Last Updated Dec 2, 2021
Codeine may not be a very potent opioid, but it is still an opioid with significant abuse and addiction potential. It should not be misused and can be especially dangerous if mixed with other drugs.
What Is Codeine?
Codeine is an opioid painkiller used to treat mild-to-moderate pain. It is sometimes combined with other medications to reduce coughing.
While it has legitimate medical uses, codeine is also a drug with significant abuse and addiction potential, and doctors must be careful when prescribing it. It should only ever be used as prescribed and, ideally, only for a limited period of time.
Key Facts About Codeine
Here are some key facts about codeine:
- Codeine is only approved by the FDA for use as a painkiller, although physicians can and do frequently use it to suppress cough, treat restless leg syndrome, and reduce persistent diarrhea.
- While a true opioid, codeine has a comparatively low potency compared to other opioids, meaning it takes more codeine to produce the same effect compared to most other opioids.
- Exact data on codeine abuse and addiction is fairly limited, but more general data shows America remains in a serious opioid abuse epidemic, with a sharp upward trend in opioid-related overdose deaths each year since 1999. In 2020, 68,630 opioid overdose deaths occurred, although only a small amount of these deaths can likely be primarily attributed to codeine.
- One major concern in this overdose crisis is people mixing prescription opioids like codeine with synthetic, street opioids like fentanyl, as these types of mixed overdose deaths are spiking upward even as overdose deaths from only using prescription opioids falls.
Common Names for Codeine
Codeine has a variety of street names, including these:
- Captain Cody
- Little C
- School boy
Codeine is also frequently mixed with Tylenol. In this combination, it is commonly called the following:
- Doors and fours
Codeine cough syrup is frequently mixed with soda. This combination is known by the following names:
- Purple drank
- Texas tea
None of these combinations should be considered safe or less potentially addictive than codeine on its own. Any drug mix that contains codeine should be considered to have high abuse and addiction potential. Polydrug use can often be more dangerous than using a drug on its own.
What Makes Codeine Addictive?
Codeine is potentially addictive for the same reason all opioids can cause addiction. Opioids act on special receptors called opioid receptors in the brain. This process triggers the same processes that make us feel good when we perform basic life functions like eating or having sex.
While this process blocks pain, the hijacking of the brain’s reward processes can also have a negative impact if the drug is not prescribed and used carefully.
With repeated use, a person can become physically and psychologically dependent on opioids. Their brain can develop lasting associations with pleasure and opioid use, and this can create strong drug cravings. Their brain can also become “rewired” by opioid use, with the brain beginning to adjust to the way opioids act on its reward center.
When a person doesn’t have opioids in their system, this adjustment can cause uncomfortable, flu-like withdrawal symptoms. Altogether, opioids can create a feedback loop, where a person craves the good effects of opioids and feels especially bad when not on opioids compared to a person who hasn’t become physically dependent on them.
Signs & Symptoms of Codeine Addiction
Most opioids cause more or less identical symptoms when used. The intensity of symptoms is dependent on a number of factors, with the amount and potency of the opioids used playing a major role.
Some common signs of opioid addiction, which would include codeine addiction, include the following:
- An inability to control opioid use, even once the negative consequences of that use are understood
- Uncontrollable drug cravings, especially when one has not used opioids for some time
- Drowsiness or fatigue
- Changes to sleep habits
- Weight loss
- Frequent flu-like symptoms (a common sign of opioid withdrawal)
- Decreased libido
- Worsening hygiene
- Changes to exercise habits
- Isolating behaviors, separating oneself from friends and family
- Stealing from friends, families, and businesses, generally to support one’s drug habit
- Financial difficulties as a result of buying drugs and potentially neglecting important duties like working
Who Typically Misuses Codeine?
Almost anyone has the potential to become addicted to opioids if they engage in opioid misuse.
Nearly all ethnic and age groups have seen a rise in opioid-involved overdose deaths, with older Black people aged 45 to 64 in large central metropolitan areas and non-Hispanic white people aged 25 to 34 years in large fringe metropolitan areas seeing especially big jumps.
Historically, opioid-involved overdose deaths have been low for non-Hispanic Black individuals and Hispanics (although these numbers have been increasing, as the previous note about rising deaths highlights). Importantly, this doesn’t paint an exact picture of the rate of codeine misuse specifically, as a major recent concern relating to overdose deaths has been illicitly manufactured fentanyl, and a person can obviously misuse codeine without overdosing.
It’s also important to note that many people who misuse opioids don’t necessarily have a strong opinion about what opioid they misuse as long as they can get the effect they want. Access to a particular drug plays a major factor in how much a person is at risk of using it.
Mixing Substances With Codeine
Mixing codeine with other drugs has the potential to be very dangerous. It can complicate treatment in the event a person has a serious medical emergency as the result of their drug use.
One common combination of drugs involves opioids and benzodiazepines. If one of these drugs is being used as part of a person’s treatment, it can significantly increase their risk of overdosing and experiencing other negative health outcomes if they take the other drug recreationally.
Mixing codeine syrup with soda to make purple drank (also called lean) is another common codeine combination. Despite the popularity of this kind of drug misuse on social media, this mixture comes with serious health risks, including respiratory depression, delirium, and overdose.
Don’t mix codeine with any substance without first asking a doctor. Codeine should only be used if prescribed and only as prescribed.
Can You Overdose on Codeine?
It’s possible to overdose on codeine, although this is likely fairly rare due to its relatively low potency. Codeine is about 1/10th as strong as morphine, which is often the “standard” opioid to which other opioids are compared when measuring potency.
With that said, an opioid overdose is just as dangerous regardless of the opioid used. Misusing codeine can also have other health effects with misuse beyond just potentially leading to an overdose.
Opioid Withdrawal Symptoms
Acute opioid withdrawal, which is the initial stage of withdrawal once a person stops taking opioids after becoming dependent, is characterized by the following:
- Runny nose
- Heavy sweating
- Irregularities with the heart
While this isn’t usually life-threatening, it can cause dehydration and is generally uncomfortable. This process can be made easier by undergoing withdrawal with the help of an addiction treatment provider.
Once this very early stage of withdrawal is over, a person may continue to feel generally unwell and experience strong drug cravings. While still uncomfortable, it is usually easier to function at this stage, although a person should still be working with addiction treatment professionals to learn strategies to get through this stage while avoiding misuse of any drugs.
Oftentimes, medication-assisted treatment (MAT) is recommended for opioid addiction (opioid use disorder). Medications like methadone or buprenorphine may be given on a long-term basis to lessen or prevent withdrawal symptoms and manage cravings. This helps people to find their footing in the early stages of recovery when they are often most vulnerable to relapse.
An opioid overdose has the potential to be fatal or cause permanent brain damage. It is a very serious occurrence that requires prompt, immediate medical attention.
If a person exhibits any of the following symptoms, or you are unsure whether they are or not, call 911 immediately and begin acting under the assumption a person is overdosing:
- Their skin is extremely pale or clammy to the touch.
- They have gone limp or are very weak.
- Their fingernails or lips have turned purple or blue.
- The person is vomiting or making gurgling sounds.
- The person is unresponsive or cannot be awakened.
- The person’s heart or breathing have stopped or slowed.
The major concern from misusing any opioid is respiratory depression. With enough opioids, especially if combined with other drugs that cause respiratory depression, a person may literally be unable to breathe in enough air to support their body and brain. If they get to this point, that is extremely dangerous, as they essentially begin to suffocate.
What to Do if You Suspect an Overdose
A person overdosing on opioids should be administered the drug naloxone if it’s available. If a person has stopped breathing or is breathing only very weakly, begin CPR.
Never “wait and see” if you suspect a person is overdosing. If you’re unsure whether a situation is a medical emergency, treat it as one and call 911.
Generally speaking, people who call for help in these situations are protected against legal action as a result of illegal drug use. This is part of an effort to reduce opioid deaths and encourage people who need medical attention to get it if it’s needed, even if they need help as the result of potentially illegal activities.
Treatment for Codeine Addiction
The best way to treat opioid addiction of any kind generally involves a comprehensive addiction treatment program that includes medical detox and therapy.
Most addiction recovery programs begin with talking with an addiction treatment professional about your options and forming a treatment plan. These plans commonly include some combination of the following:
- Medical detox
- Behavioral counseling and therapy, notably cognitive behavioral therapy
- Medications to directly combat addiction, including methadone and buprenorphine
- Medications and treatments to treat withdrawal symptoms, such as anti-nausea medications
- Evaluation and treatment for co-occurring mental health issues, such as depression or anxiety
- Long-term follow-up care to help prevent relapse
Treatment programs can broadly be broken up into two categories: inpatient and outpatient treatments.
Inpatient treatment involves staying at a facility for multiple days or weeks, where you will undergo care in a facility that is equipped to treat addiction and with medical professionals almost always nearby. Outpatient treatment provides more autonomy, as you receive treatment at a facility or even online, and then go about the rest of your day as normal.
The best option for you will depend on your own needs. Inpatient care is generally more expensive but undeniably more comprehensive. It is very helpful for some people, especially those in crisis.
Regardless of which type of treatment you get, aftercare should be part of the plan. Aftercare plans often include ongoing therapy, regular attendance at support group meetings, and activities that support a healthy lifestyle. With the right plan in place, you can maintain recovery from codeine addiction and live a balanced life.
Codeine. (December 2020). National Library of Medicine.
Codeine. (June 2022). StatPearls.
Dose Equivalents and Changing Opioids. Faculty of Pain Medicine of the Royal College of Anaesthetists.
Overdose Death Rates. (January 2022). National Institute on Drug Abuse.
Substance Use – Prescription Drugs. (April 2022). National Library of Medicine.
The Neurobiology of Opioid Dependence: Implications for Treatment. (July 2002). Science & Practice Perspectives.
Signs of Opioid Abuse. Johns Hopkins Medicine.
Racial/Ethnic and Age Group Differences in Opioid and Synthetic Opioid–Involved Overdose Deaths Among Adults Aged ≥18 Years in Metropolitan Areas — United States, 2015–2017. (November 2019). Centers for Disease Control and Prevention.
Polydrug Abuse: A Review of Opioid and Benzodiazepine Combination Use. (August 2012). Drug and Alcohol Dependence.
Representations of Codeine Misuse on Instagram: Content Analysis. (March 2018). JMIR Public Health and Surveillance.
Purple Drank: A Dangerous Cocktail. (November 2016). Archives de Pediatre.
Beyond the ‘Purple Drank’: Study of Promethazine Abuse According to the European Medicines Agency Adverse Drug Reaction Reports. (January 2021). Journal of Psychopharmacology.
Opioid Overdose. (September 2022). Substance Abuse and Mental Health Services Administration.
Opioid Withdrawal. (September 2022). StatPearls.
Treatment Approaches for Drug Addiction. (January 2019). National Institute on Drug Abuse.
Table of Contents