Table of Contents
Codeine Addiction, Abuse, and Symptoms

TABLE OF CONTENTS

I. The Basics

Primary Codeine Dangers

Codeine is typically used to relieve pain. It also has off-label use as a treatment for coughing caused by bronchitis or acute upper respiratory tract infections. The codeine found in cough medicines and pain relievers is converted to morphine, a substance that changes the way the body responds to pain signals.

In non-medical users, codeine makes it easier to relax. It may also produce a sense of euphoria or overall well-being. Some non-medical users take codeine to enhance the effects of substances such as alcohol and heroin. In some cases, a non-medical user takes codeine to cope with unpleasant emotions or high levels of stress.

Long-term use of codeine has been linked to sudden mood swings and symptoms of depression. Additionally, long-term users have an increased risk of codeine dependence, which increases the risk of overdose.

  • Addictiveness: Nutt et al. conducted a study to determine the addictive potential of several types of drugs. They assessed each substance based on the potential for physical harm, social harm, and dependence. Although Nutt et al. did not test codeine, they did test heroin, another opioid. Based on its potential for dependence, heroin scored a 3/3, giving it the highest addictive potential of any of the substances studied. In comparison, cocaine scored 2.39/3, cannabis scored 1.51/3, and ecstasy scored 1.13/3.
  • Risk of overdose: Even though codeine is a prescription medication, it can cause dangerous side effects. Long-term use is also associated with an increased risk of overdose. According to the Centers for Disease Control and Prevention (CDC), opioids were involved in 47,600 overdose deaths in 2017, representing nearly 70% of all deaths attributed to drug overdoses.
  • Unintended side effects: Codeine can cause undesirable side effects, even when it is used according to the instructions on the prescription label. These side effects include difficulty breathing, confusion, fainting, irregular heartbeat, and a racing heartbeat. Codeine can even cause an individual to experience chest pain, develop a decreased level of awareness, or stop breathing.
  • Legal risks: Products containing codeine are classified as Schedule II or Schedule III drugs depending on the amount of codeine they have. A product with no more than 90 milligrams of codeine per dose of medication is considered a Schedule III drug, while a product with more than 90 milligrams of codeine per dose is classified as a Schedule II drug. Possessing codeine without a valid prescription is usually charged as a misdemeanor, provided it is a first-time offense. Conviction typically results in a fine and up to one year in jail.
Codeine Background Information
Derived FromCan be synthesized organically from poppy plants; typically synthesized from morphine for pharmaceutical applications
Ways UsedIngested, crushed and snorted, rectal administration via suppository
Scientific Name3-methylmorphine
Slang/Street Names for CodeineCody, school boy, Captain Cody, Little C; purple drank, Texas tea, or sizzurp (codeine syrup mixed with juice or soda); T1, T2, T3, T4 (codeine with acetaminophen)
How Long in Bodily SystemHalf-life: 9-11 hours

Typically takes four days to eliminate from the body; takes as much as a week in long-term users

Punitive Legal Measures: Using/PossessionCodeine-based products are classified as Schedule II or Schedule III substances depending on how much codeine they contain. Because codeine is a controlled substance, it is illegal to possess it without a prescription from a licensed medical professional. Laws vary by state, but first-time possession of this substance without a valid prescription is typically charged as a misdemeanor. The penalties also vary by state, but the typical punishment is a fine and up to one year in jail. Subsequent offenses may lead to increased penalties.
Punitive Legal Measures: Selling/DistributingSelling or distributing codeine is usually charged as a felony, which means the legal consequences are much more severe than the ones applied for a possession conviction. An individual convicted of selling or distributing codeine could be sentenced to more than 10 years in prison and significant monetary penalties. Selling codeine and other drugs near public facilities, such as schools and government buildings, can result in higher fines or additional prison time.
DEA Drug RatingSchedule II or Schedule III depending on the amount of codeine in the product

II. Signs of Abuse

Behavioral Symptoms of Codeine Use and Abuse

How codeine affects the brain

Codeine attaches to cell receptors in the brain, changing the way the nervous system perceives pain. When codeine attaches to cell receptors, the central nervous system (CNS) also slows down. It is this slowing of the CNS that produces a calming effect. Cao et al. conducted a study to determine how codeine affects the brain’s metabolism and overall function. Healthy volunteers took one dose of codeine phosphate before undergoing functional magnetic resonance imaging (fMRI). fMRI technology lets researchers visualize what is happening inside the brain.

The scans showed that changes in brain activity occurred within one hour of taking the codeine phosphate. While the amount of choline in the frontal lobes increased, the amount of inositol in the left frontal lobe declined significantly. Choline helps transport lipids, which is important for normal brain function. Inositol is a type of sugar involved in the transmission of cell signals. Cao et al. concluded that the decrease in inositol contributes to some of the side effects that occur when an individual takes codeine.

Behavioral signs of codeine use and abuse

Due to its effects on the brain, codeine can cause significant behavioral changes in long-term users. Continued use of codeine can even cause an opioid misuse disorder to occur, putting the user at risk for serious side effects. According to the 2016 National Survey on Drug Use and Health, approximately 2.1 million people aged 12 and older — or 0.8% of this population — developed an opioid misuse disorder.

Substance misuse disorders have several characteristics in common. Elizabeth Hartney reports that one of the key characteristics of a substance misuse disorder is taking more of the substance than prescribed or using the substance for longer than intended. Individuals with an opioid misuse disorder may also have cravings for the substance, neglect their responsibilities in favor of using the substance, continue to use the substance even if it causes severe side effects or interferes with relationships, and struggle to stop using the substance even if they have expressed a desire to stop.

People who misuse codeine and other opioids may not seem like themselves when interacting with friends and family members. They may start asking to borrow money to pay bills because they have spent their own money on codeine. People who misuse codeine may even try to hide what they are doing or where they are going so that no one knows they are misusing prescription medication.

Physical Symptoms of Codeine Abuse

How codeine affects the body

By slowing down the activity of the central nervous system, codeine can produce a variety of physical effects. One of the most common is a sense of drowsiness. Users may also experience diarrhea, dry mouth, double vision, headache, stomach cramps, shakiness, and spinning sensations. More serious side effects, including trouble breathing, fainting, racing or pounding heartbeat, shallow breathing, and blue lips, may occur in some users.

Early physical effects of codeine

Codeine starts working in as little as 30 to 60 minutes after taking it. Once it takes effect, it can produce a variety of physical symptoms, some of which are uncomfortable or even dangerous.

This table illustrates the possible short-term physical effects associated with codeine.
Short-Term Physical Symptoms
Initial (direct effects of drug, 30 – 60 min.)Drowsiness
Dizziness
Feeling of warmth
Relaxed feeling
Lingering (within an hour of taking the drug)Blurred vision
Lightheadedness
Tiredness
Double Vision
Dry Mouth
Post-Use (several hours to days after use)Headache
Constipation
Difficulty sleeping
Redness of the skin
Shakiness
Stomach cramps
Loss of appetite

Severe and long-term physical effects of codeine

Individuals who are dependent on codeine typically need to take larger doses to experience the same relaxing effect they felt when they first started taking the substance. Some users also take codeine more often than prescribed. These behaviors increase the risk of codeine overdose, which can be deadly. Too much codeine can cause the user to stop breathing, and it may even cause the user’s heart to stop beating.

The risks of codeine misuse are even greater when codeine is combined with another substance, especially one that also slows down the central nervous system. Some users take codeine to enhance the effects of heroin, which can result in respiratory problems and sudden death. Codeine also increases the depressant effects of alcohol, increasing the risk for severe side effects when the two substances are combined.

Codeine may also be taken to lessen the effects of cocaine and other stimulants. This is especially dangerous, as stimulant misuse can lead to stroke, heart attack, and other serious heart problems. Stimulants can even cause the heart to age prematurely, making the heart muscle less able to withstand the effects of codeine combined with stimulant drugs.

This table illustrates the possible long-term physical effects associated with codeine.
Long-Term Physical Symptoms
CasualDry mouth
Dizziness
Headache
Drowsiness
Lightheadedness
Chronic (Including all of the above effects for casual use)Constipation
Nausea
Vomiting
Fainting
Breathing difficulties
Stomach pain
Sweating
Loss of consciousness
Racing heartbeat
Pounding heartbeat
WithdrawalMuscle pain
Agitation
Difficulty sleeping
Frequent yawning
Anxiety
Diarrhea
Nausea
Vomiting
Goosebumps

Further Resources

Both the National Institute of Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) offer in-depth information on both the symptoms and treatment of prescription stimulant addiction.

III. Codeine Usage

Codeine is an "opioid of concern" throughout the world

According to the United Nations Office on Drugs and Crime (UNODC), codeine is one of the opioids of concern in countries throughout the world. In the United States, many codeine-based products are Schedule III substances, so they are not as tightly controlled as Schedule I and II substances. Therefore, codeine is readily available, making it easier for individuals to obtain and misuse it. As a result, data from the UNODC World Drug Report indicate that the prevalence of opiate use in North America exceeds the global average.

Opioid use is increasing in Asia

As of 2017, approximately 1% of Asia’s population had used an opioid substance at least once within the past year. Although opioid use is increasing throughout all of Asia, the prevalence rate is highest in the Middle East and the South-West. Approximately 2.3% of the population in this region had engaged in non-medical use of an opioid within the past year. Due to the availability of opium in Pakistan, Iran, and Afghanistan, it is the drug responsible for driving up the total prevalence rate for the region.

Nearly 2% of the population uses opioids in West and Central Africa

In West and Central Africa, approximately five million people are past-year users of opioids, according to the World Drug Report issued by the United Nations Office on Drugs and Crime. In contrast to what is happening in Afghanistan, Pakistan, and Iran, the increased prevalence rate is driven by an increase in the non-medical use of prescription opioids, such as tramadol and codeine.

Prescription Narcotic Use Throughout the World

HighestSecondThird
Regions with the Highest Availability of Prescription OpioidsNorth AmericaAustralia and New ZealandEurope
Regions with the Largest Prevalence of Non-Medical Prescription Opioid UseNorth AmericaAustralia and New ZealandNear and Middle East

Codeine Usage Demographics in the U.S.

Non-medical use of codeine and other opioids is increasing, especially in the United States

According to the World Drug Report issued by the United Nations Office on Drugs and Crime, approximately 4.4% of the U.S. population engages in non-medical use of opioids. Furthermore, a 2016 survey by the Substance Abuse and Mental Health Services Administration (SAMHSA) indicates that 11.8 million Americans aged 12 and older were past-year users of opioids in 2016. Just under 95% of these 11.8 million Americans had misused a prescription opioid like codeine within the past year.

Although the prevalence rate of opioid misuse has increased in the United States, it has actually decreased among some groups of young people, according to data from the Monitoring the Future Study: Trends in Prevalence. In 2016, 7.8% of the 12th graders surveyed reported that they had misused a narcotic other than heroin at some point in their lives. By 2018, only 6% of 12th graders (17-18 years of age) reported that they had misused a narcotic other than heroin in their lifetime. Data on past-year use among 12th graders is also encouraging, with only 3.4% of 12th graders reporting in 2018 that they had misused a narcotic other than heroin in the past year. In comparison, 5.4% of 12th graders surveyed in 2016 said they were past-year users of narcotics other than heroin.

Demographics of Prescription Usage
Past Year (2018)Lifetime
8th grade (14-15 yo)No data collectedNo data collected
10th grade (15-16 yo)No data collectedNo data collected
12th grade (17-18 yo)3.4%6%

IV. How to Find Help

Long-term use of codeine increases the risk for dependence, making it difficult to stop taking the drug even when its use interferes with friendships, family relationships, and work responsibilities. Stopping codeine suddenly also increases the risk for serious withdrawal symptoms, making it difficult for an addict to stop using the substance without support from a qualified medical professional.

To reduce the risks associated with withdrawal, the codeine rehabilitation process focuses on tapering off the drug instead of stopping it suddenly. Rehabilitation programs also provide valuable social support that can help users stay sober and reduce the risk of relapse. To learn more about the process, visit our codeine rehabilitation guide, which offers valuable information on finding a rehabilitation program.

Staging an Intervention

If you have a loved one who’s struggling with addiction, staging an intervention is often the first necessary step towards sobriety, but it’s important to be strategic and loving in your approach. Even the most well-meaning of interventions can have a negative effect if they aren’t handled correctly.

5 Tips for Staging an Intervention

  • Don’t Do It Alone. A professional interventionist is always the most qualified to guide a successful intervention. Also, rely on non-addict family and friends — especially those who have a close relationship with you or the addict.
  • Research Ahead of Time. It’s best to do plenty of research ahead of time to gather insight on the addiction and how it affects the addict. Also, be prepared with local resources for getting help.
  • Write Out Your Statement. During the actual intervention, emotions will likely be running high, so it’s best to have a statement of how the person’s addiction has impacted you and your relationship with him or her. These statements should be honest yet written from a place of love — no personal attacks.
  • Offer Help. It’s important for everyone attending the intervention to offer tangible help and support as the person works through detox and rehabilitation.
  • Set Boundaries. If the person refuses to seek help and take the next steps outlined, it’s important that they understand that everyone present will end codependent and enabling behaviors.