Concerns have been growing globally regarding the misuse of both prescribed and over-the-counter (OTC) codeine, with research showing that both demand for codeine and misuse of OTC codeine have increased.  In 2010 the Irish Pharmacy Regulator published guidance for pharmacists on the safe supply of non-prescription codeine-in-combination products to patients.1 This guidance was published following the enactment of the Pharmacy Act 2007 2 and the Regulation of Retail Pharmacy Businesses Regulations 2008.3 The guidance states that these products are to be supplied only as ‘second-line’ medicine for pain-relief treatment. Detailed advice is also to be provided to patients about the correct short-term use of the products.

‘Codeine is my companion’

Following the above changes, a study was undertaken in Ireland to obtain individual and collective experiences of codeine use, and to gain an understanding of the pathways to misuse and dependence and of people’s experiences of treatment services.4 It was a qualitative study, based on in-depth interviews with 21 adult codeine ‘misusers’ (either currently using, in treatment or recovery) who were accessing, or had accessed, treatment services, and with their dependants.

To date, there have been only a few Irish studies on problem codeine users. These have shown that users tend to be male, with a history of psychiatric problems, co-existing medical problems and/or poly-drug use.  Quantifying the extent of misuse or dependence on codeine-containing medicines in Ireland has been difficult. The authors of the research study cite data from the National Drug Treatment Reporting System (NDTRS) for the period 2008–2012, which show that 1.9 per cent of people in drug treatment in Ireland had reported codeine as their primary or secondary problem drug.

Severity of dependence

Interviewees all completed the severity of dependence screener (SDS).2 5 Just over half of interviewees were women (12, 57%); their ages ranged between 26 and 62 years, with 71 per cent being aged between 30 and 49; and 52 per cent were unemployed. With regard to substance use, the interviewees reported as follows:

• 15 (71%) had used codeine within the last 12 months. Of these, 12 (80%) scored 10 points or higher in the SDS.
• 18 (86%) used codeine as their primary problem drug. 0f these, two (11%) reported using other opiate-type drugs, and 13 (62%) reported using codeine in combination with ibuprofen (e.g. Nurofen plus) as their primary drug of use. This combination was described by many of the interviewees as ‘optimal for intoxication purposes’ as opposed to other combinations, particularly with caffeine, which caused unwanted side effects such as nausea.
• 14 (67%) were currently on methadone maintenance treatment.
• 3 (14%) were on Suboxone treatment.
• Several had a history of use of other illicit drugs. 

Themes emerging from interviews

Two higher-level concepts emerged from the analysis of the interviews – (1) emotional pain and user self-legitimisation of use, and (2) entrapment into habit-forming and invisible dependent use. In addition, the authors identified 10 themes with 82 categories. Some of the themes are highlighted below.

Awareness of habit-forming use and harm

Most interviewees reported that they were not aware that codeine was addictive or of the potential harms of ibuprofen and paracetamol. While only two said they had read the product information leaflet, most felt prescribing doctors should provide more information about use and the associated risks.  Almost all had accessed the internet to learn which products contained codeine.

Negotiating pharmacy sales

All reported accessing codeine mainly from pharmacies. This often involved going to many different pharmacies in different locations and at different times in order to avoid suspicion. All were aware of the restrictions on the sale of codeine products and adapted to circumvent these measures. If an interviewee had been recognised by staff, they reported evasion tactics such as purchasing other products. However, interventions from pharmacists did sometimes lead participants to think about misuse.

Alternative sourcing routes

Interviewees reported asking family members or friends to purchase codeine products or obtain prescriptions on their behalf, crossing the border or travelling to areas with less strict rules around codeine products, ‘doctor shopping’ with stories of pain, and forging prescriptions. Two interviewees who were healthcare professionals reported stealing from work.

The codeine feeling

Most interviewees started to use codeine for legitimate pain-related reasons. However, many described how they progressed within several weeks to taking the drug for its pleasurable effects or for emotional reasons rather than to alleviate physical pain. 

I had really no treatment [for depression] but I was totally dependent on the codeine, codeine was my treatment, codeine was my life.

The daily routine and acute and chronic side-effects

Interviewees reported that misuse started within weeks, often involving intense cravings and the need to take codeine ‘to feel normal’ and to get though the day. Maximum daily consumption ranged from 24 to 115 tablets.  Although many did not exceed the recommended dose, they misused the products over a long period. Several commented on the cost and time spent supporting their misuse. Reported side-effects included distorted vision, itching, constipation, rebound headaches, nausea, loss of appetite and of weight.

Social isolation

Social isolation and the damaging effect of addiction on family relationships were noted by some interviewees. The pre-occupying nature of the dependence on codeine was cited as a reason for isolation from family and friends.

I don’t really have any friends any more. My friends are gone and it’s more a companion addiction. It feels like it has its arm around you.  That’s how it is for me now.  It gives me that sense of security and that’s what I am struggling with at the moment, it’s to break that cycle.

Withdrawal and dependence

The side-effects of withdrawal were one of the reasons several interviewees reported for continuing misuse, trying to self-regulate the amounts taken to keep up normality. Many had unsuccessfully tried to self-detox.

I tried to cut down on it, gradually cut down, and then I’d just have a bad day and I’d be straight back up to 24 [tablets].

Help-seeking and treatment experiences

There was an overall positive feeling towards treatment services and pharmacists when seeking help. The barriers to treatment revolved largely around the stigma associated with addiction and being labelled a drug addict. All the interviewees who commenced on tapered doses of codeine phosphate relapsed, reporting it did nothing to alleviate their cravings. Suboxone, however, was viewed very positively by the two individuals who took the drug, removing both cravings and withdrawal symptoms.

It was a miracle, a door opened for me, I was able to function, I was on no codeine. I actually walked into the chemist and I apologised to everyone who I had fooled.

Some interviewees indicated a preference for more involvement by pharmacists, rather than mainstream drug treatment facilities, in assisting treatment of addiction.

Conclusions

This qualitative study gives an additional perspective on codeine misuse and dependence addiction in Ireland, highlighting the roles of habit-forming use (encouraged by covert behaviours) and of self-medication for the relief of emotional distress in addiction formation. Given the availability of codeine-containing products and the lack of uniformity in diagnosing what is misuse of opioid pharmaceuticals, interventions for referral, treatment and management of codeine misuse remain limited.

The authors highlight the need to improve treatment pathways, and the availability and management of treatment for this group. They also highlight the need to proactively tackle the availability of codeine-containing medicines, minimise the risks associated with use when required for pain relief, and enhance consumer awareness. These initiatives need to be driven by both public health and regulatory bodies. 

1. Pharmaceutical Society of Ireland (2010) Non-prescription medicinal products containing codeine: guidance for pharmacists on safe supply to patients. Retrieved 1 April 2016 at http://www.thepsi.ie/Libraries/Consultations/Final_Codeine_Guidelines.sflb.ashx
2. The Pharmacy Act, 2007 (Private Act No. 20 of 2007). Retrieved 1 April 2016 at Act of Irish Parliament.http://www.irishstatutebook.ie/eli/2007/act/20/enacted/en/html
3. Regulation of Retail Pharmacy Businesses Regulations, 2008 (S.I. No. 488 of 2008) Retrieved 1 April 2016 at http://www.irishstatutebook.ie/eli/2008/si/488/made/en/print
4. 41. Van Hout MC, Horan A, Santlal K, Rich E and Bergin M (2015) ‘Codeine is my companion’: Misuse and dependence on codeine containing medicines in Ireland Irish Journal of Psychological Medicine, Early online, pp. 1–14. https://www.drugsandalcohol.ie/24912/
5. 52. Severity of Dependence Screener is a five-item questionnaire used to determine dependence in the past 12 months in order to determine dependent and non-dependent use.