Codeine

Codeine is a naturally occurring opioid widely used prescription medication that is commonly used for pain control. It is also available, over the counter, from pharmacies, in doses lower than those prescribed. Research in Scotland showed that, between 2003-2012, of the 948, 000 people prescribed opioids by the NHS, codeine accounted for 658,000 of these prescriptions.

As with other opioids, codeine activates opioid receptors in the body to alter pain signals. They can also provide a sense of euphoria and relaxation making them desirable to use. It is this reward element that can lead to abuse. Persistent misuse can lead to opioid use disorder (OUD).

These items, which can be purchased over the counter in a pharmacy, present additional problems as taking paracetamol at intervals of less than 4 hours apart leads to liver damage. In extreme cases this can be fatal. Ibuprofen, when taken in excessive doses, can lead to significant gastrointestinal damage, stomach ulcers and, at the end of the spectrum, blood loss leading to fatality.

Codeine is a relatively short acting drug. That means that it’s effects can wear off within 4-6 hours of taking it. As such, it is necessary to take it up to six times a day when dependent. When someone is dependent, withdrawal signs and symptoms can start to show in as little as eight to twenty-four hours after the last dose.  

• Lachrymation (runny eyes) 
• Rhinorrhoea (streaming nose) 
• Hyperhidrosis (excessive sweating) 
• Excessive yawning 
• Dysphoria (profound state of mental anguish)
• Severe insomnia 
• Cutis anserine (gooseflesh skin) 
• Tachycardia (increased heartrate) 
• Nausea/vomiting 
• Severe diarrhoea 
• Gastrointestinal discomfort (cramps)
• Extreme anxiety

Sudden withdrawal from codeine is not known for putting a user at risk of an acute medical emergency. However, the resulting symptoms of withdrawal can be incredibly uncomfortable. This is what, usually, leads someone to relapsing as the symptoms of withdrawal are too great a burden to bear.

For those with underlying medical conditions, especially hypertension (high blood pressure) there is the potential for a spike in blood pressure, as well as heart rate, which could lead to an acute medical emergency. 

Gastrointestinal distress can lead to significant dehydration and electrolyte imbalance. Severe diarrhoea and vomiting can lead to fluid loss and, on occasion, can be fatal. Those who are prone to anxiety can experience severe episodes which could necessitate medical assistance.

This depends on whether a client has already stopped using, prior to admission (not advised) or wishes to enter treatment, while still using, so that the stoppage can be fully managed. Ordinarily, Methadone or Buprenorphine would be the usual medication used for codeine. While a treatment programme using Buprenorphine can be achieved quicker than Methadone, it requires the person to be in full withdrawal so can be a little uncomfortable. Adjunctive medication can be used to assist with lack of sleep and agitation but is secondary to the underlying treatment with Methadone or Buprenorphine. The aim is to get the client comfortable on the substitute medication so that they do not experience any withdrawal and then reduce, under medical supervision until detox is achieved.

This is never advisable, mainly because a medical detox alone does not address the underlying reasons as to why someone is dependent and clients often leave with no resilience, tolerance to opioids and craving for more. As such, clients who do this are prone to overdose as they will seek large doses to satisfy their cravings but lack the physical tolerance leading to overdose.

A general rule of thumb is a minimum of four weeks. In very limited circumstances, some centres may accept a client for two weeks, but this would be the exception to the rule. Not all centres will take opioid patients, this is simply due to home office-controlled drug licencing. The medical input, methadone or buprenorphine, is an essential but small element of treatment. Most of the treatment process is a group therapy approach: either a 12 step or SMART recovery approach. Relapse prevention plays a major part of the process.

The National Health Service (NHS) have a duty of care: to what is reasonable in the circumstances. As the NHS is not funded for drug dependency, they will only treat someone if there is an acute medical need and only until the person is safe to discharge. They will not admit someone and treat for codeine dependency. As a last resort, if someone is admitted for a medical emergency, the NHS will treat the codeine dependency with symptom control: only. That is to say that they will provide substitute medication only to stave off withdrawal.

As the NHS is not funded for codeine dependency the only options open to a GP is to signpost clients to the local authority provided drug and alcohol service and/or to advise on reduction. As GP’s are now under constant scrutiny in relation to opioid prescribing more and more clients are finding that their repeat prescriptions are being reduced and/or stopped.