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OTC Meds: The Codeine Connection

Addiction doesn’t apply only to ‘hardcore’ drugs such as cocaine, heroin and crystal meth. That cough mixture or painkiller you picked up at the pharmacy can be just as addictive if it contains codeine, writes Mandy Collins.
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Richard* is a South African working and living in Dubai. When he returns to Dubai from South Africa, one of his preflight routines is to check any over-the-counter medications he might have bought here, for codeine. In South Africa, you can pick up a medication containing codeine over the counter, including some pain medications for children and babies. In Dubai, possessing codeine carries a jail sentence.

South Africa is an exception when it comes to codeine – in most countries in the world, it’s available by prescription only. Here, some codeine medications have to be prescribed by your doctor, but there are also over-the-counter (OTC) versions. These have simply had their pack size and dosages reduced in recent years. Why? Because of the scourge of codeine addiction.

Florence Phiriga, deputy nursing services manager at the Elim Clinic, a recovery centre for those battling addiction, points out that codeine is an opioid – like its cousin, morphine. And codeine addiction is a lot more common than most people realise. “Right now we are seeing many patients who are abusing codeine,” she says, “particularly in the form of cough syrups. And we don’t know why, but it seems to be more common in women than men.”

In some cases, things start off innocently enough, says Phiriga. “A doctor prescribes a flu medication containing codeine, for example, and they’ll prescribe it three times a day. But some people start to take it every two hours if they feel it isn’t working, and before they know it, the box is finished. And then they get more. We’ve even had patients who use friends and relatives to help them to get more medication if the pharmacy refuses to give them more.”

Among teenagers, however, most often the abuse is intentional – they’ll pour a whole bottle of codeine-containing cough syrup into a grape-flavoured fizzy drink, or an energy drink, to create something known as “purple drank” or “lean”. Then off they go to school, their high for the day disguised as an innocuous soft drink.

“It began with some of the rappers in about 2007, and it’s become quite the trend,” says Dy Williams of drug addiction recovery centre Houghton House. “It’s less expensive than nyaope, which is essentially heroin, and you can buy it over the counter. And the more you take, the more you need it, until you get to the point where you are physically addicted to it, and you need it to get up in the morning.”

When your doctor prescribes anything containing codeine, you’ll probably be warned that it can cause constipation. But if you start to abuse it, constipation is the least of your worries. “It can have terrible effects,” says Phiriga, “like bleeding ulcers, or kidney and liver damage. It can also lower your heart rate and blood pressure, cause sexual problems like low libido, and even cause depression.”

And don’t think you can just stop at any time. It requires that you go through the same kind of detox most of us would associate with heroin and cocaine addiction – because it comes from the same family of drugs, and has the same effects on your body.

“Codeine is a short-acting drug – it only lasts three to four hours,” explains Phiriga. “So, by the time you haven’t had it for six hours, you start to get withdrawal symptoms – pain, nausea, vomiting and chills.

“When patients come in, they will be assessed by a doctor and put onto a detox regime, which usually includes a drug called Suboxone. This helps to minimise withdrawal symptoms. Generally, patients will stay in the clinic for three weeks, where we can monitor them until they are clean.”

But it’s not enough to simply detox your body. “Addiction is in the brain, so psychotherapy is essential,” says Phiriga. “We have psychologists and social workers who work with patients in individual and group sessions while they are here.”

She emphasises that codeine is meant to be used short-term. “You can’t go on drinking that cough mixture for four weeks or more. Remember that abuse leads to addiction, so use your medicines only as prescribed by your doctor, and then stop.”

Williams adds that the biggest misconception is that codeine is safe because it’s available for sale over the counter. “Nothing is safe unless you use it in moderation and as prescribed,” she concludes.

* Not his real name

Signs and symptoms of codeine abuse

Like other opiates, codeine abuse can cause nausea, vomiting, difficulty breathing and drowsiness. Someone who is abusing codeine might appear to be sedated. Or they might have stomach pain and constipation, and have itchy skin. They might also not be able to think clearly, operate large equipment safely or drive properly. When users first start taking codeine, they might even feel dizzy, or faint.

Some people also experience changes in vision, and heavy users might have seizures. If someone overdoses on codeine, signs will include loss of consciousness, shallow and slow breathing, limpness, slow heartbeat, and cold and clammy skin.

The most important sign, however, is that someone can’t stop using a drug and their life is being damaged or even destroyed by the addiction. Many people abusing opiates don’t even get high; they simply feel as if they need the drug to function each day.


Don’t try to detox at home

Houghton House’s Dy Williams warns against DIY detox from codeine. “It’s dangerous to try and detox without assistance,” she says. “It should always be medically supervised.”

Detox comes with a range of symptoms, including anxiety, convulsions, delirium, nausea, diarrhoea and seizures. If you can’t afford a private clinic, she advises, you can be admitted to a psychiatric ward in a government hospital for your detox.

Williams says detoxing from the drug physically usually takes about five days. “But then we have to teach addicts how to cope without drugs, how to function in the world without them. That’s why the process takes several weeks.”

Fast facts: Opioids

Some opioids, such as morphine and codeine, occur naturally in opium, and are made from the liquid harvested from the unripe seed pods of the opium poppy.

Semi-synthetic opioids, such as oxycodone, hydromorphone or hydrocodone, are made by changing the chemical structure of naturally occurring opioids.

Synthetic opioids, such as methadone, meperidine and fentanyl, are made from chemicals, without using a naturally occurring opioid as a starting material.

Prescription opioids come in various forms: tablets, capsules, syrups, solutions and suppositories.

Source: Centre for Addiction and Mental Health,

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