Codeine (3-methylmorphine) is a narcotic medication that is an alkaloid found in opium. All narcotic drugs are either processed from the poppy plant or synthetic analogs of substances found in opium, which is processed from the poppy. Therefore, codeine belongs to a large class of familiar drugs, such as heroin, morphine, OxyContin (oxycodone), Vicodin (hydromorphone), etc. Most of the drugs in this class are powerful analgesic drugs that can be used to control pain, and codeine is no exception. Codeine, however, is most commonly found in other medications such as cough suppressants, and it may be used as a sleep enhancer in some cases. It is typically delivered in pill or liquid form for medicinal reasons. Codeine is a controlled substance, but it has two different classifications.
Formulas that contain less than 90 mg of codeine are Schedule III controlled substances, whereas codeine is otherwise classified as a Schedule II controlled substance by the Drug Enforcement Administration (DEA). Both classifications suggest that codeine does have a potential to be abused and may result in the development of physical dependence in people who use the drug for longer periods of time. Because of these classifications, codeine can only be legally obtained in the United States with a prescription from a physician.
Abuse of Codeine
As a member of the opiate classification of drugs, codeine acts as a central nervous system depressant, resulting in decreased sensations of pain, pleasurable sensations due to the drug’s indirect effect on the dopamine reward system in the brain, and a significant potential for the development of physical dependence. Codeine also affects areas of the brain that are involved in very basic functions, such as respiration and coughing, and the drug is commonly found as a cough suppressant in prescription cough syrups. Thus, codeine is a medication that does have medicinal uses. Even though recent research has suggested that it may not be safe for children under the age of 12, it is still prescribed for this age group in the hundreds of thousands of cases every year.
The abuse of prescription medications remains a significant concern in the United States. The Substance Abuse and Mental Health Services Administration (SAMHSA) annually surveys individuals in the US to develop estimates of the number of individuals who abuse particular drugs. In the 2015 SAMHSA survey, codeine is lumped together with other prescription narcotic medications in the class of other prescription pain relievers due to concerns that the participants in the survey might confuse the different forms of codeine that contain other drugs, such as Tylenol, with that particular drug (e.g., confusing codeine with Tylenol). The latest figures from 2015 indicate that it is estimated that about 917,000 individuals report abusing drugs in this class, which represents less than 10 percent of all individuals believed to abuse prescription pain relievers of any type.
Thus, even though codeine abuse is not a major concern, the National Institute on Drug Abuse (NIDA) continues to report on an emerging trend in individuals under the age of 25 that involves abuse of codeine. This trend consists of drinking dangerous amounts of cough syrup that contains codeine-promethazine in order to experience psychoactive effects. Promethazine is an antihistamine, and codeine acts as a cough suppressant. In large doses, these substances can produce extreme sedation, mild feelings of wellbeing, and a release of inhibitions. Street names for this particular form of cough syrup include purple syrup, syrup, and sizzurp.
Again, actual figures regarding how many individuals are abusing cocaine in this matter are not readily available, but the practice appears to be focused among younger individuals. The abuse of codeine represents a serious threat to these individuals in terms of their long-term health and the potential for overdose.
The Effects of Abusing Codeine
People abusing codeine will quickly develop tolerance to the drug and will need to take larger amounts of it to get the effects that they once got at significantly lower doses. As the individual takes higher amounts of the drug at regular intervals, they are more likely to develop physical dependence (having both tolerance and withdrawal syndromes). The development of withdrawal symptoms in individuals who abuse codeine is particularly distressing because codeine has a very short half-life, and an individual can conceivably start to experience withdrawal symptoms within several hours of discontinuing the drug.
Even though the withdrawal symptoms associated with physical dependence on codeine are reportedly mild in comparison to the symptoms that occur with morphine and heroin, individuals who use large amounts of the drug for lengthy periods of time may get caught in a cycle of abuse to avoid withdrawal symptoms. Withdrawal symptoms from codeine include:
- Flulike symptoms: These include headache, nausea, vomiting, sneezing, runny nose, sweating, fever, and chills.
- Other physical symptoms: These include changes in blood pressure (most often an increase), irregular heartbeat, changes in breathing rates, hives, rash, and/or dilated pupils.
- Mood swings: These may include bouts of anxiety, depression, irritability, mental confusion, apathy, and, in rare cases, the potential for hallucinations.
- Cravings: Severe cravings are fueled by the above symptoms and may result in issues with judgment or mood swings that become severe and lead to suicidal tendencies in some individuals.
The withdrawal process associated with codeine is not generally believed to be potentially physically dangerous; however, individuals who are emotionally unstable or prone to poor judgment may be at risk for harm due to accidents, impulsive behaviors, or even suicidality in extreme cases. Individuals who mix codeine with other drugs of abuse, such as alcohol, other narcotic medications, stimulants, or benzodiazepines, may be at risk for a number of potentially serious physical complications during the withdrawal process. These may include issues with cardiovascular functioning and the development of potential seizures (especially for individuals who abuse codeine on a regular basis with benzodiazepines or alcohol).
Signs Someone Might Be Abusing Codeine
An individual who suffers negative ramifications as a result of codeine abuse could be diagnosed with a formal opioid use disorder according to the diagnostic criteria put forth by the American Psychiatric Association (APA) in the most current edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-5. Typically, the criteria for substance use disorders include:
- A pattern of maladaptive use of the substance for nonmedicinal reasons that leads to significant impairment or distress in daily life
- A number of symptoms that indicate that the person is unable to control their use of the substance, such as:
- Frequently taking more of the substance than originally intended
- Wanting to stop or cut down on use but not doing so
- Continuing to use the drug even though its use results in a number of negative issues in life, such as issues with work or in relationships
- Repeatedly using the drug in situations where its use is potentially dangerous
- Giving up activities that were once valued as a result of using the drug
- Continuing to use the drug even though one realizes that its use is causing physical and/or emotional damage
- Experiencing repeated strong desires or cravings to use the drug
- Developing significant tolerance
- Developing withdrawal symptoms when one has stopped using the drug or cuts down on the dosage
Any individual who suspects that someone they know might be developing a substance use disorder should consult with a licensed mental health professional who has experience in treating addictive behaviors.
The American Society of Addiction Medicine, which is the largest national organization of addiction medicine physicians in the United States, offers some tips on what types of practical signs may be indicative of opioid use disorder, such as significant codeine abuse. The signs include:
- Periods of lethargy, sleepiness, or issues with coordination that may include slurred speech, slowed thinking processes, and decreases in judgment
- Spending increasing amounts of time with individuals who are known drug users
- Spending more time alone and isolated
- Losing interest in activities that used to interest them
- Personality changes that can include being overly sensitive, secretive, irritable, negative, and reactive
- An increase in dishonest behavior that can include stealing, lying, missing work, being truant at school, etc.
- A tendency to ignore personal hygiene, which is uncharacteristic
- Unexplained bouts of flulike symptoms
- Finding drug paraphernalia in the person’s room or other possessions (e.g., codeine prescription bottles or empty cough syrup bottles)
Treatment Options for Codeine Abuse
Because it appears that the majority of individuals who abuse codeine are younger, approaching these individuals with concerns about their behavior can be very tricky. It is well known that individuals who have substance abuse issues can be very defensive regarding their use of drugs and/or alcohol, and younger individuals may become even more so when confronted by a parent, friends, or other relatives. Many sources refer to this tendency to be reactive as “denial,” which itself is suggested to be a symptom of a substance use disorder; however, as it turns out, this type of reactivity is rather common in individuals who are confronted with certain types of information they feel discredits or threatens them. It can be observed in many individuals who are initially told they have serious diseases, such as terminal cancer, or in individuals who are in abusive relationships and confronted by outsiders with this fact. Thus, if one is going to approach someone with a suspected codeine abuse problem, one should expect some form of resistance.
The most productive way to handle this type of resistance is to acknowledge the person’s feelings and then continue to inquire about their behaviors. It is rarely productive to become argumentative with or attempt to force them into treatment unless one has the legal authority to do so. Simply show concern, ask questions, and bring up actual facts about the person’s behavior that suggest that there may be a problem. Ultimately, the goal is to try to get the person to agree to talk to a healthcare professional.
Treatment for opioid use disorders as a result of codeine abuse will follow a general overall plan that will be adjusted to the needs of the specific case. A general treatment plan is outlined below.
- It should begin with some form of comprehensive assessment of the person’s psychological, physical, and cognitive functioning. This assessment allows for the identification of any co-occurring issues along with the person’s substance use disorder. All of these issues can be addressed concurrently to ensure the effectiveness of the overall treatment plan.
- The first step is often medical detox. Physicians can prescribe opioid replacement medications that will reduce the symptoms of withdrawal and lessen cravings, and clients will be put on a tapering schedule that slowly decreases doses of the replacement drug. This weans them off the drug slowly and reduces any withdrawal symptoms. Individuals participating in withdrawal management programs relapse at significantly lower rates than individuals who do not. Other medically assisted treatments that are appropriate for the individual case should be implemented.
- Although medically assisted treatments are effective to address withdrawal symptoms and other symptoms that may occur as a result of having some other co-occurring psychological disorder, the main focus of recovery should be involvement in substance use disorder treatment. Therapy is a formal intervention where a trained therapist uses techniques that are based on empirically derived psychological principles to assist the person in changing their behavior. Medications cannot perform this function. Therapy can be performed on an individual basis, in groups, or in a combination of individual and group sessions.
- Social support groups, such as 12-Step groups, can be extremely advantageous to recovery. Even though they are not formal therapy groups, they provide a number of advantages, including the development of a strong support group, the ability to learn from others with experience in recovery, and the opportunity to engage in long-term activities focused at maintaining recovery.
- Depending on the individual case, a number of other specific interventions may be required. These can include other medical interventions, tutoring, speech therapy, etc.
- Remaining in treatment for a sufficient length of time is essential for those in recovery. While there is no hard and fast rule as to what defines a satisfactory period of time in treatment, research has indicated that individuals who remain in treatment longer have better success rates. Some of the latest research has suggested that individuals need to remain involved in some form of ongoing treatment for years after discontinuing drugs or alcohol and need several years of abstinence before they are considered to be at minimal risk for relapse.