Over-the-Counter Codeine—from Therapeutic Use to Dependence, and the Grey Areas in Between

Abstract

Codeine is a widely used analgesic, that is available for sale in pharmacies over the counter (OTC) in a number of countries including the UK, South Africa, Ireland, France and Australia. In these countries with OTC codeine sales there has been emerging concerns about misuse of and dependence on codeine containing combination analgesics, with increasing numbers of people presenting for help with codeine dependence at primary care and addiction treatment services. This has led to many countries reviewing availability of codeine in OTC available preparations, and considering possible measures to reduce harms from misuse of OTC codeine containing combination analgesics.

Best Practices and Innovations for Managing Codeine Misuse and Dependence

“…To date, attempts to address codeine misuse and dependence have primarily centred on practices that relate to manufacturing, responsible prescribing, dispensing, monitoring and surveillance, education and psychosocial interventions (3,6,7). While such practices, for example, 'real time monitoring' (The Codeine Care Project) are an important deterrent for misuse and dependence (7,(42)(43), they are not solely sufficient.…”

“…Neuro-adaptation occurs with repeated use (therapeutic and non-therapeutic) within a short period of time (10,11). Prolonged use is strongly associated with depression and dysphoric mood states, and how codeine can interact with other substances leading to respiratory depression and other central nervous system effects (3,5).…”

“…Of particular public health concern is that long term or excessive use of codeine combination products containing additives (ibuprofen and paracetamol/acetaminophen) can lead to chronic headache, gastrointestinal haemorrhage, inflammatory bowel conditions, hypokalaemia, acute haemorrhagic necrotising pancreatitis, and neurological damage (3,5). The rise in patient uptake of addiction treatment services for this form of opioid analgesic dependence is equally concerning (12,13).…”

“…This is complicated by the complexity of inter-relations between pharmacological, social, economic, legal and individual factors which shape consumption patterns; the heterogeneous nature of misuse; blurring between therapeutic use and misuse; focus of drug agencies on surveillance of opiate users and dependents; difficulties in estimating prevalence of misuse given the broad definition of misuse and the covert nature of medicinal misuse itself; and the presence of displacement between public sourcing of prescribed, OTC and internet sourced products (3,6,14).…”

Codeine misuse and dependence in South Africa: Perspectives of addiction treatment providers

“…[1] The problem does not only lie with over-the-counter (OTC) products where they are available, but also with inappropriate prescribing of codeine-containing medications. [1,2] Misuse refers to 'the use of a medicine, with or without a doctor's prescription, clearly outside of accepted medical practice or guidelines, for recreational purposes or in the framework of self-medication, in greater dosages or for longer periods than were indicated, in which the risks and problems associated with use outweigh the benefits' . [3] Dependence refers to a diagnosable psychiatric condition.…”