The good and bad of codeine

By Prof Dzulkifli Abdul Razak

IN view of the current debate on the sales of codeine-based medication, it is useful to review pertinent aspects of the drug.

The alleged widespread abuse of codeine has receive a lot of attention. Learning about the drug will help consumers to decide for themselves the best course of action to curb further abuse.

Codeine is generally classed as a mild narcotic analgesic (or painkiller) similar to but less potent than morphine. One of its use, therefore, is to relieve mild to moderate pain.

It is also an effective cough suppressant, found as an ingredient in many cough syrups and cold remedies. It is more effective for only certain types of coughs, namely those that are considered dry and non-productive. 

Generally it is not used in patients with productive or congestive cough. The drug acts on the brain to produce a therapeutic effect. When taken by mouth (orally) it is relatively more effective than morphine. 

Codeine and other codeine-like (narcotic) drugs have also been used to treat diarrhoea because they can slow down gut movements.

This, in fact, is a side-effect of the drug when used for other purposes. A major side-effect is its addictive or habit-forming tendency, which is now the point of contention in seeking a ban on the product.

Addiction or dependence is more likely to happen when the product is subjected to non-medical use. Indeed, drug addicts often resort to codeine as a substitute to satisfy their cravings.

Reportedly, a mixture of codeine content of nine mg per five ml of syrup is much sought after. For a sensation of being 'high' (hallucinatory feelings), it is said that at least one 60 ml to 100 ml bottle a day is needed. 

Some schoolchildren and factory workers have also been reported to abuse the cough remedy for such a purpose.

When used appropriately over a short period of time and at the recommended dose, addiction can be avoided. The US Food and Drug Administration advisory panel has concluded that under usual conditions therapeutic use of codeine has low-dependency liability.

Taken at the recommended dose, the onset of 'action' occurs within 30 to 60 minutes and lasts for four to six hours.

Signs and symptoms of overdose include slow or irregular breathing (respiratory depression), severe drowsiness (central nervous system depression) or loss of consciousness, and subsequently addiction. 

Dependence on codeine is both physical and psychological in nature. The latter is the emotional craving for the drug. Physical dependence results in physiological changes to the body, without which withdrawal symptoms (namely, severe physical disturbances) and development of tolerance will take place.

Withdrawal symptoms occur when the drug has not been taken over a prolonged period, for example, for more then eight hours. The withdrawal reactions reach a peak in about 48 hours and then gradually lessen, returning to normal in about one to two weeks.

At any time during this period, the reactions may be terminated when the drug is taken again or when antagonist (a drug that counteracts or prevents the action of another drug or endogenous body chemical) to the drug is taken.

Drug tolerance, on the other hand, occurs as the body adapts to the actions of a drug. Individuals can develop tolerance to many drugs and this is very dangerous.

Those who develop tolerance need larger and larger doses to achieve the same effects and therefore tend to increase the dosage. This will only increase the risk of toxic effects and dependence.

A few years ago, the Ministry of Health had decided to tighten regulations pertaining to the sales of codeine. This included a ban on the import and manufacture of cough mixture containing codeine in combination with ephedrine or pseudoephedrine. It also restricted sales packs to larger volumes.

The penalty for illegal sale is a maximum fine of RM5,000 or two years' jail or both. However, the problem still crops up.

Codeine needs greater and more effective control. This includes more judicious sales of the substance to the public by professionals. Otherwise, an outright ban is inevitable.