Europe's silent opioid epidemic

April 5, 2018 by Gary Finnegan, From Horizon Magazine, Horizon: The EU Research & Innovation Magazine
Codeine addiction is a widespread problem which can be hard to diagnose, study says. Credit: U.S. Air Force/ Senior Airman Hailey R. Staker

As opiate addiction continues to grip the United States – killing more than 100 people per day in 2016 – researchers are trying to get a handle on the scale of the problem in Europe.

The US is grappling with a major crisis driven by dependency on opioid painkillers such as fentanyl. These highly addictive prescription drugs are chemical cousins of heroin, morphine and methadone.

Strong opiates are tightly controlled in Europe but several EU countries allow over-the-counter sales of a milder pain medication: . While less dangerous than heroin or fentanyl, codeine is turned into morphine in the liver and can still be toxic in high doses.

'It's a hidden addiction,' said Dr. Michael Bergin of Waterford Institute of Technology, Ireland. 'Codeine abuse affects people with diverse profiles, from children to older people across all social classes.'

Some are children who got hooked on cough medicine that contains codeine – although these products are not recommend for children. Others are heroin and morphine addicts who use codeine as an occasional substitute for harder opiates.

'But we have also identified middle-aged respectable women who became addicted to codeine having used it for pain relief or, in some cases, anxiety,' Dr. Bergin explained.

Globally, demand for codeine is high and rising – up by approximately 27% over the last decade, although precise data on codeine use is hard to come by. Information on sales is deemed by companies to be commercially sensitive and, as the painkiller is often paid for directly by consumers rather than reimbursed by a medicines payment scheme, there is no central database tracking how many people are using it, nor how much they are buying.

One project, CODEMISUSED, set out to understand how widespread codeine abuse is by interviewing users, pharmacists and doctors. It found that access to the drug varies widelyacross Europe, with pharmacists in some countries requiring a doctor's prescription before they can dispense it.

In other jurisdictions, codeine is sold on demand. Several countries allow over-the-counter sales but apply limits to how much can be purchased and provide pharmacists with guidelines on how to limit abuse. Online sales have also grown strongly, according to researchers, with patients obtaining the drug without needing to engage with health professionals at all.

An online survey of 450 codeine users found high levels of craving among regular users. The research, conducted by King's College London, UK, and Waterford Institute of Technology, found 20% of respondents were dependent on codeine.

'My helper'

In-depth interviews by the Waterford-based research team found codeine addicts sometimes combine the drug with alcohol and other drugs. Users said they turn to over-the-counter codeine at the first sign of pain, anxiety or stress, some referring to it as 'my helper' and 'companion'. However, several interviewees were surprised to learn that a relatively accessible product was addictive and a member of the opiate family.

For community pharmacists, codeine abuse is a real challenge. The drug has legitimate uses, making it difficult to refuse a customer who may be taking codeine appropriately. 'Codeine addicts speak about what they call pharmacy hopping or pharmacy tourism,' said Dr. Bergin. 'They would go from one pharmacy to another, sometimes buying 40 or 50 boxes in a single day.'

Dr. Pádraig McGuinness, superintendent pharmacist of the CARA Pharmacy group, who worked with CODEMISUSED, said a brief intervention – warning the patient of the risks of opiate addiction – can be more effective than flatly refusing to sell it. 'The customer may simply go down the street or to a different town with a different story,' he said.

One solution examined by the project could be to implement an online tracking system similar to one introduced in South Africa, which allows pharmacists to share data on codeine purchasers and cap sales to any individual at 4 grams per month.

CODEMISUSED, which finished last year, published an extensive review of best practices and innovative approaches to balancing access to codeine with reducing the risk of addiction. These include manufacturing formulations of codeine that are less easily converted to the stronger opioid injectable deso-morphine, public information campaigns, tighter surveillance of codeine sales, training for pharmacists to help them identify codeine dependency, and responsible prescribing practices where prescriptions are required.

Doctors also play a crucial role in recommending codeine and in identifying dependency. As health professionals with long-standing relationships with patients, they are well-placed to tackle addiction but are also in the difficult position of having to refuse or moderate the use of painkillers for people in their own community.


Better training could help them play a more decisive role. A survey of almost 400 medical professionals carried out by CODEMISUSED found that 77% of doctors routinely reviewed patients prescribed codeine, but only 21% said they were confident in identifying codeine dependence. Three-quarters said more instruction on alternative pain management options would be valuable.

The role of educating general practitioners (GPs) in managing addiction is the focus of a separate project, BEAMED. Through a collaboration between Ireland and Canada, researchers are testing a specialised training programme used in Canada in a European context.

'GPs are well placed to identify and treat mental health and substance use problems,' said Dr. Walter Cullen, professor of urban general practice at University College Dublin (UCD), Ireland.

'Improving the identification and treatment of addiction-related issues through education and training is a global challenge. The lessons from this programme (in Canada) will be examined to inform future developments in the EU.'

Across Europe, family doctors have a growing role in addiction, ranging from the provision of methadone for opioid users to managing other addictions such as alcohol and nicotine.

The British Columbia Centre on Substance Use has developed an addiction medicine fellowship which equips to lead state-of-the-art addiction services. By borrowing from this model, services in Ireland and other EU countries can be improved, according to Dr. Jan Klimas who works at the University of British Columbia in Canada and UCD.

'By applying proper training, evidence-based tools and resources, the pool of addiction specialists will increase,' he said. 'This will help to identify drug use earlier, preventing its escalation to substance use disorders and reducing the number of patients in need of treatment.'

Explore further: Why making codeine products prescription-only is a good idea

Related Stories

Why making codeine products prescription-only is a good idea

May 6, 2015
Australia's drug regulator is looking into reclassifying about 150 codeine-based drugs as prescription-only. This means they will no longer be available for purchase over the pharmacy counter. The easy and widespread availability ...

Black box warning slows, but doesn't stop, codeine for kids after tonsil removal

November 16, 2017
Despite an FDA black box warning against prescribing children codeine following tonsil and adenoid removal, 1 in 20 children undergoing these surgeries continued to receive the opioid, a new study suggests.

Codeine risky for kids after certain surgeries, FDA says

February 21, 2013
(HealthDay)—Children who are given codeine for pain relief after surgery to remove tonsils or adenoids are at risk for overdose and death, U.S. health officials said Thursday.

FDA bans use of opioid-containing cough meds by kids

January 12, 2018
(HealthDay)—Trying to put a dent in the ongoing opioid addiction crisis, the U.S. Food and Drug Administration on Thursday slapped strict new restrictions on the use of opioid-containing cold and cough products by kids.

FDA further restricts pain medication use in kids

April 21, 2017
U.S. regulators are strengthening warnings about the dangers of two types of powerful painkillers due to risks of slowed breathing and death.

MDs strengthen advice against codeine for kids' coughs, pain

September 19, 2016
The American Academy of Pediatrics has strengthened its warnings about prescribing codeine for children because of reports of deaths and risks for dangerous side effects including breathing problems.

Recommended for you

Medicating distress: Risky sedative prescriptions for older adults vary widely

October 18, 2018
Despite years of warnings that older adults shouldn't take sedative drugs that put them at risk of injury and death, a new study reveals how many primary care doctors are still prescribing them, how often, and exactly where.

Medical management of opioid-induced constipation differs from other forms of condition

October 17, 2018
Traditional laxatives are recommended as first-line agents to treat patients with a confirmed diagnosis of opioid-induced constipation (OIC), according to a new guideline from the American Gastroenterological Association ...

Research assesses geographic distribution of new antibiotics following market introduction

October 16, 2018
There is a growing need for new antibiotics to help combat the looming threat of antimicrobial resistance. According to a new study conducted by researchers at the Center for Disease Dynamics, Economics & Policy (CDDEP) with ...

Health insurer policies may discourage use of non-opioid alternatives for lower back pain

October 5, 2018
Public and private health insurance policies in the U.S. are missing important opportunities to encourage the use of physical therapy, psychological counseling and other non-drug alternatives to opioid medication for treating ...

Opioid overdoses, depression linked

October 3, 2018
The link between mental health disorders and substance abuse is well-documented. Nearly one in 12 adults in the U.S is depressed, and opioid-related deaths are skyrocketing. As these numbers continue to climb, some mental ...

Do price spikes on some generic drugs indicate problems in the market?

October 1, 2018
A new USC study reports that sudden price spikes for some generic drugs—such as the recently reported increases of a decades-old generic heart medication and an antibiotic—are becoming more common.


Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.