Codeine addiction and pregnancy

As of 2016, the UK was the second biggest consumer of codeine in the world. It’s the most prescribed opioid in the UK and is also available over-the-counter, combined with ibuprofen or paracetamol. Codeine’s widespread availability means that it is commonly misused. In 2014, it was the first or second drug of choice for 2.2% of people in structured drug treatment – and codeine prescriptions increased 5-fold between 2007 and 2017.

Codeine abuse can lead to serious consequences for a person’s physical and mental health, including physical dependence, withdrawals, overdose and organ damage. The ibuprofen or paracetamol found in over-the-counter codeine introduces an extra element of risk – paracetamol is toxic to the liver, and ibuprofen can cause gastrointestinal issues. People abusing over-the-counter codeine may be taking many times the recommended dose, which means they will be consuming far more paracetamol or ibuprofen than recommended.

Pregnancy introduces an extra dimension to codeine addiction. Codeine addiction can be harmful to developing foetuses – but mothers who are addicted to codeine are often fearful of seeking treatment due to the stigma attached to addiction during pregnancy and fears about legal repercussions or losing custody of their children. This can lead to pregnant individuals suffering in silence instead of reaching out for the help they need – but help is absolutely crucial.

Codeine addiction

Codeine is less potent than other opioids and is considered one step above nonsteroidal anti-inflammatory drugs and paracetamol for pain management. It is prescribed to manage moderate pain. Because it isn’t as strong as other opioid painkillers it isn’t considered to be as addictive – but it still has addictive potential, and unlike most other opioids is available without a prescription.

Codeine addiction falls into the category of opioid use disorders (OUD) as outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). An opioid use disorder can be diagnosed if at least two of the following criteria are met.

• Taking codeine in larger amounts or over a longer period than intended
• Unsuccessful efforts to cut down or stop
• Spending a lot of time obtaining codeine or recovering from its effects
• Cravings
• Failing to fulfil obligations due to codeine usage
• Continued codeine usage despite interpersonal problems
• Giving up or reducing other activities in favour of using codeine
• Using codeine in dangerous situations, such as driving under the influence
• Continued use despite physical or mental health problems that have been caused or worsened by codeine
• Tolerance
• Opioid withdrawal

Like other opioids, changes to the brain that occur when codeine is taken over a long time lead to addiction. Opioids interact with mu-opioid receptors in the brain, which causes pleasurable effects. Opioids also stimulate the brain’s dopamine reward system, which drives repeated use of the drug.

Codeine addiction and pregnancy

Struggling with a codeine addiction while pregnant is a complex situation that requires outside help. Quitting codeine cold turkey is dangerous for both the pregnant individual and the foetus. This means tapering, or medication-assisted treatment, needs to be considered depending on the severity of the addiction. Ultimately, pregnancy is an extremely vulnerable time, and no one should feel they have to deal with addiction alone while pregnant.

Codeine’s effect on the foetus

Codeine use during pregnancy can increase the risk for multiple pregnancy-related problems, such as poor growth of the baby, stillbirth, and pre-term delivery. It can increase the need for a C-section or cause heavier bleeding after delivery.

One of the most serious effects of opioid addiction on developing foetuses is Neonatal Abstinence Syndrome (NAS). NAS is caused by withdrawals from drugs or medications the baby was exposed to in the womb. In the case of opioids, NAS symptoms include difficulty breathing, drowsiness, vomiting and diarrhoea, irritability, sweating and tremors.

Children born with NAS may need treatment in a neonatal intensive care unit, which separates the child from the new parent. The baby may require pharmacological treatment to manage the condition. In the long term, NAS can impact neurodevelopment and is associated with cognitive deficits, behavioural issues and increased mortality.

Codeine addiction and breastfeeding

The NHS says that codeine should not be used during breastfeeding. If it is used, it should be at the lowest dose necessary for the shortest duration and under close supervision. This is because codeine passes into breast milk and can cause issues for the baby, such as drowsiness, trouble latching, breathing problems, slow heart rate and low oxygen.

Paracetemol and ibuprofen

Over-the-counter codeine in the UK is combined with either paracetamol or codeine. Some people who are addicted may be supplementing their prescription with over-the-counter codeine due to their tolerance increasing, or they could be solely taking a large amount of over-the-counter codeine medication to sustain their addiction. This leads to ingesting far more ibuprofen or paracetamol than desirable.

High doses of paracetamol are harmful to the liver, and this can be dangerous for pregnant individuals who need to be at full strength when carrying a child. There isn’t a lot of research on whether paracetamol can also affect the liver of foetuses. Still, there is some evidence that the foetal liver starts to metabolise paracetamol at 18 weeks, meaning liver toxicity is possible.There is also some emerging evidence suggesting that high paracetamol use can negatively impact foetal development and may be associated with an increased risk of autism and ADHD – but these findings are not conclusive, and some studies didn’t find a link.

Ibuprofen is not recommended for use during pregnancy, as it can cause kidney damage to the foetus and other complications.

Getting help

Managing codeine addiction during pregnancy is fraught with challenges. Pregnant individuals may struggle to reach out for help due to the stigma associated with addiction while pregnant and out of fear of legal repercussions. However, it’s vital to get help, both for the individual and the baby. Withdrawal symptoms are dangerous during pregnancy and can cause miscarriage, meaning close monitoring is crucial.

Opioid substitution therapy is used for pregnant patients as this is considered far safer than acute withdrawal or continued usage. Some pregnant patients who are already on opioid substitution therapy may choose to withdraw when they find out they’re pregnant, but this needs to be managed extremely carefully, as even mild withdrawals increase the risk of neonatal mortality.

The NHS does not recommend stopping or reducing the amount of drugs you are taking if you find out you’re pregnant without speaking to a doctor first. Midwives, GPs, and drug treatment services can help pregnant individuals get the help they need and can refer them to other services, such as antenatal and family support.

Because of the complications that can arise when dealing with addiction while pregnant, residential treatment is an excellent option and will provide the careful monitoring you need to keep you and your baby safe and healthy.

We can help

Codeine addiction during pregnancy requires specialised care. The health of the pregnant individual and the baby must be carefully balanced, and the treatment must be meticulous and evidence-led. As well as this, codeine addiction is something no one should have to face alone. If you’re struggling with addiction while pregnant, it’s important to know that non-judgemental and compassionate care is available.

Reach out today to get the help you need.