Over-the-counter opiates: Does Britain have a codeine problem?

Main analgesic drugs dispensed in England by item.

Earlier this year, the NHS announced it had cut opioid prescriptions by nearly half a million in four years. But opioids are not only available on prescription in the UK. They can be bought over the counter at pharmacies in the form of co-codamol pills which contain codeine and acetaminophen.

Each co-codamol pill contains a fixed amount of 500 mg of acetaminophen and between 8 mg and 12.8 mg of codeine, depending on the product. (Co-codamol with more than 12.8 mg of codeine is available by prescription only.)

Co-codamol is the second most widely distributed painkiller in England after paracetamol with over 15 million packs sold in 2021. In 2023, the UK was estimated to be the third largest consumer of codeine with over 28 tonnes after India and Italy (75 tons and 33.5 tons, respectively).

Main analgesic drugs dispensed in England by item.
Main analgesic drugs dispensed in England by item.
Matej Mikulic/Statisman

Codeine is considered a weak opioid. 10 mg of codeine is equivalent to 1 mg of oral morphine. Once ingested, a liver enzyme called CYP2D6 converts codeine into morphine. However, some ethnic groups, such as people from North Africa, produce a higher amount of the enzyme CYP2D6 (so-called ultrarapid metabolizers) and therefore are more at risk of harm, even at regular doses.

Co-codamol is meant to be used to treat mild to moderate pain such as menstrual pain or toothache, but because it can also create a euphoric effect, it is prone to abuse.

Codeine can cause serious harm, including dizziness, confusion, breathing difficulties and even death. These risks are particularly high among ultrarapid metabolizers and people using other drugs, such as benzodiazepines.

Some people buy co-codamol to treat their heroin cravings when there are local heroin shortages. But anecdotal reports suggest that this drug could be abused by people who start out on pain relief pills and end up addicted.

Extraction with cold water

In theory, the acetaminophen contained in the pills should prevent people from abusing them.

A maximum single dose of acetaminophen for an adult should not exceed 1,000 mg (two pills of co-codamol) as it can damage the liver. However, online groups share a simple method called cold water extraction to remove the acetaminophen.

Clinical toxicologists at Guys and St Thomas Hospital in London have found case studies suggesting the method is quite effective at removing paracetamol from pills, and a lab test backs it up.

It’s unclear how widespread this form of tampering is, but a (now removed) YouTube clip showing viewers how to do the procedure had been viewed more than half a million times.

Pharmaceutical companies have yet to find a proper way to prevent this type of tampering.

Twenty-five countries have banned over-the-counter codeine

Given the abuse potential of the pills, at least 25 countries, including Germany, Japan and the United States, have banned over-the-counter codeine sales.

Australia also implemented a ban in February 2018, despite warnings that people would switch to stronger opioids. However, researchers at the University of Sydney found that one year after the ban was implemented, there was an overall 51% drop in codeine overdoses (including high concentration codeine). And there has been a 79 percent drop in overdoses from low-strength codeine, the kind now available only by prescription.

In the UK, the medicines regulator, the Medicines and Healthcare products Regulatory Agency (MHRA), took action in 2009 to reduce the harm caused by over-the-counter opioids, for example by limiting pack sizes to 32 pills per pack and adding important warnings on the packaging not to take the pills for more than three days.

In 2019, the MHRA conducted a review and decided not to make co-codamol a prescription product.

Although codeine-related deaths in England and Wales are quite low, they have increased from 24 deaths in 1993 to 200 deaths in 2021 (200 deaths). It is unclear whether these deaths relate to over-the-counter codeine, prescription codeine, or illicit codeine (for example, bought on the dark web). However, if codeine-related deaths continue to rise, the government may want to reconsider its stance on over-the-counter sales of codeine.

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