Codependency on Codeine

Article by Katie Tennant, Content Developer

In recent years, figures have shown a substantial rise in the prescription and misuse of opioid medicines such as codeine, which are generally used to treat moderate to severe pain. Too much of any painkiller can be damaging to a person’s health, but the addictive potential of opioids like codeine, can ruin lives like an illegal drug.

A study* on opioid prescribing trends shows that between 1998 and 2016, opioid prescriptions increased by 34% in England, and the Office for National Statistics notes that codeine deaths increased from 131 in 2016 to 156 in 2017; an increase of nearly 20%.

In response to this rise, the Opioid Expert Working Group have begun a review that will look at the benefits and risks of opioid medicines, including dependence and addiction.

How Does Codeine Work?

Codeine is an opiate; a drug that is derived from opium, the chemical that originates in the poppy plant. It is used in prescription medicines, such as Codeine Phosphate and can also be prescribed or bought over the counter as a combination medicine, mixed with other substances like paracetamol, aspirin or ibuprofen.

Codeine is first and foremost a painkiller, and whilst some people may take it for other purposes (medicinal or recreational), most users will initially take it to relieve pain that hasn’t been relieved by milder painkillers.

Codeine works to relieve pain by reacting with the receptors in the brain that are responsible for pain and pleasure. This means that not only do they relieve pain, but they can also bring on intense pleasurable feelings of warmth, relaxation, sleepiness and a general sense of wellbeing.

It may be these intense pleasurable feelings that can encourage people to take the drug again to replicate the experience.

When people first start taking these medicines, they may be unaware of how prolonged use may affect them. Over time, the body can build up a tolerance to codeine, meaning a person may need to take a higher dose to get the desired effect.

Even if the codeine is taken as prescribed or directed, a person can find that they become dependent and need to take a certain amount of codeine just to feel ‘normal’.

It may only be when the person tries to cut down their codeine use or tries to stop taking codeine altogether, that they experience unpleasant withdrawal symptoms, which are only suppressed by taking more codeine.

Although not easy, it is important for clinicians and patients to recognise and address misuse and addiction and address this as soon as possible to avoid a pandemic of addiction.

People can find themselves in a cycle of misuse, dependence and addiction, just by taking a medicine that they have been prescribed or have bought over the counter.

Of course, these medicines do have their place, but it is vital that people only take them whilst they are still suffering with serious pain. When the pain starts to alleviate, the codeine has done its job, and it is important to then switch to a milder medicine, that doesn't carry the same risk of addiction.

Views of a Clinical Pharmacist

I recently spoke with Davina Gadhia, a clinical pharmacist who has worked in various environments where she has experienced opioid addiction.

She explained that opioid addiction may be initiated within General Practice or could be continued following hospital discharge. It is also observed within NHS 111, with health professionals witnessing pill-seeking behaviour from individuals who are dependent on opioids.

Whilst working in a drug and alcohol misuse service, Davina found that easy access to opioids was an issue and that there was a lack of patient awareness. She believes that patient education is vital, and although information regarding the risks of opioid medicines is already provided on the packaging and in the patient information leaflet, she questions how many patients actually take note of this.

Even if patients are made aware of the risks of taking codeine, the realisation of addiction is often only felt after taking the drug, and at this point the person may already be dependent.

Davina spoke about the rules regarding over the counter codeine-based medicines. In pharmacies, they are only sold as a maximum of 32 tablets in a pack.

These restrictions may stop some individuals from misusing codeine, however, individuals demonstrating pill-seeking behaviour may encourage friends and family to purchase further supplies or could buy more codeine from different pharmacies.

There are drug and alcohol specialist services that patients can access.

These services can educate patients and provide them with support; however, they rely on patients who are willing to recognise that they have an addiction problem or are misusing codeine.

Davina believes that, “although not easy, it is important for clinicians and patients to recognise and address misuse and addiction and address this as soon as possible to avoid a pandemic of addiction”.

How Can We Ensure That These Medicines Are Used Appropriately?

The first step is to ensure that clear and prominent information is provided to anyone that interacts with these types of medicines, making sure that they are well informed of the risks of taking them and that they fully understand how to use them safely.

Access to codeine-based medicines may also need to be reviewed, to ensure that individuals cannot take advantage of these easily available medicines.

Professor Jamie Coleman, Chair of the Opioid Expert Working Group, said, “no one should be unaware of the potential risks of opioid medicines”.

Their study on the benefits and risks of opioid medicines will look at the changes that could be made to the labelling and packaging of opioids, as well as the Summary of product characteristics and patient information leaflet.

They want to ensure that the warnings on opioid medicines are consistent, clear, relevant and represent the known risks of tolerance and addiction. The study will look at both prescription and over the counter opioid medicines, and review the way that these can be accessed.

They can also bring on feelings of warmth, relaxation and general sense of wellbeing...it may be these intense pleasurable feelings that can encourage people to take the drug again to replicate the experience.

This study is still in its early stages and has not yet been published. I hope that the conclusions of the study present some ideas on how clearer information can be provided to people who will take these medicines, and ensure that they are educated on the known risks of tolerance and addiction.