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Codeine

Also known as

AC/DC, coties, schoolboy, DFs, cody, captain cody, syrup, sizzurp, purple drank, little C, T1 (2, 3, 4, etc), texas tea

Classification

Opioid, depressant, analgesic, cough suppressant, sedative

Overview

Codeine is an opiate, closely related to morphine, and comes from the opium poppy, but possesses around one fifth of the strength of morphine. It is still a very effective analgesic. Most mild pain killers contain small quantities of codeine, e.g. co-codamol. However, the formulations are too weak to be used in the treatment of dependence, and because they contain other drugs such as paracetamol and aspirin, it may be harmful, if taken in sufficient quantity, to feel the opiate effect of codeine [1].

Codeine is part of the opioid family whose family members include heroine. Codeine, however, is much milder than many of the other opioids. The drug's intent is to alleviate moderate to severe pain due to outpatient surgery and intense dental work but it easy for someone to develop a codeine addiction due to its calming effects.

Codeine has also been used as a cough suppressant, though less so currently due to the addictive nature of the medication.

Most codeine-based products are synthetically produced, and is often combined with other painkillers such as acetaminophen and aspirin.

Codeine is offered in pill and liquid form. It is not an over-the-counter drug; a patient needs a doctor's prescription for codeine [2].

Codeine is an opiate drug used to treat mild to moderate pain. It is available either from doctors as a prescription only medicine or, directly from a pharmacy combined in lower doses with aspirin, ibuprofen or paracetamol. It is used to treat pain that does not respond to simple painkillers.

Someone who takes the combination painkillers containing codeine at higher than recommended doses in order to get a stronger codeine effect, can easily consume doses of aspirin, ibuprofen or paracetamol that could be fatal.

The key effects and risks of codeine itself include -

  • Feelings of warmth and well-being, relaxation and sleepiness,
  • Nausea, constipation, confusion, sweating, itching, mood swings and feelings of laziness [3].

Medical usage

Mild to moderate pain, diarrhoea, cough suppression [4].

What does it look like?

Codeine is available in tablet form, as a syrup (e.g. as a cough syrup) and as a solution for injection. It is normally swallowed. Some people misusing the medicine prefer to crush up the tablets and snort them, and some may try to inject them [3].

Source

This is a pharmaceutical drug which is sometimes diverted from manufacturers, pharmacies or GP's prescriptions [5].

Street price

Tablets of codeine can cost between £1 - £2.50 per tablet obtained from illicit sources [3].

Why take it?

Sought after effects

  • good for opiate detox/reduction,
  • minor euphoric action,
  • less stigmatised (compared to other opiates) [1],
  • calmness,
  • reduced anxiety,
  • relaxation,
  • pain relief [5].

Undesired effects

  • very constipating (could be considered positive if suffering from IBS-type symptoms),
  • minimum euphoria compared with other options,
  • dose conversion is difficult,
  • urine tests as morphine/heroin [1],
  • drowsiness,
  • confusion,
  • disorientation,
  • nausea,
  • vomiting,
  • itching and flushing of the skin [5].

Abuse

The attraction to codeine is the high it gives, which is similar to other opioids. It is short-acting, which means it acts quickly once it is taken, but the effects tend not to last very long.

Nonetheless, users report the codeine high to be quite intense if a high enough dosage is taken. Part of the reason codeine is one of the most abused opioids may come from the drug's characteristic to metabolise into morphine [2].

The 'high'

Codeine not only relieves pain, but in high enough doses the drug can also produce a sense of pleasure and reward, along with a euphoric calm.

When codeine enters the brain, the brain responds by activating its hormones which are part of the brain's "reward system".

According to users of codeine, the excessive release of these hormones and stimulation of the reward system, is much like that of heroin, though in a milder form.

The problem is to reach and maintain that initial high takes increasingly larger amounts of codeine, which in a short amount of time will lead one to dependence on, then addiction to the drug [6].

Causes

Codeine is typically prescribed for its pain relieving properties, and when taken as indicated, can be an effective medicinal treatment for pain management. However, men and women who use codeine chronically or long-term may develop a physical dependence to the drug. Other individuals may attempt to numb emotional or mental pain in addition to physical pain, and thus turn to codeine as an overall pain suppressant.

Men and women who are inclined to abuse drugs may have several factors contributing to the addictive nature. Such influencing causes included biological, psychological, social, and environmental factors. Biological causes would include a genetic influence or a disruption in normal body mechanisms. Psychological factors would include unresolved traumas or distressing situations that been coped with insufficiently. Examples of social causes include influences from peers or having family members who are addicted to codeine. Finally, environmental factors include homelessness or inadequate food or medical treatment [7].

Dosage

Therapeutic

  • By mouth, adult over 18 years, 30 - 60 mg every 4 hours when necessary, to a max. of 240 mg daily,
  • By intramuscular injection, adult over 18 years, 30 - 60 mg every 4 hours when necessary [4].

Diarrhoea

  • Acute diarrhoea, adult and child over 12 years, 30 mg 3 - 4 times daily (range 15--60 mg) [4].

Cough suppression

  • Linctus (= oral solution), codeine phosphate 15 mg/5 mL [4].

Abuse

Oral

  • Threshold 30 - 50 mg,
  • Light 50 - 100 mg,
  • Common 100 - 150 mg,
  • Strong 150 - 200 mg,
  • Heavy 200 mg + [8].

What are the different forms?

Codeine is an opiate drug used to treat mild to moderate pain. On its own codeine is only available on prescription.

Smaller doses of codeine are in some medicines that can be bought without prescription in pharmacies.

Lower dose codeine is usually combined with other medicines such as paracetamol, ibuprofen or aspirin and are used for treating headache, period pain etc. that has not responded to simpler pain-killers.

Codeine-containing medicines carry warnings on the packs about the risk of addiction and advise that the non-prescription medicines should only be used for up to three days at a time without medical advice [3].

How long do its effects last?

Onset of effects

  • oral - 30 - 45 minutes [8].
  • all ROA's - 30 - 45 minutes [9].

Duration of effects

  • oral - 3 - 6 hours [8].
  • all ROA's - 3 - 6 hours [9].

After-effects

  • all ROA's - 1 - 12 hours [9].

Pharmacology

Codeine is selective for the mu receptor, but with a much weaker affinity than morphine. The analgesic properties of codeine have been speculated to come from its conversion to morphine, although the exact mechanism of analgesic action is less well understood than the more potent members of the opiate family.

Codeine is absorbed from the gastrointestinal tract with maximum plasma concentration occurring 60 minutes post administration. Codeine is absorbed quickly from the gastrointestinal tract and its first pass through the liver results in very little loss of the drug. This contrasts with morphine in which over 90% of the drug is metabolised in the first pass through the liver resulting in a considerable loss of potency when administered orally. This is why codeine is a common opiate in the relief of pain, the ease of oral administration.

Dihydrocodeine is an opioid analgesic. It is related to codeine and has similar analgesic activity. It is a stronger variant with more euphoric effect and consequently greater dependence potential. After oral doses peak concentrations of dihydrocodeine occur after about 1.2 to 1.8 hours; oral bioavailability is only about 20%, probably because of substantial first-pass metabolism in the gut wall or liver.

In its simple form it has a short half-life but longer acting controlled release tablets are available. One frequently cited reason it never really achieved the prominence its properties warranted as an opiate treatment option was not least because of a largely inaccurate perception at the Home Office that the tablet form is frequently crushed and injected. The usual formulation is dihydrocodeine tartrate [1].

Codeine is not itself centrally active, and must first be converted via first pass metabolism into morphine by the cytochrome P450 enzyme CYP2D6 (as such, it is a prodrug for morphine). Codeine is also metabolised into the inactive norcodeine via the CYP3A4 enzyme system. Both resultant forms are conjugated by UGT2B7 into their corresponding 3-glucuronide.

Some percentage of the population produce less CYP2D6 enzymes and so experience a significant reduction of effects from codeine in comparison to that of the average person. However, others produce CYP2D6 enzymes in higher quantities which can result in a hypersensitivity to the drug.

There is an upper limit to the amount of codeine which can be converted by enzymatic metabolism into morphine throughout an individual session. This limit is commonly referred to as the ceiling dose, which is commonly believed to be around 400mg. Consuming higher doses will lead to greater side effects such as itchiness and nausea, but will not necessarily increase the euphoria experienced.

The active metabolites of codeine, notably morphine, exert their effects by binding to and activating opioid receptors, mainly the μ-opioid receptor. This occurs because opioids structurally mimic endogenous endorphins which are naturally found within the body and also work upon the μ-opioid receptor set. The way in which opioids structurally mimic these natural endorphins results in their euphoria, pain relief, muscle relaxing and anxiolytic effects. This is because endorphins are responsible for reducing pain, causing sleepiness, and feelings of pleasure. They can be released in response to pain, strenuous exercise, orgasm, or general excitement.

Codeine itself is a weak ligand for the opioid receptors however its main active metabolite - morphine shows much stronger agonistic effects [8].

Pharmacodynamics

Codeine, an opiate agonist in the CNS, is similar to other phenanthrene derivatives such as morphine. It is selective for the mu receptor, but with a much weaker affinity than morphine. The analgesic properties of codeine have been speculated to come from its conversion to morphine. The principle therapeutic action is analgesia. Codeine concentrations do not correlate with brain concentration or relief of pain. The minimum effective concentration is highly variable is influenced by numerous factors, including but not limited to, age, previous opioid use, age, and general medical condition. However, the effective dose for patients that have developed tolerance is significantly higher than the opioid-naive patients [10].

Absorption

Well absorbed following oral administration with a bioavailability of approximately 90%. Maximum plasma concentration occurs 60 minutes post-administration. Food does not effect the rate or extent of absorption of codeine [10].

Bioavailability

Oral 90%, rectal 90% [9].

Metabolism

Hepatic. Codeine is a prodrug, itself inactive, but demethylated to the active morphine by the liver enzyme CYP2D6 to morphine. 70%--80% of the dose undergoes glucuronidation to form codeine-6-glucuronide. This process is mediated by UDP-glucuronosyltransferase UGT2B7 and UGT2B4. 5% - 10% of the dose undergoes O-demethylation to morphine and 10% undergoes N-demethylation to form norcodeine. CYP2D6 mediates the biotransformation to morphine. CYP3A4 is the enzymes that mediates the conversion to norcodiene. Morphine and norcodeine are further metabolised and undergo glucuronidation. The glucuronide metabolites of morphine are morphine-3-glucuronide (M3G) and morphine-6-glucuronide (M6G). Both morphine and morphine-6-glucuronide are active and have analgesic activity. Norcodiene and M3G do not have any analgesic properties [10].

Half-life

Plasma half-lives of codeine and its metabolites have been reported to be approximately 3 hours [10].

Elimination

90% of the total dose of codeine is excreted through the kidneys, of which 10% is unchanged codeine [10].

Lethal dosage

The LD50 of rats is 2.8450 mol/kg [10], the human LD50 is unknown.

Tolerance

Tolerance to many of the effects of codeine develops with prolonged and repeated use. The rate at which this occurs develops at different rates for different effects, with tolerance to the constipation-inducing effects developing particularly slowly for instance. This results in users having to administer increasingly large doses to achieve the same effects. After that, it takes about 3 - 7 days for the tolerance to be reduced to half and 1 - 2 weeks to be back at baseline (in the absence of further consumption). Codeine presents cross-tolerance with all other opioids, meaning that after the consumption of codeine all opioids will have a reduced effect [8].

Mechanism of action

Opiate receptors are coupled with G-protein receptors and function as both positive and negative regulators of synaptic transmission via G-proteins that activate effector proteins. Binding of the opiate stimulates the exchange of GTP for GDP on the G-protein complex. As the effector system is adenylate cyclase and cAMP located at the inner surface of the plasma membrane, opioids decrease intracellular cAMP by inhibiting adenylate cyclase. Subsequently, the release of nociceptive neurotransmitters such as substance P, GABA, dopamine, acetylcholine and noradrenaline is inhibited. Opioids also inhibit the release of vasopressin, somatostatin, insulin and glucagon. Codeine's analgesic activity is, most likely, due to its conversion to morphine. Opioids close N-type voltage-operated calcium channels (OP2-receptor agonist) and open calcium-dependent inwardly rectifying potassium channels (OP3 and OP1 receptor agonist). This results in hyperpolarization and reduced neuronal excitability [10].

Mode of use

Tablets are swallowed orally. Codeine should not be injected intravenously (like Dihydrocodeine) - users who have attempted crushing tablets to inject report a painful experience. Injectable ampoules are for intra-muscular injection only [5].

Signs of usage

  • dizziness,
  • staggering,
  • itchiness,
  • scratching (often of the nose),
  • constricted or pinpoint pupils,
  • slow breathing,
  • confused mental state,
  • complaints of constipation,
  • cyanosis,
  • nausea,
  • vomiting,
  • delirium,
  • hallucination,
  • seizures [11].

Emotional/mood symptoms

  • depression,
  • anxiety,
  • emotional numbing,
  • euphoria,
  • sense of well-being and calmness,
  • mood swings [12].

Behavioural symptoms

  • withdrawing socially from loved ones,
  • isolation from others,
  • forging prescriptions in order to obtain more codeine,
  • doctor shopping, which is visiting a series of doctors to obtain greater amounts of codeine,
  • frequent er visits for vague complaints of pain,
  • stealing or borrowing codeine from friends and loved ones,
  • indifference toward loved ones, job, and social activities,
  • faking illnesses to obtain more codeine,
  • lying to hide the amount of codeine being abused,
  • sleepiness,
  • poor work or school performance,
  • "nodding off" during conversations [12].

Effects

Common

  • dizziness,
  • tiredness,
  • confusion,
  • difficulty concentrating,
  • euphoria,
  • restlessness,
  • blurred vision,
  • dry mouth,
  • limbs feeling heavy or muscles feeling stiff,
  • sweating,
  • mild allergic rash,
  • itching and hives,
  • decreased heart rate,
  • palpitations,
  • stomach-ache,
  • nausea,
  • vomiting,
  • constipation,
  • difficulty urinating [13].

These side-effects may disappear with continued treatment, but if they persist, speak to a health professional [13].

Short-term effects

  • nausea,
  • vomiting,
  • excessive drowsiness,
  • dysphoria,
  • confusion,
  • dry mouth,
  • constipation,
  • allergic skin reaction,
  • rash [6].

Long-term effects

  • constipation,
  • reduced sex drive,
  • irregular periods,
  • tension and muscle twitches,
  • cravings,
  • dependence,
  • financial, work and social problems [13],
  • vertigo,
  • dizziness,
  • upset stomach,
  • loss of appetite,
  • indigestion,
  • hallucinations,
  • tremors,
  • depression,
  • urinary retention,
  • inability to urinate [6].

Physical effects

  • physical euphoria,
  • pupil constriction,
  • appetite suppression,
  • cough suppression,
  • orgasm suppression,
  • pain relief,
  • respiratory depression,
  • sedation,
  • constipation,
  • difficulty urinating,
  • itchiness,
  • nausea [8].

Cognitive effects

  • cognitive euphoria,
  • compulsive redosing,
  • dream potentiation,
  • anxiety suppression,
  • decreased libido,
  • sleepiness [8].

Positive

  • euphoria,
  • pain relief,
  • elevated mood,
  • overall feeling of contentedness [14].

Neutral

Negative

  • nausea,
  • constipation,
  • cns depression,
  • drowsiness,
  • hot/cold flashes,
  • dizziness,
  • vomiting,
  • urinary retention (difficulty urinating) [14].

Overdose

  • cyanosis,
  • breathing problems,
  • cold, clammy skin,
  • coma,
  • confusion,
  • dizziness,
  • drowsiness,
  • fatigue,
  • lightheadedness,
  • loss of consciousness,
  • low blood pressure,
  • muscle twitches,
  • tiny pupils,
  • spasms of the stomach and intestines,
  • weakness,
  • weak pulse [15],
  • inability to pass urine,
  • severe constipation,
  • obstructed bowel,
  • agitation,
  • mental numbness,
  • very slow, shallow breathing,
  • hallucinations,
  • seizures,
  • death [13].

Risks

Short-term

  • tolerance,
  • accidents,
  • overdose [5].

Long-term

  • Physical and psychological dependence with repeated use [5].

Purity

If the codeine has been prescribed as a medicine (alone or mixed with other drugs such as paracetamol or ibuprofen), the purity will be very high and the doses consumed will be predictable. If you are not sure the tablets have come directly from a reputable pharmacy, you cannot be sure what is in them [3].

Addiction

Can you get addicted

Yes, like all opiates, codeine is addictive.

Over time it can produce 'cravings' and a psychological desire to keep on using.

Tolerance can also build, so that users have to take more just to get the same effects or to avoid an unpleasant withdrawal [3].

Codeine addiction can occur even when one legitimately and responsibly uses the drug as it is intended. The pain relief as well as the feel-good sensation codeine provides the brain receptors, make it very attractive in its relief.

The problem is that relief can in turn make it difficult for a person to stop using codeine once their prescription runs out.

The brain becomes used to the influences of codeine, and once use has stopped, both brain and body can have a tough time functioning without the drug.

Individuals who become victim to a codeine addiction need more and more of the drug just to feel normal, which sadly is a typical expectation of any person; they want to feel normal, and in doing so, have no desire to abuse codeine, though they may soon do exactly that.

Scientists and researchers in the medical and pharmaceutical profession have determined that all a user needs to become addicted to codeine is five to seven days of continual use. After that, the user is more than likely hooked on the drug [2].

Dangerous interactions

Although many drugs are safe on their own, they can become dangerous and even life-threatening when combined with other substances. The list below contains some common potentially dangerous combinations, but may not include all of them. Certain combinations may be safe in low doses of each but still increase the potential risk of death. Independent research should always be done to ensure that a combination of two or more substances is safe before consumption [8].

  • Depressants (1,4-Butanediol, 2m2b, alcohol, barbiturates, benzodiazepines, GHB/GBL, methaqualone) - This combination can result in dangerous or even fatal levels of respiratory depression. These substances potentiate the muscle relaxation, sedation and amnesia caused by one another and can lead to unexpected loss of consciousness at high doses. There is also an increased risk of vomiting during unconsciousness and death from the resulting suffocation. If this occurs, users should attempt to fall asleep in the recovery position or have a friend move them into it.
  • Dissociatives - This combination can result in an increased risk of vomiting during unconsciousness and death from the resulting suffocation. If this occurs, users should attempt to fall asleep in the recovery position or have a friend move them into it.
  • Stimulants - It is dangerous to combine codeine, a depressant, with stimulants due to the risk of excessive intoxication. Stimulants decrease the sedative effect of codeine, which is the main factor most people consider when determining their level of intoxication. Once the stimulant wears off, the effects of codeine will be significantly increased, leading to intensified disinhibition as well as other effects. If combined, one should strictly limit themselves to only taking a certain amount of codeine [8].

Dangerous

  • Ketamine - Both substances bring a risk of vomiting and unconsciousness. If the user falls unconscious while under the influence there is a severe risk of vomit aspiration if they are not placed in the recovery position.
  • MXE - This combination can potentiate the effects of the opioid
  • DXM - CNS depression, difficult breathing, heart issues, hepatoxic, just very unsafe combination all around. Additionally if one takes dxm, their tolerance of opiates goes down slightly, thus causing additional synergistic effects.
  • Cocaine - Stimulants increase respiration rate allowing a higher dose of opiates. If the stimulant wears off first then the opiate may overcome the patient and cause respiratory arrest.
  • Alcohol - Both substances potentiate the ataxia and sedation caused by the other and can lead to unexpected loss of consciousness at high doses. Place affected patients in the recovery position to prevent vomit aspiration from excess. Memory blackouts are likely
  • GBL / GHB - The two substances potentiate each other strongly and unpredictably, very rapidly leading to unconsciousness. While unconscious, vomit aspiration is a risk if not placed in the recovery position
  • Tramadol - Concomitant use of tramadol increases the seizure risk in patients taking other opioids. These agents are often individually epileptogenic and may have additive effects on seizure threshold during coadministration. Central nervous system- and/or respiratory-depressant effects may be additively or synergistically present
  • Benzodiazepines - Central nervous system and/or respiratory-depressant effects may be additively or synergistically present. The two substances potentiate each other strongly and unpredictably, very rapidly leading to unconsciousness. While unconscious, vomit aspiration is a risk if not placed in the recovery position Blackouts/memory loss likely [9].

Caution

  • PCP - PCP can reduce opioid tolerance, increasing the risk of overdose,
  • Nitrous oxide - Both substances potentiate the ataxia and sedation caused by the other and can lead to unexpected loss of consciousness at high doses. While unconscious, vomit aspiration is a risk if not placed in the recovery position. Memory blackouts are likely.
  • Amphetamines - Stimulants increase respiration rate allowing a higher dose of opiates. If the stimulant wears off first then the opiate may overcome the patient and cause respiratory arrest.
  • MAOIs - Coadministration of monoamine oxidase inhibitors (MAOIs) with certain opioids has been associated with rare reports of severe and fatal adverse reactions. There appear to be two types of interaction, an excitatory and a depressive one. Symptoms of the excitatory reaction may include agitation, headache, diaphoresis, hyperpyrexia, flushing, shivering, myoclonus, rigidity, tremor, diarrhoea, hypertension, tachycardia, seizures, and coma. Death has occurred in some cases [9].

Withdrawal

Depending on what kind of opiates you take, these symptoms can kick in -

  • 6 - 12 hours after your last dose (in the case of short-acting opiates),
  • Within 30 hours of your last dose (in the case of long-acting opiates) [16].
  • nervous tremors,
  • anxiety,
  • yawning,
  • sweating,
  • runny nose,
  • sleep disturbance,
  • nausea,
  • goose-bumps,
  • restlessness,
  • diarrhoea,
  • abdominal cramps,
  • muscle spasms [3],
  • cravings,
  • dilated pupils,
  • vomiting,
  • lack of appetite,
  • sneezing,
  • insomnia,
  • trembling, aching muscles and joints,
  • fever,
  • chills,
  • irritability,
  • nervousness,
  • depression [13],
  • mood swings,
  • restlessness,
  • watery eyes,
  • stomach cramps,
  • loss of appetite,
  • weight loss [6].

Drug testing

Determining exactly how long codeine is detectable in the body depends on many variables, including which kind drug test is being used. Codeine - also known as Tylenol with Codeine, Empirin with Codeine, Robitussin A-C, Fiorinal with Codeine, Tylenol #3, Codate, Codephos Syrup - can be detected for a shorter time with some tests, but can be "visible" for up to three months in other tests.

The timetable for detecting codeine in the system is also dependent upon each individual's metabolism, body mass, age, hydration level, physical activity, health conditions and other factors, making it almost impossible to determine an exact time codeine will show up on a drug test [15].

The following is an estimated range of times, or detection windows, during which codeine can be detected by various testing methods -

How long does codeine show up in urine?

Codeine is detectable in a urine test for 2 - 4 days [15], between 24 - 48 hours after your last dose [17].

How long does codeine stay in the blood?

A blood test will detect codeine for up to 12 hours [15], up to 24 hours after your last dose [17].

How long will codeine show up in a saliva test?

A saliva test will detect codeine from 1 - 4 days [15], [17].

How long does codeine remain in hair?

Codeine, like many other drugs, can be detected with a hair follicle drug test for up to 90 days [15].

Legality

Under the Misuse of Drugs Act 1971 codeine is a Class B controlled substance or a Class A drug when prepared for injection [18]. The possession of controlled substances without a prescription is a criminal offence [19]. However, certain preparations of codeine are exempt from this restriction under Schedule 5 of the Misuse of Drugs Regulations 2001. It is thus legal to possess codeine without a prescription, provided that it is compounded with at least one other active or inactive ingredient and that the dosage of each tablet, capsule, etc does not exceed 100 mg or 2.5% concentration in the case of liquid preparations [8].

  • Codeine is a substance controlled under Class B of the Misuse of Drugs Act. That means it's illegal to have, give away or sell.
  • Codeine on its own is only available on prescription, unauthorised possession can get you up to five years in jail and an unlimited fine.
  • Supplying someone else, including your friends, can get you up to 14 years and an unlimited fine [3].

Small amounts of codeine are in some medicines which can be bought without prescription but only in pharmacies. These medicines include cough syrups, and tablets or capsules where the codeine is combined with other medicines, such as paracetamol, ibuprofen or aspirin, for treating headaches, period pain etc. Codeine containing medicines carry warnings on the packs about the risk of addiction and advise that the non-prescription medicines should only be used for up to three days at a time without medical advice [3].

Did you know?

  • A conviction for a drug-related offence could have a serious impact. It can stop you visiting certain countries - for example the United States - and limit the types of jobs you can apply for.
  • Like drinking and driving, driving while impaired by codeine is illegal - and you can still be unfit to drive the day after using codeine. You can get a heavy fine, be disqualified from driving or even go to prison [3].

Mixing with other drugs

Codeine is most often mixed with alcohol or marijuana. Due to the fact that alcohol and codeine are both depressants, taking them at the same time can result in dangerous respiratory depression. This can lead to brain damage, coma, and even death. Marijuana tends to be more unpredictable, but psychological effects of both cannabis and codeine can exacerbate each other and cause panic or severe depression [20].

Harm reduction

As codeine use is not as stigmatised as other opiates, it is used by many people who would not perceive themselves as addicts. The overdose effects are also atypical, with the traditional slip in unconsciousness rarely encountered. Restlessness, nausea, confusion and disorientation, as well as chest pain and palpitations, are reported and ultimately, respiratory failure. The gender, Body Mass Index, age, weight and the tolerance of the individual are, as ever important, but a key guideline is not to increase the dose by more that fractions of the highest dose you know you are tolerant to and not to use alone. There is debate on the LD50 of codeine, but generally for initiates 300 mgs may be prove fatal, although a chronic user could tolerate many times as much. As with all opiates, if it is possible keep some Narcan at hand. Do not mix with other CNS depressants [1].

Paraphernalia

If injected, prepared ampoules, needle, syringe [5].

Detox

The Substance Abuse and Mental Health Administration states that it is not usually recommended for opioid abusers go through medical withdrawal without the use of medications, so make sure the inpatient program you choose offers not only a pharmacological option but the best one for your needs [21].

  • methadone - best for those with severe dependencies on codeine,
  • buprenorphine - best for those with less severe dependencies,
  • naltrexone - Best for those who are no longer dependent on opioids and who have a strong motivation to stop using these drugs [21].

In most rehabilitation centers, patients suffering from codeine addiction will have a customised program of detox and rehabilitation assigned to them.

This programme is important as each addiction differs from the next, and specialised treatment might be needed in a particular person's case.

Secondly, most opioids are extremely dangerous to detox from without medical supervision.

An addict should especially not quit codeine cold turkey as the withdrawal symptoms can be life threatening.

In some cases, patients will be treated with Suboxone to help alleviate the withdrawals and allow the patient to detox with less distress [22].

Statistics

  • The Texas State Board of Pharmacy found that more than 145 gallons of codeine cough syrup were used for illegal purposes over a 5-year period [11].
  • Within five to six weeks a person can become addicted to codeine [22].

History

In 1832, codeine was isolated from opium, which has a codeine content of 2 to 30/0 (see Papaver somniferum). Codeine is also biosynthesised in the roots of Papaver somniferum 1. cv. Marianne (Tam et al. 1980). It is possible that trace amounts of codeine can also be found in other Papaver species (Papaver bracteatum, Papaver decaisnei; cf. Papaver spp.) (Theuns et al. 1986). Codeine is also an endogenous neurotransmitter in humans (cf. morphine). A dosage of 20 to 50 mg produces "general mental stimulation, warmth in the head, and an increase in the pulse rate, as also appear after the consumption of alcohol" (Rompp 1950*). Codeine does not appear to be metabolised in the body and is excreted unchanged. Because codeine suppresses the urge to cough, its most important pharmaceutical use is in cough syrups.

The dosage when codeine is used as a cough suppressant is 50 mg three times a day. A dosage of 100 to 200 mg results in sleep and sedation. Higher dosages elicit effects comparable to those of morphine. The medical literature contains repeated mentions of "codeine addiction." Codeine "addicts" are said to ingest up to 2 g of codeine daily (Rompp 1950, 115*). Today, codeine is gaining increasing medicinal importance as a substitution therapy for heroin addicts (Gerlach and Schneider 1994). The pharmaceutical industry synthesizes codeine primarily from thebaine, the main active constituent in Papaver bracteatum Lindl. (cf. Papaver spp.) (Morton 1977, 125*; Theuns et al. 1986). Codeine has acquired a certain significance in the music scene (jazz, rock, psychedelia), primarily as a substitute for heroin or morphine. Buffy Saint-Marie sang about the anguish of her codeine dependence in the song "Cod'ine" (LP It's My Way! Vanguard Records 1964). Quicksilver Messenger Service later covered the song and made it famous. In the 1990s, the wave band Codeine had several albums out through Sub Pop. Cough syrups496 with a high codeine content were often consumed as inebriants at concerts, festivals, et cetera (usually in combination with alcohol and cannabis) (Bangs 1978, 158).

Since the 1990's codeine has gained popularity in the rap music scene where a mixture containing codeine promethazine cough syrup is consumed under the name purple drank and several artists have released songs about it [23], [14].


References

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  16. How long do opiates stay in your urine?, 2017, https://www.blvdcenters.org/opiate-rehab-treatment-centers/how-long-do-opiates-stay-in-your-urine
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  18. Misuse of Drugs Act 1971, 2014, http://www.legislation.gov.uk/ukpga/1971/38/schedule/2
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