Concerns over growing misuse of cough medicine Rikodeine



The addictive cough suppressant is popular with young people, more potent than codeine, and poses a serious risk of harm.

GPs are reporting an increase in teenagers using cough syrup containing codeine recreationally – mixing it with lemonade to produce a high.

In recognition of the severe harm and death caused by codeine and evidence of its limited analgesic efficacy, the opioid was scheduled to become a prescription-only S4 drug in 2018.

This decision has helped to significantly reduce addiction, associated harms and overdose deaths.

But now stories are emerging of new risks associated with an over-the-counter codeine-based cough medicine.

Rikodeine, sold as Rikodeine Oral Liquid, contains the active ingredient dihydrocodeine tartrate – a codeine derivative that was not affected by the 2018 update.

The drug has long been used recreationally after gaining popularity among celebrities in the US, but a GP has noticed a recent increase in young people abusing the cough medicine, which is available from pharmacies in as an S3 drug.

“I’ve had a growth of teenagers becoming addicted to Rikodeine since COVID,” said Perth GP Dr Andrew Leech newsGP.

“A few of my teenage patients have told me that they go from drugstore to drugstore to hoard the syrup, then mix it with lemonade to make a drug called ‘lean.’

Dr Leech fears that although it may not be on every GP’s radar, it could lead to harm and addiction.

“It’s quite serious and puts people at risk for an array of medical complications,” he said.

“I have a teenage patient who drinks 200ml of Rikodeine every night. She pours it into a 1.5L lemonade bottle, then sips it on parties.

“I obviously made her aware of the serious issues and risks associated with this – her risk of overdose and even death is significant.”

Dihydrocodeine is an opioid analgesic related to codeine with similar analgesic activity, in which the double bond at the seventh position is saturated. It is about one-tenth as potent as morphine and 2-3 times as potent as codeine, and similar to codeine in other ways.

Being a stronger variant with a more euphoric effect, it has a greater potential for abuse and addiction.

Although more potent, dihydrocodeine is less absorbed than codeine, which is easily absorbed orally, but both have the same dose equivalent.

Dr. Hester Wilson, Chair of RACGP Special Interest Addiction Medicine, has also raised concerns about the misuse of Rikodeine.

She said newsGP that while she doesn’t think many of her patients use it, there are two specific groups that do – teenagers and older adults who have developed addictions, who may regularly drink large amounts and several bottles a day.

“For these people who have developed a codeine addiction, they absolutely need care and support to change this use,” said Dr. Wilson.

“Some of them do very well on buprenorphine or methadone as part of an opioid treatment program.”

For younger people, Dr Wilson said they are more likely to experiment with the drug, stressing the importance of education around harm minimization.

“It’s important to give young people really credible information that it’s an opioid,” she said.

“Some young people don’t realize what it is…it’s a sedative, a painkiller that can potentially make you very sedated, put you to sleep if you mix it with other sedatives.

“And potentially, with high doses, there are risks of overdose.” I had a young person who came to see me because he ended up in the emergency room after taking cough syrup and alcohol at the same time.

Dr. Leech thinks Rikodeine should become script only.

‘The problem is [recreationally using the cough medicine] is considered a ‘normal and fun’ thing to do, and given the easy access to the counter, it’s not considered potentially serious,” he said.

“The chemists are quite lenient, given that one of my patients managed to maintain her daily habit. They need to be stricter in how they supply the drug and be on the lookout for teenagers who might appear to be abusing it.

“This drug needs to be urgently reviewed and become prescription only, especially since COVID where people are using it and realizing the potential euphoric effects of higher doses of codeine.”

A spokesperson for the Pharmaceutical Society of Australia said newsGP that dihydrocodeine is “equipotent” to codeine, but declined to say whether the drug should be scheduled for prescription only.

‘It’s a question for the TGA [Therapeutic Goods Administration]given that they are in charge of drug planning and rescheduling,” the spokesperson said.

Although Dr Wilson is not keen on a TGA review of Rikodeine, she believes more information is needed about its misuse and that GPs need to be involved and approach the issue holistically.

“Rikodeine causes harm to a small group of people and its benefits as a medicine are limited…but we need to collect more data on what actually happens with this medicine and the risks and harms it causes,” she said.

“While I don’t want to limit people’s access to medication, with something like codeine-containing medication, it makes sense that there’s a medical professional in the picture.

“As a GP, I want to make sure this is the best treatment for my patients and make sure nothing else is going on.”

Dr-Hester-Wilson-article.jpgIt’s important to give young people “really credible information” that cough syrup is an opioid and carries a risk of addiction, says Dr. Hester Wilson.

In addition to providing risk information, Dr. Wilson uses the HEADSS rating scale to work with young people on biopsychosocial dimensions.

“It’s a cough suppressant, but probably as a GP it’s not one I would easily prescribe,” she said.

“Because what I really want to know is, why are you coughing? Do we really need to look more into what’s happening to you?

“Assessing what is happening in this young person’s life to lead to this behavior – whether it is in a peer network, fun, party, or is it actually a signal that there are more serious things going on for them like with their mental health and well-being?

“It’s an important dynamic.”

For older people who may misuse or become addicted to cough syrup, Dr. Wilson says it’s helpful to assess whether there’s an ongoing infection or problem that needs attention, rather than just suppress a cough.

In all cases, consideration of the risk of addiction is essential, especially for young people who may not be aware of the harms.

“Even if it’s not used daily, one of the things for teenagers is that they can start to develop an addiction to opioids,” Dr. Wilson said.

“So having a very strong index of suspicion as to whether it has become addictive for that person [is important].

“If they are showing withdrawal symptoms, they may have developed an opioid addiction that would require management.”

Various international studies have shown that codeine has limited efficacy for mild to moderate pain, with the risks outweighing the benefits.

For these reasons, Dr. Wilson does not recommend it.

“As far as medication goes, it’s not that helpful…and there are concerning side effects, so I’d rather avoid them,” she said.

“Rikodeine is available over the counter, but it’s an S3 drug, so that means the pharmacists are in the picture and having the conversation, but there’s a problem that a person can go to multiple pharmacies, so the GPs should be aware. ‘

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