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Codeine is an opioid medication used to treat pain and cough.1 Codeine and substances mixed with codeine are referred to by many slang terms like:5

  • Captain Cody.
  • Schoolboy.
  • Lean.
  • Sizzurp.
  • Purple Drank.

Like other prescription opioid medications, codeine misuse may lead to physical dependence and addiction.1


What Is Codeine?

codeine medication poured onto spoonCodeine is the name for a prescription medication used to treat mild to moderate pain and problematic coughing.1 When prescribed for pain, codeine may be combined with acetaminophen (Tylenol 3) or aspirin.1 When prescribed for cough, the medication has been combined with expectorants (Robitussin AC) or antihistamines like promethazine.1

Codeine is one of many prescription opioid drugs regularly prescribed in the U.S. Other opioids include oxycodone (OxyContin), hydrocodone (Vicodin), and fentanyl.2  Like all opioids, as codeine enters the body and is circulated to the brain via the bloodstream, it will interact with certain opioid receptors in the brain, spinal cord, gastrointestinal tract, and other organs.2 Once these receptors are activated by codeine, an individual will experience a diminishing of pain signaling being sent from the body to the brain, resulting in temporary pain relief.

In the brain, opioids also trigger the release of a neurotransmitter called dopamine, a signaling molecule associated with positive feelings, like a strong sense of well-being and relaxation.2 These feelings can be extremely rewarding to the user and increase their motivation to abuse the drug.

Prescription opioid abuse and addiction is a huge problem in the United States and is a risk factor for heroin use.

Eventually, if an individual keeps returning to codeine for the euphoric sensations it provides, they can develop an addiction.2,3 Prescription opioid abuse and addiction is a huge problem in the United States and is a risk factor for heroin use.3 For years, the number of opioid prescriptions in the U.S. rose significantly, contributing to an epidemic of opioid abuse. In 2013, there were about 207 million prescriptions for opioid painkiller medications, and while codeine may have a lower abuse potential because it isn’t as potent as other painkillers, any misuse of a prescription opioid is dangerous and can lead to addiction.In 2015, about 3.8 million Americans admitted to actively abusing prescription opioids.4

Codeine abuse occurs in a number of ways, including:2 

  • Taking a medication that is not prescribed for you (even if you’re taking it for pain or cough).
  • Taking more of the medication than is prescribed.
  • Taking the medication more frequently than is prescribed.
  • Taking the prescription through another route of administration like crushing and snorting a codeine pill.
  • Mixing codeine with other drugs or alcohol to boost or alter its effects.

Street Names

Codeine and mixtures of other drugs with codeine have historically been referred to by the following names:5

  • Codeine alone:

    • Captain Cody.
    • Cody.
  • Codeine cough syrup (containing promethazine):

    • Lean.
    • Sizzurp.
    • Purple Drank.
  • Codeine combined with the sedative, glutethimide:

    • Doors and fours.
    • Loads.
    • Pancakes and syrup.

Side Effects of Abuse

Someone intoxicated by codeine will initially seem euphoric but may later display symptoms like:6 

  • Apathy.
  • Low mood.
  • Appearing sped up or slowed down.
  • Poor judgment.
  • Constricted pupils.
  • Slurred speech.
  • Inability to pay attention and impaired memory.

Other side effects a person abusing codeine may experience include:1,2,6 woman sitting on steps experiencing side effects of codeine abuse

  • Headaches.
  • Lightheadedness.
  • Sleepiness.
  • Constipation.
  • Stomach pain
  • Difficulty urinating.
  • Nausea.
  • Vomiting.
  • Weight loss.
  • Confusion.
  • Weakness.
  • Sudden or unexpected mood changes.
  • Vision problems.
  • Sexual side effects like:
    • Erectile dysfunction.
    • Irregular menstruation.
    • Lowered interest in sex.
  • Irregular heart rate.
  • Shallow or slowed breathing.
  • Trouble breathing.

Codeine may also lower an individual’s seizure threshold, making seizures more likely for some users.1

Long-Term Health Consequences

Ongoing use of prescription opioid medications may negatively impact multiple aspects of an individual’s health. Long-term health consequences of codeine include:7

  • Breathing problems during sleep, including sleep apnea.
  • Heart problems with an increased danger of heart attack and heart failure.
    • Codeine appears to pose a higher risk for experiencing adverse cardiovascular events than hydrocodone.
  • Nervous system problems like:
    • Higher pain sensitivity.
    • Heightened risk of falls and injury as a result of dizziness and impaired coordination.
  • Endocrine/hormonal-related problems such as:
    • Low testosterone levels.
    • Sexual dysfunction.
    • Lowered sexual interest.
    • Osteoporosis.
    • Irregular periods.
    • Lactation, unrelated to childbirth.
    • Fatigue.
  • Impaired immune system functioning.

The decreased respiratory drive associated with codeine abuse has the potential to affect the brain. When breathing is inadequate, the brain and other body tissues/organs may not receive enough oxygen. This situation, called hypoxia, can damage and deteriorate parts of the brain and may also result in a coma.8

Chronic opioid use has also been associated with parts of the brain relating to: 

  • Decision-making skills.
  • Stress response.
  • Behavior regulation.

In addition to the physical health issues described, long-term opioid use can adversely affect an individual’s mental health and lead to higher rates of depression.7 

Codeine Cough Syrup (Lean/Sizzurp)

In the late 1990s, mixing codeine-containing cough syrup with soft drinks or alcohol became a popular trend, especially among musicians that referenced the drug cocktail (and its effects) in their songs.9 Some young people influenced by these musicians began obtaining and misusing this drug mixture.9glass of purple drank consisting of codeine mixed with a soft drink

There are several formulations of codeine cough syrup, but the one called “lean,” “purple drank,” or “sizzurp” (popularized by musicians like Lil’ Wayne) refers to codeine with promethazine, an antihistamine and antiemetic that causes sedation in high doses.9 The substances boost the effects of each other to produce a “high” when consumed in large amounts.9 The combination was marketed under the brand names Phenergan or Phenergan VC but due to its abuse potential, these syrups were pulled off the market.1 Some users may still be able to access them illicitly or as generic formulations.

Abusing codeine cough syrup can be extremely dangerous. Celebrities like Justin Bieber and Lil’ Wayne have reportedly experienced erratic behavior and negative health effects linked to abusing this drug, though the latter denied the connection.10 Sadly, some of the prominent figures that helped bring “purple drank” and “sizzurp” to notoriety died from drinking it.9

Can You Overdose on Codeine?

Yes, you can overdose if you abuse codeine; however, codeine alone is not as potent as other opioids like oxycodone, so overdose is more likely when you combine it with alcohol or other drugs that depress the central nervous system such as benzodiazepines (Valium, Xanax, etc.).2

The signs of codeine overdose include:1,2 

  • Severely slowed or labored respiration, or stopped breathing.
  • Significantly slowed heartbeat.
  • Excessive drowsiness; marked difficulty or inability to rouse.
  • Loss of consciousness/fainting.
  • Weak or flaccid muscles.
  • Skin that is cold and clammy.
  • Blue lips and fingernails.
  • Uncontrollable shaking.
  • Vomiting.

If you think someone is overdosing on codeine, call 911 immediately for medical help. Be sure to tell the emergency providers if the victim used any other drugs apart from codeine.

Dependence and Addiction

Codeine addiction is characterized by strong urges to get and use more of the drug regardless of the possible negative outcomes.11 A person with an addiction, or an opioid use disorder, may show behavioral signs like:6

  • Using larger amounts of codeine over a longer period of time than intended.
  • Multiple unsuccessful attempts to end use.
  • Spending a lot of time and effort getting, using, and recovering from codeine.
  • Neglecting important responsibilities and relationships with loved ones.
  • Experiencing significant shifts in interests, activities, and social connections.
  • Continuing to use codeine even though it can be dangerous.

The development of tolerance and physical dependence/withdrawal are also diagnostic features of opioid use disorders.6 Tolerance is the need for higher doses or more frequent use of codeine to produce the wanted effects over time.6 Physical dependence is a state where the brain has become so accustomed to the presence of codeine in the system that it functions more normally when available.6,12 When the level of codeine drops below the desired level, withdrawal symptoms will emerge.12 Although addiction, tolerance, and physical dependence are separate issues, they commonly co-occur.

Codeine Withdrawal

Codeine withdrawal will likely begin within several days of last use and last for a week or more with symptoms such as:6Man sitting on bed portraying insomnia due to codeine withdrawal

  • Depressed mood.
  • Nausea and vomiting.
  • Diarrhea.
  • Pain and aches.
  • Yawning.
  • Watery eyes and running nose.
  • Dilated pupils.
  • Goosebumps.
  • Increased sweating.
  • Fever.
  • Trouble sleeping.

Some symptoms can last past the acute withdrawal period. These protracted withdrawal symptoms may include:6

  • Anxiety.
  • Depression.
  • Low energy/fatigue.
  • Insomnia.

Finding Treatment for Addiction

Professional treatment for codeine addiction can help to ensure safety, increase comfort, and promote longer periods of recovery.11 For many, medically assisted or medically supervised detoxification will be the first step in treatment.11,13 Professional detox helps the body process and remove codeine from the system while minimizing the discomfort of withdrawal. Detox can occur in a range of settings depending on the intensity of use and the risks of dangerous or life-threatening withdrawal symptoms.13 Longer stays in treatment are correlated with longer periods of recovery.

Those at greater risk may benefit from inpatient detox (often conducted in an acute care hospital setting) followed by inpatient/residential treatment. Inpatient/residential treatment programs offer intense, 24-hour services that focus on improving the overall well-being of the individual.11,13 This type of treatment offers the opportunity to live at the center while receiving therapy and medication services.11,13 Inpatient treatment can last anywhere from a few weeks to a year based on the progress made. Therapeutic communities (TCs) are a type of long-term residential rehabilitation that help to modify faulty thinking and behavior patterns to achieve recovery.11

People with relatively less severe opioid dependence and, consequently, a decreased risk of complicated withdrawal sometimes receive their detoxification and subsequent addiction therapy services in an outpatient setting. Outpatient substance abuse programs may also be appropriate for those that have completed inpatient or residential treatments. During outpatient treatment, the individual attends sessions at the facility before returning to home or work. Intensities of treatment vary. Options include:13

  • Partial hospitalization programs (PHPs) – Sometimes called “day treatment,” these services offer around 30 hours per week of treatment that might include individual, group, and family therapy.
  • Intensive outpatient programs (IOPs) – These provide about 9 hours of treatment per week spread over 2-3 sessions. IOP is usually a stepdown treatment from PHP.
  • Standard outpatient – Individuals attend therapy that can last for months or years, usually on a weekly, biweekly, or monthly basis.

woman portraying doctor prescribing patient with medication for medication assisted treatmentNo matter the location of care, medication-assisted treatment (MAT) is a common strategy used to combat opioid addiction. Combined with behavioral therapy, MAT employs medications to first stabilize an opioid-dependent individual and later diminish cravings and the drive to continue use to help break the cycle of addiction.11 Some medications used in MAT are:11

  • Methadone – This is a powerful synthetic opioid with long-acting properties that eases cravings without the intense high of other opioids.
  • Buprenorphine – A partial agonist, this opioid drug (often combined with naloxone and prescribed under the brand name Suboxone) does not cause pronounced euphoria or sedation when used as directed.
  • Naltrexone – Given after acute withdrawal has ended, this is an opioid antagonist that blocks codeine from attaching to opioid receptors. Without the reward of use, the individual is less likely to abuse codeine.

With addiction, longer stays in treatment are correlated with longer periods of recovery, so when one service concludes, it is a great idea to seek out effective aftercare/follow-up care options.11,13

Support groups and 12-step programs like Narcotics Anonymous (NA) are good aftercare options at any stage of recovery due to their focus on fellowship, sobriety, and giving back.11

Finding appropriate addiction treatment can be overwhelming with so many options available. If you or someone you know is struggling to access care, consider:

  • Speaking with a trusted physician or addiction professional.
  • Seeking advice or recommendations from people that have treatment experience.
  • Calling your insurance plan to see what treatment types are covered.
  • Completing online searches for facilities and helplines.

Addiction is a serious, complicated condition, but it can be treated effectively with professional assistance.11 Starting treatment early and sticking to it will significantly boost your odds of living a drug-free life.


References:

  1. National Library of Medicine: MedlinePlus. (2017). Codeine.
  2. National Institute on Drug Abuse for Teens. (2017). Prescription Pain Medications: Opioids.
  3. National Institute on Drug Abuse. (2014). America’s Addiction to Opioids: Heroin and Prescription Drug Abuse.
  4. Substance Abuse and Mental Health Services Administration. (2016). Key Substance Use and Mental Health Indicators in the United States: Results from the 2015 National Survey on Drug Use and Health.
  5. National Institute on Drug Abuse. (2017). Commonly Abused Drug Charts.
  6. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  7. Baldini, A., Von Korff, M., & Lin, E. H. B. (2012). A Review of Potential Adverse Effects of Long-Term Opioid Therapy: A Practitioner’s Guide. The Primary Care Companion to CNS Disorders14(3).
  8. National Institute on Drug Abuse. (2015). DrugFacts: Prescription and Over-the-Counter Medications.
  9. National Institute on Drug Abuse for Teens. (2017). Cough and Cold Medicines.
  10. National Institute on Drug Abuse. (2013). Sizzurp: Its Not Cool.
  11. National Institute on Drug Abuse. (2012). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition).
  12. Mescape. (2016). Withdrawal Syndromes.
  13. Substance Abuse and Mental Health Services Administration. (2015). Detoxification and Substance Abuse Treatment.

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