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From pain treatment to opioid dependence: a qualitative study of the environmental influence on codeine use in UK adults
  1. Emma Kinnaird1,
  2. Andreas Kimergård2,
  3. Stacey Jennings2,
  4. Colin Drummond2,
  5. Paolo Deluca2
  1. 1 Department of Eating Disorders, Psychological Medicine, King’s College London, London, UK
  2. 2 Addictions Department, King’s College London, London, UK
  1. Correspondence to Dr Andreas Kimergård; Andreas.Kimergard{at}


Objectives To investigate the views and experiences of people who use codeine in order to describe the ‘risk environment’ capable of producing and reducing harm.

Design This was a qualitative interview study. Psychological dependence on codeine was measured using the Severity of Dependence Scale. A cut-off score of 5 or higher indicates probable codeine dependence.

Setting Participants were recruited from an online survey and one residential rehabilitation service.

Participants 16 adults (13 women and 3 men) from the UK who had used codeine in the last 12 months other than as directed or as indicated. All participants began using codeine to treat physical pain. Mean age was 32.7 years (SD=10.1) and mean period of codeine use was 9.1 years (SD=7.6).

Results Participants’ experiences indicated that they became dependent on codeine as a result of various environmental factors present in a risk environment. Supporting environments to reduce risk included: medicine review of repeat prescribing of codeine, well-managed dose tapering to reduce codeine consumption, support from social structures in form of friends and online and access to addiction treatment. Environments capable of producing harm included: unsupervised and long-term codeine prescribing, poor access to non-pharmacological pain treatments, barriers to provision of risk education of codeine related harm and breakdown in structures to reduce the use of over the counter codeine other than as indicated.

Conclusion The study identified microenvironments and macroenvironments capable of producing dependence on codeine, including repeat prescribing and unsupervised use over a longer time period. The economic environment was important in its influence on the available resources for holistic pain therapy in primary care in order to offer alternative treatments to codeine. Overall, the goal is to create an environment that reduces risk of harm by promoting safe use of codeine for treatment of pain, while providing effective care for those developing withdrawal and dependence.

  • codeine
  • dependence
  • over-the-counter
  • prescribing
  • risk environment

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  • EK and AK are joint first authors.

  • Contributors PD and AK designed and planned the study. AK wrote the research protocol. AK recruited and collected the data. EK performed the literature research and undertook data analysis with AK and SJ. EK and AK contributed to theoretical implications of study analysis. EK and AK led on writing the paper with input from CD, SJ and PD. All authors had access to the data used and provided final approval of the manuscript to be published.

  • Funding This work was supported by the European Community’s Seventh Framework Programme FP7/2007-2013 under grant agreement no. 611736 as part of the CODEMISUSED Project. PD was supported by South London and Maudsley (SLaM) NHS Foundation Trust. PD and CD were partly funded by the National Institute for Health Research (NIHR) Biomedical Research Centre (BRC) for Mental Health at King’s College London and SLaM. EK received funding from the Medical Research Council: MR/N013700/1. AK, SJ and CD were partly funded by the NIHR Collaboration for Leadership in Applied Health Research and Care South London. CD received funding from an NIHR Senior Investigator award.

  • Disclaimer The views expressed are those of the authors and not necessarily those of the NIHR, SLaM NHS Foundation Trust and the BRC.

  • Competing interests None declared.

  • Ethics approval This qualitative study was imbedded in the CODEMISUSED project approved by King’s College London, Psychiatry, Nursing & Midwifery Research Ethics Subcommittee and the NRES Committee London – London Bridge.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement No additional data are available.

  • Patient consent for publication Not required.

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