the brain greatly increase the risk of codeine addiction. Mental health issues associated with brain chemistry – for example, depression and anxiety – are also very important risk factors for codeine addiction.

Environmental

Environmental factors including childhood abuse, stress and/or trauma, associating with a peer group in which substance abuse is common, having easy access to codeine, suffering from an injury or illness requiring pain medication, and financial difficulties, are all known to increase the likelihood that a person will abuse codeine and develop an addiction to it.

Psychological and personality factors

Individuals who are prone to engage in risk-taking behaviour, fill a strong desire to fit in, have a tendency to show off, have an inclination towards engaging in substance abuse generally or have low self-esteem are all more likely than the average to develop codeine addiction.

Signs and Symptoms of Codeine Addiction

It can be quite difficult to identify the presence of an addiction, even in someone very close to you, because the stigma associated with substance abuse and addiction, and the ramifications of it being discovered, are very significant. Addicts frequently go to great lengths to hide their condition, especially from loved ones.

Nevertheless, various signs and symptoms may be observed which can betray an addiction. However, it is vital to bear in mind that these symptoms are not necessarily caused by addiction, and may result from other causes.

Emotional state

Some of the emotional symptoms of codeine abuse and addiction include:

  • euphoria
  • depression
  • anxiety
  • mood swings

Psychological symptoms

Various psychological symptoms of codeine addiction may manifest including:

  • hallucinations
  • delusions
  • memory loss
  • lack of emotions

Behavioural symptoms

Some prominent behavioural indicators of codeine addiction may include:

  • drowsiness
  • increase in amount of time sleeping
  • decreased appetite
  • apathy
  • increased hospital visits
  • no longer caring for loved ones
  • “doctor shopping” (visiting a number of doctors to obtain more codeine prescriptions)
  • prescription forgery
  • stealing prescriptions or opiates from friends and family
  • healthcare fraud
  • lying to cover up amount used
  • decreased libido

Physical symptoms

Physical symptoms of codeine addiction can include:

  • constipation
  • blue tinge to lips and fingernails
  • muscle twitches
  • dizziness
  • fainting
  • nausea and vomiting
  • dry mouth
  • itching
  • rashes
  • urinary retention
  • hypotension
  • seizure
  • respiratory depression

Serious and Long-Term Effects of Codeine Abuse

Long-term codeine consumption can have many extremely deleterious consequences for the user. Most obviously, addiction and dependence can develop comparatively quickly. Drug addiction is frequently catastrophic for the affected individual, with potentially permanent ramifications for relationships, professional and academic prospects, reputation, finances and physical and mental health.

As with any opioid, taking codeine gives rise to the risk of overdose, which can be fatal. Three prominent symptoms of overdose form the so-called “opioid overdose triad”: reduced level of consciousness, respiratory depression, and pinpoint pupils. Other symptoms of codeine overdose include muscle spasms and seizures. Hypoxaemia caused by respiratory depression can kill, and even in cases of non-fatal overdose permanent life-changing brain damage can result. If you see any of these symptoms in an individual you know to have taken codeine, contact the emergency services immediately.

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Frequent codeine consumption can cause tolerance. Like dependence, tolerance develops when someone takes a specific substance regularly over a period of time, and their system adjusts to certain levels of the substance.

If you develop tolerance, you may need to take more and more of the substance in question to achieve the same effects you originally experienced, but with taken smaller doses. Tolerance can be problematic in many ways, including the financial and other consequences of having to consume larger quantities of a given substance. If a certain level of tolerance is already present, stopping your drug consumption will pause the further development of tolerance and sometimes may even turn back the effects.

However, upon recommencing substance abuse, people often forget about tolerance and take the same dosages to which they were accustomed to previously. This would be too much for their current state, consequentially being too much for the body to handle. This usually results in an overdose.

As well as addiction, dependence, tolerance and the heightened risk of overdose, some of the more significant potential consequences of long-term codeine abuse include:

  • acute pancreatitis
  • major depression
  • liver damage
  • kidney damage
  • uncontrollable muscle twitches
  • muscle spasms, cramps, and pain
  • loss of productivity at school or work
  • impaired social relationships
  • anxiety disorders
  • bipolar disorders
  • schizophrenia
  • depressive disorders
  • conduct disorders
  • antisocial personality disorders
  • respiratory depression
  • bradycardia
  • cold, clammy skin
  • decreased muscle tone

Co-Occurring Disorders with Codeine Addiction

Substance abuse often co-occurs with other mental health issues; this is also valid for codeine abuse and addiction. The relationship between substance use disorders and mental health is complex; mental health issues can both drive, and result from, substance abuse and addiction.

Individuals suffering from various mental health issues may desire or feel the need to engage in substance abuse as a means of self-medicating and/or of escapism from a difficult or unpleasant reality. The numbing and euphoric effects of opioids make them particularly popular substances of abuse in this regard. Some mental health disorders may also make behavioural regulation very difficult, with those suffering from them potentially compelled to engage in substance abuse or even unaware of the negative consequences of doing so.

Substance abuse and addiction can also cause a variety of mental health issues, either because of the direct effects upon the brain of the substance/s in question, because of the manifestation of mental health disorders as withdrawal symptoms and because of the impact of addiction on an individual’s life circumstances and prospects.

This last possibility can cause depression, anxiety, suicidal ideation and various other serious issues.

The co-occurrence of a substance use disorder alongside another mental health disorder is known as dual diagnosis. Treating dual diagnosis is typically significantly more complicated than treating an addiction by itself. Depending on the mental health issue involved, some forms of therapy or some kinds of medication which would otherwise be provided may not be appropriate. While some addiction treatment clients may be unable or unwilling to participate in or focus on their treatment and recovery as a result of their mental health disorders, specialist care is usually required.

Relationship Between Prescription Codeine and Using Other Substances

Codeine can have dangerous interactions with a number of other drugs including alcohol, other opioids, some antibiotics, various antidepressants, including selective serotonin reuptake inhibitors (SSRIs), antifungals including itraconazole, ketoconazole and voriconazole, antiseizure medications including carbamazepine, muscle relaxants, benzodiazepines, barbiturates, antipsychotics and some sleep aids. Taking codeine whilst under the influence of other recreational substances – especially including any depressants – is highly advisable, and potentially very dangerous.

If you are taking prescription codeine, it is advised that you do not consume any of the aforementioned substances. If, for any reason, it is required that you do so, always consult your doctor and pay strict attention to the instructions on the packaging of your medication.

Prescription codeine is often obtained illicitly for recreational use, especially by individuals who are regular users of, or addicted to, other opioids including heroin. This is against the law, with serious criminal consequences, but can also be extremely dangerous, posing a risk of overdose.

Symptoms of Withdrawal

Withdrawal from opioid addiction is notoriously unpleasant, and though not considered to be potentially directly fatal. This process and the resulting state of mind can also be dangerous in that individuals who have gone through a period of detoxification and have reduced tolerance, as a result, are at a much greater risk of overdose if they relapse.

Some of the most common symptoms of codeine withdrawal include:

  • cravings
  • flulike symptoms
  • heavy sweating
  • stomach cramps
  • nausea
  • vomiting
  • diarrhoea
  • mood swings
  • chills and an increased susceptibility to cold
  • restless legs syndrome
  • muscle spasms
  • fatigue
  • apathy
  • depression
  • irritability
  • aggression
  • headache
  • loss of appetite
  • decreased libido
  • sexual dysfunction
  • anhedonia
  • anorgasmia
  • anxiety
  • clammy skin
  • confusion
  • dizziness
  • low blood pressure

it is important to recognise that every case of codeine withdrawal is unique, and one person may experience withdrawal very differently from another, with different symptoms manifesting.

Dealing with withdrawal symptoms

As with withdrawal from any opioid, codeine withdrawal can be extremely unpleasant, and in some cases has led to suicide, whilst relaxing can be extremely dangerous if tolerance has been lowered.

As a result, you should not attempt to withdraw from codeine addiction independently: detoxification and withdrawal should be managed and monitored by medical professionals. Speak with your GP and/or an addiction specialist about appropriate withdrawal treatment.

Some symptoms of codeine withdrawal can be alleviated by medication. While some such medication is available for sale, it is crucial that you do not take any medicines without getting professional medical advice.

It is important to bear in mind that withdrawal effects end relatively quickly. Going through a short period of unpleasantness is much better than continuing to labour under the burden of an addiction.

Codeine Withdrawal Timeline

While every instance of codeine withdrawal is unique, it is possible to provide a rough withdrawal timeline to which many cases of withdrawal will approximate. Do bear in mind, however, that individual circumstances may vary considerably.

First stage

The early symptoms of codeine withdrawal may start to manifest anywhere between 12 and 36 hours after the last dose. Flulike symptoms typically begin to develop, along with restlessness, irritability and fatigue.

Second stage

Withdrawal symptoms usually peak two to four days after the onset of withdrawal; the earliest symptoms are usually joined by nausea, gastric disturbances, chills and cramps, profuse sweating, clammy skin, very strong cravings, extreme restlessness and insomnia.

Third stage

Peak symptoms usually begin to subside a week to 10 days after last dose; the third stage of withdrawal sees the diminution of symptoms over a further week or two, with depression, cravings, chills and muscle spasms usually persisting the longest.

Fourth stage

While most cases of codeine withdrawal subside after between a fortnight and a month, some individuals go on to develop post-acute (or protracted) withdrawal syndrome (PAWS), with symptoms – usually psychological – persisting for months or even years.

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Inpatient and Outpatient Treatment

One silver lining to the proliferation of codeine addiction in the UK is that there are now many high-quality treatment facilities operating across the country. Residential rehabilitation (rehab) facilities may offer addiction treatment on either an inpatient or outpatient basis.

Inpatient stays, during which addiction treatment is provided in a relaxed, secure and confidential environment, typically last between one and three months. A holistic inpatient treatment programme provided at rehab will typically include a detoxification and withdrawal phase followed by therapy and may also feature bespoke dietary and fitness plans and a range of other elements varying by facility.

Outpatient treatment may be appropriate for individuals who feel that they cannot afford the time out from family and professional obligations which inpatient treatment would require.

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However, outpatient treatment can be problematic in that it does not remove the addict from their daily environment of substance abuse, and thus preventing relapse can be a very significant challenge.

Codeine detox

Detoxification from codeine can be provided in rehab, monitored and managed by experienced medical professionals, and possibly made somewhat easier with pharmaceutical assistance. The exact details of a codeine detox programme will vary from one rehab to another. Make sure to consult the relevant doctors as fully as possible if you are contemplating a codeine detox in rehab, so you know exactly what to expect.

Because withdrawal can be extremely distressing and can have dangerous ramifications, it is imperative that you never attempt to go through detoxification without professional support.

Always be completely candid about your medical history and the severity and duration of your codeine abuse and addiction.

Therapy for Codeine Addiction

Therapy lies at the heart of all addiction treatment: while detoxification and withdrawal remove the immediate physical pressures of dependence, they do not address the underlying psychological causes of addiction. Therapy can reveal and tackle the root causes of addiction, enabling you to identify and remediate the behaviours which have led to the development of addiction, as well as providing you with psychological defence mechanisms against relapse which you can leverage throughout recovery.

Therapy in addiction treatment comes in a very wide variety of forms and methodologies, and in rehab may be provided in both group and one-to-one settings. Individuals undergoing addiction therapy may need to try out more than one different therapy style before settling on one which is most beneficial to them.

Cognitive behavioural therapy (CBT)

Cognitive behavioural therapy is one of the most common forms of psychotherapy. CBT focuses on identifying and challenging negative thoughts and behaviours, and on developing personal coping strategies aimed at addressing current problems (such as addiction). In addiction treatment, CBT usually consists of six phases: assessment, reconceptualisation, skill acquisition, skill consolidation, maintenance, and follow-up.

Motivational interviewing (MI)

Motivational interviewing is a client-centred counselling approach aimed at eliciting behavioural change by examining and resolving ambivalence. Rather than allowing clients to explore issues in a nondirective manner, motivational interviewing therapists try to influence their clients in a directed (though non-judgemental and non-confrontational) way, with the intention of getting the clients to consider making changes in their lives.

Contingency management (CM)

Contingency management (also sometimes known as operant conditioning) uses stimulus control and positive reinforcement to change problematic behaviours. In addiction therapy specifically, clients are rewarded or punished according to their ability to adhere to the elements and conditions of their addiction treatment plans. Rewards could be, for example, privileges in rehab, vouchers or even cash incentives. CM is considered one of the most effective therapies in the treatment of addiction.

12-step programme

Some organisations – most famously, Alcoholics Anonymous[5] and Narcotics Anonymous[6] – offer 12-step programmes: a set of 12 guiding principles defining a course of recovery from addiction. Twelve-step programmes focus on the physical, mental and spiritual health and development of each addict, and are often long-term efforts, with individual addicts attending group meetings regularly (usually weekly) for months or years.

How to find the right treatment centre

There are numerous high-quality addiction treatment centres operating across the UK where you can get help for your codeine addiction. The treatment provided at one facility may differ significantly from that given at another; moreover, which facility may be right for you will depend on your personal circumstances. For example, you may prefer a centre close to your home – or on the other hand, you may wish to be as far as possible from the environment in which you have succumbed to addiction.

To find out about the pros and cons of various treatment centres in your area or beyond, speak with an addiction specialist about your condition and circumstances and what you wish to achieve.

Safety Warning for Giving Codeine Tablets to Under-18s

The NHS gives the following warnings relating to codeine use by under-18s[7]:

  • “Do not take more than 4 doses of codeine in 24 hours if you’re a child (aged 12 to 18 years)”
  • “Do not give codeine to children who are under 18 years old and have had their tonsils or adenoids removed because of a sleep problem called obstructive sleep apnoea.”

Authorities in many countries including the United States recommend not giving codeine to under-12s.

Codeine Addiction Facts and Statistics

  • In 2017, GPs in England prescribed 23.8 million opioid-based painkillers – the equivalent of 2,700 per hour.
  • More than 2,000 deaths in England and Wales in 2016 involved opioids.
  • The number of patients being provided opioid painkillers in the UK has doubled in the last 15 years.
  • Codeine was discovered in 1832 by Pierre Jean Robiquet.
  • In 2013, more than 249,000kg of codeine were used worldwide, making it the most commonly consumed medicinal opiate.

Cost of codeine addiction to society

The cost of codeine addiction is fundamentally incalculable, as nobody can put a price on all the ruined lives, broken hearts and destroyed dreams which it causes. It is also effectively impossible to get an accurate measurement of the social cost of codeine addiction in cash terms, though NHS social welfare and police resources deployed as a result of codeine addiction certainly cost UK taxpayers many millions of pounds each year. As early as 2010, the Home Office estimated that illicit drug use in the UK cost the country over £10 billion.

Ready to get Help for Codeine Addiction?

If you are labouring under the burden of a codeine addiction, you may feel a sense of despair and be able to see no way out from your situation. However, it is vital that you do not give up hope: high-quality treatment facilities are operating around the UK and have saved countless lives. No matter how serious your addiction, you can get the assistance you need if you are prepared to acknowledge your condition and ask for help.

Speak with your GP and an addiction specialist today about codeine addiction treatment options which may be available to you. Making that call could be your first step on the road back to a happy, healthy and successful life.

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How can I spot codeine addiction?
It can be very difficult to spot an addiction even in someone very close to you; addicts frequently go to great lengths to hide their condition, and many codeine addicts may be very good at concealing their intoxication. Nevertheless, various signs may reveal the presence of an addiction, including physical, emotional and behavioural symptoms. For more details, see the section ‘Signs and Symptoms of Codeine Addiction’ above.
What is the goal of codeine addiction treatment?
Codeine addiction treatment is aimed at helping addicts overcome addiction and breaking the cycle of substance abuse by tackling both dependence and the psychological root causes of addiction, enabling individuals to enter recovery and eventually to resume healthy and happy lives.
How quickly can you get addicted to codeine?
Every instance of codeine addiction is unique. Different individuals respond differently to codeine, and some may become addicted much more quickly than others. The higher the dosage and the more frequently you take codeine, the greater the chance that you will go on to develop an addiction. Usually, it is recommended that you do not take codeine for more than a few days in succession. Always follow the advice of your doctor and the guidelines on the packaging of any medication prescribed.
Who abuses codeine?
Codeine is abused by people from every demographic and from all parts of the country. There is no one stereotypical codeine abuser.
How to cure codeine addiction?
It can be dangerous and misleading to talk about a “cure” for addiction. Many people who have experienced addiction and who have been through recovery, even years ago, still describe themselves as addicts, because they know that recovery is something which needs to be fought for every day. However, with the right combination of medicinal help and therapy, even the longest-lasting and most severe codeine addiction can be overcome.
Why is codeine used if it is so addictive?
Codeine is a very useful medication in the treatment of pain, coughs and diarrhoea. Used in accordance with the instructions of a prescribing physician, codeine can be non-problematic. It is only when it is abused or taken in excess or for too long that problems typically arise. If you are concerned about its effect o you or a loved one, share your concerns with you/their doctor to discuss other options.

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