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It's time to phase out codeine: CMAJ editorial [Updated]

By Balzafire, Oct 5, 2010 | Updated: Oct 8, 2010 | | |
Rating:
4/5,
  1. Balzafire
    Codeine might be a widely used painkiller, but it's also a risky medication that should be phased out until more research can be done, argues an editorial in the Canadian Medical Association Journal.

    Pediatricians Dr. Noni MacDonald and Dr. Stuart MacLeod write in the editorial that codeine is simply not effective enough as a pain reliever to justify its risks, which include unpredictable reactions and even death.

    Codeine is found in a number of over-the-counter medication mixtures, such as some forms of Tylenol and Aspirin, as well as in prescription formulations.

    The drug is converted in the body into its active metabolite, morphine, which relieves pain. The problem is that some people have genetic variations that cause them to become ultra-rapid metabolizers of codeine

    These people convert standard doses of codeine into morphine much faster than others, leading to higher-than-expected morphine levels in their blood. This can lead to toxicity symptoms such as extreme sleepiness, shallow breathing and in some cases, death.

    Infants and children are particularly vulnerable to morphine overdose, and reports are emerging of infants who died after breastfeeding from their mothers who turned out to be rapid metabollizers.

    People of North African, Ethiopian and Arab origin are most likely to have the genetic variant that makes them rapid metabolizers, but people of Caucasian and Asian background can also have the gene variant.

    The only way to know who will over-metabolize the drug and who won't is to test for the variant through a medical research lab.

    The authors note that genetic testing prior to prescribing codeine is impractical, since the testing is expensive.

    "Perhaps a more direct approach is now needed: to stop using the prodrug codeine altogether and instead use its active metabolite, morphine," they write.

    "Not only is the metabolism of morphine more predictable than that of codeine, but also it is cheaper."

    The authors note that although codeine can been prescribed for decades, there is really very little research on its safety.

    "Because codeine has been in common use for over 200 years, it was never subjected to the regulatory requirement for the rigorous safety studies that are now mandatory for new drugs," the authors note.

    Given the risks of codeine, it's time to reevaluate the drug and how to lessen its risks, they write. Restricting access to codeine for infants and young children is one option, they note, but because not a lot of research has been done on codeine, it is unclear at what age the risks of the drug start to fall.

    The authors say that until more research has been done, doctors should be warned about the potential risks of codeine, especially for newborns and children.


    CTV.ca News Staff
    Oct. 4, 2010
    http://www.ctv.ca/CTVNews/Health/20101004/codeine-cmaj-101002/

Comments

  1. Code9
    Re: It's time to phase out codeine: CMAJ editorial

    I feel odd about critiquing the Canadian Medical Association Journal but this is just absurd. The full editorial is available here. CTV claims it's in the October edition, but it is not. It may appear in the November issue but I highly doubt that it will. The editorial makes no references to actual injury statistics and only discusses the possibility of injury. [Edit: On second thought this does discuss that 20% of opiate deaths in Ontario involve Codeine. It's not said, however, whether Codeine was the only substance or not. One would suspect without more information that some NSAID played a part.]

    The only good suggestion made here is to replace codeine with morphine in various preparations but if this was to happen, you can say goodbye to OTC codeine out of fears of home-brew heroin batches.

    Considering 500 people die in the US every year from liver failure due to acetaminophen [1], it's clear that the CMAJ isn't only concerned with safety. This is a clear example of an 'expert' using public fear to try to manipulate his/her personal agenda.

    [1] Lee, William. Acetaminophen and the U.S. Acute Liver Failure Study Group: lowering the risk of hepatic failure. Hepatology. 2004 Jul;40(1):6-9.
  2. cra$h
    Re: It's time to phase out codeine: CMAJ editorial

    lol, and these are the professionals of society? Elementary school kids woulda figured this out quicker.

    But as for the use of codeine, the biggest problem I had with this is why the fuck would you give babies opiates? The overmedication in society is going to be the death of us. Fuck it, lets start using coke for teething babies again, hell, at least it worked! Oh yea, so does a shot of some Jack Daniels. Logic fail.

    Well, now that that rant's over....

    Ok, so codeine is a tricky drug, but lets look at how it's used. For MODERATE pain. When tyelnol ain't enough, and morphine's too much. It's a good middle ground for now. If we find something new, then we'll switch, but right now, that's where we stand, and should stand until we step forward, instead of backwards and jump forward.
  3. Balzafire
    Re: It's time to phase out codeine: CMAJ editorial

    Codeine's bad rep: should it be banned?

    [imgl=white]http://www.drugs-forum.com/forum/attachment.php?attachmentid=17196&stc=1&d=1286552539[/imgl]The painkiller codeine has been implicated in several celebrity overdoses, most notably that of Elvis Presley, and now it’s killing innocent children too. This has resulted in Canadian researchers calling for its use to be halted until further studies into its safety are conducted, potentially creating a headache for millions of legitimate users.

    The most famous codeine addict ever was perhaps Howard Hughes, the aviator, film-maker and industrialist. Hughes was always a maverick character, but as his life progressed, this tendency towards the eccentric manifested itself as mentally instability. (To be fair, we imagine living for four months in a film studio, without once ever leaving, would make anyone crazy, even if they weren’t before.)

    Hughes, who suffered from obsessive-compulsive disorder, spent a lot of his later life in pain as a result of the numerous plane crashes he was involved in, and became severely addicted to morphine, codeine and other painkillers. He died in 1976, and although his death certificate states he died of kidney failure, it has been alleged that Hughes’ personal physician administered a fatal codeine dose.

    Hughes is far from the only celebrity to have been undone by his codeine craving. It’s suspected that a codeine overdose killed rap artist Pimp C, and Lil Wayne has publicly admitted to being addicted to the drug. Steve Clark, the co-lead guitarist for the British hard rock band Def Leppard also passed away from an accidental lethal overdose of codeine (along with valium, morphine and alcohol), with an autopsy showing that his blood contained at more than three times the British legal limit. Incidentally, significant levels of codeine (as well as other drugs) were found when Elvis Presley was autopsied.

    But just what’s so bad about codeine, as opposed to other pain-relieving medication? Well, when digested by the body, codeine breaks down into morphine, but the amount of morphine generated is contingent on the genetic make-up of a person and on their metabolism, so the effect and reactions cannot be generalised for all users. The dosage of codeine that is considered safe is from 10mg to 60mg, but again, this depends on an individual’s make-up. In other words, taking codeine is a little like playing Russian Roulette (albeit with a greater chance of survival than one in six).

    Although codeine is a widely-used painkiller throughout the globe, the hit-or-miss nature of predicting its potency, its lack of efficacy in some users, and serious side effects in other people, have resulted researchers at Vancouver’s University of British Columbia saying it should be banned.

    Stuart MacLeod and Noni MacDonald published their research in the Canadian Medical Association Journal. They say that infants, in particular, are susceptible to harm from codeine, and cite the example of two children who were administered codeine after a tonsillectomy and died. They also refer to two studies that have indicated infants breastfed by codeine-using mothers can be non-fatally damaged.

    Their public appeal has not gone unheard. The Hospital for Sick Children in Toronto has already stopped codeine usage. The researchers are now asking for more institutions to follow suit. Currently, the Medicines and Healthcare Products Regulatory Agency of the UK has no plans to stop over-the-counter sale of the drug. Florence Palmer from the MHRA, says that the only people who suffer such ill effects have an enhanced metabolism, which is just 1% to 2% of the population, and hence a recall or ban is not called for.

    Australia has planned to introduce some form of regulation of codeine-based painkillers, with a proposal that medicines containing more than 12mg of codeine should be kept behind the counter; a pharmacist is only to dispense them after recording the customer’s details. In South Africa, as in the UK, over-the-counter sales of codeine are legal, and fairly widespread. Whether you need a prescription or not depends on the level of dosage, but codeine-based painkillers such as Syndol, Myprodol and Nurofen Plus are freely available.

    Codeine is extremely popular around the world, but it suffers from the same problem that all painkillers do: since the tolerance of the user grows over time, the dosage needs to increase to bring the same level of relief, potentially planting the seeds of addiction and dependence. The stats on usage can be scary; in France up to 95% of codeine cough syrup consumption is attributed to non-medical use.

    Given the findings of the Canadian research, it would seem a sensible precaution to place greater restrictions around access to codeine, and prohibit hospitals and doctors from handing it out to children. But this won’t bring back Howard Hughes, or any other overdosees, famous or otherwise. Addicts have an uncanny ability to acquire whatever drugs they want – legal or not.

    The Daily Maverick
    8 October 2010
    http://www.thedailymaverick.co.za/article/2010-10-08-codeines-bad-rep-should-it-be-banned
  4. Moving Pictures
    Wow, I never knew that about codeine. It's a weird drug. I always wondered why it effected some people stronger than others.
  5. Code9
    Its generally the same people that define what "medical use" is and report the (95%) statistic.

    All the box needs to say to prevent problems and liability is: "Please consult a health professional if you have never used and codeine-containing products before as it does not metabolize at a constant rate across individuals. Use with caution."

    I linked the CMAJ 'article' in an earlier post but here it is again if anyone's interested.

    Actually, the only research done was literary. It's more like doing a book report than a medical research trial. There there can be no findings, only opinions that could lead to clinical studies.

    It actually hasn't been published yet. The released document is still pending revision. It might appear in a later edition. I wouldn't count on it, the statistics are too vague to even support an editorial opinion.
  6. Code9
    An update: This article was not published on the subsequent (Oct 19th) issue of the Canadian Medical Association Journal.

    It looks as though this will not make the hard copy.
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