Codeine represents an interesting quandary. Its effects vary from one individual to the next; when self-medicating, patients have very different estimates of what is safe; the potential for misuse, dependence and related harm are well known; and national regulatory responses vary.

Codeine is a weak opiate, used for management of mild to moderate pain. It is often prescribed for coughs and can be bought without a prescription in many countries. What many people don’t realise is that with consecutive and/or excessive use, tolerance occurs over time, and the user can experience withdrawal symptoms when the drug is stopped. This, especially when pain is present, increases the risk of habit-forming use and the potential for dependence, explains the principal investigator within the CODEMISUSED project, Marie Claire Van Hout of Ireland’s Waterford Institute of Technology.

Misuse includes:

• self-medicating at higher doses or for longer than advised;
• use other than the instructions on the label or the intended use;
• recreational use for mind-altering effects;
• situations where risks and adverse consequences outweigh the benefits.

As a mild opiate, prolonged use of codeine in combination products containing paracetamol and ibuprofen can cause health problems, including neurological damage, gastric ulcers, pancreatitis and gastrointestinal bleeding.

The project is tackling the problem from every angle. A scoping review has created a knowledge base of all existing research. The team will study online purchase trends and national reports on prescribing and treatment trends, monitor drug fora, collect survey responses from customers, medical, pharmacist and addiction treatment providers, and interview individuals in treatment.

The results will feed into innovations including pharmacy-based screening and intervention initiatives and the provision of health and product information during the customer-pharmacist transaction.

Learning from South Africa

South Africa has already recognised the problems associated with codeine, and is ahead of Europe in responding. Pharmacies are now connected to a central database that registers each purchase of medicine containing codeine. Each customer must provide their ID number. Problem users cannot therefore move from one pharmacy to the next to secure a supply. A maximum of 4g can be bought each month.

South Africa also has smartphone app that helps a user establish whether he or she is likely to have a codeine problem through a series of questions.

The system is only in its infancy, emphasises Van Hout, but the model could be of interest in Europe – especially as the same approach could be applied to other drugs susceptible to misuse, such as anti-histamines and laxatives.

Treating the ‘respectable’ addiction

The project will recommend risk management and customer monitoring systems, as well as appropriate training and protocols for community pharmacy intervention. “We want to empower pharmacies as custodians of codeine medicines,” says Van Hout.

At the moment, when a pharmacist suspects a problem, he or she has nowhere to refer a customer. Those caught up in this ‘respectable form of addiction’ are not typical drug addicts and don’t fit into standard drug programmes.

And once a problem is identified, codeine abusers don’t want to queue up for methadone – an effective treatment – like a heroin addict. An alternative approach could be tapered prescriptions that gradually reduce the amount of codeine provided. This would integrate primary care and community pharmacies.

A first step is however patient awareness. “People need to know that codeine is addictive,” says Van Hout.

One result of which the project team is already proud is the acceptance of CODEMISUSED as a European Network of Centres for Pharmacoepidemiology and Pharmacovigilance project on the European Medicines Agency register. This will not only give visibility to the project, but open a discussion within the pharmacovigilance sector – the results of which will feed back into the project’s eventual guidelines.

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