Codeine, found in a number of pain reliever medicines, is a member of the opiate family, meaning it is derived from opium and is a sibling to heroin, methadone and morphine.

Over the past couple of years, sales have rocketed of a number of products available over the counter in pharmacies. The problem for some people, however, is that they have been drawn into a dependence on codeine rather than just taking it as an occasional pain reliever.

According to the Irish Pharmacy Union (IPU), patients who use pain relievers that contain codeine for longer than three days at a time or exceed the recommended dosage could also experience what is called rebound headaches.

Guidance
Last year, in response to the rise in codeine dependence, the Pharmaceutical Society of Ireland published draft guidance for pharmacists on the safe supply of non-prescription medicinal products containing codeine. The IPU and the Irish Pharmaceutical Healthcare Association also jointly produced a protocol to assist pharmacists in the sale of codeine-containing medicines.

Welcoming the new guidelines, Pamela Logan, director of pharmacy services in the IPU, explains: “People who misuse non-prescription pain relievers can become addicted to certain substances and suffer withdrawal symptoms if they do not continue to take them. The pattern of usage then becomes a vicious circle resulting in dependency.

Mindful of problems
“We hope that, by highlighting this issue, patients will be mindful of the problems that can result from the misuse of such medications and will consult with their pharmacist, who can advise them on appropriate medical care, which will minimise any potential risks to themselves or their families.”

Just how many people are already addicted in Ireland? Dr Garrett McGovern, a Dublin GP specialising in substance abuse, says this is unknown. “We don’t have any prevalence figures so nobody knows the extent of this problem. In terms of treatment, people don’t come for treatment because it’s generally heroin-based addiction treatment. Whether the GPs are seeing people, I don’t know. I suspect that a lot of people that have this addiction are not coming for treatment.”

Though codeine dependence is not something that is immediately recognisable as an issue amongst older age groups, McGovern says that “a lot of young people are taking these willy nilly”.

Physically addictive
However, any age group is at risk. As codeine is part of the opiate family, it is physically addictive and people who take it more often than recommended will develop a dependence on it.

Codeine on its own requires a prescription. However, it is through over-the-counter painkillers that many people are introduced to codeine. Through using these remedies, people develop a tolerance and maintain a dependence, explains McGovern.

The problem with this, he says, is the other elements that make up these over-the-counter painkillers (for example, paracetamol or anti-inflammatory ibuprofen). Too much paracetamol can cause liver failure. When codeine is combined with non-steroidal anti-inflammatory (NSAIDs) drugs, it can cause stomach ulcers.

Discovering dependence
Many people’s dependence only comes to light when they present to their GP or A&E with ulcers, for example. For older people and people with chronic illnesses, the liver is not going to be as hardy against the doses of paracetamol that may accompany an over-the-counter codeine fix, McGovern warns.

He explains that, for those who do develop a tolerance, the effect is staving off withdrawal. Withdrawal symptoms include stomach cramps and craving the drugs. Also, he notes, people may be neglecting themselves or spending a lot of time trying to acquire the next fix.

Talk to your GP
McGovern says that, because addiction is stigmatised, he’s not sure that a specialised clinic for codeine addiction is the best approach. He believes that, if the person has the courage to discuss their addiction with a GP, that is a good first step. If the GP is not proactive about dealing with the situation, look for a second opinion.

Possible treatment options include detox, being prescribed some other drugs to help with the codeine withdrawal or a maintenance dose to wean somebody off it.

Dependence on codeine can happen within days so, if you’re on that slippery slope, it’s definitely time for a prescription of that overused cliché: “Quit while you’re ahead.”