Codeine Dependence

Codeine dependence

Codeine is used as an analgesic in both prescription and over-the-counter (OTC) preparations in Australia. It is often combined with paracetamol or ibuprofen, non-steroidal anti-inflammatory drug (NSAIDs) codeine-containing cough suppressants.1
The main reasons why codeine-containing preparations can be problematic when misused:2
•    Codeine can be addictive.
•    If codeine-containing medicines are taken in doses higher-than-recommended, more of the other active ingredients in the medicine are also being consumed, which can cause serious side effects.
•    Codeine may be associated with side effects, such as nausea, constipation, dizziness, and, in some cases, respiratory depression. 
Dependence and misuse
Although codeine has a role to play in the management of pain relief, misuse of the codeine-containing preparations may lead to the development of a physical and psychological dependence and has been associated in some cases with increased mortality.3 Experts have often referred to codeine dependence as the "hidden addiction" because codeine is readily available with some restrictions.

Many people with codeine dependence may have a high prevalence of comorbid conditions, including pain, mental health, and substance abuse problems; so it is clearly necessary to increase the capacity to identify those at high-risk and to respond more effectively to their needs.

Recognising codeine dependence

Hospital clinicians have a key role to play in identifying codeine dependence. Patients showing any of the following behaviours may benefit from being evaluated and closely monitored for signs of opioid painkiller dependence:

•    Use of multiple opioid medications.
•    Reports of opioid withdrawal symptoms such as:4
o    Cravings for codeine
o    Dilated pupils
o    Abdominal cramps, diarrhoea, nausea, vomiting
o    Lack of appetite
o    Runny nose and sneezing
o    Yawning and difficulty sleeping
o    Trembling, aching muscles and joints
o    Goosebumps, fever, chills, sweating
o    Restlessness, irritability, nervousness, depression

Clinicians should ensure that patients prescribed codeine-containing preparation at discharge are aware of the potential for abuse and offer patients clear guidance on how long the medication should be taken. In addition, physicians responsible for patients in the outpatient setting should be made aware through discharge letters that their patients have been prescribed a codeine preparation. 

Treating dependence

There are a number of approaches to treating codeine-dependence. These include abstinence-focused programs, behavioural interventions, and self-directed intervention such as participation in Narcotics Anonymous. In situations where these measures are unsuccessful or are not appropriate, Medication Assisted Therapy or MAT (formerly known as opioid substitution therapy) is considered.5

MAT is indicated for opioid withdrawal and long-term maintenance. To manage withdrawal symptoms, reducing doses of an opioid substitute (eg, buprenorphine, methadone) are administered for approximately a week, followed by referral to counselling services. 5 Relapse following detoxification alone is common, thus most patients embark on abstinence-oriented treatment and substitution maintenance treatment after initial detoxification. 6

If you suspect one of your patients may be dependent on codeine or other opioids, try and discuss your concerns and refer the customer to an addiction specialist for further assessment and appropriate treatment.

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1.    Crews KR, et al. Clin Pharmacol Ther 2014;95:376-82.
2.    NPS Medicinewise. (Accessed November 30, 2015, at
3.     Roxburgh A, et al. Med J Aust 2015;203:299
4.     DrugInfo. Codeine Facts. (Accessed April 27, 2015, at
5.    McDonough M. Aust Prescr 2013;36:83-7.
6.    World Health Organization, United Nations Office on Drugs and Crime, UNAIDS. (Accessed at