Concerns over growing misuse of Rikodeine cough medicine

In recognition of the serious harms and deaths caused by codeine and evidence of its limited analgesic efficacy, the opioid was up-scheduled to an S4 prescription-only medicine in 2018.
 
That move helped to significantly reduce dependence, associated harms and overdose deaths.
 
But now, stories are emerging of new risks associated with a codeine-based over-the-counter cough medicine.
 
Rikodeine, sold as Rikodeine Oral Liquid, contains the active ingredient dihydrocodeine tartrate – a derivative of codeine that was unaffected by the 2018 up-scheduling.
 
The drug has long been used recreationally after gaining popularity among celebrities in the US, but one GP has noticed a recent surge in young people misusing the cough medicine, which is available in pharmacies as an S3 medicine.
 
‘I’ve had a growth of teenagers becoming addicted to Rikodeine since COVID,’ Perth GP Dr Andrew Leech told newsGP.
 
‘A couple of my teenage patients have told me they drive from chemist to chemist to accumulate the syrup then mix it with lemonade to make a drug called “lean”.’
 
Dr Leech is concerned that although this might not be on all GPs’ radar, it has the potential to lead to harm and addiction.
 
‘This is quite serious and puts people at risk of a range of medical complications,’ he said.
 
‘I have one teenage patient who is drinking 200 ml of Rikodeine nightly. She pours it into a 1.5 L bottle of lemonade, then sips it at parties.
 
‘I have obviously advised her the serious issues and risks involve with doing this – her risk of overdose, even death, is significant.’
 
Dihydrocodeine is an opioid analgesic related to codeine with similar analgesic activity, in which the double bond in the seventh position is saturated. It is about one-tenth as potent as morphine and 2–3 times more potent than codeine, and similar to codeine in other respects.
 
Being a stronger variant with more euphoric effect, it has greater potential for misuse and dependence.
 
Although more potent, dihydrocodeine is less absorbed than codeine, which is readily absorbed orally, but both have the same dose equivalent.
 
Dr Hester Wilson, Chair of RACGP Specific Interests Addiction Medicine, has previously also raised concerns around misuse of Rikodeine.
 
She told newsGP that although she does not think many of her patients are using it, there are two specific groups who do – teenagers and older people who have developed a dependency, who may be regularly drinking large amounts and multiple bottles daily.
 
‘For these people who have developed a codeine dependency, they absolutely need care and to be supported to change that use,’ Dr Wilson said.
 
‘Some of them actually do very well on buprenorphine or methadone as part of an opioid treatment program.’
 
For young people, Dr Wilson said they are more likely to be experimenting with the medicine, highlighting the importance of education around harm-minimisation.
 
‘It’s important to give young people really credible information that this is an opioid,’ she said.
 
‘Some young people don’t realise what it is … that it’s a sedative, a painkiller that can potentially make you very sedated, put you to sleep if you’re mixing it with other sedatives.
 
‘And potentially with big doses there are risks of overdose. I’ve had one young person coming to me because they ended up in the emergency department after taking some cough syrup and alcohol at the same time.’
 
Dr Leech believes Rikodeine should become script only.
 
‘The problem is [recreationally using the cough medicine] is seen as a “normal and fun” thing to do, and given the easy access over the counter it is not seen as being potentially serious,’ he said.
 
‘Chemists are fairly lenient, given one of my patients has managed to maintain her habit daily. They need to be more stringent in the way they supply the drug and be on the lookout for adolescents who may appear to be abusing it.
 
‘This drug urgently needs review and to become prescription only, especially since COVID where people have been using it and realising the potential euphoric effects of higher doses of codeine.’ 
 
A spokesperson from the Pharmaceutical Society of Australia told newsGP that dihydrocodeine is ‘equipotent’ to codeine but declined to comment on whether the drug should be up-scheduled to prescription only.
 
‘This is a question for the TGA [Therapeutic Goods Administration], given they are in charge of medicine scheduling and rescheduling,’ the spokesperson stated.
 
While Dr Wilson doesn’t feel strongly about a TGA review of Rikodeine, she believes more information is needed on its misuse, and that GPs need to be involved and to approach the issue holistically.
 
‘Rikodeine does cause harm to a small group of people and it has limited benefit as a medication … but we need to collect more data around what’s actually happening with this medication and the risks and harms that it’s causing,’ she said.
 
‘While I don’t want to limit people’s access to medicine, with something like a codeine-containing medicine, it makes sense for there to be a health practitioner in the picture.
 
‘As a GP, I want to make sure that this is the best treatment for my patients and making sure there’s not something else going on.’
 
It is important to give young people ‘really credible information’ that the cough syrup is an opioid and carries a risk of addiction, says Dr Hester Wilson.

As well as providing information on the risks involved, Dr Wilson uses the HEADSS assessment scale to work through the biopsychosocial dimensions with young people.
 
‘It is a cough suppressant, but probably as a GP is not one that I would readily prescribe,’ she said.
 
‘Because what I’m really wanting to know is: Why are you coughing? Do we actually need to be looking more at what’s going on for you?
 
‘Assessing for what is going on in this young person’s life to lead to this behaviour – whether it is part of a peer network, fun, party thing, or is it actually a flag that there is more serious stuff going on for them like with their mental health and wellbeing?
 
‘That’s an important dynamic.’
 
For older people who may be misusing or developing a dependency on the cough syrup, Dr Wilson says it is useful to assess whether there is an infection or ongoing issue that needs attention, rather than simply suppressing a cough.
 
In all cases, reviewing the risk of addiction is critical, particularly for young people who may be unaware of the harms.
 
‘Even if it’s not used daily, one of the things for adolescents is that they can start developing a dependency to opioids,’ Dr Wilson said.
 
‘So having a very strong index of suspicion around whether it has become a dependency for this person [is important].
 
‘If they are having withdrawal symptoms they may have developed an opioid dependency that would need support management.’
 
Various international studies have found 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 useful … and there are concerning side effects, so I prefer to avoid it,’ she said.
 
‘Rikodeine is available over the counter, but it is an S3 medicine so it does mean that pharmacists are in the picture and having the conversation, but there is an issue that a person may go to multiple pharmacies, so GPs need to be aware.’
 
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