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Identifying and treating codeine dependence: a systematic review

Suzanne Nielsen, Tim MacDonald and Jacinta L Johnson
Med J Aust 2018; 208 (10): 1. || doi: 10.5694/mja17.00749

Abstract

Objectives: Codeine dependence is a significant public health problem, motivating the recent rescheduling of codeine in Australia (1 February 2018). To provide information for informing clinical responses, we undertook a systematic review of what is known about identifying and treating codeine dependence.

Study design: Articles published in English that described people who were codeine-dependent or a clinical approach to treating people who were codeine-dependent, without restriction on year of publication, were reviewed. Articles not including empirical data were excluded. One researcher screened each abstract; two researchers independently reviewed full text articles. Study quality was assessed, and data were extracted with standardised tools.

Data sources: MEDLINE and EMBASE were searched for relevant publications on 22 November 2016. The reference lists of eligible studies were searched to identify further relevant publications. 2150 articles were initially identified, of which 41 were eligible for inclusion in our analysis.

Data synthesis: Studies consistently reported specific characteristics associated with codeine dependence, including mental health comorbidity and escalation of codeine use attributed to psychiatric problems. Case reports and series described codeine dependence masked by complications associated with overusing simple analgesics and delayed detection. Ten studies described the treatment of codeine dependence. Three reports identified a role for behavioural therapy; the efficacy of CYP inhibitors in a small open label trial was not confirmed in a randomised controlled trial; four case series/chart reviews described opioid agonist therapy and medicated inpatient withdrawal; two qualitative studies identified barriers related to perceptions of codeine-dependent people and treatment providers, and confirmed positive perceptions and treatment outcomes achieved with opioid agonist treatments.

Conclusion: Strategies for identifying problematic codeine use are needed. Identifying codeine dependence in clinical settings is often delayed, contributing to serious morbidity. Commonly described approaches for managing codeine dependence include opioid taper, opioid agonist treatment, and psychological therapies. These approaches are consistent with published evidence for pharmaceutical opioid dependence treatment and with broader frameworks for treating opioid dependence.

PROSPERO registration: CRD42016052129.

  • Suzanne Nielsen1
  • Tim MacDonald2,3
  • Jacinta L Johnson4,5

  • 1 National Drug and Alcohol Research Centre, University of New South Wales, Sydney, NSW
  • 2 Currumbin Clinic, Gold Coast, QLD
  • 3 Griffith University, Gold Coast, QLD
  • 4 University of South Australia, Adelaide, SA
  • 5 Southern Adelaide Local Health Network, Adelaide, SA


Acknowledgements: 

Suzanne Nielsen holds a National Health and Medical Research Council Research Fellowship (1132433).

Competing interests:

Suzanne Nielsen is a named investigator on untied educational grants from Reckitt–Benckiser and Indivior. Tim MacDonald has received honoraria, fees and professional development resources from Servier, the Australian and New Zealand Mental Health Association, and Healthe Care; he works in the private sector and receives income for clinical services.

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