Codeine Withdrawal Timeline
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The potential and danger of codeine as a medication of abuse has led the Drug Enforcement Administration to upgrade its status from a Schedule III drug to a Schedule II substance – an acknowledgement that misuse of codeine is a much more serious problem than originally thought. Withdrawal is a big part of drug abuse. The withdrawal timeline for codeine can be affected by how much codeine has been taken, how long the abuse has been in effect, and a number of other factors.
Codeine and Opioids
Codeine is a painkiller and a sleep-inducing medication that is derived from morphine. Both codeine and morphine are opioids, which the National Institute on Drug Abuse describes as a class of drug that interacts with the opioid receptors in the brain and the central nervous system. When a person takes an opioid, they bind to those receptors, cutting off the perception of pain as well as boosting the production of a neurotransmitter that causes the person to feel pleasure, satisfaction, and a desire for the experience to continue.
Opioid painkillers are normally safe when taken for a short period of time and according to a doctor’s prescription, but due to the pleasure they produce as well as their very effective painkilling properties, they can easily and even unintentionally be misused, either by increasing the consumption of the substance or taking the drugs without a prescription. Even regular use can lead to an unhealthy physical and psychological dependence, especially if a person has other drugs or mental and medical health issues that compel continued consumption. When taken in excess, opioid pain relievers can lead to a full addiction, overdose, and death.
Despite being derived from morphine, codeine is not as strong as morphine. For that reason, codeine is prescribed for the treatment of mild to moderate levels of pain, and it is sometimes an ingredient in cough syrups since codeine has historically been used to suppresses the cough response in people who have bad coughs. Codeine’s relative mildness was such that in some countries, it was legal to purchase without a doctor’s prescription; however, after fears of drug diversion, more governments are enforcing regulatory standards on the medication, such as Australia, where the distribution of non-prescription codeine was outlawed in February 2018.
In the United States, codeine was originally considered a Schedule III substance by the Drug Enforcement Administration. The criteria for Schedule III is that a drug has to have a “moderate to low potential for physical and psychological dependence,” but in the wake of the opioid epidemic, the DEA put pure, painkilling codeine in its Schedule II category. This means it has a high potential of abuse but still some acceptable medical applications.
Codeine prescribed in combination with aspirin or paracetamol is considered a Schedule III substance, where there are fewer restrictions around prescriptions. Cough syrups that contain codeine can be as low as Schedule V, depending on the formula. Some states have taken it upon themselves to reclassify Schedule V codeine formulas into more regulated categories, as a way of doing damage control on the abuse of prescription codeine. Minnesota’s legislature chose to reclassify Schedule V codeine formulas as a Schedule II controlled substance because of the high rate of opioid abuse in that state.
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Even though codeine is a relatively mild opioid, its mechanism of action is similar to that of other opioids: binding to opioid receptors in the brain, boosting the production of neurotransmitters that produce feelings of pleasure and anticipation, and dulling the reception of pain. For people going through mild to moderate levels of pain, this relief from their discomfort is very alluring to the point where some are tempted or compelled to take more codeine than prescribed in order to keep the pain at bay even longer. Others enjoy the euphoria or emotional disconnectedness from even the idea of feeling pain and continue their codeine consumption even if they have no physical ailment.
Among the problems this form of abuse causes is the development of drug tolerance, which is what happens when the body gets used to the level of codeine.
With each dose, the brain’s reward and pleasure systems are rewired to want more and more of the opioids in codeine because no other sensation or experience compares to the burst of euphoria that comes with the codeine intake.
As the reward systems become used to the constant overstimulation over a long period of time, the brain unwittingly starts to anticipate the overstimulation, which manifests as the person taking increasing amounts of codeine to try and satisfy the anticipation. However, the actual effects are no different to the initial consumption of the drug, so users are often compelled to keep taking codeine in ever-futile attempts to re-experience that level of euphoria and disconnectedness from pain. This behavior may continue even after the initial pain for which the codeine was prescribed is no longer an issue, especially in the case of users who have risk factors for substance abuse. For example, a family history of substance abuse or mental health conditions, or environmental or lifestyle circumstances, increases the risk of excessive drug consumption.
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The more the brain anticipates codeine, the harder it is to break the habit of fulfilling that anticipation. Taking more and more codeine seems like a perfectly natural and healthy response to the desire for the medication, even long after the pain symptoms have been addressed and even as other parts of the user’s life suffer as a result of the constant narcotic effects of the substance. One such part is the individual’s health. Despite the euphoric and painkilling effects of codeine, the medication causes side effects that require attention even when the drug is taken according to prescription. If a user enjoys codeine to the point of abusing it, the side effects become more pronounced, and they can be harder to control if the drug intake is not tapered off. They can include:
- Constant itching
- Persistent fatigue
- Difficulty concentrating
- Disrupted sleep patterns
- Problems with memory
- Being continually out of breath
The development of any of these side effects should be reported to a doctor as soon as they are experienced. With users who are becoming physically and psychologically dependent on codeine, however, the chance of stopping the codeine use when problems arise is low, even to the point of more severe side effects, like continually shallow breathing and heart problems, becoming the norm.
Additionally, attempting to stop the codeine intake, or simply going without codeine for a period of time, makes the brain overcorrect. With the opioid receptors deprived of the opioids upon which they have become so accustomed, the disoriented central nervous system sends off a flood of panicked signals, throwing the body and mind into disarray. This process and state is known as withdrawal, and the symptoms manifest in a number of different ways:
- Pain in the muscles and joints
- Nausea, vomiting, or diarrhea
- Unpredictable mood swings
- Cravings for more codeine
For someone attempting to stop taking codeine, or who has to go without their codeine intake, the withdrawal symptoms can be so severe that the temptation to seek relief from the symptoms by taking another drug can be irresistible. The fear of experiencing withdrawal is often enough to keep a person from trying to quit. Since the body’s systems are rendered very weak by the withdrawal effects, going back on codeine or introducing another substance to try and ease the distress can deepen the dependence on the medication and make future attempts at discontinuing it very difficult.
The Withdrawal Process
How long withdrawal lasts depends on a number of different factors, both related to the consumption of the codeine (e.g., how long the abuse has been going on and how much codeine has been taken) and with the user (e.g., age, medical and mental health, environmental and lifestyle factors, etc.). In general terms, the longer the drug use, the more difficult the withdrawal process. Long-term users of codeine can usually expect five consecutive days of withdrawal symptoms, after which the body will be roughly back to where it was before codeine abuse started. Mental health and behavioral symptoms, like anxiety, insomnia and depression, might last for weeks or even months after physical withdrawal has ended. For this reason, people who want to fully quit their codeine problem must participate in counseling and therapy to address the long-term psychological issues that come with opioid dependence.
When a person is withdrawing from codeine, the first of the physical symptoms will make their presence known as the sedative effects of the medication wear off, and the nervous systems are re-stimulated. In the case of a strong opioid like heroin, users usually experience withdrawal in the first 12 hours after the last dose. As codeine is on the milder end of the spectrum, it can take as long as two days from the time of the last dose for the first withdrawal symptoms to appear.
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The First Days of Withdrawal
The first two days of withdrawal are usually the most difficult period of the process, and if individuals do not have medical supervision, the risk for relapsing is highest at this point. Deprived of the numbing effects of the codeine, the person’s muscles, bones and joints are the first to feel pain return.
By the third day of withdrawal, the pain will be mostly gone, but there might still be some physical discomfort: sweating and cold chills, vomiting, loss of appetite, and fatigue, to name a few. Eating solid foods will be almost impossible at this point, but sustenance is vital. If withdrawal is done under medical supervision, doctors can administer nutrients intravenously.
When the sixth day of withdrawal is reached, most people would be over the worst of the symptoms, although care should still be taken. The body is still very weak at this point, and it is imperative that the person gets as much rest as possible. Some residual symptoms of the physical phase of withdrawal might remain, but by this stage, the brain has mostly regained the balance it needs to work without a constant codeine influence.
In cases of severe codeine abuse, the physical withdrawal symptoms can last between two and three weeks, and the emotional and psychological symptoms will need months of time and treatment to be fully addressed. For many people, this latter part of withdrawal is an ongoing process, requiring regular therapy sessions and peer support from other people who have gone through the same experience.
Codeine withdrawal is not a pleasant experience, but it is a necessary one in the process of breaking a dependence on the medication. When conducted properly with medical supervision, the worst of the symptoms can be managed, and the process can be streamlined to minimize the physical and psychological distress of uncoupling from opioid abuse. This clears the path to therapy and healing, giving individuals the tools and strength they need to put codeine misuse behind them.