Under-reporting of codeine dependence is highly likely and interventions are needed, say Australian researchers in new systematic review

A systematic review published this week in the Medical Journal of Australia has looked at approaches to treating codeine dependence in the wake of the recent upschedule.

Dr Suzanne Nielsen, a Senior Research Fellow at the National Drug and Alcohol Research Centre at the University of New South Wales, and co-authors analysed 41 articles to identify key findings that could inform clinical responses to codeine dependence.

Articles comprised identification studies and treatment studies, including randomised and non-randomised controlled trials, before-and-after studies, prospective and retrospective cohort studies, case-control studies, analytic cross-sectional studies, qualitative studies, case reports and series.

They found problematic codeine use was associated with mental health problems, and that patients experienced serious complications associated with excessive consumption of combination products that included codeine.

Inherent to cases of acute harm were complications attributable to the co-medications paracetamol and ibuprofen, including distal renal tubular acidosis, hypokalaemia, gastritis and other enteropathies, medication overuse headache, hepatic necrosis, hypoalbuminaemia, microcytic anaemia, and weight loss.

Clinical identification of dependence was often delayed, with some qualitative studies referring to stigma acting as a barrier to treatment.

“The quality and methodology of the studies we assessed varied considerably, but their depictions of the features associated with codeine dependence were consistent, describing a clinically challenging area in which under-reporting is highly likely,” Dr Nielsen and colleagues write.

“The reports highlight the importance of asking about the use of non-prescribed analgesics in a range of healthcare situations, particularly when gastrointestinal complications are identified.”

“Careful questioning about recent patterns of use, the reasons for taking codeine, and withdrawal symptoms upon cessation may help identify when a patient should be comprehensively assessed for an opioid use disorder.”

The authors also reviewed approaches to treatment, which include self-management with internet support, psychological treatments, symptomatic medications for opioid withdrawal, and opioid agonist treatments.

“Codeine dependence can be identified by screening patients who present with acute complications associated with taking combination analgesics, and by routine questioning about over-the-counter medication use,” the authors conclude.

“Common treatment approaches include detoxification and opioid agonist treatment, with many treatment studies supporting the use of buprenorphine-naloxone in this clinical population.

“Clinical leadership in responding to the treatment needs of those codeine dependence is required as a matter of public health, and is timely given the recent rescheduling of codeine in Australia.”