Codeine Addiction: Signs, Symptoms, and Treatment

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Codeine is a prescription opioid analgesic used to treat diarrhea, cough, and moderate pain.¹ The drug is available as an oral tablet, such as Tylenol Codeine, as well as in a liquid form as a prescription cough suppressant. Opioids include natural and synthetic substances that bind to opioid receptors in the brain. Like other opiates, codeine is considered to have a high risk of potential misuse and addiction. In the U.S., the incidence of codeine addiction or dependence is approximately 8-12% of the population.⁵

Why Codeine Misuse Happens

Codeine use often begins with taking prescription cough syrup with codeine to relieve cough. Along with codeine’s cough suppressant action, it works on the central nervous system to reduce pain while producing a sense of euphoria and relaxation.

Your doctor may choose to prescribe a cough syrup with codeine if you experience prolonged or intense coughing, profound body aches, or you have a respiratory illness (e.g., bronchitis or sinusitis), and if your symptoms do not respond to over-the-counter cold and flu medicine or non-opioid painkillers.

Coughs related to the common cold and seasonal flu typically do not call for prescription medication. Cough suppressants containing codeine are not indicated for anyone under the age of 18 due to a high risk of severe side effects.

If codeine is taken when it is not needed for cough, pain, or diarrhea, its sedative and euphoric effects may be intense. Euphoria is an intense feeling of physical and emotional well-being.⁴ This use can lead to a pattern of misuse, including taking more codeine to achieve the same feelings of relaxation or pleasure. Those addicted to codeine often attribute the onset of continuous use with wanting to experience its euphoric effects repeatedly.⁵

Other reported effects that may lead to misuse of codeine inlcude:⁵

• Decreased anxiety
• Higher functioning related to pain decrease
• Mood improvement
• Increased ability to cope

Misuse of codeine may include:¹

• Using more of the medication than prescribed
• Using the drug for longer than prescribed
• Using the drug for reasons other than why it was prescribed, such as to “self-medicate” anxiety or depressive symptoms
• Taking the medication for recreational uses

Causes of Codeine Addiction

When you take codeine in any form, there is a risk of developing a tolerance. Tolerance occurs when more medication must be taken to get the same symptom relief or recreational effects. Tolerance can encourage a pattern of repeated and progressive codeine use that may lead to dependence and potential addiction.

Although codeine misuse may begin when taking codeine for nonmedical reasons, physical dependence can happen even if you take codeine as prescribed. Physical dependence describes the state where you start to need a certain amount of codeine to function normally, such as completing tasks, focusing, and sleeping well. You may experience discomfort—known as withdrawal symptoms—if you do not take codeine.

Dependence is not the same as addiction, but the development of tolerance and dependence can lead to a substance use disorder—the clinical diagnosis of addiction.

Using codeine in any way other than the drug is prescribed increases a person’s risk of tolerance, dependence, and addiction.  While the exact cause of any addiction—including an addiction to opioids—is not well understood, there are certain factors known to contribute to the risk of developing the pattern of behaviors that rises to the clinical threshold of addiction, such as:⁸

• Early antisocial behavior
• Hyperactivity
• Depression
• Anxiety
• History of physical or sexual trauma
• Family history of substance use disorder
• Socioeconomic status

These risk factors are not causes or predictors of addiction but should be considered potential contributing factors. For example, antisocial behavior may be a risk factor because it is associated with early exposure to substances rather than the behaviors themselves.

Similarly, individuals who live in a low-income neighborhood should not be considered at higher risk due to income level or perceived strength of character. This increased risk is likely due to social determinants of health such as housing instability, food insecurity, living in an economically depressed area, lack of healthcare access, and few opportunities to improve socioeconomic status. These social determinants of health are associated with a higher occurrence of illness, less access to and personal attention from doctors, a higher presence of illicit drugs in a geographic area, and a lack of funding for community addiction and mental health services.

Codeine Addiction Symptoms and Signs

Addiction to codeine falls under opioid use disorder (OUD), a diagnosis established by the Diagnostic and Statistical of Mental Disorders (DSM-5). Mental health providers use the DSM-5 to evaluate and diagnose mental health conditions. OUD involves an unmanageable relationship with codeine that has detrimental effects on one’s quality of life and well-being.³ The DSM-5 criteria used to determine if an individual has OUD and how the addiction should be categorized (i.e., mild, moderate, or severe) include:³

• Taking more opioids than planned or taking the medication longer than intended
• Ongoing desire to limit or quit using opioids
• Unsuccessful efforts to stop using opioids
• Excessive time spent obtaining, using, or recovering from substances
• Intense cravings to use opioids
• Inability to meet personal, academic, or professional obligations related to opioid use
• No longer engaging in meaningful social, recreational, occupational, or community activities because of drug use
• Repeatedly putting oneself in potentially dangerous situations to obtain or use opioids
• Continuing opioid use even when experiencing negative physical or mental consequences from the use
• Tolerance development
• Withdrawal symptoms when stopping the use of opioids
• Continuing to use opioids to avoid unpleasant withdrawal symptoms

Signs and Symptoms of Opioid Intoxication

The primary reason that opioids are addictive is due to their intoxicating effects. Opioid intoxication involves various psychological and mental changes, such as elevated mood. An elevated mood is often followed by a negative mindset, lack of interest, agitation, slowness, and poor judgment.³

Other signs and symptoms of opiate intoxication include:³

• Risk-taking
• Word-slurring
• Pupil constriction, or “pinpoint pupils”
• Nausea and vomiting
• Poor attention span
• Impaired memory

Risks of Codeine Use, Misuse, and Addiction

There are many physical and psychological risks associated with codeine, some of which can occur with prescription use. When misuse or addiction happens, these symptoms can increase in frequency or intensity. Types of risks of codeine use include the following.

Mood Changes

Codeine and other types of opioid misuse may affect mood and emotional regulation, in part due to the high level of brain activation that occurs when taking opioids and the “crash” that follows when the effects wear off. Mood-related symptoms may include:⁷

• Depression
• Extreme irritability
• Agitation

Mood changes have been associated with patterns of misuse. If you notice your mood has changed since you started taking codeine or a loved one expresses concern, describe your symptoms to your doctor.

Progressive Physical Conditions

Codeine may cause physical symptoms, even when taken as prescribed. If you take codeine for an extended period at a high amount, these symptoms can become progressively worse and potentially cause permanent damage. Discuss the risk of physical side effects and report any side effects you experience to your prescribing doctor.

Physical side effects may include: ^5,7

• Slowed heart rate
• Loss of appetite
• Vomiting
• Muscle weakness
• Stomach bleeding
• Reproductive dysfunction, including decreased libido
• Liver toxicity

Neurological Symptoms

Opioids can produce neurological symptoms, especially during periods of withdrawal. These symptoms may include: ^5,7

• Confusion
• Hallucinations
• Visual disturbances
• Seizure

If you experience a seizure, seek medical attention. Report any neurological changes to your doctor the first time you experience them. Your doctor may reduce your dose or change your medication. If you have misused codeine, you may need to go through detox to reduce the risk of neurological symptoms—which can be medically significant or life-threatening—occurring again.

Respiratory Depression

Codeine causes respiratory depression, or slow, shallow breaths, particularly when used in high amounts.⁷ The risk of breathing problems related to codeine intake is worsened when codeine is combined with certain medications, including:⁷

• Specific antibiotic and antifungal medications
• Benzodiazepines and other sedative medications (e.g., Xanax, Valium, Klonopin)
• Muscle relaxers
• Sleep medications

When codeine is combined with these medications, the risk of overdose exponentially increases. If you notice any symptoms of overdose after taking codeine, seek immediate emergency medical care due to the risk of loss of consciousness, which can be followed by permanent injury (e.g., brain damage) or life-threatening loss of oxygen to the brain.

Overdose

Overdose is perhaps one of the most significant risks of codeine addiction. Signs and symptoms of codeine overdose can include:³

• Difficulty breathing
• Extreme sleepiness
• Lack of muscle tone
• Cold, clammy skin
• Fainting and lightheadedness
• Slow heart rate
• Slow respirations
• Unresponsiveness

If you experience any signs of codeine overdose, seek emergency medical attention right away.

If you have a loved one who is taking an opioid medication, including codeine, talk to the prescribing doctor or a pharmacist about keeping naloxone at home. Naloxone can restore breathing in the event of an opioid overdose, allowing for a longer window of time for your loved one to receive emergency medical treatment.

How to Treat Codeine Addiction

The first phase of codeine addiction treatment is detoxification (detox). Medical detox provides close medical observation and intervention while the body rids itself of codeine. Mitigating the dangers of withdrawal is the overall goal of detoxification.

­­Rehabilitation (Rehab)

If a mental health professional diagnoses you with opioid use disorder (OUD) before or after detox, they will likely refer you to a rehab program.

Rehab offers long-term support in a safe environment for those diagnosed with codeine addiction. Types of rehabilitation programs include:⁴

• Residential treatment programs
• Inpatient hospitalization or partial hospitalization
• Outpatient treatment
• Aftercare services
• Long-term residential care, such as a sober living house

Services offered by many addiction treatment programs include:⁴

• Group, individual, and family therapy
• Educational classes on understanding addiction
• Medication-assisted treatment
• Peer support groups, such as 12-step groups or SMART recovery
• Behavioral therapy
• Motivational therapy

Aftercare and Ongoing Support

Recovery from codeine addiction is often a life-long process. Many treatment options aim to support long-term recovery and abstinence. For those with codeine addiction, lifestyle changes may involve spending a period of time living in a sober living environment,  participation in ongoing intensive outpatient treatment, or attending community support groups like Narcotics Anonymous (NA).

To learn more about addiction and discuss your treatment options, call 800-681-1058 (Who Answers?) .

Resources

1. Nielsen, S., Van Hout, M.C., Bruno R., Schenk, S. (2016, January 15) Over-the-Between.Counter Codeine—from Therapeutic Use to Dependence, and the Grey Areas in  Vol 34. Springer, Cham.
2. S. Drug Enforcement Agency. (2020). Drugs of Abuse: A DEA Resource Guide 2020.
3. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. American Psychiatric Association Publishing
4. Lambert, L. (2020). The dangers of codeine addiction. South African Pharmacist’s Assistant, 20(2), 18-19.
5. Lee, E., Cooper, R.J. (2019, April 25) Codeine Addiction and Internet Forum Use and Support: Qualitative Netnographic Study. JMIR Mental Health, 6(4),
6. McAnally H.B. (2017, September 12). Understanding the Agent, Part III: Specific Drugs. Opioid Dependence. Springer International Publishing.
7. S. National Library of Medicine. (2020, December 15). Codeine. MedlinePlus.
8. Mistry, C.J., Bawor, M., Desai, D., Marsh, D.C., Samaan, Z. (2014, July 07). Genetics of Opioid Dependence: A Review of the Genetic Contribution to Opioid Dependence Current Psychiatry Reviews, 10(2), 156-167.