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Codeine is a member of the opioid class of medications and is used to manage pain. Codeine is also used to treat cough. For mild-to-moderate pain, codeine is often used as a combined medication with acetaminophen or with an NSAID like ibuprofen. The drug is often available as a combination product with promethazine or an NSAID like salicylic acid for cough and cold. Codeine is often marketed in the form of tablets and syrups. While opioids are valuable agents for treating pain, they also carry a high risk of misuse, abuse, addiction, and increased mortality, as demonstrated by the current opioid epidemic and accompanying overdose deaths. This activity outlines the indications, mechanism of action, contraindications, adverse events, and other important aspects relating to the use of codeine in the clinical setting. The use of codeine by interprofessional team members relates to the potential for opioid misuse and the associated consequences, along with the appropriate indications. Objectives: Differentiate between appropriate and inappropriate candidates for codeine therapy, considering factors like age, medical history, and potential drug interactions. Screen patients for risk factors of opioid misuse, abuse, or addiction before initiating codeine therapy. Assess the patient's response to codeine therapy, including pain relief, adverse effects, and any signs of misuse or addiction. Implement collaboration within an interprofessional team to develop comprehensive pain management plans that address individual needs while minimizing the risks associated with codeine use. Access free multiple choice questions on this topic.

Deaths related to opioid toxicity have increased in the past decades, and a significant proportion of the increase derives from accidental overdoses. Opioid overdose is characteristically associated with a triad of abnormally slow respiration (apnea), decreased consciousness (coma), and pinpoint pupils (miosis). Codeine has a narrow therapeutic index, with a dose of 500 to 1000 mg usually proving fatal, though codeine-dependent individuals have been reported to use as much as 1536 mg daily.[2] This patient population is presumed to have a history of issues related to substance misuse/abuse, injection drug use, and chronic pain. These patterns indicate that, in accidental deaths, any number of strategies are being used by patients who engage in codeine misuse, including supplementing codeine with prescribed pain medication, persistently escalating dosages without clinician approval, and selling/buying the drug outside of regulatory control. Therefore, a clear need exists for specialist intervention for pain management in a complex patient population.[26] Maximum Tolerated Dose Immediate-release preparation: 360 mg per day Controlled-release preparation: 600 mg per day Treatment of toxicity depends on both the symptoms and degree of intoxication. Toxicity involves symptomatic treatment (ie, enema for constipation) and definitive reversal with the opioid antagonist naloxone for life-threatening adverse effects like respiratory depression. If the patient is physically dependent on opioids, the administration of opioid antagonists may precipitate acute withdrawal syndrome. Consequently, clinicians should prescribe opioid antagonists cautiously in patients with physical opioid dependence, and decreased dosages of antagonists should be considered for known dependent patients.

Managing drug overdose requires an interprofessional team of nurses, laboratory technologists, pharmacists, and clinicians in different specialties. While codeine is effective for its approved indications, without proper management, the morbidity and mortality from codeine overdose remain high. The moment the triage nurse has admitted a codeine overdose, the emergency department clinician is responsible for coordinating the care, which may include any number of the following: Ordering blood and urine samples Monitoring the patient for signs and/or symptoms of respiratory depression, cardiac arrhythmias, and narcotic bowel syndrome Possibly performing any number of interventions designed to help limit the absorption of the drug in the body. Consulting with the pharmacy about the use of activated charcoal and naloxone[27] Consulting with toxicology and nephrology regarding further management, up to and including dialysis Imaging may be used to help evaluate the extent of ingestion (ie, suicide attempts involving ingestion of whole pill bottles) The management of codeine overdose does not stop in the emergency department or with the prescribing clinician. When the patient is stabilized, clinicians should try to ascertain how and why the patient overdosed. Consultation with a mental health counselor is advised to determine whether it was an intentional act of self-harm by the patient. Further, the possibility of addiction and withdrawal symptoms has to be considered. Only by working as an interprofessional team can the morbidity of codeine overdose decrease. Initial short-term data reveal that the use of naloxone can be life-saving.[28] The long-term outcomes of detoxification and drug rehabilitation remain guarded since addiction is a chronic disease.[29] In 2018, the FDA implemented the Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS) program, designed to reduce the risk of misuse, abuse, addiction, overdose, and deaths due to prescription opioid analgesic use. As part of this program, drug companies with approved opioid analgesics provide unrestricted grants to accredited CE clinicians to develop courses on how to safely and properly write and dispense these medications for common acute and chronic pain indications.

In 2018, the FDA implemented the Opioid Analgesic Risk Evaluation and Mitigation Strategy (REMS) program, designed to reduce the risk of misuse, abuse, addiction, overdose, and deaths due to prescription opioid analgesic use. As part of this program, drug companies with approved opioid analgesics provide unrestricted grants to accredited CE clinicians to develop courses on how to safely and properly write and dispense these medications for common acute and chronic pain indications. All care team members are tasked with informing the rest of the interprofessional team if they note any concerns with patients using codeine, from therapeutic failure to possible misuse; open communication channels are crucial. Nursing staff should routinely assess for signs of overuse or toxicity and conduct interviews to ascertain appropriate administration. Pharmacists can observe for signs of "doctor shopping" and other at-risk behaviors and alert prescribers regarding their observations. They can also provide patient counsel and answer questions to help prevent accidental overdosing. All healthcare professionals are strongly recommended to complete the REMS education program and advise patients and their caregivers on the safe use and serious risks associated with opioids based on these parameters.[30] Similarly, the efficient use of the Prescription Drug Monitoring Program (PDMP) can identify patients who are likely at risk of developing dependence and subsequent addiction to opioids.[24] Given the potential for misuse, clinicians must be aware of a patient exhibiting adverse effects of codeine use. Only with a collaborative, interprofessional, team-centered approach can the drug be safely used for its intended purpose without causing adverse outcomes.