Codeine - Wikipedia, The Free Encyclopedia

6/12/13 Codeine - Wikipedia, the free encyclopedia

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Codeine

Systematic (IUPAC) name

(5,6)-7,8-didehydro-4,5-epoxy-3-methoxy-17-

methylmorphinan-6-ol

Clinical data

AHFS/Drugs.com monograph

MedlinePlus a682065

Pregnancy cat. C (US)

Legal status Controlled (S8) (AU)

Schedule I (CA) POM (UK)

Schedule II (US)

Dependence liability Moderate

Routes Oral, intra-rectally, SC, IM

Pharmacokinetic data

Bioavailability ~90% Oral

Metabolism Hepatic, via CYP2D6

(cytochrome P450 2D6)[1]

Half-life 2.53 h

Identifiers

CAS number 76-57-3

ATC code R05DA04

combinations: N02AA59,

N02AA79

PubChem CID 5284371

IUPHAR ligand 1673

DrugBank DB00318

ChemSpider 4447447

UNII Q830PW7520

CodeineFrom Wikipedia, the free encyclopedia

Codeine or 3-methylmorphine (a natural isomer ofmethylated morphine) is an opiate used for its analgesic,antitussive, antidiarrheal, antihypertensive, anxiolytic,antidepressant, sedative and hypnotic properties. It is alsoused to suppress premature labor contractions, myocardialinfarction, and has many other potential and indicated uses.Codeine is the second-most predominant alkaloid in opium,at up to three percent. Although codeine can be extractedfrom natural sources, a semi-synthetic process is the primarysource of codeine for pharmaceutical use. It is considered theprototype of the weak to midrange opioids (tramadol,dextropropoxyphene, dihydrocodeine, hydrocodone,oxycodone).

Contents

1 Medical uses

1.1 Formulations

2 Adverse effects

2.1 Withdrawal and dependence

3 Pharmacokinetics4 Relation to other opiates

5 History

6 Recreational use

6.1 Detection

7 Legal status

7.1 Australia

7.2 Denmark

7.3 France7.4 Germany, Switzerland and Austria

7.5 Greece

7.6 Hong Kong

7.7 Iceland

7.8 India

7.9 Ireland

7.10 Italy

7.11 Japan

7.12 Russia

7.13 Sri Lanka7.14 North America

7.15 Spain



UNII

KEGG C06174

ChEBI CHEBI:16714

ChEMBL CHEMBL485

Chemical data

Formula C18H21NO3

Mol. mass 299.364 g/mol

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7.16 United Arab Emirates

7.17 United Kingdom

8 References

Medical uses

Codeine is used to treat mild to moderate pain and to relieve

cough.[2] Codeine is also used to treat diarrhea and diarrheapredominant irritable bowel syndrome, although loperamide(which is available OTC for milder diarrhea), diphenoxylate,paregoric or even laudanum (also known as Tincture of

Opium) are more frequently used to treat severe diarrhea.[3]

Formulations

Codeine is marketed as both a single-ingredient drug and in combination preparations with paracetamol (as co-codamol: e.g., brands Paracod, Panadeine. Paramol, and the Tylenol-with-codeine series, including Tylenol 3 and1,2,4); with aspirin; (as co-codaprin); or with ibuprofen (as Nurofen Plus). These combinations provide greaterpain relief than either agent alone (drug synergy). Codeine is also commonly marketed in products containingcodeine with other pain killers or muscle relaxers, as well as codeine mixed with phenacetin (Emprazil WithCodeine No. 1, 2, 3, 4 and 5), naproxen, indomethacin, diclofenac, and others, as well as more complex mixtures,including such mixtures as aspirin + paracetamol + codeine caffeine antihistamines and other agents, such asthose mentioned above.

Codeine-only products can be obtained with a prescription as a time release tablet (e.g., Codeine Contin 100 mgand Perduretas 50 mg). Codeine is also marketed in cough syrups with zero to a half-dozen other activeingredients, and a linctus (e.g., Paveral) for all of the uses for which codeine is indicated.

Injectable codeine is available for subcutaneous or intramuscular injection; intravenous injection can cause a seriousreaction that can progress to anaphylaxis. Codeine suppositories are also marketed in some countries.

Adverse effects

Common adverse effects associated with the use of codeine include drowsiness and constipation. Less common areeuphoria, itching, nausea, vomiting, dry mouth, miosis, orthostatic hypotension, urinary retention, depression, and,

paradoxically, coughing. Rare adverse effects include anaphylaxis, seizure, and respiratory depression.[4] As with allopiates, longer-term effects can vary but can include diminished libido, apathy and memory loss. Some people may

also have an allergic reaction to codeine, such as the swelling of skin and rashes.[5]

Codeine and morphine as well as opium were used for control of diabetes until relatively recently, and still are inrare cases in some countries, and the hypoglycemic effect of codeine, although usually weaker than that ofmorphine, diamorphine, or hydromorphone, can lead to cravings for sugar.

SMILES

InChI



Tolerance to many of the effects of codeine develops with prolonged use, including therapeutic effects. The rate atwhich this occurs develops at different rates for different effects, with tolerance to the constipation-inducing effectsdeveloping particularly slowly for instance.

A potentially serious adverse drug reaction, as with other opioids, is respiratory depression. This depression isdose-related and is the mechanism for the potentially fatal consequences of overdose. As codeine is metabolized tomorphine, morphine can be passed through breast milk in potentially lethal amounts, fatally depressing the

respiration of a breastfed baby.[6][7] In August 2012, the Federal Drug Administration issued a warning aboutdeaths in pediatric patients < 6 years old after ingesting "normal" doses of acetaminophen with codeine after

tonsillectomy.[8] Some patients are very effective converters of codeine to its active form, hydromorphone, resultingin lethal blood levels. The FDA presently is recommending very cautious use of Codeine in young tonsillectomypatients: use the drug in the lowest amount that can control the pain, use "as needed" and not "around the clock",and seek immediate medical attention if a child on codeine exhibits excessive sedation or abnormally noisybreathing.

Withdrawal and dependence

As with other opiate-based pain killers, chronic use of codeine can cause physical dependence. When physicaldependence has developed, withdrawal symptoms may occur if a person suddenly stops the medication.Withdrawal symptoms include: drug craving, runny nose, yawning, sweating, insomnia, weakness, stomach cramps,nausea, vomiting, diarrhea, muscle spasms, chills, irritability, and pain. To minimize withdrawal symptoms, long-term

users should gradually reduce their codeine medication under the supervision of a healthcare professional.[9]

Codeine is metabolized to codeine-6-glucuronide (C6G) by uridine diphosphate glucuronosyl transferase UGT2B7,and, since only about 5% of codeine is metabolized by cytochrome P450 CYP2D6, the current evidence is that

C6G is the primary active compound.[10] Claims about the supposed "ceiling effect" of codeine doses are based onthe assumption that high doses of codeine saturate CYP2D6, preventing further conversion of codeine to morphine,

however it is now known that C6G is the main metabolite responsible for codeine's analgesia.[11] There is also no

evidence that CYP2D6 inhibition is useful in treating codeine dependence,[12] though the metabolism of codeine tomorphine (and hence further metabolism to glucuronide morphine conjugates) does have an effect on the abuse

potential of codeine.[13] However, CYP2D6 has been implicated in the toxicity and death of neonates whencodeine is administered to lactating mothers, particularly those with increased 2D6 activity ("ultra-rapid"

metabolizers).[14][15]

Pharmacokinetics

The conversion of codeine to morphine occurs in the liver and is catalysed by the cytochrome P450 enzymeCYP2D6. CYP3A4 produces norcodeine and UGT2B7 conjugates codeine, norcodeine, and morphine to thecorresponding 3- and 6- glucuronides. Srinivasan, Wielbo and Tebbett speculate that codeine-6-glucuronide isresponsible for a large percentage of the analgesia of codeine, and, thus, these patients should experience some

analgesia.[16] Many of the adverse effects will still be experienced in poor metabolizers. Conversely, 0.5-2% of thepopulation are "extensive metabolizers"; multiple copies of the gene for 2D6 produce high levels of CYP2D6 andwill metabolize drugs through that pathway more quickly than others.

Some medications are CYP2D6 inhibitors and reduce or even completely block the conversion of codeine tomorphine. The most well-known of these are two of the selective serotonin reuptake inhibitors, paroxetine (Paxil)and fluoxetine (Prozac) as well as the antihistamine diphenhydramine and the antidepressant, bupropion (Wellbutrin,



also known as Zyban). Other drugs, such as rifampicin and dexamethasone, induce CYP450 isozymes and thusincrease the conversion rate.

CYP2D6 converts codeine into morphine, which then undergoes glucuronidation. Life-threatening intoxication,including respiratory depression requiring intubation, can develop over a matter of days in patients who havemultiple functional alleles of CYP2D6, resulting in ultra-rapid metabolism of opioids such as codeine into

morphine.[17][18][19]

Studies on codeine's analgesic effect are consistent with the idea that metabolism by CYP2D6 to morphine isimportant, but some studies show no major differences between those who are poor metabolizers and extensivemetabolizers. Evidence supporting the hypothesis that ultrarapid metabolizers may get greater analgesia from

codeine due to increased morphine formation is limited to case reports. [20]

The active metabolites of codeine, notably morphine, exert their effects by binding to and activating the -opioidreceptor.

Relation to other opiates

Codeine has been used in the past as the starting material and prototype of a large class of mainly mild tomoderately strong opioids; such as hydrocodone (1920 in Germany), oxycodone (1916 in Germany),

dihydrocodeine (1908 in Germany), and its derivatives such as nicocodeine (1956 in Austria).[citation needed]

However, these opiates are no longer synthesized from codeine and are usually synthesized from other opioid

alkaloids; specifically thebaine.[citation needed] Other series of codeine derivatives include isocodeine and itsderivatives, which were developed in Germany starting around 1920. As an analgesic, codeine comparesmoderately to other opiates. Related to codeine in other ways are codoxime, thebacon, codeine-N-oxide(genocodeine), related to the nitrogen morphine derivatives as is codeine methobromide, and heterocodeine, whichis a drug six times stronger than morphine and 72 times stronger than codeine due to a small re-arrangement of themolecule, viz. moving the methyl group from the 3 to the 6 position on the morphine carbon skeleton. Drugs bearingresemblance to codeine in effects due to close structural relationship are variations on the methyl groups at the 3position including ethylmorphine a.k.a. codethyline (Dionine) and benzylmorphine (Peronine). While having nonarcotic effects of its own, the important opioid precursor thebaine differs from codeine only slightly in structure.Pseudocodeine and some other similar alkaloids not currently used in medicine are found in trace amounts in opiumas well.

History

Codeine, or 3-methylmorphine, is an alkaloid found in the opium poppy, Papaver somniferum var. album, aplant in the papaveraceae family. Opium poppy has been cultivated and utilized throughout human history for avariety of medicinal (analgesic, anti-tussive and anti-diarrheal) and hypnotic properties linked to the diversity of itsactive components, which include morphine, codeine and papaverine.

Codeine is found in concentrations of 10 to 3.0 per cent in opium prepared by the latex method from unripe podsof Papaver somniferum. The name codeine is derived from the Greek word kodeia () for "poppy head".The relative proportion of codeine to morphine, the most common opium alkaloid at 4 to 23 per cent, tends to besomewhat higher in the poppy straw method of preparing opium alkaloids.



Until the beginning of the 19th century, raw opium was used in diverse preparations known as laudanum (seeThomas de Quincey's "Confessions of an English Opium-Eater", 1821) and paregoric elixirs, a number of whichwere popular in England since the beginning of the 18th century; the original preparation seems to have beenelaborated in Leiden, the Netherlands around 1715 by a chemist named Lemort; in 1721 the LondonPharmocopeia mentions an Elixir Asthmaticum, replaced by the term Elixir Paregoricum ("pain soother") in 1746.

The progressive isolation of opium's several active components opened the path to improved selectivity and safetyof the opiates-based pharmacopeia.

Morphine had already been isolated in Germany by German pharmacist Friedrich Sertrner in 1804.[21] Codeinewas first isolated decades later in 1832 in France by Pierre Robiquet, a French chemist and pharmacist alreadyfamous for the discovery of alizarin, the most widespread red dye, while working on refined morphine extractionprocesses. This paved the way for the elaboration of a new generation of safer, codeine-based specific antitussiveand antidiarrheal formulations.

Codeine is currently the most widely-used opiate in the world,[22][23] and is one of the most commonly used drugsoverall according to numerous reports by organizations including the World Health Organization and its League ofNations predecessor agency. It is one of the most effective orally administered opioid analgesics and has a widesafety margin. Its strength ranges from 8 to 12 percent of morphine in most people; differences in metabolism canchange this figure as can other medications, depending on its route of administration.

While codeine can be directly extracted from opium, its original source, most codeine is synthesized from the much

more abundant morphine through the process of O-methylation.[23][24]

By 1972, the effects of the Nixon War On Drugs had caused across-the-board shortages of illicit and licit opiatesbecause of a scarcity of natural opium, poppy straw, and other sources of opium alkaloids, and the geopoliticalsituation was growing difficult for the United States. After a large percentage of the opium and morphine in the USNational Stockpile of Strategic & Critical Materials was tapped in order to ease severe shortages of medicinalopiates the codeine-based antitussives in particular in late 1973, researchers were tasked with finding a wayto synthesize codeine and its derivatives. They quickly succeeded using petroleum or coal tar and a processdeveloped at the United States' National Institutes of Health.

Numerous codeine salts have been prepared since the drug was discovered. The most commonly used are thehydrochloride (freebase conversion ratio 0.805), phosphate (0.736), sulphate (0.859), and citrate (0.842). Othersinclude a salicylate NSAID, codeine salicylate (0.686), and at least four codeine-based barbiturates, thecyclohexenylethylbarbiturate (0.559), cyclopentenylallylbarbiturate (0.561), diallylbarbiturate (0.561), anddiethylbarbiturate (0.619).

Recreational use

Codeine can be used as a recreational drug.

In some countries, cough syrups and tablets containing codeine are available without prescription; some potentialrecreational users are reported to buy codeine from multiple pharmacies so as not to arouse suspicion. A heroin

addict may use codeine to ward off the effects of a withdrawal.[25]



Codeine is also available in conjunction with the anti-nausea medication promethazine in the form of a syrup. Brandnamed as Phenergan with Codeine or in generic form as promethazine with codeine. Called 'syrup', this medication

is quickly becoming one of the most commonly misused codeine preparations.[26] Rapper Pimp C, from the group

UGK, died from an overdose of this combination.[27]

Codeine is also demethylated by reaction with pyridine to illicitly synthesize morphine, which can then be acetylatedto make heroin (diacetylmorphine). Pyridine is toxic and possibly carcinogenic, so morphine illicitly produced in this

manner (and potentially contaminated with pyridine) may be particularly harmful.[28] Codeine can also be turnedinto -chlorocodide, which is used in the clandestine synthesis of desomorphine (Permonid) (desomorphineattracted attention in 2010 in Russia due to an upsurge in clandestine production, presumably due to its relatively

simple synthesis from codeine.[citation needed] The drug is easily made from codeine, iodine and red

phosphorus,[29] in a similar process to the manufacture of methamphetamine from pseudoephedrine, butdesomorphine made this way is highly impure and contaminated with various toxic and corrosive byproducts.).

Detection

Codeine and/or its major metabolites may be quantitated in blood, plasma or urine to monitor therapy, confirm adiagnosis of poisoning or assist in a medicolegal death investigation. Drug abuse screening programs generally testurine, hair, sweat or oral fluid. Many commercial opiate screening tests directed at morphine cross-reactappreciably with codeine and its metabolites, but chromatographic techniques can easily distinguish codeine fromother opiates and opioids. It is important to note that codeine usage results in significant amounts of morphine as anexcretion product. Furthermore, heroin contains codeine (or acetylcodeine) as an impurity and its use will result inexcretion of small amounts of codeine. Poppy seed foods represent yet another source of low levels of codeine inone's biofluids. Blood or plasma codeine concentrations are typically in the 50300 g/L range in persons takingthe drug therapeutically, 7007000 g/L in chronic users and 100010,000 g/L in cases of acute fatal

overdosage.[30][31][32]

Legal status

In Australia, Canada, New Zealand, Romania, Russia, Sweden, the United Kingdom, the United States, and manyother countries, codeine is regulated under various narcotic control laws. In some countries it is available withoutprescription in combination preparations from licensed pharmacists in doses up to 15 mg/tablet in Australia, NewZealand, Poland, Romania (Codamin), and Costa Rica, 12.8 mg/tablet in the UK, 10 mg/tablet in Israel and

8 mg/tablet in Canada and Estonia.[citation needed]

Australia

In Australia, codeine preparations must be sold only at a pharmacy. Preparations will often be a combination ofparacetamol (500 mg), ibuprofen (200 mg) and doxylamine succinate (5 mg), and the codeine content may rangefrom 5 mg to 15 mg; preparations with in excess of 30 mg per tablet are S4 (schedule 4, or Prescription Only)medications. The item is given over the counter, no prescriptions, at the discretion of the Pharmacist. Mostpreparations are considered S3 (schedule 3, or Pharmacist Only) medications, meaning that they must be sold withthe direct involvement of a pharmacist. It must be labelled and usage history monitored by the Pharmacist to helpdeter misuse and dependence. The exception to this rule is cold and flu preparations such as "Codral". These

preparations contain phenylephrine (5 mg), paracetamol(500 mg) and codeine(9.5 mg).[33]



Preparations containing pure codeine (e.g., codeine phosphate tablets or codeine phosphate linctus) are availableon prescription and are considered S8 (schedule 8, or Controlled Drug (Possession without authority illegal)).Schedule 8 preparations are subject to the strictest regulation of all medications available to consumers.

Denmark

In Denmark codeine is sold over the counter with max 9.6 mg in mixture.[citation needed] The item is given over thecounter, no prescriptions. The strongest available over the counter preparation containing codeine has 9.6 mg (withaspirin, brand name Kodimagnyl); anything stronger requires a prescription.

France

In France, most preparations containing codeine do not require a doctor's prescription. Example productscontaining codeine include Nocodion (cough pills, ad sirup), Codoliprane (codeine with paracetamol), Prontalgine

and Migralgine (codeine, paracetamol and caffeine).[34]

Germany, Switzerland and Austria

Codeine is listed under the Betubungsmittelgesetz in Germany and the similarly named narcotics and controlledsubstances law in Switzerland. In Austria, the drug is listed under the Suchtmittelgesetz in categoriescorresponding to their classification under the Single Convention on Narcotic Drugs. Dispensing of productscontaining codeine and similar drugs (dihydrocodeine, nicocodeine, benzylmorphine, ethylmorphine etc.), in general,requires a prescription order from a doctor or the discretion of the pharmacist. Municipal and provincial regulationsmay impact availability, in particular in Austria and Switzerland, which allows cities and provinces to regulate theselling of the least-regulated schedule of the SMG/BtMG; and, of course, individual chemists' shops can opt out ofproviding them or imposing volume, frequency, or single-purchase limitations and other things of the same store.Plain codeine hydrochloride tablets (which in the USA would share CSA Schedule II with drugs like morphine,cocaine, hydromorphone, and bezitramide) as well as other non-injectable forms of codeine and its midrangederivatives can be dispensed in this way; the same goes for most chemical classes of benzodiazepines, the majorityof non-barbiturate sedative/hypnotics, and at least a handful of barbiturates.

Title 76 of the Schengen treaty has made it possible for countries within the signatory states to import and exportdrugs with various provisos, recording and ordering requirements, and various other rules.

Greece

Codeine is classed as an illegal drug in Greece, and individuals possessing it could conceivably be arrested, even ifthey were legitimately prescribed it in another country. It is sold only with a doctor's prescription (Lonarid-N,

Lonalgal).[35]

Hong Kong

In Hong Kong, codeine is regulated under Schedule 1 of Hong Kong's Chapter 134 Dangerous DrugsOrdinance. It can be used legally only by health professionals and for university research purposes. The substancecan be given by pharmacists under a prescription. Anyone who supplies the substance without prescription can be



fined $10,000 (HKD). The maximum penalty for trafficking or manufacturing the substance is a $5,000,000 (HKD)fine and life imprisonment. Possession of the substance for consumption without license from the Department ofHealth is illegal with a $1,000,000 (HKD) fine and/or 7 years of jail time.

However, codeine is available without prescription from licensed pharmacists in doses up to 0.1% (5 mg/5ml)according to Hong Kong "Dangerous Drugs Ordinance".

Iceland

Preparations of paracetamol and codeine require a prescription in Iceland. These tablets are known as Parkdn.

India

Codeine preparations require a prescription in India. A preparation of paracetamol and codeine is available inIndia. Codeine is also present in various cough syrups as Codeine Phosphate.

Ireland

In the Republic of Ireland, new regulations came into effect on August 1, 2010[36] concerning codeine, due toworries about the overuse of the drug. Codeine remains a semi non-prescriptive, over-the-counter drug up to a limitof 12.8 mg per pill, but codeine products must be out of the view of the public to facilitate the legislative

requirement that these products are not accessible to the public for self-selection.[37] In practice, this meanscustomers must ask pharmacists for the product containing codeine in name, and the pharmacist makes a judgementwhether it is suitable for the patient to be using codeine, and that patients are fully advised of the correct use of

these products. Products containing more than 12.8 mg codeine are available on prescription only.[38]

Italy

Codeine tablets or preparations require a prescription in Italy. A preparation of paracetamol and codeine isavailable in Italy as Co-Efferalgan.

Japan

Codeine and similar mid-level centrally acting agents in combination with non-opioid analgesics, antihistamines,vitamins, inert GI agents like kaolin & pectin, mild laxatives, antacids, and herbal preparations, can be purchasedover the counter, with 10 mg being the ceiling for OTC dispensing. This is also true of ethylmorphine anddihydrocodeine, and also diphenoxylate, some weak relatives of the thiambutene opioid family.

Russia

According to ITAR-Tass and Austria Presse-Agentur, OTC availability of codeine products was rescindednationwide in 2012 because of the discovery of the Krokodil method of underground desomorphine synthesis.Opponents of the move point out that codeine has not been available OTC in 22 of Russia's oblasts for years andthe demand will call forth its own supply, meaning that only legitimate end users are negatively impacted (activistquoted in Pravda story on issue)



Sri Lanka

Codeine preparations are available as over the counter pharmacy medicines in Sri Lanka. The most commonpreparation is Panadeine, which contains 500 mg of Paracetamol and 8 mg of Codeine.

North America

Narcotic content numbers

Narcotic content number in the US names of codeine tablets and combination products like Tylenol With CodeineNo. 3, Emprin With Codeine No. 4, and pure codeine tablets are as follows: No. 1 - 7 or 8 mg (1/8 grain), No.2 - 15 or 16 mg (1/4 grain), No. 3 - 30 or 32 mg (1/2 grain), No. 4 - 60 or 64 mg (1 grain). The Canadian "Frosst

222"[39] series is identical to the above list: "222" contains 8 mg codeine, "282" 15 mg, "292" 30 mg, and "293"60 mg. This system, which is also used at present in the trade names of some dihydrocodeine and ethylmorphineproducts both in and outside of North America, was inaugurated with the Pure Food and Drug Act of 1906 andrelated legislation and refined since.

Equivalent scales for labeling stronger opioids such as diacetylmorphine (heroin), morphine, opium salts mixtures,and others were in common use in the past, and on occasion one can find past references to brand names forhydrocodone (invented 1920, introduced in US 1943), hydromorphone (invented 1924), oxycodone (invented1916), paregoric and similar drugs containing narcotic content numbers. For example. from circa 1900 to 1925, themost common cough medicine was terpin hydrate With Heroin Elixir No. 2.

Contrary to the advertising matter of some pharmacies, 60 mg is No. 4, not No. 6, and tablets with 45 mg ofcodeine are not No. 4 and would in all likelihood be classified as No. 3 under that system. Whether the scalegoes to No. 5 and higher is moot at this point, as in the United States and Canada single-dose-unit concentrationsof more than 64 mg are not manufactured. The United States Controlled Substances Act of 1970 does placedosage unit strengths of 90 mg of codeine and higher in Schedule II, even if mixed with another active ingredient.Oral tablets, hypodermic tablets, liquid forms, and capsules of less common doses are available in some cases theequivalent dihydrocodeine, dionine, benzylmorphine, and opium dosages were previously available in NorthAmerica (and in most cases still are in other countries, particularly the 45 mg paracetamol/codeine and 50 and100 mg single-ingredient codeine tablets).

United States

In the United States, codeine is regulated by the Controlled Substances Act. Federal law dictates that codeine be aSchedule II controlled substance when used in products for pain-relief that contain codeine alone or more than90 mg per dosage unit. Tablets of codeine in combination with aspirin or acetaminophen (paracetamol/Tylenol)made for pain relief are listed as Schedule III; and cough syrups are Schedule III or V, depending on formula. Theacetaminophen/codeine pain-relief elixir (trade name Tylenol Elixir with Codeine) is a Schedule IV controlled

substance.[40] Some states, however, have chosen to classify Schedule V codeine preperations into a morerestrictive schedule in order to cut down the abuse of prescription codeine preperations. Minnesota, for instance,has chosen to reclassify Schedule V codeine preparations (such as Cheratussin) as a Schedule II controlled

substance. [41]



Preparations for cough or diarrhea containing small amounts of codeine in combination with two or more otheractive ingredients are Schedule V in the US, and in some states may be dispensed in amounts up to 4 fl. oz. per 48hours (one or two states set the limit at 4 fl. oz. per 72 hours) without a prescription. Schedule V specificallyconsigns the product to state and local regulation beyond certain required record-keeping requirements (adispensary log must be maintained for two years in a ledger from which pages cannot easily be removed and/or arepre-numbered, and the pharmacist must ask for photo identification) and also maintain controlled substances in theclosed system at the root of the rgime intended by the Controlled Substances Act of 1970; the codeine in theseproducts was a Schedule II substance when the company making the Schedule V product acquired it for mixing upthe end-product.

In locales where dilute codeine preparations are non-prescription, anywhere from very few to perhaps a moderatepercentage of pharmacists will sell these preparations without a prescription. However, many states have their ownlaws that do require a prescription for Schedule V drugs. The December 2008 issue of The Bulletin of theNational Codeine OTC Lobby (Vol. XVIII, No. 4) listed 12 states with some kind of OTC access to codeine,noting that small independent pharmacies are the most likely to have it. This situation is roughly equivalent to that inFebruary 1991, when the aforementioned organisation undertook its first comprehensive study of Schedule V andoverall codeine, dihydrocodeine, ethylmorphine, and hydrocodone availability.

Other drugs that are present in Schedule V narcotic preparations like the codeine syrups are ethylmorphine anddihydrocodeine. Paregoric and hydrocodone were transferred to Schedule III from Schedule V even if thepreparation contains two or more other active ingredients, and diphenoxylate is usually covered by stateprescription laws even though this relative of pethidine is a Schedule V substance when adulterated with atropine toprevent abuse.

Around the world, codeine is, contingent on its concentration, a Schedule II and III drug under the Single

Convention on Narcotic Drugs.[42]

Spain

Codeine tablets or preparations require a prescription in Spain, although this is often not enforced and many

pharmacies will sell codeine products without the requirement of a prescription.[citation needed]

United Arab Emirates

The UAE takes an infamously strict line on medicines, with many common drugs, notably anything with containingcodeine being banned unless you have a notarized and authenticated doctor's prescription. Visitors breaking therules, even inadvertently, have found themselves deported or jailed. The US Embassy to the UAE maintains anunofficial list (http://abudhabi.usembassy.gov/restricted_medication.html) of what may not be imported.

United Kingdom

In the United Kingdom, neat codeine and higher-strength codeine formulations - such as 30/500 co-codamol(where 30 mg of codeine phosphate is combined with 500 mg paracetamol) are prescription-only medicines(POM). Lower-strength combinations, such as 8/500 (various brands) or 12.8/500 (Panadol Ultra, SolpadeineMAX and others) are available as pharmacy medicines over the counter. Codeine is also available combined withIbuprofen; a common formulation is 12.8 mg codeine alongside 200 mg Ibuprofen. It is also available 'behind the



counter' with aspirin in doses of 8 mg codeine phosphate and 500 mg aspirin (Codis). Codeine Linctus of 15 mgper 5ml is also available behind the counter at some pharmacies, although a purchaser would have to request itspecifically from the pharmacist.

Under the Misuse of Drugs Act 1971, possession of codeine is legal without a prescription in quantities of up to12.5 mg when in tablet form. As with most opioids, possession of neat codeine without a prescripion is illegal inquantities over 12.5 mg and is currently a class B controlled drug. However, if it prepared for intra-muscularinjection, it is then considered to be a class A controlled drug. Thus it is legal for a person to carry neat codeine inquantities over 12.5 mg assuming that they possess a valid prescription, subject to the quantities carried being for

personal use only and with no indication that there is intent to supply.[43]

References

1. ^ Shen H, He MM, Liu H, et al (August 2007). "Comparative metabolic capabilities and inhibitory profiles of

CYP2D6.1, CYP2D6.10, and CYP2D6.17". Drug Metab. Dispos. 35 (8): 1292300. doi:10.1124/dmd.107.015354(http://dx.doi.org/10.1124%2Fdmd.107.015354). PMID 17470523 (//www.ncbi.nlm.nih.gov/pubmed/17470523).

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