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Updated on January 26, 2022

What is Codeine?

Codeine is a naturally occurring substance that makes up 0.7 to 2.5% of opium. 

It’s available as a solo prescription pain medication. It’s also mixed with other substances in some over-the-counter medicines. 

Codeine, in solo or combined form, is used to:

  • Relieve mild to moderate pain
  • Reduce coughing 
  • Treat diarrhea, especially related to irritable bowel syndrome (IBS)

Purple drank is a street term for the mixture of codeine and promethazine. Formerly a common cough syrup, it’s now often used to get a ‘buzz.’ 

Promethazine is used for nausea and to alter sensorium (what you feel, hear, see, and think). It’s sometimes mixed with alcohol or other substances.

In Europe, codeine is mixed with hydrocodone and dihydrocodeine to form an illicit opioid mixture called Brown.1

In the U.S., codeine is a Schedule II drug. This means it has a high potential for abuse, leading to severe psychological or physical dependence.2

Is Codeine an Opioid?

Codeine is technically an opiate, though it’s also referred to as an opioid.

Here’s the difference: 

Opiates are naturally occurring compounds extracted from the opium poppy plant. Examples include opium, morphine, heroin, and codeine.

Opioids are synthetic or semi-synthetic compounds made in a lab. Examples include hydrocodone, oxycodone, oxymorphone, and fentanyl.

Opiates and opioids have similar effects. They are prescribed as pain relievers and cough suppressants. Some people also illicitly use them for their euphoric effects.

Due to these similarities, the terms “opiates” and “opioids” are often used interchangeably.1, 3, 4

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How is Codeine Used?  

Codeine is available in tablet, capsule, and solution forms. It’s usually taken as needed every 4 to 6 hours. 

Here are a few guidelines for using codeine safely:5, 6

  • Take codeine exactly as prescribed by your doctor
  • Don’t increase your dose or frequency of use
  • Don’t crush, chew, or dissolve the pills
  • Don’t stop taking codeine suddenly, as this may cause withdrawal if you’re dependent
  • Ask your doctor how to stop taking codeine safely
  • Tell your doctor if you develop withdrawal symptoms or an increased urge to take more codeine
  • Don’t share codeine with anyone, especially someone with a drug abuse history
  • Don’t keep leftover medication, as this can lead to overdose if accidentally or improperly used by other people
  • Don’t drink alcohol while taking codeine
  • Don’t ingest codeine with interacting drugs
  • Skip a missed dose if it’s time for the next, and don’t take 2 doses to make up for a missed one
  • Tell your doctor if you’re pregnant, as a newborn baby might undergo withdrawal if the mother took codeine regularly during pregnancy

Codeine Abuse

Codeine is usually abused by: 

  • Taking the pill for non-medical purposes
  • Crushing the tablet and snorting the powder

Like other opioids, codeine can cause relaxation, euphoria, and a dopamine rush. 

Prolonged codeine use may lead to tolerance, dependence, and addiction. The first couple doses provide the strongest effects, and subsequent doses aren’t as effective. 

Those using the drug to feel a ‘buzz’ need to take higher and more frequent doses to try and get close to the initial feeling. 

Young people are likely to abuse prescription codeine. They may start ingesting the cough syrup, Purple Drank, and think it’s harmless. But once they develop a tolerance, they often seek more potent opioids.7, 8

Opioid users sometimes switch to codeine in the absence of heroin or stronger opioids. Codeine may still cause euphoria, although less intense. It may also reduce cravings and withdrawal symptoms. 

People who take prescription codeine may also misuse the drug. Once they develop tolerance, their doctor might prescribe a higher dosage. In some cases, people self-medicate with higher doses.

In 2016, 11.5 million people in the U.S. misused prescription opioids. About 62% of this population said they used them to treat pain.9

Risks of Codeine Abuse 

Abuse of opioids like codeine can lead to risks like overdose, addiction, or death. If dependent users stop taking codeine suddenly, they may experience withdrawal symptoms. These symptoms are unpleasant but rarely physically dangerous.

Side Effects

Common side effects of codeine include:5, 6, 10

  • Slowed breathing
  • Slow heart rate
  • Dizziness or drowsiness
  • Euphoria or dysphoria
  • Headaches
  • Nausea
  • Vomiting
  • Constipation
  • Stomach pain
  • Difficulty urinating
  • Allergic reactions 
  • Low cortisol levels
  • Serotonin syndrome 

Prolonged codeine use can lead to long-term side effects, including:5, 6, 10

  • Memory impairment
  • Depression
  • Anxiety
  • Fatigue
  • Kidney disease
  • Liver damage
  • Infertility
  • Erectile dysfunction
  • Decreased sex drive

Drug Interactions

Opioids like codeine can interact with other drugs and cause adverse reactions or death. Medicines that should never be mixed with codeine include:5 

  • Medications for cough, cold, allergy, asthma, motion sickness, IBS, or overactive bladder
  • Other opioids
  • Sedatives like Valium
  • Sleeping pills, muscle relaxants, and other drugs that cause sleepiness or slowed breathing
  • Drugs that affect serotonin levels

Overdose 

From 1999 to 2019, about 500,000 people died from opioid overdose. Nearly half of these overdose deaths were caused by prescription opioids like codeine.11, 12

Codeine is a weaker opioid, but its overdose can still be fatal. 

The body metabolizes codeine into morphine, which can cause life-threatening respiratory depression or even death. This is why codeine is no longer appropriate for people under 18 years old. 

In 2018, the U.S Food and Drug Administration (FDA) required labeling changes for cough and cold medicines to limit codeine intake.13

Some symptoms of codeine overdose include:5, 6

  • Slowed breathing 
  • Cold, clammy skin
  • Dizziness or drowsiness
  • Muscle weakness
  • Lightheadedness
  • Fainting
  • Vomiting
  • Slow heartbeat, low blood pressure, or weak pulse
  • Intestinal spasms
  • Convulsions
  • Bluish lips or fingernails
  • Pinpoint pupils
  • Coma
  • Death

If you or someone you know has overdosed on codeine, seek emergency medical attention. Medical professionals will conduct life-saving procedures, including providing supplemental oxygen.

Naloxone is the rescue medication for opioid overdoses. When administer intravenously, under the tongue, or through the skin, it can reverse the life-threatening effects of any opioids.1, 6, 14

Addiction & Withdrawal

Like other opioids, codeine is addictive. You should only take it as directed and for a short time.

Codeine addiction develops after excessive, regular use. The body becomes used to the drug’s effects and relies on it to feel ‘normal.’ If use is stopped abruptly, the body tries to adjust to the absence of the drug. This process causes withdrawal symptoms

Withdrawal is a primary reason many people find it hard to quit. They continue using the drug to avoid unpleasant symptoms like:5, 6

  • Runny nose
  • Watery eyes
  • Nausea
  • Vomiting
  • Stomach cramps
  • Diarrhea
  • Loss of appetite
  • Weight loss
  • Muscle aches
  • Sweating
  • Goosebumps
  • Agitation
  • Anxiety
  • Cravings for more codeine
  • Restlessness
  • Widened pupils
  • Irritability
  • Difficulty falling asleep or staying asleep
  • Fast breathing or heartbeat 

Taking large doses of codeine, not as prescribed, is dangerous. Doing so can result in serious side effects or even death. 

Consult your doctor before attempting to quit taking codeine. They will provide the safest way to stop.

Signs of Codeine Addiction 

Certain behaviors that may indicate codeine addiction include:16, 17

  • Buying codeine illegally or on the street
  • Faking symptoms for prescription codeine
  • “Shopping” for doctors to get multiple prescriptions
  • Stealing codeine from a healthcare provider 
  • Stealing money to buy the drug
  • An inability to stop taking codeine after unsuccessful attempts
  • Taking other opioids if codeine is unavailable
  • Experiencing withdrawal symptoms when not taking codeine

Diagnosing any opioid addiction requires a thorough medical evaluation. This includes lab tests and monitoring of prescription medications. 

Doctors use the 11 criteria from the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) to diagnose opioid use disorder (OUD). These criteria include excessive cravings, recurrent use, tolerance, and withdrawal symptoms.9

Treatment for Codeine & Opioid Addiction 

Treatment for codeine addiction does not differ from that of other opioids. Treatment approaches include:18

Medication-Assisted Treatment (MAT)

Treating codeine withdrawal is often much easier than treating other, more potent opiate withdrawals. But it may include medication-assisted treatment (MAT). 

This approach uses one of these 3 medications:9, 18

  1. Methadone: An opioid agonist. It activates opioid receptors but doesn’t elicit euphoria. It can relieve cravings and prevent withdrawal symptoms.  
  2. Buprenorphine: A partial opioid agonist. It partially activates opioid receptors but doesn’t elicit euphoria. It shares similar effects as methadone. 
  3. Naltrexone: An opioid antagonist. Instead of activating opioid receptors, it blocks them to prevent other opioids from taking effect.

Behavioral Therapies

Behavioral treatments:

  • Help users change their attitudes and behaviors concerning drug use
  • Teach skills in handling situations and triggers that may lead to relapse
  • Enhance the effectiveness of medications
  • Help users stick to their treatment

Examples of behavioral approaches include:18

  • Cognitive behavioral therapy (CBT): Short-term talk therapy that helps change unhealthy thoughts and behavior patterns 
  • Contingency management therapy: Sometimes called “motivational incentives,” it offers rewards to recognize positive behavioral changes
  • Motivational enhancement therapy: Helps resolve doubts or hesitations towards drug addiction treatment
  • Family therapy: A therapist and family members are involved in solving family conflicts and helping the user, especially if they are young, deal with drug problems
  • Twelve-step facilitation (TSF): Semi-structured programs usually delivered in 12 weekly sessions to help users abstain from drugs such as AA or NA
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Resources

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  1. National Center for Biotechnology Information. "PubChem Compound Summary for CID 5284371, Codeine." PubChem. 1 Jan. 2022.
  2. Controlled Substance Schedules.” Diversion Control Division, Drug Enforcement Administration, U.S. Department Of Justice.  
  3. Opiates or Opioids — What's the difference?” Alcohol and Drug Policy Commission, Oregon Department of Veterans’ Affairs. 
  4. Opioid Addiction 2016 Facts & Figures.” American Society of Addiction Medicine. 
  5. Healthwise. “Codeine.” University of Michigan Health. 17 Oct. 2019.
  6. Codeine.” MedlinePlus, National Library of Medicine. 15 Dec. 2020.
  7. “Syrup,” “Purple Drank,” “Sizzurp,” “Lean.”” National Institute on Drug Abuse. May 2015.
  8. Cough and Cold Medicines.” National Institute on Drug Abuse. 9 Dec. 2021.
  9. Module 5: Assessing and Addressing Opioid Use Disorder (OUD).” Centers for Disease Control and Prevention, U.S. Department of Health & Human Services.
  10. Codeine Side Effects.” Drugs.com. 11 May 2021.
  11. Opioid Data Analysis and Resources.” Centers for Disease Control and Prevention, U.S. Department of Health & Human Services. 10 Mar. 2021.
  12. Overdose Death Rates Involving Opioids, by Type, United States, 1999-2019.” Centers for Disease Control and Prevention, U.S. Department of Health & Human Services. 10 Mar. 2021.
  13. FDA Drug Safety Communication: FDA requires labeling changes for prescription opioid cough and cold medicines to limit their use to adults 18 years and older.” U.S. Food and Drug Administration, U.S. Department of Health & Human Services. 22 Jan. 2018. 
  14. Opioid Addiction Treatment.” American Society of Addiction Medicine. Accessed 2 Jan., 2022.
  15. Volkow, Nora. “America’s Addiction to Opioids: Heroin and Prescription Drug Abuse.” National Institute on Drug Abuse. 14 May 2014.
  16. Savage, Seddon R et al. “Challenges in using opioids to treat pain in persons with substance use disorders.” Addiction Science & Clinical Practice vol. 4,2 : 4-25. 
  17. Signs of Opioid Abuse.” Johns Hopkins Medicine. 
  18. Treatment Approaches for Drug Addiction.” National Institute on Drug Abuse. Jan. 2019.

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