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Codeine is an Opiate: Get the Facts

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Opiates are among the most powerful medications that doctors can prescribe for chronic pain, and no medications work quite as well for curing a persistent cough than cough syrup. Codeine is the most widely-used opiate in the world, according to the World Health Organization.

Codeine cough syrups and painkillers that contain the drug are found in the medicine cabinets of millions of people in the United States – but just because codeine has a reputation for being the safest of all opiate painkillers, do not assume that it is always safe.

There are many people who become physically dependent or addicted to codeine after repeatedly using it. Codeine can also cause symptoms of withdrawal if it is suddenly discontinued. The problem is that codeine is a depressant. It slows down the central nervous system in the brain which can slow down breathing and cause death.

The other problem is that some people metabolize codeine into morphine very fast which dramatically increases their risk of side effects. There is no easy way to know if you are an “ultra-rapid metabolizer” of codeine until you try it – and because the risk of breathing problems and death is so serious, the FDA says codeine should never be used by children under 12 or by breastfeeding women.

What is an Opiate?

Opiates are also called narcotics. They are prescribed by doctors for the treatment of moderate to severe pain, coughing, and diarrhea. Codeine is less powerful than other opiates, like heroin or morphine, but it can still lead to dependence and addiction if it is taken too long.

What is Codeine Used For?

Codeine is available in a pill that is taken orally for the treatment of pain, but it is most commonly used in cough syrup. It is an antitussive, which means it works in the brain to stop the urge to cough. Almost all prescription cough syrups in the U.S. contain codeine. It is a popular treatment for lung diseases like sinusitis, bronchitis, or persistent allergies. And, because codeine can also reduce nausea and diarrhea, cough syrup is also a popular remedy for the flu and the common cold.

Is Codeine a Good Treatment for Coughing?

Codeine is widely regarded as the “gold standard” cough-suppressant medication. Cough syrup with codeine is one of the most effective treatments for persistent coughing with few alternatives that work as well. Cough syrup also contains a drug called promethazine, which acts as a sedative. Most codeine cough syrups are only available with a prescription in the U.S. due to the risk of side effects and the potential for abuse and addiction. Codeine stops coughing, but it also slows down the respiratory system, which slows down breathing. Too much codeine can completely stop breathing and cause death.

Where Does Codeine Come From?

Opiates are derived from the opium poppy, Papaver soniferum, a plant that has been cultivated for its medicinal uses for thousands of years. The milky fluid that seeps from razor cuts in an unripe poppy seed pod is scraped off and air-dried to make opium. Opium looks like black or brown tar and it is commonly smoked for pleasurable effects. Further chemical processing is necessary to make opiates like codeine and morphine.

Is Codeine a Natural Opiate?

Codeine is found in very small amounts (1-3%) in a poppy plant. It would take a massive amount of poppies to make a small quantity of codeine, so pharmaceutical companies usually make codeine by changing the chemical structure of morphine to produce purified codeine for use as a general painkiller. Codeine is an all-natural opiate. In comparison, the term “opioid” is used to refer to non-natural synthetics. For example, fentanyl is an opioid that is made entirely in a laboratory rather than extracted from a plant.

Why is Codeine So Addictive?

Over time, a person who uses codeine will develop a tolerance for the drug. That means they need more codeine to get the same effects that they used to get from a lower dose. If they do not take a higher dose, they will experience unpleasant withdrawal symptoms and intense cravings for more. This can quickly spiral out of control and lead to an addiction to codeine.

How Does Codeine Work?

To understand why codeine is so addictive, it’s important to know how it works. The brain naturally makes its own opiate-like chemicals called endorphins. They reward people with feelings of pleasure for doing activities that promote basic life functions, such as eating and sex.

Codeine binds to the same receptors in the brain as endorphins, but codeine produces far more powerful effects. When a person uses codeine continuously, the brain stops making its own endorphins and starts depending on codeine alone. Not only is this a dramatic change in brain chemistry, it also changes the brain itself. Opioid receptors in the brain are damaged from being continuously activated by codeine.

What Happens When a Person Stops Taking Codeine?

If a person in this situation were to suddenly stop taking codeine, he or she would experience withdrawal. Most people will experience mild withdrawal symptoms after continuously taking codeine for 3-10 days. Longer use will result in a more severe withdrawal if it is discontinued. The symptoms of withdrawal can become so severe that a person who has been using codeine for a long time will not be able to stop.

One way to think of it is to imagine that opiates borrow happiness from tomorrow. The more you borrow, the longer you pay for what’s due. Fortunately, severe withdrawal symptoms can usually be avoided by gradually tapering off codeine under a doctor’s supervision, rather than suddenly stopping it. This allows the body to slowly adjust to less and less codeine until it no longer needs codeine to function properly. A doctor might also prescribe drugs that make withdrawal less intense.

What are the Symptoms of Withdrawal?

Many of the symptoms of codeine withdrawal are the opposite of what a person would experience while they are taking codeine. For example, codeine can cause sleepiness and withdrawal can cause insomnia. The early symptoms of codeine withdrawal include:

  • Irritability
  • Trouble sleeping
  • Runny nose
  • Teary eyes
  • Sweating
  • Shivering
  • Yawning
  • Muscle aches
  • Elevated heartbeat

The symptoms can progress to become far more severe in a person who has been taking codeine continuously for several weeks or months. Later, symptoms of withdrawal from codeine also include:

  • Loss of appetite
  • Nausea
  • Vomiting
  • Stomach aches
  • Diarrhea
  • Dilated pupils
  • Chills
  • Goose-bumps
  • Feeling restless

How Long Does Codeine Withdrawal Last?

The symptoms of codeine withdrawal are the worst in the first few days after abruptly discontinuing use. How long withdrawal lasts depends on how long a person was taking codeine, and how much. Most symptoms are gone within 2 weeks, but some people still have symptoms and cravings for codeine after many months or even years. The experience of codeine withdrawal is different for everyone.

Does Codeine Work the Same in Everyone?

Codeine is a “prodrug,” which means it does not work on its own. It must be converted into morphine by a liver enzyme called CYP2D6. About 10% of a dose of codeine is converted into morphine by the liver, but some people convert it to morphine faster than others – and in people who lack the CYP2D6 enzyme, codeine barely works at all.

The reason why there is a lot of individual variability in the effectiveness of codeine all depends on genetics. Codeine does not work very well in up to 30% of people because they were born with two nonfunctional copies of the CYP2D6 gene. Their genetics makes them bad at converting codeine into morphine, so they experience less painkilling or euphoric effects.

On the other hand, some people naturally convert codeine into morphine very fast and completely. These “ultra-rapid metabolizers” have two active copies of the CYP2D6 gene. They experience far more painkilling and euphoric effects from codeine than a “poor metabolizer” would experience from the same dose. They are also more likely to suffer side effects or addiction to codeine.

The approximate number of CYP2D6 ultra-rapid metabolizers is about 1-10% of white European / North Americans, 3-4% of black African Americans, 1-2% of East Asians (Chinese, Japanese, Korean), and estimated to be less than 10% of Oceanian, Northern African, Middle Eastern, Ashkenazi Jews, and Puerto Rican populations.

Is Codeine Safe for Children?

Children younger than 12 years old should not take codeine due to the risk of slowed or difficult breathing and death, according to a U.S. Food and Drug Administration (FDA) warning in April 2017. The FDA also warned against using codeine in teenagers under 18 years old who are obese, or have severe lung disease or sleep apnea, because these conditions may increase the risk for fatal breathing problems.

Is Codeine Dangerous?

Codeine is considered to be the safest opiate painkiller because it is so much weaker than morphine. Furthermore, because codeine is such a fast and effective treatment for diarrhea and coughing, many people keep a bottle of codeine cough syrup in their medicine cabinet.

All medications have safety risks that you should discuss with a doctor.  It is one of the most effective treatments for people who are suffering from pain or an unstoppable cough. This drug can be perfectly safe when used appropriately, but Codeine can also have severe side effects.

The important thing to remember is that codeine has the same side effects of morphine, and it can be just as dangerous – especially in children and people who metabolize codeine very quickly. The only difference is that it might take a little longer to get addicted to codeine.

What are the Dangers of Using Codeine Recreationally?

Codeine is abused by some people as a recreational drug to get a “buzz” or high. One of the most common recreational concoctions is a sweet-flavored drink that mixes codeine-based cough syrup with soda and candy, sometimes called “Purple Drank” or “Sizzurp.” Recreational users describe a warm feeling of happiness and pleasant apathy, like a “baby heroin.”

Unfortunately, overdoses of codeine cough syrup are just as dangerous as an overdose of heroin – breathing failure and death can occur. Another danger is that some types of cough syrup with codeine also contain Tylenol (acetaminophen), which can cause liver damage or death if taken in excessive amounts.

Can I Take Codeine While Breastfeeding?

Breastfeeding is not recommended for women who are taking codeine due to the risk of serious side effects in breastfed infants. Codeine passes into breast milk and it can cause an infant to develop symptoms of an opioid overdose. These symptoms include increased sleepiness, difficulty breastfeeding, limpness in the baby, and serious breathing problems that may result in death. If a baby shows these symptoms, the baby’s doctor must be called right away. If the doctor cannot be reached right away, the baby should be taken to a hospital.

What are the Long-Term Effects of Codeine?

The long-term side effects of codeine include sexual dysfunction, chronic constipation, seizures, tremors, shakes, agitation, confusion, stomach ulcers, nausea, liver damage, and more. These effects can take months to reverse, resulting in a very unpleasant recovery time. Unfortunately, some people experience irreversible long-term side effects, meaning they have done permanent damage to the body.

Codeine is more likely to cause permanent long-term side effects in people who have abused the drug for years or become addicted. It is very rare for people who have used codeine appropriately to experience any side effects that last more than a few days or weeks.

Another problem is the risk of long-term psychological side effects. After the physical withdrawal symptoms go away, a person who has been taking codeine for a long time may still experience psychological symptoms like intense cravings for codeine or abnormal behavior patterns.

Codeine addiction can also worsen the symptoms of underlying mental illnesses in some people, such as depression. These side effects can potentially lead to long-term health problems. When taking codeine, make sure to consult a doctor about the proper dosage and length of treatment. If you or a loved one is addicted to cocaine, Luminance Recovery can help. Our Orange County rehab has helped many people break free from the chains of a painkiller addiction. Call us today for more information.

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