The quiet dangers of codeine

Oh the relief: Nurofen Plus is an effective painkiller in the right hands.
Oh the relief: Nurofen Plus is an effective painkiller in the right hands.

At base, says the witness, drug abuse is none of the things you see in the movies. There is no riding around with hip young nihilists like Drugstore Cowboy, no fleeing from authority to an electro-pop beat as in Trainspotting.

What it comes down to in real life is the solitary mutation of a healthy being into an old person. They drool, they fall asleep mid-sentence, they can't remember, their eyes roll back, they get fat, they're hot and cold at random, awake and asleep in dribs and drabs all round the clock, short of the toilet by a few steps fairly often and they get things wrong. Again and again and again. They ding their cars, heads loaded after the big trips around town to the chemists. They screw up and can't get another job. It's voluntary Alzheimer's and no matter what they once meant to you, no matter what the life they once led, no matter how popular and lovely and bright they once were, they become a weight.

The over-the-counter pill of choice for most is codeine. It's in the opioid family and comes packed in pain relief from the chemist. Heavy users' moments without it are given over to exactly two things: A crushing despair mixed with a cloying self pity and the need for more drugs. The second is to drown the first and produces an almost supernatural drive, the sort of obsessed hunger you only otherwise see in top sportsmen or businesspeople. The pill-junkie Jesus would go through your pockets looking to score, would lie to the face of God with a smile and leave you on the cross in a heartbeat to get high instead.

They like television. But even that passive nullity is too much. They nod out all the time. A user's giveaway is the corona of cigarette burns on the floor and clothes, curtains and furniture. Even on the mats that cover the original burns on the carpet. Even on the cat. They will watch the same thing over and over because it's always new to them, again. They become a lump of biology, human only in the strict legal sense.

Codeine is simple to score. The most popular brand for abusers is Nurofen Plus, with a nice 12.8 milligrams of cody inside. They are locked away in a glass display, but it's just a matter of asking for them. Say you have back pain. The lady in the chemist shop will take your name. That is, they will take a name. It doesn't have to be yours - they won't ask for ID. A big show is made of entering it into the shop's computer. That's OK, too - that doesn't go anywhere, pharmacists don't datashare. You can walk around the block to the next drugstore and buy more right away. In a bigish city, it is possible for a heavy user to drive around the chemist shop circuit practically infinitely without raising suspicions. As long as you don't hit the same store again too soon, it will be cool.

At least up to the point it burns a hole in your stomach. Because what usually gets codeine junkies into A and E is not the codeine itself. That's because the N-Plus fun-pack pill comes with a boring chunk of ibuprofen painkiller. You can't separate it from the codeine and too much of it will drill your lining through like you drank a cup of Janola.

Geoffrey Robinson is the chief medical officer at Capital and Coast DHB. In 2010, he helped write a paper for the New Zealand Medical Journal.

He and fellow researchers looked at seven Nurofen Plus abusers who wound up in emergency. None had actually overdosed, though that happens. All instead turned up with serious damage to their stomachs.

The maximum recommended dose per day is six. The lowest level junkie was a 63-year-old woman who had been topping up her prescribed codeine with 20 a day for three years. The worst was a 31-year-old woman supplementing her booze and dope with an incredible 120 Nurofen Plus every 24 hours for two years, despite already having part of her stomach removed.

Robinson says no one knows how many people are abusing codeine.

Only the acute cases get to hospital or into therapy and even they aren't collated anywhere. There are some indications. The National Poisons Centre is rung up by doctors and ambulances and even hospitals for advice when someone has swallowed something they shouldn't have. In the period from July 2007 to June this year, the centre consulted on just 53 intentional overdoses of ibuprofen/codeine combos. But that's not everyone who takes too much.

Only two of the seven over-the-counter drugs favoured by abusers contain ibuprofen, anyway. Most counselling services say at the level they see people (which is usually court-ordered or desperate), it is not a big problem. The majority of codeine users rot peacefully under the radar.

Robinson's paper in the journal wasn't about the junkies or how to treat them. It was about why there should be any at all.

“At low doses, the codeine is probably not doing much, anyway.

"If you take Panadeine, it's got 8mg. Those sorts of doses don't do much for analgesia [pain relief].”

Codeine doesn't kick in as a pain reliever, over and above the ibuprofen or paracetamol in the drugs already, until around the 30mg level.

“I don't know why it's in there - I think because no one in authority has ever taken a stand.”

Ross Bell, of the NZ Drug Foundation, says it simply: The codeine makes the pills moreish. Tim Harding, chief executive of addiction treatment provider Care NZ, describes it as an arms race.

“In the old days, there used to be things like Codral Forte that contained 30mg of codeine,” he says.

"It took us a lot of time to get that down and when it went down to the Panadeine 8mg, we were kind of relieved. There didn't seem to be nearly as much problem with that. But we watched [UK multinational Reckitt Benckiser] come out with Nurofen Plus [12.8mg] and thought: oh jeez, that's a lot of codeine. It was really popular and then Panadeine [made by UK multinational GlaxoSmithKline] came out with Panadeine Plus [15mg, now called Panadeine Extra]. And if you don't regulate it, they will keep doing that and go higher and higher.”

It is still not an emergency at the top end of the treatment scale, but 10 years ago, it was just about unknown. The lower level addicts are out there.

“Codeine makes you feel good,” says Harding.

“They take some for a headache and it makes them feel better that day. And then they take a couple more and feel even better. Then they take a couple in the morning and find they feel really good. And in the afternoon they start to feel a bit down, so they take another couple. A week or two later they might be taking three lots of two a day.”

Care NZ sees more over the counter junkies now than it used to, but Tim Roper wants hard figures.

“Unless I see some data to suggest there is an increase or a problem with abuse, the whole issue as far as [the Government's medical safety authority] Medsafe is concerned was dealt with a couple of years ago when there was, to some extent, a problem around products containing codeine.”

In 2010, Medsafe dropped the maximum pack size to 30 pills. Before that it was possible to buy up to 100 pills a pop in some of the codeine classes.

A warning label was stuck on the pack, too. Roper is the executive director of the Self Medication Industry Association, a group representing those who make and sell over-the-counter drugs. It would be easy to paint him as the bad guy and the association as an all-powerful octopus, funnelling orders from drug HQs in Slough and London to Wellington. But that doesn't appear to be the case. The association tried to keep pseudoephedrine in over-the-counter flu medicines in 2009, but lost.

The substance was made prescription only as the Government responded to panic over its use in making methamphetamine.

This, despite experts pointing out most precursors for meth were imported in containers rather than bought piecemeal from chemists and that the replacement phenlyphine was not nearly as good. New Zealanders took a step back in terms of healthcare, frightened off good drugs by criminals.

Roper doesn't want to see it happen again.

“You are always going to have a hard core who are addicted to codeine and will abuse it. But the problem is Nurofen Plus and Panadeine are very effective analgesics.”

With pseudoephidrine, the association originally pitched a solution for New Zealand that is used in Queensland - data-linked computers in chemists monitored by the cops. Roper denies there is a need for a similar solution to codeine abuse, because it's not clear there is a big problem.

There is also resistance to taking the codeine out of the drug altogether.

“I'm not sure codeine is not effective. The fact is, people take Nurofen Plus and find it more effective than taking paracetamol or ibuprofen on their own. If that's the case, why is that?”

Maybe they like getting high?

“I don't buy that,” he says.

“I'm not familiar with people who take codeine to enhance their mood.”