Codeine Self‐medication in a Headache Patient

Abstract

Self-medicating behavior for the treatment of headaches is a widespread phenomenon with costly and hazardous consequences. The case presented illustrates the ramifications of such behavior and suggests an integrated approach to the management of headaches. Biological mechanisms for the aggravation of headaches by self-medication are discussed and integrated with psychological observations. The existing epidemiologic studies of self-medication are reviewed and reveal a need for further studies, particularly in the United States. Key words: codeine, self-medication (Headache 1996;36:452-455) The extent of self-medicating behavior for chronic headaches has had minimal attention in the medical literature. Yet, it is a widespread phenomenon in this common disorder. Limitations to the systematic study of self-medication in headaches include inconsistent patient contact with the medical community and inaccurate or underreporting of drug use. The latter is particularly common in instances of narcotic abuse. In the former case, it is quite clear that many individuals can bypass medical attention and obtain treatment at their local pharmacy, where a host of over-the-counter (OTC) medications advertise prompt headache relief. CASE HISTORYThe following is a case report of a chronic headache patient with a 25-year history of acetaminophen (Tylenol ® ) and codeine self-medication. The case illustrates the complications resulting from self-medicating behaviors. It also affords an opportunity to study the role of psychological treatments and how such treatments can be integrated into the management of chronic headaches.A 54-year-old patient was referred to a drug treatment program after he was caught by his pharmacist forging a prescription for Tylenol ® No. 4 with codeine. The patient stated that he "pops 6 to 15 pills a day" in order to medicate severe headaches which began when he was in his 20s. Initially, the headaches responded to acetaminophen alone but over the past 10 years, he began to abuse acetaminophen with codeine in gradually increasing doses. He obtained it by using forged prescriptions or from the "black market" to medicate the pain. He often took the pills at the slightest suggestion of a headache and sometimes even when he was asymptomatic in order to avert headaches, particularly when he had an important matter to take care of at work.The patient reported obtaining medical attention for his headaches many times in the past 10 years. Multiple evaluations, including physical examinations, neurological evaluations, complete blood screening, ECG, and several CT scans of the head, were unremarkable. The headaches were described as "stinging" and localized in the forehead. They might occur at any time of the day, and they often woke him at night. The headaches were not preceded by any aura or accompanied by visual, gastrointestinal, or neurological symptoms. His only other health problems were hypertension for 5 years treated with clonidine 0.1 mg orally tid for the past 5 years, a peptic ulcer which had been q...

Identifying and treating codeine dependence: a systematic review

“…Psychiatric comorbidity in people with codeine dependence was dominated by high prevalence conditions (depression and anxiety disorders) 20 , 27 , 44 , 48 , 53 , 58 , 60 , 61 . Some reports described prior or comorbid addictions (benzodiazepines, opioids, alcohol), 34 , 35 , 40 , 42 , 60 and mental health conditions 20 , 40 .…”

“…Individual patient reports described treatment approaches, including attempted self‐management, 45 , 65 use of symptomatic medications, 60 prescribed codeine or dihydrocodeine 49 , 52 or buprenorphine and naloxone, 52 , 54 , 65 and detoxification with methadone 48 . Management of mental health symptoms with antidepressants and behavioural therapies was described 48 , 54 , 55 , 65 . One notable case combined methadone taper, cognitive behavioural therapy, and relaxation strategies, enabling codeine cessation and self‐management of pain 48 .…”

“…Management of mental health symptoms with antidepressants and behavioural therapies was described 48 , 54 , 55 , 65 . One notable case combined methadone taper, cognitive behavioural therapy, and relaxation strategies, enabling codeine cessation and self‐management of pain 48 . Resolution of presenting complaints (obsessive–compulsive disorder, medication overuse headache) after codeine cessation was described 62 , 63…”

“…Headache is a common reason for initiating codeine use by patients who develop dependence 19 , 61 . Paradoxically, medication overuse headache — in this context, exacerbation of a pre‐existing headache disorder by excessive intake of codeine — is another potential complication of codeine dependence 48 , 55 , 63 . Data that might guide the management of codeine overuse headache specifically have not been published.…”