President Donald Trump officially declared the opioid crisis a public health emergency in 2017. Provisional numbers from 2017 suggest there were nearly 50,000 overdose deaths involving opioids in the United States. With the introduction of fentanyl, carfentanil, and the newly US Food and Drug Administration- approved (FDA) opioid Dsuvia, the danger of overdose and withdrawal are imminent.
While it is a less potent opioid, data from 2011 reveals that almost 10,000 people were admitted to Emergency Departments (ED) related to non-medical use of codeine. That number has steadily grown over the previous years. Unfortunately, the numbers also show how few people actually get the help they need. Overall around less than 10% of the people needing treatment are able to benefit from quality detox followed by a long-term treatment program to address their substance use, as well as the underlying factors.
Codeine, like morphine, is an opioid. Opioids refer to a class of drugs that when derived naturally, come from the opium poppy plant. In the early 1800s, morphine was isolated from opium and later in that century; heroin was derived from morphine. Codeine is synthesized from morphine and is considered to have a lesser effect, as well as being less likely to result in dependence or addiction.
However, when it is taken in addition to other opioids or alcohol, the side effects can range from manageable to life-threatening such as depressed breathing, slowed heart rate, constipation, nausea, vomiting, dry mouth.
Codeine is typically prescribed for mild to moderate pain, as an anti-diarrhea medication, or included in cough medication with other pain relievers such as ibuprofen or acetaminophen.
Codeine is metabolized in the liver, and depending on an individual’s genetics; one may be a “fast” or “slow metabolizer.” In the case of fast metabolizers, codeine may be processed, and the effects felt much more quickly than the slow or normal rate of metabolism. It is in these cases where the danger for dependence and addiction, and even overdose, lie. Due to this danger, there has been extreme caution issued in the medical community when prescribing medication with codeine to children or nursing mothers.
The brain and the body are constantly seeking harmony to function well. The medical term is homeostasis, and it means that when anything disrupts the CNS, efforts must be made to return to a certain level of stability. For example, when the body becomes hot from exercise or being outside in the sun, we sweat in an effort to cool off or reach the previous level of homeostasis.
Over time, codeine use will interfere with the CNS’ ability to return to a balanced state.
Everything we do affects our central nervous system. The foods we eat, how much sleep we get, the quality of the air we breathe, and water we ingest, and even things like stress and unseen toxins in cleaning products will have some kind of an effect.
Codeine acts specifically on certain receptors that are keyed to respond to opioids, most notably the Mu receptors, and can produce a feeling of euphoria. The euphoria is a result of the flood of dopamine in the brain that opioids produce. Dopamine is the “feel-good” neurotransmitter and is associated with motivation and the reward center in our brains. However, the effect of codeine alone is likely to be less potent than other opioids, as its effect on the receptors are a fraction of what morphine produces.
The opioid receptors are located in areas of the brain that are involved with emotion (the amygdala), memory (the hippocampus), and the reward center of the brain (nucleus accumbens). Opioids also have a depressive effect on two important centers found in the brain stem: the respiratory center, which controls breathing, and the vomiting center, which also allows us to cough. This is why codeine is included in cough medications.
Additionally, opioids produce an analgesic effect. In other words, they relieve pain. While codeine is likely to treat mild or moderate pain only, when taken with other substances, it can become a dangerous situation. For example, both alcohol and codeine have depressive effects on breathing and heart rate, so combining the two can be lethal.
Codeine withdrawal, while not fatal, can be extremely uncomfortable, and should not be undertaken alone. The extent and severity of the withdrawal symptoms will depend on the type, frequency and amount of codeine used by the individual. Typically the experience of withdrawal involves the opposite of the effect the drug produced.
For example, because we know opioids repress the vomiting center and slow digestion to create constipation, one might experience diarrhea or vomiting upon stopping their use.
In extreme cases, chronic withdrawal symptoms can last 10-14 days after the last use of codeine and will often be a less severe experience of the symptoms that occurred during the acute phase.
Chronic use can lead to a number of other health complications including, but not limited to: endocarditis, a swelling within the lining and valves of the heart; collapsed veins; abscesses at injection sites that can become infected, toxic and even need surgery, if untreated.
It is critical to get the help you need to successfully manage withdrawal symptoms and begin a life without the use of codeine. Long-term codeine use can negatively affect respiratory, gastrointestinal, musculoskeletal, cardiovascular, immune, endocrine, and central nervous systems.
When medically managed, most withdrawal symptoms are alleviated within seven days. However, it is important to note that treatment following a medically managed detox will result in a better success rate. Safely removing the codeine from the brain and body is only the first step. There are other psychological, emotional,and behavioral issues to address that will set you up for continued sobriety.
Precipitated withdrawal can occur when an opioid antagonist is introduced in someone who is dependent, and enough of the opioids are still attached to the receptors in the brain. The antagonist will displace the opioids from their receptor sites, and it will feel like a magnified experience of the withdrawal symptoms outlined above. Unless treated, symptoms from precipitated withdrawal can last up to four days.
For example when a patient is not fully transparent about their last use, to include the dose and the time, as well as frequency and usual use, and Suboxone (a medication used to manage withdrawal symptoms and cravings associated with opioid use) is administered too soon, the patient can go into precipitated withdrawal. This is an unfortunate event and can lead the patient to believe that buprenorphine (the active ingredient in the medication) is ineffective in treating their symptoms.
Post-Acute Withdrawal Syndrome (PAWS) refers to a set of symptoms experienced by individuals that are addicted to opioids after a prolonged period of withdrawal. PAWS is known by various terms, which include protracted withdrawal, prolonged withdrawal, and post-withdrawal. PAWS is separate and distinct from the acute phase, which usually occurs in the first two weeks after someone stops using the drug.
PAWS will generally occur two months or more after someone stops using codeine. They are typically psychological in nature and will affect someone’s mood, how they respond to stress, and their sleep patterns. The symptoms will last for several months, and in some rare cases, can last for a year or more. It can be a real threat to a person’s sobriety, and anybody that is experiencing PAWS must speak with their physician about options.
When seeking treatment, it’s important to understand the difference between the various levels of care so you can get the most out of your treatment experience.
Medical detoxification, or plainly detox, is a medically managed detoxification from codeine. Following a thorough history and physical examination, the medical staff will determine the best medication protocol to manage your withdrawal symptoms safely. A full detox can take from three to 10 days, depending on the severity and extent of drug use and is up to the discretion of the medical providers.
Medical complications, using more than one substance, or a history of mental health diagnoses are all examples of when detox may take longer than usual. Treatment centers will require you to successfully complete detox to safely and fully participate in their programs.
Detox can take place in a hospital setting if you have severe or unmanageable medical complications, or it can take place in a standalone detox facility. These standalone, privately run facilities must be staffed 24 hours a day with medical personnel, as well as support staff, to monitor your symptoms and ensure the safest, most comfortable experience possible. Specially trained staff will know how to observe your progress throughout the detox process and will be able to respond to any potentially life-threatening situations.
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Residential treatment typically follows a successful detox and involves living on-site and participating in a variety of therapy options. Individual sessions with a trained therapist, along with group and family therapy sessions, are some of what is required at each residential facility. It’s during this time, you will be examining patterns of thoughts, emotions, and behaviors that may have contributed to your substance use. Residential treatment length of stay will vary depending on your needs, but can typically last from 30 – 90 days following the detox.
Outpatient treatment is intended for those individuals who are in a more stable position medically, physically, and emotionally. After the support from detox and residential care, the activities of daily living on your own are more manageable and you will remain involved with outpatient treatment to continue your journey of recovery.
You will continue to participate in therapy on a less frequent basis and maintain connections with your support system and therapist. This is an important part of your recovery, as it will allow you to transition to the next phase of your life with the support that played such a beneficial role.
Medication-Assisted Treatment, or MAT, is typically a form of outpatient care. It is intended to support those suffering from opioid or alcohol use disorders with a form of medication administered on a longer-term basis than the typical medical detox. FDA-approved medications for the treatment of opioid use disorder are designed to manage withdrawal symptoms, reduce or eliminate cravings to use, and help prevent relapse.
For these reasons, some studies suggest there are better outcomes for those addicted to codeine who participate in medication-assisted treatment following detox. Some form of therapy and medical supervision will still take place during MAT and your provider can assess whether this option is right for you.
In a recovery treatment program, you will be able to address the physical, psychological, medical, and social aspects of codeine addiction, learning through various therapeutic tools how to manage your addictive behaviors effectively and maintain long-term sobriety. This is done through an individualized treatment plan, which you will customize with your therapist.
Again, it is critical to note the best outcomes for the treatment of codeine addiction are associated with participating in the full spectrum of care. A detox treatment alone won’t give you the benefits or the support of a full continuum of therapy. There are many reasons that substance use may have grown into an addiction, but what’s most important is focusing on the resources and solutions that will help you find a new life free from codeine use.
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