Earlier this yr, the NHS introduced that it had lower opioid prescriptions by nearly half one million in 4 years. But opioids aren’t simply out there on prescription within the UK. They might be purchased over-the-counter at pharmacies within the type of co-codamol – drugs that comprise codeine and paracetamol.
Each co-codamol capsule incorporates a set quantity of 500mg of paracetamol and between 8mg and 12.8mg of codeine, relying on the product. (Co-codamol with greater than 12.8mg of codeine is just out there on prescription.)
Co-codamol is the second most allotted painkiller in England after paracetamol – with over 15 million packs offered in 2021. In 2023, the UK was estimated to be the third largest client of codeine at over 28 tonnes after India and Italy (75 tonnes and 33.5 tonnes, respectively).
Codeine is taken into account a “weak opioid” – 10mg of codeine is the same as 1mg of oral morphine. Once ingested, a liver enzyme referred to as CYP2D6 converts codeine into morphine. However, some ethnic teams, akin to individuals from north Africa, produce extra of the CYP2D6 enzyme (so-called ultra-rapid metabolisers) and so are at better danger of hurt, even at common doses.
Co-codamol is supposed for use to deal with gentle to average ache – akin to interval ache or toothache – however as a result of it may additionally create a euphoric impact, it’s prone to being abused.
Codeine could cause severe hurt, together with dizziness, confusion, problem respiration and even loss of life. These dangers are particularly nice amongst ultra-rapid metabolisers, and amongst individuals who use different drugs, akin to benzodiazepines.
Some individuals purchase co-codamol to deal with their longing for heroin when there are native heroin shortages. But anecdotal reviews recommend that this drug could also be abused by individuals who begin taking the drugs to deal with ache and find yourself being addicted.
Cold-water extraction
In principle, the paracetamol within the drugs ought to forestall individuals from abusing them.
A most single dose of paracetamol for an grownup mustn’t exceed 1,000mg (two co-codamol drugs) as it may hurt the liver. However, on-line teams share a easy methodology referred to as “cold water extraction” for eradicating the paracetamol.
Clinical toxicologists at Guys’ and St Thomas’ Hospital in London discovered case research which recommend that the tactic is pretty efficient at eradicating paracetamol from the drugs, and a laboratory check backs this up.
It just isn’t clear how widespread this type of tampering is, however a YouTube clip (now eliminated) exhibiting viewers find out how to carry out the process had been watched greater than half one million instances.
Pharmaceutical corporations have but to give you an enough approach to forestall this type of tampering.
Twenty-five international locations have banned over-the-counter codeine
Given the drugs’ potential for abuse, not less than 25 international locations, together with Germany, Japan and the US have banned over-the-counter codeine gross sales.
Australia additionally applied a ban in February 2018, regardless of warnings that folks would change to stronger opioids. However, researchers on the University of Sydney discovered {that a} yr after the ban was applied, there was a 51% drop in codeine overdoses total (together with high-strength codeine). And there was a 79% drop in overdoses from low-strength codeine, the kind now solely out there on prescription.
In the UK, the medication regulator, the Medicines and Healthcare merchandise Regulatory Agency (MHRA), intervened in 2009 to cut back harms from over-the-counter opioids, akin to limiting pack sizes to 32 drugs per pack and including outstanding warnings on packs to not take the drugs for greater than three days.
In 2019, the MHRA performed a overview and determined in opposition to making co-codamol a prescription-only product.
While codeine-related deaths in England and Wales are pretty low, they’ve elevated from 24 deaths in 1993 to 200 deaths in 2021 (200 deaths). It’s not clear if these deaths relate to over-the-counter codeine, prescription codeine or illicit codeine (say, purchased on the “dark web”). Nevertheless, if codeine-related deaths proceed to rise, the federal government might want to rethink its place on over-the-counter gross sales of codeine.
Author: Amira Guirguis – Swansea University