Bad medicine: co-codamol

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The UK Home Office has recently highlighted the sharp rise in prescribing, misuse, and deaths linked to tramadol.1 We’ve known tramadol as a problem in general practice for years. And death from prescription drugs is but the merest tip of an addiction iceberg, with at least 800 other misusers for every death, according to US data.2 The UK has been slow to acknowledge misuse of prescription drugs, a problem described as an epidemic in the US, where prescribed opioids kill 15 000 people a year2 and misuse of prescription drugs is as big a problem as illegal drugs and alcohol.

We have another, far bigger potential problem than tramadol: codeine combined with paracetamol—co-codamol. A parliamentary report in 2009 highlighted addiction to low strength co-codamol sold over the counter.3 The report called for more awareness, control, and education. Yet since this report, use has increased further, with a doubling of co-codamol prescriptions in a decade.4 Prescribed co-codamol is stronger and is dispensed in much larger pack sizes than that sold over the counter. Indeed, doctors prescribe five times as much total codeine than is bought over the counter.4 5

I witness addictive behaviours, especially with co-codamol 30/500 (30 mg codeine phosphate and 500 mg paracetamol per tablet), with patients massively exceeding the recommended dose, taking many tablets as a single dose, and sourcing prescriptions from relatives. Patients can be aggressive and defensive if questioned and experience classic physical and psychological opioid withdrawal. Patients risk fulminant liver failure from unintentional paracetamol poisoning. The medical indication for co-codamol was a long forgotten, vague, musculoskeletal pain. Yet repeat prescriptions of co-codamol are churned out monthly on repeat prescribing systems, out of the sight and consciousness of doctors. Co-codamol—a legal, seemingly safe, and legitimate addiction—has an atypical dependent population: young women. This may be simple anecdote lacking in evidence, but the internet rattles with accounts of co-codamol addiction. There are also huge anomalies in prescribing, with a fivefold difference in prescribing rates by region, unexplainable by disease rates.6

Doctors have been encouraged to use opioids in non-malignant pain syndromes, told that, if used therapeutically, opioids do not cause addiction. This is not true. Co-codamol addiction is grossly under-reported because official statistics relate to referrals to addiction services. General practitioners do not refer patients with co-codamol dependency to addiction teams. The true scale of the problem is reflected in a UK website for codeine dependence, which has counted more than three million visitors since 2007.7 We need some urgent research, action, and honesty. Doctors and patients are in denial about the scale of unaddressed addiction to co-codamol. This is very bad medicine.