What Are the Signs of Codeine Abuse?

As America comes to grips with the opioid epidemic, the role of codeine has come under scrutiny. The popular medication found in cough syrups has been a standard remedy for many people, but codeine has been implicated in many cases of opioid diversion. Recognizing the signs of codeine abuse and how they pertain to codeine addiction can help friends and family members intervene on behalf of a loved one before too much time is lost.

What Is Codeine?

Codeine is widely known because of its use in cough syrups and its effectiveness in treating diarrhea. What is less known is that it is an opioid, derived from the same chemical compounds found in legal medications like oxycodone and hydrocodone, and illegal drugs like heroin. For these reasons, many territories and jurisdictions can only sell codeine to consumers if they have a doctor’s prescription. Other areas might not require a prescription, but they will monitor patient purchases to try and deter customers from repeatedly buying codeine to use it recreationally.

Even before the opioid epidemic took hold, codeine was one of the most widely prescribed painkillers in the country, according to Healthline. Its popularity was such that it could be purchased without a prescription, but that changed once the dangers of unregulated opioid distribution became clearer. The Drug Enforcement Administration placed pure codeine in its Schedule II list of controlled substances, the most tightly regulated category for legal drugs. Schedule II recognizes that there are acceptable medical uses for codeine, but the risk of physical and psychological use is so high that sales of codeine have to be restricted to the fullest possible extent. Only Schedule I drugs, substances with absolutely no medical value, are subject to more control.

Codeine also turns up on the DEA’s Schedule III list for products that have less than 90 milligrams of codeine per dosage unit. Schedule III drugs have medical uses and a lower risk of abuse than Schedule II; products with under 90 mg of codeine per dosage unit are (theoretically) not as likely to compel abuse as pure codeine.

How Does Codeine Abuse Start?

There are many people who find themselves unwittingly using more codeine than they should. Codeine is an opioid, and if the medication is taken for a severe cold or diarrhea, the general painkilling and euphoric effects can be very appealing to patients who have chronic pain, who struggle with feelings of depression and anxiety, or who have a risk of substance abuse because of a family history or environmental concerns. There are also people who abuse codeine recreationally; the opioid molecules in codeine bind to opioid receptors in the brain and central nervous system, fully activating them to create sensations of warmth and tranquility. This mechanism is behind the abuse of prescription opioids like OxyContin and Vicodin that has seen thousands of overdoses and fatalities since the 2000s. It also drives users to cheaper substances like heroin, which is also an opioid and works in much the same way – albeit to a much more dangerous and deadly degree.

Who Is At Risk for Codeine Abuse

Regardless of the reasons behind abuse of codeine, there are always signs and symptoms that indicate whether a person is using codeine per a doctor’s orders or if the use is veering into risky territory. Some of the signs are based on behavior while others demonstrate specific changes that the increasing opioid consumption is causing in the brain and central nervous system.

Behavioral changes as a result of codeine abuse can simply be buying more codeine than is necessary even after the initial malaise has been treated. In areas where a prescription is required for codeine purchases, some people fake symptoms or visit multiple doctors in order to get scripts they can present to pharmacists. Many people today use the Internet (especially social media) to illegally buy stolen or diverted codeine supplies from other consumers.

A person who refuses to stop codeine intake or hides continuing codeine consumption is displaying a sign of abuse.

Those who start spending increasing amounts of money getting codeine through questionable or outright illegal methods are also demonstrating behaviors that suggest the use of codeine is no longer purely medicinal.

As the opioid receptors in the brain and central nervous system are repeatedly activated by the opioid molecules in the codeine, it becomes more difficult for the brain to produce its own opioids, which would have similar (if less powerful) painkilling and tranquilizing effects. This reaches the point where the codeine becomes intrinsically linked to those feelings, eventually becoming the only way that people can feel free of pain or even simply relaxed and happy. Depriving people of codeine leads to the perception of pain returning even if there is no actual pain stimulus; this compels people to not only continue their codeine consumption but even increase it. Ultimately, this reaches the point where the only time the person feels any sense of normalcy is when they take codeine. Behavior like this is on the more serious end of codeine abuse, but it is a definite sign that the consumption of codeine has become a problem.

Tolerance and Withdrawal

Another sign of codeine abuse is when standard amounts of the medication no longer have the desired effect. When too much codeine is taken over a period of time, the brain adapts to the constant bombardment of the opioid molecules in the drug. This means that the opioid receptors in the brain and central nervous system will gradually stop responding to the amount of the medication that the person started with. This process is known as drug tolerance, and it is a clear indication that the codeine consumption is beyond normal parameters. Patients who are experiencing drug tolerance will want more codeine, and take more codeine, to try and recapture the same feelings of euphoria and freedom from pain that they first felt. However, since the threshold for opioid activation increases exponentially, it becomes all but impossible to reach that sweet spot again, so people respond by taking even more codeine. The cycle repeats itself, but with the added risk of increasing the psychological dependence on codeine for pain relief and calmness even though those goals keep getting further and further away.

Opioids are prescribed in such a way that when they are no longer needed, their use is tapered down, so patients get used to the feeling of being on less and less of the medication until it is gone entirely. This is the recommended way of stopping opioid use of any kind. For a person who is abusing opioids like codeine, gradually winding down intake is not always easy. Many people try to quit cold turkey, or some simply run out of their prescription or otherwise lose access to codeine. However, the brain does not respond well to the sudden starvation of opioids, especially after it has become so dependent on the opioid molecules for even basic functioning.

Abruptly stopping codeine intake can cause severe and distressing withdrawal symptoms, which is another sign that the codeine abuse has become a problem in and of itself. There might be some normal discomfort associated with proper stoppage of prescribed codeine intake, but withdrawal symptoms are serious medical symptoms of opioid abuse. They are not life-threatening on their own, but they can cause other medical problems, and they often compel users to go back to codeine (in the event of voluntary attempted discontinuation), or seek out other drugs (in the event of involuntary attempted discontinuation).

Signs of Codeine Withdrawal

Additionally, many users are aware of how uncomfortable it is to go through codeine withdrawal. As a result, they opt to continue their abuse of codeine, even if they are aware of the consequences, because it is preferable to the process of readjusting to the lack of opioid molecules after an extended period of abuse.

Signs of codeine withdrawal can include:

  • Feelings of anxiety
  • Flulike symptoms
  • Insomnia
  • Deep pain in the muscles and bones
  • Vomiting and diarrhea
  • An intense craving for codeine or a similar opioid

Signs of codeine withdrawal usually set in a few hours after the last use of codeine. They spike 72 hours into the process and gradually subside over the next three or four days. However, some people go through a longer withdrawal process if their codeine abuse was severe or they have other health conditions.

Regardless of how long it takes to go through withdrawal, a person who has bad physical reactions to going without codeine, or who outright refuses to stop taking codeine out of fear of what will happen, is most likely abusing the drug.

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Breathing Problems

As an opioid, codeine will put its users into an intensely relaxed and drowsy state. This effect may be therapeutically necessary for those who struggle with chronic pain or certain other conditions, but a person who displays these signs to intrusive or disruptive extents might be abusing their codeine prescription or could be reacting negatively to the drug. People who frequently nod off, who are perpetually fatigued, or who do not have the energy to be interested in relationships and activities are displaying signs of troublesome codeine intake.

Breathing and Opioids

Furthermore, codeine’s opioid effects can influence breathing. The full and repeated activation of opioid receptors interferes with the body’s respiratory system to the point where continued exposure to opioids can reduce the breathing rate to such levels that it becomes a physical struggle to simply draw breath. However, since opioids relax people to such a strong degree, they may not have the strength to fight for their breaths, putting them in serious danger of respiratory depression, where their vital organs (especially the brain and heart) do not get the required oxygenated blood to function. A person who is taking codeine normally should not have to struggle to breathe; persistently shallow breaths is a sign that the codeine intake is causing serious problems.

The danger of opioid-induced respiratory depression opens the door to the possibility of codeine overdose. If a person cannot get enough oxygen but is too heavily sedated to make the effort to draw breath, then there is a legitimate danger of the body and brain effectively shutting down as the result of oxygen deprivation. An overdose is an obvious sign of codeine use going on for too long, but recognizing the other signs of codeine use should alert friends and family members that a loved one’s use of the medication has reached a critical point.

About The Contributor

Editorial Staff
Editorial Staff

Editorial Staff, American Addiction Centers

The editorial staff of Desert Hope Treatment Center is comprised of addiction content experts from American Addiction Centers. Our editors and medical reviewers have over a decade of cumulative experience in medical content editing and have... Read More

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