Codeine Addiction: The Signs, the Dangers and the Other Painkillers That Cause Dependence
Codeine is an opioid. Learn the signs of dependence, what withdrawal really involves and why South African combination painkillers carry extra risk.
Codeine is an opioid, and taking it regularly for weeks or months can lead to dependence and addiction, even when every pack was bought legally for genuine pain. The earliest signs are needing more tablets for the same relief and feeling unwell when a dose is late. Withdrawal usually starts 8 to 24 hours after the last dose, peaks at 48 to 72 hours and lasts four to ten days, based on World Health Organization (WHO) and NSW Health clinical guidance.
Between January and June 2025, 341 people admitted to South African specialist treatment centres, about 4% of all admissions, reported non-medical use of codeine. The codeine products involved include combination painkillers and cough medicines, many of which are dispensed through pharmacies.
How Dependence on a Pharmacy Painkiller Develops
Your liver converts part of every dose into morphine, using an enzyme called CYP2D6, and that morphine does most of the pain-relieving work. Some people inherit extra working copies of the gene behind this enzyme. These ultra-rapid metabolisers make morphine faster and in larger amounts, which is why the US Food and Drug Administration warns that even normal doses can cause dangerously slowed breathing in them.
With daily use, the brain adapts to the opioid. With repeated use, the body can develop tolerance and physical dependence. The same dose may provide less relief, while missing a dose can trigger withdrawal. In someone who has developed dependence, taking another dose may then relieve withdrawal symptoms as well as pain. Dependence does not by itself mean that someone has an addiction or opioid use disorder.
South African researchers describe a pattern that catches many people out. Some stay within the dose on the box but take it so often that the tablets end up treating headaches caused by withdrawal itself.
Clinicians draw a line between physical dependence and addiction. Someone taking an opioid exactly as a doctor prescribed can develop tolerance and withdrawal without having an addiction. The American Psychiatric Association’s diagnosis of opioid use disorder looks at the wider pattern, such as losing control over the amount, cravings, failed attempts to cut down and carrying on despite the harm.
Is codeine addictive?
Yes. SAHPRA, South Africa’s medicines regulator, classifies it as an opioid with a known potential for dependence and warns that it carries a risk of tolerance and eventually dependence. The leaflet for Mybulen tablets, a well-known combination brand, warns that exceeding the prescribed dose with prolonged, continuous use may lead to dependency and addiction.
The Signs of Codeine Addiction to Watch For
Physical symptoms between doses can be a sign that the body has become dependent on codeine. They do not, on their own, mean someone has an addiction. WHO lists these symptoms of opioid withdrawal:
- nausea and vomiting
- diarrhoea
- hot and cold flushes with sweating
- muscle cramps
- watery eyes and a runny nose
- anxiety and trouble sleeping
WHO compares the experience to a very bad flu. A “flu” that eases after a dose and returns when the next one is late is a strong clue.
The more concerning signs of addiction are changes in behaviour and loss of control over use. Watch for:
- buying from several pharmacies, or seeing more than one doctor for scripts
- running out earlier than planned and finding reasons to buy more
- drinking cough syrup with no cough to treat
- taking a dose before stressful situations that have nothing to do with pain
- hiding supplies in a car or bag, and getting defensive when asked about them
The psychological side is the hardest to see, partly because the person often cannot see it either. In a 2017 South African Medical Journal study, addiction treatment providers named denial as one of the barriers to people getting help. The research found that many people dependent on codeine see themselves as respectable, high-functioning professionals and struggle to think of themselves as addicts.
In clinical terms, this pattern is opioid use disorder, diagnosed when at least two of eleven set criteria appear within 12 months. The same diagnosis applies to a pharmacy painkiller as to heroin.
Who Ends Up in Treatment in South Africa
The most recent national figures come from SACENDU, the South African Medical Research Council’s network that tracks admissions to specialist treatment centres. Its May 2026 research brief covers 7 975 admissions at 84 centres between January and June 2025. Of these, 341 people (4%) reported non-medical use of codeine, and the brief notes that this rate has fallen over the last three reporting periods.
Admissions where an over-the-counter or prescription medicine was the main drug made up between 1% and 7% of admissions, depending on the region, with the Eastern Cape highest. These patients had an average age of 37, and the split between men and women was close to even at 51% and 49%. In some regions most were women, reaching 83% in the Eastern Cape.
An earlier South African Medical Journal analysis of 2014 admissions shows which products were involved. Stilpane and Adco-Dol tablets were named most often, followed by Benylin with codeine syrup and Myprodol. For more than two thirds of those patients, codeine sat alongside another main drug, mostly alcohol or cannabis.
These figures only count people who reached a specialist centre. Many others only ever see a GP, or never ask for help at all.
What Combination Painkillers Do to the Rest of Your Body
Most of these products sold in South Africa are combinations. To get more of the opioid, someone escalating their use also swallows more of everything else in the tablet, and those ingredients carry their own risks at high doses.
The Myprodol and Mybulen leaflets both warn that the paracetamol they contain may be fatal in overdose, and too much of it damages the liver. Ibuprofen can cause stomach ulcers and bleeding, and Myprodol’s professional information notes that reversible kidney failure has been reported.
Myprodol’s professional information warns that alcohol and sedatives strengthen codeine’s depressant effects, and its overdose section describes breathing slowed to the point of oxygen starvation. Researchers at the South African Medical Research Council have also raised concern about lean, a mix of codeine cough syrup and soft drink, being used by school children at so-called codeine parties.
Is Myprodol addictive?
It can be. Each capsule contains 10 mg of codeine phosphate alongside 200 mg of ibuprofen and 250 mg of paracetamol, and its professional information warns that exceeding the prescribed dose with prolonged, continuous use may lead to dependency and addiction. Myprodol capsules are Schedule 3, so they need a prescription.
What Withdrawal Actually Looks Like
How long do codeine withdrawals last?
WHO guidance puts withdrawal from short-acting opioids at four to ten days, starting 8 to 24 hours after the last dose. NSW Health’s clinical guideline, which names codeine specifically, says symptoms peak at 48 to 72 hours and largely subside within five to seven days. Cravings and disturbed sleep can last for weeks after that.
| Stage | Timing after the last dose | What happens |
|---|---|---|
| Onset | 8 to 24 hours | The first withdrawal symptoms appear |
| Peak | 48 to 72 hours | Symptoms are at their most intense |
| Acute phase ends | Largely within 5 to 7 days, range 4 to 10 days | Physical symptoms settle |
| Protracted phase | Up to six months | A lower sense of wellbeing and strong cravings, which WHO notes often lead to relapse |
WHO describes opioid withdrawal as very uncomfortable but not usually life-threatening on its own. Pregnancy is an important exception. WHO recommends that pregnant women who are dependent on opioids do not go through withdrawal, because it can cause miscarriage or premature delivery, so pregnancy calls for a doctor straight away.
Dependence on alcohol or benzodiazepines (sleeping tablets and tranquillisers) alongside the opioid also needs medical supervision. Alcohol withdrawal can be life-threatening in rare cases, and WHO advises tapering benzodiazepines gradually partly to prevent seizures. Tolerance falls once withdrawal is over, and WHO warns that going back to the old dose carries a real risk of overdose.
Other Painkillers That Can Cause Dependence
Tramadol
Tramadol is a prescription-only opioid painkiller that also affects serotonin, one of the brain’s chemical messengers. Its official prescribing information carries three separate warnings, and they are easy to blur together.
The first concerns seizures while taking it. Seizures have been reported within the recommended dose range, and the risk rises above that range and with certain other medicines, some antidepressants among them. People with epilepsy or a history of seizures are also at higher risk.
The second is serotonin syndrome, a potentially life-threatening reaction that mainly occurs when tramadol is combined with other medicines that raise serotonin, including many antidepressants and the migraine medicines called triptans.
The third concerns stopping. The labels say tramadol should not be stopped suddenly in someone physically dependent on it, because rapid reduction of opioids has led to serious withdrawal symptoms, uncontrolled pain and suicide. South African prescribing information also lists unusual discontinuation symptoms, among them panic attacks, hallucinations and ringing in the ears, so coming off it should be a gradual taper under medical supervision.
Morphine and oxycodone
These strong opioids are prescribed for severe pain. In the US, the prescribing information for both morphine and oxycodone carries a boxed warning that they expose users to the risk of addiction, abuse and misuse, which can lead to overdose and death. Tolerance and withdrawal can keep use going long after the original pain has healed.
Painkillers that are not opioids
Paracetamol on its own and anti-inflammatories such as ibuprofen are not opioids and do not cause opioid dependence. They can still do real harm at high doses, as described above, which makes that a medical problem rather than an addiction.
Getting Help and What Treatment Involves
Opioid withdrawal on its own is not usually dangerous, but stopping alone often does not last. WHO notes that relapse after withdrawal is very common and treats withdrawal management as the first step before psychological treatment.
For moderate to severe withdrawal, WHO names buprenorphine as the best opioid medicine for easing symptoms and cravings, with clonidine as another option for the physical symptoms.
Seek emergency medical help if someone who has taken codeine is:
- difficult or impossible to wake
- breathing very slowly, shallowly or irregularly
- making unusual choking/gurgling sounds
- extremely sedated or confused
- showing signs of inadequate oxygenation.
At Changes Rehab in Northcliff, Johannesburg, detox from opioids such as codeine usually takes five to ten days with 24-hour nursing cover, and buprenorphine is sometimes used for severe dependence. Detox leads into a 21-day inpatient programme for prescription and pharmacy medicine dependence.
Substance dependence is included under South Africa’s Prescribed Minimum Benefits. The relevant PMB provides for hospital-based management of up to three weeks per year, although the exact treatment setting, authorisation requirements and funding arrangements depend on the medical scheme and the clinical circumstances.
Talking to someone who treats this every day is a sensible next step, even before you decide anything. Call the admissions team on 081 444 7000 or book an assessment. For support at any hour, see our list of helplines.