A rapid influx is seen in the cases of abuse and addiction, related to opioids in the UK. The spike in this trend is upsetting as the number of deaths related to opioids such as codeine doubled in 2020 as compared to the last ten years. In 2020, 222 deaths were reported related to codeine which is a stark rise compared to 91 deaths reported a decade ago. 

This sudden increase can be attributed to the fact that opioid prescriptions have increased by many folds in the UK. According to BBC News investigation, general practitioners (GPs) in England prescribed nearly 24 million opioid-based painkillers in 2017, which is equivalent to 2,700 items prescribed every hour. Along with the prescription for opioids, the number of addicts has also risen, hinting that there is a certain linkage between the increase in opioid prescription and the number of opioid addicts and related deaths.

Owing to the addictive property of opioids with the potential for dependency and overdose, opioids including codeine are available as prescription medications only since their sales are strictly regulated by the authorities in the UK. However, opioids such as codeine when formulated with analgesics such as ibuprofen and paracetamol are available as over-the-counter medications for mild to moderate pain relief. These over-the-counter medications and the sale of codeine and other opioids sourced through the black web have been the reason for the alarming rise in the cases of opioid addiction and abuse. 

Co-codamol is a similar analgesic that has codeine and paracetamol combined. It is available both as an over-the-counter and as a prescription medication. Initially, co-codamol was regarded as medicine with minimal potential for addiction but as the trend of misuse of co-codamol is on the rise the opinion has changed making co-codamol one of the drugs with significant addiction potential if not used as per physician’s recommendation. The addiction potential of co-codamol is exacerbated if it is used concomitantly with other CNS depressants including sedatives and alcohol among others resulting in a heightened risk of overdose and death.

Co-codamol is an analgesic medication that is a combination of two drugs namely paracetamol (acetaminophen) and codeine phosphate (an opioid). 

Paracetamol also known as acetaminophen is a non-narcotic analgesic and antipyretic. Antipyretics are medications used to treat fever by acting on part of the brain that regulates the body’s temperature. Paracetamol is used as an alternate for NSAIDs in patients with gastric complaints or risks and in those who do not require the anti-inflammatory action of NSAIDs.

Codeine is a naturally occurring opioid. It is a weak analgesic as compared to morphine and is used to treat mild to moderate pain. The codeine component in co-codamol is responsible for the worrisome trend of addiction, related to this medicine.

What is co-codamol used to treat?

Co-codamol is used for the short-term treatment of non-malignant pain when other pain medications have not proved to be effective. Co-codamol is used in the following condition:

  • headache
  • toothache
  • muscular pain
  • migraine 

Co-codamol is a combination of two drugs that work through their separate mechanism of action.

Paracetamol in co-codamol acts by inhibiting the synthesis of certain chemicals in the body, known as prostaglandins that are responsible for the sensation of pain. By inhibiting prostaglandin formation, paracetamol blocks the pain sensation thus resulting in pain relief.

Codeine is an opioid that acts on the opioid receptors, present throughout the body including the central nervous system, gastrointestinal tract, and urinary bladder. Codeine is transformed to morphine and acts by inhibiting the transfer of pain signals and further interferes with the dopamine neurotransmitter. It increases dopamine levels by inhibiting its reabsorption thus interfering with the brain’s reward system and creating a feeling of euphoria and generalized well-being. This mild euphoric effect is the reason that co-codamol is often misused as a drug of recreation to achieve a high.

Co-codamol strengths in the UK

Co-codamol comes in the form of tablets and capsules in three different strengths. 

The tablets or capsules contain 8mg, 15mg, and 30mg of codeine. 

However, the paracetamol is 500mg in all the preparations, similar to the standard dose of paracetamol.

Moreover, the packaging contains two numbers depicting the strength of both the drugs such as 8/500 refers to 8mg of codeine and 500mg of paracetamol. Whereas, 15/50 and 30/500 mean 15mg and 30mg of codeine in 500mg of paracetamol each. 

The lowest strength (8/500) is available as an over-the-counter pain medication, while the higher strengths (15/500 and 30/500) are available only on prescription by a general practitioner (GP).

Dosage

1-2 tablets of any strength of co-codamol can be taken four times a day for individuals 16 and older years of age. You must take a 6-hour gap in between the two doses. Moreover, the maximum dose of co-codamol is 8 tablets/capsules in a day.

If you have taken co-codamol from a pharmacy, do not use it for more than 3 days since dependence on co-codamol can develop in 3 to 5 days of continuous use.

If your doctor has advised you co-codamol then should follow the dosage prescribed to you by your doctor and should not double the dose or take it longer than prescribed as it has the potential for abuse due to codeine. In addition, too much paracetamol can damage your liver.

Moreover, these tablets are orally administered and should not be chewed or crushed.

Like every other medicine, certain side effects are associated with co-codamol use. They are as follows:

  • drowsiness
  • constipation
  • nausea
  • vomiting
  • headache
  • confusion
  • abdominal pain
  • dependency and addiction

The most dangerous side effect is the development of dependency and addiction owing to the opioid component, codeine in co-codamol, and therefore, you should strictly monitor your drug dose throughout the day and the doses of your loved ones to prevent taking co-codamol in excess. 

Some serious and less common side effects of co-codamol include:

  • change in eyesight
  • dizziness
  • difficulty in urination

Some people may face an allergic reaction to the drug which presents as itchy, red blisters on the skin accompanied with tightening of the chest and this condition needs to be treated immediately in the hospital.

Long-term use of the drug can lead to liver damage, seizures, and kidney damage. High doses can also cause respiratory depression that can lead to coma and death.

Co-codamol has significant addiction potential. For this reason, it should be the last medication advised after all other medications have failed to relieve pain. It is assumed that the high-dose, prescription-only co-codamol has the potential for causing addiction and that on-the-counter available, a lower dose of co-codamol is safer which is a misconception at the consumer end. Codeine when combined with other central nervous system depressants such as sedatives and tranquilizers along with alcohol results in deleterious consequences even if taken in the lowest dose.

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Taking co-codamol for 3 to 5 days regularly can result in withdrawal symptoms when medication is stopped. Hence, it proves that a very short duration of time is required to develop a dependence on the drug. Moreover, if you take higher doses of the drug for a longer duration even after the pain has subsided, chances are that you will experience severe withdrawal symptoms. 

Ian Hamilton, a senior lecturer in addiction and mental health at the University of York explains the addiction associated with codeine. According to him, the rise in deaths due to codeine along with other drugs is a result of combining multiple drugs either to achieve a particular effect or to counter the effect of one drug by taking the other. This results in harmful drug interactions and detrimental consequences.

When an individual has prescribed an analgesic with an opioid component, along with the pain-relieving effect, the individual experience a mild euphoric effect which leads to the persistent use of the drug. It is seen that when teenagers and adults are prescribed the medication for headache or other mild pain, they enjoy the mild euphoric opioid effect and are drawn back to the drug at the time of stress or simply for recreational purposes. This leads to the development of tolerance and dependence on the drug and a greater quantity of co-codamol is consumed which increases the risk of overdose.

According to Dr. Paul McLaren, medical director at the Priory’s Hayes Grove Hospital, over-the-counter containing opioids can be the gateway drugs for the stronger prescription opioid painkillers and heroin. This explains the hazards for the future if addiction to co-codamol and other over-the-counter opioids is not controlled.

Co-codamol abuse refers to the use of a drug other than the purpose for which it was indicated or prescribed. Co-codamol when used in excess for a prolonged period can result in addiction and abuse. 

People often use it for recreational reasons and to get high. To achieve this state of pleasure, people use various means. Some of them are as follow:

  • Mixing co-codamol with alcohol, sedatives, and other CNS depressants
  • Crushing and snorting the tablets and also preparing a liquid form of co-codamol and injecting it into their vein for an exaggerated effect
  • Taking a higher dose of co-codamol that was not prescribed 
  • Buying co-codamol from various other means such as the dark web
  • Going for pharmacy shopping that is buying the drug from different places so as not to arouse suspicion

As with abuse of other drugs, the symptoms of co-codamol abuse are not very different. There are a certain set of findings that can be referred to as ‘red flags for the identification of a case of addiction. In co-codamol abuse following symptoms may be present:

  • Taking larger doses of co-codamol and more frequently
  • Taking co-codamol long after the pain has subsided
  • Hiding medicine from friends and family due to the fear of being caught
  • Going to different pharmacies to get medicine supplies
  • Manipulating doctors to get co-codamol prescription
  • Obtaining co-codamol through illicit means such as the black web
  • Experiencing withdrawal symptoms when you stop taking co-codamol

The risk associated with Co-codamol abuse 

Co-codamol abuse is associated with multiple risks and hence misusing the drug should be avoided. 

  • Respiratory depression can lead to coma and death
  • Co-codamol overdose
  • Developing dependence on co-codamol
  • Developing addiction on co-codamol
  • Indulging in risk-taking behaviour under the high caused by co-codamol
  • Suffering from paracetamol hepatotoxicity
  • Coma

Since co-codamol addiction affects the physical and psychological state of the person, there will be a myriad of negative effects as a consequence of co-codamol addiction.

Some of the physical side effects are as follows:

  • slurred speech
  • drowsiness
  • pinpoint pupils
  • loss of appetite
  • shallow breathing
  • staggering gait 
  • loss of balance
  • experiencing withdrawal symptoms

Behavioural and psychological symptoms are as follows:

  • anxiety
  • depression
  • loss of interest in activities that earlier used to excite them
  • isolating themselves
  • hiding their tablets 
  • unexplained mood swings
  • agitated
  • impaired thinking and judgment 
  • becoming withdrawn from their responsibilities
  • failing academically and/or financially
  • declining personal hygiene or grooming
  • experiencing insomnia and having nightmares
  • preoccupied with thoughts of arranging the drug

People who are addicted to co-codamol are trapped in a vicious cycle of arranging the drug, using it, experiencing withdrawal effects once the drug wears off, and then arranging the drug again. These people often neglect the relations associated with them and find it hard to pursue life normally. 

There are detox programs and rehabilitation centers that help people to come off the drug and mitigate their withdrawal effects.

The exact dose for co-codamol overdose is not known since the drug interaction varies in every individual. Since co-codamol contains paracetamol, it should not be used with other medications containing paracetamol to prevent paracetamol overdose. Liver damage is bound to happen in people who take more than 10g of paracetamol. Moreover, codeine should not be used with other opiates, sedatives, and alcohol to minimize the risk of overdose.

Effects of co-codamol overdose

As co-codamol is a combination of paracetamol and codeine, the effects of overdose are attributed to both the drugs individually.

In the first 24 hours of paracetamol overdose symptoms such as sweating, pallor, anorexia, abdominal pain and vomiting appear. 

12 to 48 hours after taking the drug, liver damage becomes apparent. It is manifested as abnormalities in glucose metabolism resulting in hypoglycemia. In severe cases of paracetamol poisoning, liver failure progresses to hepatic encephalopathy which means that liver damage has affected the brain and consequently results in hemorrhage, hypotension, cerebral edema (swelling in brain tissue), coma, and death. Bleeding time may increase as the liver damage progresses.

Acute tubular necrosis (damage to kidney tubules) occurs as a result of overdosing paracetamol which results in renal failure and the person experiences loin pain and has blood and protein in the urine. This condition may present even in the absence of liver damage.

Cardiac arrhythmias (disturbance in the rhythm of the heart) are also reported with paracetamol overdose.

Codeine overdose, on the contrary, is associated with the central nervous system depression that results in respiratory depression, extreme sedation that progresses to coma, along with weakness of the skeletal muscle with cold and clammy skin.

Respiratory depression is present in codeine overdose but its severity is unlikely unless associated with concomitant use of alcohol and medicines such as benzodiazepines or related drugs that increase the risk of drowsiness, difficulty in breathing, coma, and then an overdose may be life-threatening. Another condition is when an overdose of co-codamol is very large.  The findings of coma, pinpoint pupil and respiratory depression is a triad associated with opioid overdosage. However, dilation of the pupil is noticed as soon as hypoxia (lack of oxygen) develops. 

Other codeine (opioid) overdose symptoms include hypothermia, convulsions, confusion, extreme dizziness, drowsiness, hypotension and tachycardia, nervousness, excitement, hallucination, bradycardia, hypotension, and shallow breathing. 

In severe overdose with codeine, circulatory collapse, cardiac arrest and death may occur.

You should know about the sign and symptoms of overdose so that if unfortunately, such a situation develops you can recognize it and help your loved ones and your family member should be aware of these signs too so that prompt action can be taken as immediate hospital admission is vital to save a life.

If a person attempts to stops taking co-codamol they experience an abundance of withdrawal symptoms. Since their body has developed a dependency on the drug, it is hard for the body to function without it. The dopamine levels in the brain decrease interrupting the brain’s reward system negatively and thus producing altered events that one has to cope with after withdrawing from the drug. The brain tries to adapt to working without the drug and hence, a series of symptoms ensue that include both physical and psychological symptoms. During this phase, seeking professional help stays the cornerstone of withdrawal treatment. 

Withdrawal symptoms of Co-codamol

 Addiction to co-codamol results in withdrawal symptoms as soon as you stop taking this medication. Codeine in co-codamol can lead to uncomfortable withdrawal episodes and at times it can be quite painful. 

Following symptoms manifest in co-codamol withdrawal:

  • diarrhea
  • restlessness
  • loss of appetite
  • shaking
  • sweating 
  • shivering
  • nausea
  • vomiting
  • difficulty sleeping
  • palpitations 
  • increased blood pressure
  • agitation
  • confusion 
  • anxiety
  • watery eyes
  • cravings for co-codamol

The physical findings of co-codamol withdrawal may last for 7 days but the psychological effects can persist for months. 

It is advised that you should not abruptly stop co-codamol since it leads to severe episodes of withdrawal that are hard to cope with. You should consult your doctor, who will advise you to gradually taper the dose before stopping completely.

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