Treatment for codeine addiction - Dr Colin O39Gara
Treatment services and rehab is not readily available for codeine addiction A physiological withdrawal state when codeine use is stopped or reduced.
Codeine addicts, like most addicts are secretive and will aim to keep the habit secretive for as long as possible. Although codeine is considered a weak opioid, when taken in large amounts its intoxicating effect is far from benign. Codeine addiction has a major impact on the family - the emotional and financial pain of the spouse and children affected by codeine addiction is no less than that of alcohol, heroin or any other addiction.
What are the symptoms when patients present to a doctor? • Repeated inappropriate requests for codeine based analgesia • Epigastric pain from gastric erosion • Renal or hepatic damage • Constipation • Nausea • Small pupils, blurred vision, poor night vision • Bradycardia, hypotension • Depression • Sexual problems.
Mrs. Y, a busy mother of four young children suffered headache and stress on a regular basis. A friend suggested Nurofen Plus would be helpful. She initially took as recommended on the packet but soon found she needed more to obtain the same desired effect. Eventually Mrs.Y was taking 3 packets of Nurofen Plus per day. She would take 24 tablets first thing in the morning, another 24 in the afternoon and the final 24 at 8 in the evening. Her husband had noticed her slurring on the phone during the day and that this had become progressively worse. Mrs Y denied excessive Nurofen use. She finally admitted to codeine addiction when she crashed her car. Her GP referred her for detoxification in the inpatient setting where she was offered detox options. She declined all medications including sedatives. She coped well with withdrawal symptoms and subsequently took part in the inpatient treatment programme for codeine addiction. Mrs Y completed 2 years of the aftercare support programme and has been well since.
Most inpatient rehabilitation treatment programmes for codeine addiction last between 1 and 3 months and provide intensive therapy in groups and with individual therapists. When patients present to our service they will often have little previous input from counsellors and need to learn the basics of interacting in therapeutic groups or with individual counsellors. Cognitive behavioural therapy provided on a 1:1 basis with the patient or in a small group aims to challenge the negative self defeating thoughts that maintain the addiction. In the case of codeine addiction such thoughts might be "I cannot cope with this pain without Nurofen". Therapists would help patients to replace this thought with more helpful thoughts e.g. "I will cope with this pain by becoming more active and managing my stress better". Maintenance Treatment.
Treatment Options - Detoxification.
Specialist inpatient detoxification programmes usually offer a choice of options as patients requests will vary considerably around detoxifcation. The options are as follows:
1) No intervention – Some patients will request no intervention at all. Often these patients are under time constraints and view "cold turkey" as the most time efficient option. 2) Sedatives – Benzodiazepines and sedative antipsychotic medication have long been used for detoxification from opioids. Both alleviate glutamate and adrenaline mediated overactivity of the central and peripheral nervous systems. 3) Lofexidine (Britoflex) – is and alpha adrenergic agonist which alleviates the noradrenergic surge associated with withdrawal. 4) Buprenorphine (Subutex) – A partial mu-opioid agonist, has proven benefit in withdrawal, alleviating the acute symptoms. Not widely available yet in Ireland and cost within Ireland is potentially a problem. We commence patients who choose this option on 4mg per day, increasing to up to 16mg a day, then reducing over 5 days. Rehabilitation.
Treatment for codeine addiction in Ireland is in its infancy. Treatment services and rehab is not readily available for codeine addiction compared to treatment available for alcoholism and illicit drug use. In the US, prescription medicines are ranked as the second most misused class of drug after cannabis. The full extent of codeine addiction in Ireland is unknown but 2010 pharmacy statistics indicate that codeine-containing products were the bestsellers nationally. Codeine is available in Ireland over the counter (OTC) and by prescription. In recent years codeine availability has reduced due to restrictions on its sale at pharmacies. Codeine dependence and the need for codeine addiction treatment remains a serious issue in Ireland as evidenced by the numbers of patients looking for treatment in this area. Doses of codeine vary according to the preparation – e.g. OTC Solpadeine contains 8mg of codeine whereas Solpadol (prescription) contains 30mg of codeine per tablet. Presentations.
For patients continuously failing to maintain abstinence, substitution with an alternative opioid is from a harm minimisation perspective, a sensible option. The other components of OTC codeine products, paracetamol or NSAIDs in large doses are dangerously toxic to the liver and small bowel. Methadone or Buprenorphine are accepted options and there is some evidence that Dihydrocodeine substitution can also be useful. Availability.
Dr. O'Gara provides rehab services for codeine addiction in the inpatient and outpatient settings.
The vast majority of people will take codeine OTC or as prescribed for a limited period. Current recommendations in Ireland and the U.K. suggest that the drug should not be taken for more than 3 days. A minority however will take codeine in increasing amounts and as tolerance develops, become addicted. Addicted patients use repeat prescriptions or the internet to feed an addiction of up to 1000mg of codeine per day. Another group of patient take codeine purely for the purposes of "recreation" – ingesting hundreds of milligrams of codeine in a binge. Consistent with other drugs of abuse, it is probably only 10% of this group that go on to exhibit features of dependence with the 90% moving on from the behaviour. It is this 10% that should get treatment as soon as possible.
Mr. X had a recent car accident where he required an operation. He was prescribed Solpadol in the postoperative period. He continued to take the pain killers as he felt he had uncontrolled pain. He went online to purchase more and failed to follow up with his GP, eventually taking the equivalent of 600mg of codeine a day (20 Solpadol tablets). He felt it was better to stop and did so, but after 2 days developed diarrhoea, muscle pain and intense lethargy. These symptoms were relieved by taking the pain killers again. After discussing this with his GP, he discovered he was addicted to codeine. Mr. X was admitted to an addiction unit where he was observed to be in acute opioid withdrawal with tachycardia, sweating, nausea and diarrhoea. Detoxification options were discussed with Mr. X. He opted for buprenorhine (Subutex). He was administered a starting dose of 4mg and the dose was increased over 3 days to 16mg. Thereafter the 16mg was reduced over 5 days. Following detoxification, Mr. X took part in the inpatient rehabilitation treatment programme for codeine addiction. He entered the 2-year aftercare support programme on leaving hospital. He engaged well and maintained abstinence during the initial months of the aftercare programme but began drinking alcohol. Following education around cross-addiction Mr. X abstained from alcohol and has enjoyed protracted abstinence. Case Study 2.
Do I have a problem with codeine addiction? The features of codeine addiction are: • 1. A strong desire or sense of compulsion to take codeine-containing products • 2. Difficulties in controlling codeine-taking behaviour in terms of its onset, termination, or levels of use; • 3. A physiological withdrawal state when codeine use is stopped or reduced, as evidenced by: the characteristic withdrawal syndrome for the substance; or use of the same (or a closely related) substance with the intention of relieving or avoiding withdrawal symptoms; • 4. Evidence of tolerance, such that increased doses of codeine are required in order to achieve effects originally produced by lower doses; • 5. Progressive neglect of alternative pleasures or interests because of codeine use, increased amount of time necessary to obtain or take codeine or to recover from its effects; • 6. Persisting with codeine use despite clear evidence of overtly harmful consequences, such as harm to the liver, depressive mood states or impairment of cognitive functioning.
Within the small world of addiction medicine, it makes perfect sense to make all codeine-containing products prescription only. Some of my patients would never have been patients were it not for the OTC availability of codeine-containing products. For the majority of people who take codeine without any problem however, having to attend a GP for Nurofen plus or Solpadeine would surely be irritating. In my view what we need is accurate information on the extent of the problem in Ireland with a mature reflection on the impact of the current pharmacy restrictions. Perhaps on balance the current measures are enough.
Common symptoms of codeine withdrawal: • Runny nose, sweating, muscle twitching and muscle pain • Headache • Arrythmias • Nausea, vomiting, and stomach cramps • Hypertension • Insomnia • Dehydration • Weakness and yawning Case Study 1.