Codeine Withdrawal: Symptoms and Treatment

man sitting down clasping hands together Codeine (3methylmorphine) is an opiate or narcotic medication. All opioid medications are either extracted from the poppy plant or synthetic substances that are similar to substances occurring in opium. Codeine belongs to the same category of medications as morphine, Vicodin, OxyContin, etc., and is also a controlled substance.

The United States Drug Enforcement Administration (DEA) classifies all formulations of codeine that contain less than 90 milligrams of codeine as controlled substances in the Schedule III category, whereas other substances containing codeine are classified as Schedule II controlled substances. This indicates that codeine can only be purchased with a prescription from a physician and that it carries a moderate potential for abuse and the development of physical dependence, which can vary slightly depending on its concentration.

All narcotic medications have significant effects on an individual’s subjective experience of pain, and codeine can definitely be used for pain relief; however, it is more often used as a cough suppressant in formulations of cough medicine and as a sleep enhancer. It is most commonly prescribed in a liquid or pill form. Like all narcotic medications, anyone who uses the substance regularly for more than several weeks may develop some level of physical dependence on it.

How Codeine Works

According to the book Pain Management: A Guide for Clinicians, the mechanism of action associated with codeine is similar to the mechanism of action associated with other opiate drugs. This class of drugs has an affinity for specialized neurons in the brain that are the receptor sites for endogenous neurotransmitters, which are very similar in structure to opiate drugs. These neurotransmitters, such as endorphins, are involved in the subjective experience of pain; when these neurotransmitters are activated, they reduce one’s experience of pain in the same way that narcotic drugs do. They are also involved in the experience of stress, fatigue, anxiety, etc. When these endorphins and other neurotransmitters are repeatedly activated, they act in conjunction with other neurotransmitters, such as dopamine, to produce pleasurable feelings like euphoria and reinforcing effects.

The effects of all of the drugs in the classification of opiate or narcotic drugs are achieved by generally suppressing certain aspects of the central nervous system’s activity (brain and spinal cord). Thus, these drugs are often referred to as central nervous system depressants. This designation does not mean that these drugs cause individuals to become sad and depressed, although in some cases this may occur; rather, the firing rates of the neurons in the central nervous system are suppressed as a result of use of these drugs. Codeine has an added benefit of being particularly prone to bind to neurons in areas of the brain stem that are involved in controlling the coughing reflex, thus making it an effective cough suppressant.

All of these substances also result in a reduction of anxiety, stress, exertion, etc., as a result of their sedative effects. Thus, these substances (both endogenous neurotransmitters, such as endorphins and enkephalins, and opiate drugs) have the potential to induce or motivate an individual to repeat the actions associated with their effects. Some individuals may become “exercise junkies.” They get feelings of reinforcement and euphoria from exercise associated with the release of endorphins in the brain to reduce the subjective experience of stress and exertion. Other individuals get similar reinforcements from taking opiate drugs.

However, the development of a substance use disorder is a far more complicated issue than the simple mechanism of action of any drug. Individuals prone to developing substance use disorders typically have other risk factors, such as certain genetic factors, environmental experiences, and other tendencies, that all interact together to increase the risk to develop the disorder. The mechanism of action of any drug or other substance alone cannot sufficiently explain the development of a substance use disorder in any person or group of people.

Withdrawal from Codeine

The withdrawal syndrome is one of the two symptoms of the development of physical dependence on a drug. Physical dependence consists of a process where an individual first develops tolerance to the drug and later develops withdrawal symptoms when they cut down on the amount of drug they are using or attempt to stop using it abruptly.

Tolerance occurs when one’s system habituates to the effects of the drug, and the person finds that they need higher amounts of the drug to achieve the effects that were once achieved at lower doses. Tolerance is relatively common for individuals who use all kinds of different drugs, either for medicinal reasons or as a result of abuse. Withdrawal symptoms are less common but do occur in conjunction with repeated use of a number of different medications.

Withdrawal symptoms occur when an individual’s system has been exposed to the drug for a significant period of time and it adjusts its functioning to account for the drug’s presence. When the levels of the drug in the person’s system decline, the system is thrown out of balance, and the individual experiences a number of negative effects that will vary depending on the type of drug or medication being used.

Individuals who have developed physical dependence on codeine will undergo some level of withdrawal symptoms that are often uncomfortable, but not considered to be potentially physically dangerous. However, any individual undergoing withdrawal symptoms may become emotionally distraught and be at risk for engaging in poor judgment or having accidents. As a result, it is always a good idea to consult with an addiction medicine physician or addiction psychiatrist when attempting to discontinue any drug of abuse. If one is prescribed codeine and has been using it for more than several weeks, it’s important to consult with the prescribing physician before stopping use of the drug.

Withdrawal Timeline for Codeine

According to Drugs The Straight Facts: Codeine, the symptoms an individual experiences when undergoing withdrawal from codeine can be quite varied.

  • Flulike symptoms are common. These can include nausea, stomach cramps, diarrhea, vomiting, fever, chills, profuse sweating, runny nose, sneezing, headaches, jitteriness, shakiness, muscle aches, and trembling in the extremities. Some individuals may present with dilated pupils, and some may develop a rash. Individuals who are experiencing significant gastrointestinal effects, such as vomiting and diarrhea, can potentially become dehydrated.

  • Changes in blood pressure, respiration rate, and irregular heartbeat are common.

  • Psychological and cognitive symptoms can be quite varied but may include issues with anxiety (can range from mild to severe and may even include panic attacks in some individuals), mood swings, irritability, depression, confusion, issues with memory, issues with concentration, an inability to sleep, and poor appetite. In very rare cases, individuals may develop hallucinations, and individuals who mix codeine with other drugs on a regular basis may be at risk to develop seizure-like activity during the withdrawal process. Individuals who develop seizures during withdrawal from codeine but have no history of poly-substance abuse most often have some other condition that contributes to this, such as a past history of seizure disorders or some other neurological or even psychological issue.

  • Extreme cravings to use codeine are common during the withdrawal process. Individuals who give in to these cravings often find that any withdrawal symptoms they are experiencing disappear rapidly once they start using the drug again.

The timeline for withdrawal from codeine can vary depending on a number of factors. A general outline of the timeline for withdrawal symptoms follows.

  • Codeine does not remain in an individual’s system very long. Individuals who have used large amounts of the drug on a regular basis may begin to experience withdrawal symptoms rather rapidly after they stop using the drug. Often, the onset of withdrawal symptoms motivates individuals to take more of the drug, which reinforces use, contributes to the development of tolerance, and contributes to more rapid and severe withdrawal symptoms. The average time that withdrawal symptoms appear is approximately 12 hours after discontinuation of codeine, but some individuals may begin to experience mild headaches, nausea, shakiness, etc., within 24-40 hours of stopping the drug. The initial symptoms are typically flulike symptoms, muscle aches, shakiness, irritability, and cravings.

  • For most individuals, symptoms will peak within 3-5 days after they have discontinued the drug, and then their level of distress will begin to decline. Issues with general malaise, shakiness, headaches, cravings, insomnia, appetite loss, etc., may still continue.

  • For most individuals, the symptoms will have generally resolved within a week of discontinuation. Some individuals still continue to experience issues with appetite, motivation, mood swings, cravings, etc., even after a week.

  • In some cases, individuals may continue to experience these types of issues for months or even years following discontinuation. Some sources still refer to these prolonged issues as a post acute withdrawal syndrome; however, research has never validated these prolonged issues as a formal withdrawal syndrome, and they most likely represent other factors, including other mental health issues.

The withdrawal syndrome from any substance can be quite variable and affected by a number of factors. These include:

  • The type of drug taken, the amount of the drug typically taken, and the length of time the individual had been taking the drug
  • The way the individual typically used the drug (Individuals who smoke, snort, or inject drugs develop tolerance to the substance more rapidly and have more severe withdrawal syndromes than individuals who take them orally.)
  • Poly-substance abuse, which makes withdrawal more intense and lengthier
  • The manner in which an individual stops using the drug (Stopping the drug abruptly will result in more intense symptoms, but also results in a shorter withdrawal process compared to slowly tapering the dosage of the drug.)
  • Individual variations in metabolism and psychological functioning

Treatment for Withdrawal

The approach to treating a withdrawal syndrome from codeine is to get a physician involved in the process. Typically, medical detox consists of a physician administering a replacement medication for an opioid drug (e.g., methadone or Suboxone) or some other medication on a tapering schedule. A tapering schedule consists of the physician establishing a starting dose of the medication that results in the patient not experiencing any significant withdrawal symptoms (most often, no withdrawal symptoms at all) and then slowly reducing the dosage of that medication over specific intervals to wean the individual off the drug. This results in the period of withdrawal being extended in length, but the recovering individual does not experience significant negative symptoms associated with withdrawal. In addition, physicians can administer other medications as needed to control any residual symptoms or cravings. Withdrawal management programs are highly successful in helping individuals get through the withdrawal process without relapsing or experiencing any other serious issues; however, they are not sufficient to result in a successful recovery.

The cornerstone of any recovery program for any type of substance use disorder, including those associated with codeine abuse, is therapy. In addition, support group participation, education, and other interventions may be needed and helpful given the individual’s specific case. Individuals who simply go through withdrawal and do not engage in any form of substance use disorder treatment will relapse the vast majority of the time. Formal recovery programs are associated with much better long-term success rates.

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