According to the book The Chemistry of Plant Natural Products, codeine (3-methylmorphine) is an alkaloid found in opium that is processed from the poppy plant. Codeine is an opioid or narcotic drug, which puts it in the same class as drugs like morphine, Vicodin, OxyContin, heroin, etc. Like other prescription narcotic drugs, codeine has several medicinal uses. It is found in cough syrups as a cough suppressant, and it still sometimes used for pain relief. It can be used to induce sleep, and it is still used for other purposes occasionally, such as to control cravings for sugar in diabetics.
Codeine is typically taken in liquid or pill form. Medications or drugs that contain less than 90 mg of codeine are classified by the Drug Enforcement Administration as Schedule III controlled substances, and codeine is otherwise classified as a Schedule II controlled substance outside of that particular situation. This indicates that it has a potential for abuse and the development of physical dependence.
Abuse of Codeine
Although it has a number of medicinal uses, codeine is also a potential drug of abuse. When taken orally, the effects of the drug are typically felt within 20-30 minutes after using it and last from 4-6 hours. It is typically taken orally in liquid form, such as in cough syrup, and it is often abused with other drugs, such as alcohol or other prescription medications. It is sometimes abused with stimulant drugs including cocaine. Of course, mixing large amounts of codeine with any other drug can be a potentially dangerous and even lethal practice.
According to the National Institute for Drug Abuse, an emerging trend with younger individuals is to drink fairly copious amounts of codeine-promethazine cough syrup to achieve the euphoric effects of these drugs. This medication is intended for individuals who have colds, the flu, or allergies. The promethazine component of the medication is an antihistamine, and the codeine is intended to be used as a cough suppressant.
Its use in large doses produces sedation, euphoria, and overall feelings of well being. Street names for this particular drug are lean, syrup, purple syrup, and sizzurp.
Both of these drugs can act as central nervous system depressants and be dangerous if taken in large quantities (see below). Actual statistics on the prevalence and demographics associated with codeine abuse are not readily available, but it is believed that most individuals who abuse codeine are younger individuals, such as children, adolescents, and young adults under the age of 25.
Effects of Abuse
Because codeine is an opioid drug, its effects are similar to other drugs in its class, such as heroin and morphine. Codeine acts as a central nervous system depressant, producing sedation, extreme calmness, mild euphoria, pleasurable sensations as a result of its indirect action on the dopamine reward system in the brain, and the potential for relatively rapid physical dependence (the development of tolerance and withdrawal symptoms).
Individuals abusing codeine will develop tolerance very quickly and need to take increasingly higher amounts of codeine to get the effects that they achieved earlier at much lower doses. This can result in individuals who chronically abuse codeine taking doses far in excess of what would be considered the maximum daily dose for this drug. In addition, the development of tolerance in individuals is also often associated with withdrawal symptoms if the person abruptly stops using codeine, is unable to maintain the dosage that they are used to taking, or stops taking codeine long enough for levels of the drug in the system to decrease. Codeine does have a relatively short half-life of about 2.5-3 hours, so withdrawal symptoms can appear relatively quickly in individuals who chronically abuse the drug.
Withdrawal symptoms and side effects from codeine abuse typically include:
- Flulike symptoms that can include nausea, vomiting, headache, sweating or trembling, sneezing, runny nose, hives or rashes, and dilated pupils
- Other physical symptoms, such as irregular heartbeat, increased blood pressure, and increased or decreased respiration
- Psychological symptoms, such as feelings of anxiety, mood swings, panic attacks, irritability, and extreme cravings for the drug
When individuals mix codeine with other drugs that also have potentially serious physical effects and withdrawal symptoms, such as alcohol, other narcotic medications, and cocaine, there is a potential for the individual to develop seizures and other cardiovascular issues that can potentially be fatal. Because tolerance to codeine develops rather quickly, there is always the potential for overdose. Overdose on codeine or any opioid medication or drug is a potentially fatal situation because the depressant qualities of the drug can slow vital functions to dangerous levels, such as repressing heartbeat or breathing. If an overdose is suspected, call 911 immediately.
Indications of Codeine Abuse
There are some indications that someone may be abusing a narcotic medication like codeine. According to the American Society of Addiction Medicine, some of the signs that may be observed are:
- Extreme lethargy, slurring of words, problems with motor coordination, and other similar effects
- Periodic displays of flulike symptoms that frequently come and go
- Spending more time alone or with a different group of friends who are known to be drug users
- A loss of interest in activities or other events that the individual used to be interested in
- Finding empty cough syrup bottles in the home
- Changes in personality that can include being irritable, overly sensitive, a tendency toward isolation, and even secretive behaviors, such as getting text messages or phone calls and not answering them in the presence of others
- Increasingly becoming dishonest in the form of lying, stealing things, truancy from school, missing work, etc.
- Changes in physical appearance that indicate that the person does not seem to be as concerned about their general appearance or personal hygiene as they once were
- Failing to fulfill personal obligations, such as work responsibilities, issues at school, social obligations, and obligations to friends and family
The American Psychiatric Association has a formal list of symptoms of opioid use disorders listed in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition, which include the abuse of and or addiction to codeine. These formalized symptoms include cravings, the negative impacts of drug use, using drugs more often or for longer periods than originally intended, difficulty quitting using the drug, and so forth. A formal diagnosis of a substance use disorder, which includes both the notions of substance abuse and addiction, can only be made by a licensed mental health professional with experience in recognizing and diagnosing these symptom patterns. Individuals who suspect that they, or someone else close to them, have a substance use disorder should contact a licensed health care worker, such as a psychologist or psychiatrist.
Treatment Options for a Codeine Use Disorder
If someone is suspected of abusing codeine, it can often be a challenge just to approach the person to discuss your concerns. This is because many individuals who abuse drugs become very defensive when someone suggests that they may have an issue with drug abuse. This type of denial is not specific to drug abuse alone, although many individuals in the healthcare industry seem to think it is qualitatively different than other similar forms of denial, such as that which occurs in individuals who are first diagnosed with terminal cancer denying that they are sick, individuals in dysfunctional relationships denying the specifics of the abuse in the relationships, and so forth. Nonetheless, whether or not denial is a relatively common defensive reaction to a number of different potentially distressing situations has no bearing on the fact that negotiating the denial associated with drug abuse can be difficult and frustrating.
The best way to handle denial is to simply roll with it by acknowledging the person’s feelings and then continuing to probe into the person’s substance abuse. It is rarely, if ever, productive to accuse someone of denying the substance abuse, attempt to chastise them, or attempt to force them into treatment unless the accuser is a judge in a formal court of law (and even then many individuals who are required to enter substance abuse treatment by the court system may not comply with treatment).
When discussing suspected drug abuse with someone, the best thing to remember is to be concerned, ask questions, point out facts regarding the individual’s behavior, and suggest that there might be a problem. It is always extremely helpful to engage the assistance of a mental health professional or an experienced recovering drug addict to discuss an individual’s behavior with them.
Once an individual agrees to get into treatment for their codeine use disorder, there are several considerations to make. According to professional sources, such as the book Interventions for Addiction: Comprehensive Addictive Behaviors and Disorders, these primary considerations include the following:
- First, many individuals will experience withdrawal symptoms if they abruptly stop using codeine. While the withdrawal symptoms are not themselves considered to be potentially physically dangerous, individuals going through withdrawal are often at a high risk for relapse and can even be at risk for self-harm due to the severe physical discomfort. One should consider enrolling the person in a medically assisted detox program, which can either be performed on an inpatient or outpatient basis. This program will likely use medications, such as opioid replacement medications or other medications, and institute a tapering program to minimize the discomfort of the withdrawal process. This can ensure success in early recovery; however, it does not ensure later success. Individuals who complete this phase of their treatment will need to remain in treatment and address other issues.
- People will need to participate in some form of counseling or therapy. Therapy will address issues that led to and maintained the substance abuse, help clients develop stress management techniques, help clients develop coping skills, and institute a program of relapse prevention. The therapeutic process is one of self-discovery, learning new skills and behaviors, and then instituting them.
- There should be some form of social support, such as family counseling, participation in social support groups, and other support, such as vocational counseling, academic counseling, etc. Many individuals will find that certain types of social support groups, such as Narcotics Anonymous or other groups, can be extremely helpful.
- Continued medically assisted treatment may be needed for some individuals to deal with certain psychological issues, medical complications, etc. This will require the consultation of a physician.
- Provisions should be made for long-term success. For many individuals, this will include some form of long-term counseling or participation in social support groups. It is important that someone recovering from any substance use disorder makes significant changes to old habits, and establishes new, healthier habits, in order to maintain long-term recovery.