Codeine Addiction: Signs and Side Effects of Codeine Abuse

Codeine is an opiate found in some prescription pain relievers and cough syrups. Despite its medical uses, this substance can lead to misuse, dependence or addiction.

Some of the most common codeine-containing products on the market include:

• Tylenol with codeine (Tylenol #3, Tylenol #4)
• Ibuprofen with codeine (Nurofen Plus)
• Promethazine with codeine (Phenergan cough syrup)
• Guaifenesin with codeine (Cheratussin AC cough syrup)

Slang can vary by location, but common street names include Lean, purple drank and sizzurp. Some people refer to it as “drank” or syrup. When used recreationally, codeine is often mixed with candy or soda, making it difficult to determine how much you’re consuming. Many codeine products contain acetaminophen, promethazine or other medications, making them riskier than codeine and other opioids on their own.

This page explains why codeine can be addictive, codeine side effects and warning signs of misuse. It focuses on the signs and health effects of codeine misuse and doesn’t cover addiction treatment options or rehab programs.

When you take codeine, your liver turns it into morphine, a powerful opioid. This stimulates mu-opioid receptors in the brain, relieving pain and making you feel calm. In some people, it produces a sense of euphoria, an intense state of happiness or well-being.

Relief from pain, stress or insomnia can reinforce repeated use of codeine, increasing the risk of tolerance, which means you need more of a substance to get the same effects. Withdrawal discomfort also promotes continued use, even when it’s causing physical or psychological harm. This creates a cycle where you continue taking it even when you want to stop.

Codeine overdose can occur when you take more medication than your body can safely metabolize. The risk is higher when you take high doses, drink codeine-containing mixtures or mix codeine with alcohol or benzodiazepines.

Codeine abuse involves taking it outside of medical guidance. Examples include:

• Taking more codeine than a healthcare professional recommends.
• Using someone else’s codeine prescription.
• Continuing codeine use longer than necessary.
• Taking codeine to get high.

Codeine addiction is different from codeine abuse, as it’s characterized by compulsive use. If you have an opioid use disorder, you may experience cravings or have trouble controlling your codeine use. Compulsive opioid use is also associated with continuing to use the drug even when it causes harm.

Clinicians now use the term “substance misuse” to describe the use of codeine outside of medical guidelines. “Substance use disorder” is a broader term used to characterize compulsive substance use as a chronic disease.

For some people, misuse starts with medical use of codeine. You may take it to relieve a bad cough or address moderate pain. Over time, this medical use may turn into misuse, causing you to use codeine for sleep, stress relief or avoidance of withdrawal symptoms.

If medical use crosses into misuse, you may run out of codeine early or take extra doses in case you encounter a stressful situation. Some people hide their codeine use or buy pills/syrup from nonmedical sources.

It’s possible to develop a physical dependence on opioids, leading to withdrawal symptoms if you attempt to stop using codeine. Psychological dependence is another concern. This is when you rely on codeine to help you fall asleep, deal with stress or relax.

The risk of dependence increases if you:

• Take higher-than-recommended doses
• Use codeine longer than necessary
• Turn to opioids when you need help managing your emotions
• Increase the frequency of codeine use

Dependence isn’t the same as addiction, as it doesn’t necessarily involve compulsive use. However, it can be an early warning sign that you’re at risk of developing a substance use disorder.

Many signs of codeine addiction involve behavioral changes. For example, you may seek early refills, hide your use from loved ones or buy codeine products from illegitimate sources.

Some people engage in “doctor shopping,” which involves obtaining opiates or other controlled substances from multiple doctors without telling each doctor about the other prescriptions. Doctor shopping increases the risk of fatal opioid overdose, according to research published in the journal Pain Medicine.

Another common behavior is cough syrup misuse, which may involve mixing codeine syrup with soda, using codeine-containing cough syrup in social settings or hiding codeine mixtures.

Physical Signs

When codeine attaches to mu-opioid receptors in the central nervous system (CNS), it slows down your brain activity and bodily functions.

This may cause:

• Constipation
• Pinpoint pupils
• Itching
• Slowed breathing
• Nausea

Signs Related to Cognition and Mood

Because codeine is a CNS depressant, it can affect your mood and cognition. You may experience mood swings, cravings or anxiety between doses.

Cognition is the set of mental processes involved in learning, storing and retrieving information. Codeine misuse sometimes causes confusion, impaired memory and decreased mental alertness. You may also find it more difficult to make decisions while it’s in your system.

Safety Red Flags

In some people, opioid use disorders result in red-flag behavior. These are use patterns that come with an increased risk of harm. Red flags associated with codeine addiction include using opioids alone, mixing codeine with alcohol or benzodiazepines or taking higher doses as your tolerance builds.

When going through codeine withdrawal, you may feel like you have a severe form of the flu. It’s also possible to experience restlessness or intense opioid cravings.

Other opioid withdrawal symptoms include:

• Anxiety
• Yawning
• Sweating
• Runny nose
• Muscle aches
• Insomnia
• Watery eyes

Later in the withdrawal process, you may notice these symptoms:

• Nausea
• Vomiting
• Diarrhea
• Chills
• Abdominal cramps
• Goosebumps

Symptom severity varies based on how long you’ve been using codeine, how often you use it and whether you’ve been combining it with other substances.

Codeine side effects can be physical or psychological in nature.

Short-term effects include:

• Dizziness
• Sedation
• Impaired judgment
• Slowed breathing

With long-term use, codeine may cause tolerance, dependence or worsening constipation. There’s also a risk of overdose, which may cause life-threatening symptoms, including respiratory depression, loss of consciousness and death. Severe overdose symptoms are more likely if you’ve been mixing codeine with alcohol, benzodiazepines or other sedatives.

Because codeine is often combined with other substances, there are also some product-specific risks. Tylenol with codeine can cause liver damage at high doses, while promethazine with codeine may lead to heavy sedation after misusing cough syrup.

Some side effects of codeine abuse relate to your preferred route of administration. The nasal cavity contains blood vessels, so snorting codeine and other opioids can cause nosebleeds. You may also notice some inflammation of your nasal passages. There’s also a risk of infection if you inject it, especially if you share needles with other people.

In the mental health field, a risk factor is any trait, characteristic or environmental exposure that increases your risk of developing a mental health condition. The risk factors for codeine addiction are varied.

Some factors are modifiable, which means you can change them. Non-modifiable risk factors can’t be changed. For example, you can’t change your genes, so genetics often plays a role in substance misuse.

You’re more likely to develop an opioid use disorder if you have chronic pain or a recurrent cough. As you attempt to manage these symptoms, your body may become dependent on codeine, leading to uncomfortable withdrawal symptoms if you attempt to stop taking it.

A common environmental risk factor is easy access to codeine and other prescription medications. If another person in your household uses codeine, they may leave leftover pills or cough syrup in the medicine cabinet, making medication accessible, even if it wasn’t prescribed for you.

Mental Health, Substance Use and Social Factors

Codeine misuse is also associated with certain mental health conditions. For example, you might use it to calm anxiety or relieve the emotional pain caused by depression.

People with a history of trauma sometimes use codeine to self-medicate. Its sedating effects may help you forget emotional pain, anxiety or distress associated with traumatic events.

Codeine addiction is more likely if you have a history of substance misuse. This includes alcohol, opioids, benzodiazepines and other drugs.

Certain social factors can also contribute to codeine misuse. For example, spending time with people who use “drank” at parties may normalize the idea of misusing opioids.

When diagnosing codeine addiction, clinicians use a set of established criteria to assess patterns of use over time. Misusing codeine a few times isn’t the same thing as having a substance use disorder, so it’s important to receive a professional evaluation.

During this evaluation, a healthcare provider typically asks questions about your:

• Risky use patterns
• Cravings
• Tolerance
• Loss of control
• Continued codeine use despite harm

A codeine misuse assessment usually includes a mental health screening, which helps determine if you have a co-occurring disorder, such as anxiety or depression. Clinicians also need to know about your risk of overdose. They’ll ask if you’ve been mixing codeine with other substances or engaging in other high-risk patterns of use.

Although drug testing can confirm codeine exposure, it doesn’t distinguish between substance misuse and a substance use disorder. It’s possible to have a positive opioid drug test even if you don’t use it compulsively.

Anyone can develop an addiction to opioids. Having a substance use disorder isn’t a personal failure or a sign of weakness. You may benefit from professional support if you have a history of mixing codeine with other depressants or need higher doses to avoid withdrawal symptoms. It’s also important to seek help if you’ve ever had an overdose scare.

Help.org is a free resource that can help you find help for codeine addiction. Use this confidential treatment finder to compare treatment centers based on your needs, location and personal preferences.