Drug reviews: use, side effects, effectiveness

Codeine over the counter – 17 OTC products

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Without a doubt, codeine-containing products are one of the most commonly sold medicines in the UK. Codeine can be purchased over the counter in the UK. Most codeine products are combination products of codeine and another drug. Codeine over the counter can only be purchased on its own in one form; please read on. I will list most of the codeine over the counter product in the UK; specifically, I will talk about:

  • Forms of codeine available over the counter in the UK
  • Where to buy over the counter codeine from?
  • Restrictions on the supply of codeine-containing products
  • Is codeine over the counter the best pain killer?
  • Codeine over the counter: UK list of products.
  • Prescription-only codeine

The main focus of this post is to introduce the most common over the counter codeine-containing products in the UK and review their codeine content. For more details, such as dosage instructions, warnings, possible side effects please refer to product information leaflet(s) or speak to the pharmacist.

What form of codeine can you buy over the counter in the UK?

The following over the counter combination products with codeine will be reviewed:

Codeine linctus (syrup)

As I already mentioned in the introductory part, codeine can be purchased on is own only in one form. Codeine Linctus (syrup) can be bought from pharmacies. Each 5ml of codeine linctus contains 15mg of codeine phosphate.

Co-codamol (paracetamol & codeine)

The most common form of codeine-containing medicine is co-codamol, which can be purchased over the counter from pharmacy counters. Co-codamol is a combination product containing 8mg of codeine and 500mg of paracetamol per tablet.

There are many other codeine containing-products which are available in pharmacies. Many branded products are sold, which are equivalent to co-codamol. Some branded products contain more than 8mg of codeine phosphate per tablet.

Codeine and ibuprofen over the counter

It is possible to get codeine in combination with ibuprofen. Ibuprofen belongs to a different class of drugs than paracetamol, called nonsteroidal anti-inflammatory drugs (NSAIDs), which additionally to its pain-relieving properties, have anti-inflammatory action. Few products are currently available in the UK with both ingredients – codeine and ibuprofen.

Codeine and aspirin

Like ibuprofen, aspirin belongs to the NSAID group of drugs. At higher doses, aspirin can be taken to manage pain, fever and inflammation.  

The above list is a general list of codeine and codeine-containing products. More specific products are reviewed in the latter part of this post.

Where to buy codeine over the counter from?

All codeine-containing products are pharmacy-only medicines (P). P medicines are sold in pharmacies only including online chemists, which operate under the supervision of a responsible pharmacist. Pharmacy-only medicines are not available for self-selection by customers.

Restrictions on the supply of codeine-containing products

A few years back, the Government introduced a ‘tighter controls’ for over the counter medicines containing codeine (and dihydrocodeine). The reasons for restrictions was to minimise the risk of overuse and addiction, which is possible with codeine use. Restrictions which are currently in place for over the counter codeine products:

  • Codeine containing products are only licensed for acute pain (for example to relieve a toothache), which is not relieved by paracetamol, ibuprofen or aspirin alone, except for codeine linctus, which can be used to manage non-productive coughs.
  • Codeine products are pharmacy-only medicines with the sales restricted to pharmacies and online chemists only.
  • Use of codeine-containing products is restricted to three days only
  • products containing codeine over the counter are restricted to 32 tablets.
  • Codeine containing products should not be used by children under 12 years of age, except for a combination of aspirin and codeine, which can only be taken by adults and children over 16 years of age.
  • Codeine linctus is licensed for adults 18 years of age and over.  

Is codeine over the counter the best pain killer?

As per licensing restriction combination products with codeine are recommended if simple analgesic such as paracetamol or ibuprofen fail to control the pain. Combination of codeine and paracetamol may provide better pain relief than paracetamol alone. A systemic review (review of all existing evidence) which looked at 24 different clinical trials (single dose trials) concluded that ‘analgesic effect between paracetamol-codeine combinations and paracetamol alone was small. This review included a range of codeine products, including higher doses of codeine combination drugs, which are not available over the counter (de Craen, et al., 1996).

In multi-dose studies (patient takes more than one dose of the drug), treatment with the paracetamol-codeine combination was associated with a significantly higher number of side effects as compared to paracetamol alone.

Differences in response to codeine treatment

A small proportion of codeine is changed in the body into morphine. It has to be noted that there is a significant variation in how people ‘process’ codeine. Some people (10% of white people, 2% of Asian people, and 1% of Arabic) are ‘poor metabolisers’ of codeine, which means that in this group of people codeine will have a little effect.

On the opposite, some people are ‘ultra‐metabolisers’, which means they convert codeine into more morphine in the body. This group of people is at risk of codeine toxicity, even at standard doses (Wiffen et al., 2016).

What is the highest amount of codeine available over the counter?

Codeine linctus contains the highest amount of codeine phosphate (15mg/5ml), although its licensed use is limited (see more in the next paragraph). The highest amount of codeine in codeine & paracetamol combination products is 12.8mg of codeine per tablet.  

Are combination products with codeine good for neuropathic (nerve) pain?

I discussed the management of nerve pain with amitriptyline (a prescription-only antidepressant) previously. In this post, I briefly talked about the use of over the counter analgesics such as paracetamol to manage nerve pain. Paracetamol alone is unlikely to provide pain relief from nerve pain. There is no sufficient data to support the use of codeine in neuropathic pain. Codeine is not recommended as the standard treatment of nerve pain.

Codeine over the counter: UK list of products

Codeine over the counter – cough medicine

1. Codeine linctus

Codeine over the ciOUE

Codeine lintus is a pharmacy-only medicine licensed for the management of dry coughs. Codeine linctus has is the only medicine, which contains codeine only, without any other active ingredients. 

  • Active ingredients (per tablet): codeine phosphate
  • Codeine content: 15mg of codeine per 5ml of linctus
  • Age restrictions: codeine linctus is licensed in adults 18 years of age and over for symptomatic relief of non-productive (dry) coughs.

Other notes: Many pharmacies do not stock codeine linctus. Likewise, a pharmacist may not agree to sell codeine linctus over the counter, due to potential misuse of this medication.

2. Pulmo Bailly 

Pulmo Bailly - codeine cough syrup

Pulmo Bailly is an oral solution (syrup) containing two active ingredients:

  • Codeine content: 7mg per 5ml of syrup and
  • Guaiacol (1949): 75mg per 5ml of syrup.

Pulmo Bailly is used to manage coughs caused by colds, including influenza (flu) and other respiratory tract infections.

Pulmo Bailly is licensed for adults over 18 years of age.

Combination products containing codeine and paracetamol

3. Co-codamol

Co-codamol - most popular codeine product

Co-codamol is sold by most pharmacies and supermarket pharmacies as own branded product, for example, Tesco Co-codamol, LLoyds Co-codamol, etc., Tesco co-codamol is one of the cheapest options for this medicine. A box of 32 co-codamol tablets cost under £3 (2020).

  • Active ingredients (per tablet): codeine phosphate (8mg) and paracetamol (500mg).
  • Codeine content: 8mg per tablet.  

 4. Veganin

Veganin - vegan and vegetarian co-codamol

In addition to a ‘standard’ amount of paracetamol and codeine Veganin tablets contain caffeine. Veganin tablets are suitable for vegans and vegetarians. Learn more about Veganin in a separate post.

  • Active ingredients (per tablet): codeine phosphate (8mg), paracetamol (500mg) and caffeine (30mg).  
  • Codeine content: 8mg per tablet. The same amount of codeine content as co-codamol tablets.

4. Syndol tablets

Syndol - combination of paracetamol, doxylamine and codeine over the counter

Syndol tablets contain a combination of paracetamol and codeine, and additionally, doxylamine succinate, which is the main difference to Syndol Headache Relief Tablets (next paragraph). Doxylamine is an antihistamine, which acts as an antiemetic agent (stops nausea), which can be associated with, for example with migraines.

  • Active ingredients (per tablet): codeine phosphate (10mg), doxylamine succinate (5mg), paracetamol (450mg) and caffeine (30mg).
  • Codeine content10mg per tablet.  A higher concentration of codeine than in ‘standard’ co-codamol.

5. Syndol Headache Relief tablets

Syndol Headache relief tablets with codeine

  • Active ingredients (per tablet): codeine phosphate (10mg) paracetamol (500mg) and caffeine (30mg).
  • Codeine content8mg per tablet. The same amount of codeine phosphate as in ‘standard’ co-codamol.

 6. Solpadeine Max tablets

Solpadine range of paracetamol and codeine

Solpadeine range of tablets (Solpadeine Max and Plus) is one of the best-known brands of combination medicines containing paracetamol and codeine. Solpadeine Max tablets do not contain caffeine, but a soluble version of Solpadeine Max does contain caffeine.

  • Active ingredients (per tablet): codeine phosphate (12.8mg) paracetamol (500mg).
  • Codeine content12.8mg per tablet.  The highest amount of codeine phosphate which can be bought over the counter in combination with paracetamol.

7. Solpadeine Plus capsules

  • Active ingredients (per capsule): codeine phosphate (8mg) paracetamol (500mg) and caffeine (30mg)
  • Codeine content8mg per tablet.  The same amount of codeine phosphate as in standard -co-codamol.

8. Migraleve tablets

Migraleve Pink & Yellow - paracetamol & codeine OTC

Migraleve range of tablets is mostly known for their use in the symptomatic management of migraines. Migraleve, like other codeine products, can be used to treat moderate pain, which is not relieved by paracetamol, ibuprofen, or aspirin alone. Migraleve rangle include three different products:

  • Migraleve (Pink and Yellow)
  • Migraleve Pink tablets
  • Migraleve Yellow tablets

All Migraleve products are pharmacy-only medicines, which can be used by adults and children over 12 years of age. Migraleve was out of stock for most of 2019 due to licensing issues, which are now resolved, and there is no stock issue with Migraleve products. At that time, I wrote a post about Migraleve Pink alternative products, which may interest you.

Migraleve contains two different tablets inside one pack: pink and yellow tablets.

Active ingredients in PINK Migraleve tablets:

  • Active ingredients (per tablet): codeine phosphate (8mg), paracetamol (500mg) and buclizine hydrochloride (6.25mg)
  • Codeine content: 8mg per tablet.

Other notes: Buclizine hydrochloride is an antihistamine, which is included in the formulation to relieve symptoms of nausea associated with migraines.

Active ingredients in YELLOW Migraleve tablets:

  • Active ingredients (per tablet): codeine phosphate (8mg) and paracetamol (500mg).
  • Codeine content: 8mg per tablet. An equal amount of codeine to ‘standard’ co-codamol tablets.
Which Migraleve tablet should you take first: Pink or Yellow?

Pink Migraleve tablet(s) should be taken on the onset of a migraine; if more tablets are needed to control the symptoms, one should take yellow Migraleve tablet(s), every four hours.

For more detail, please refer to product information leaflet.

As you can tell from the above, there is no difference between Miraleve Yellow tablets and co-codamol in terms of their active ingredients. 

Patients who do not respond to Migraleve or other codeine-containing products or analgesics may try Sumatriptan over the counter, which works differently to stop migraines.

9. Panadol Ultra tablets

Panadol Ultra tablets (codeine and paracetamol) have not been on the market for a long time, therefore this product is not well known.

  • Active ingredients (per tablet): codeine phosphate (12.8mg), paracetamol (500mg).
  • Codeine content12.8mg per tablet.  The highest amount of codeine phosphate available over the counter in the form of codeine & paracetamol combination.  

Soluble (effervescent) codeine over the counter

Soluble (effervescent) tablets dissolve in the water giving a solution (water + drug). Generally, it can be said that soluble tablets are absorbed and get to work faster than standard tablets.

10. Solpadeine Max soluble

Solpadeine Max soluble tablets - paracetamol with highest amount of codeine over the counter

Solpadeine Max soluble tablets have similar composition of active ingredients to Solpadine Max tablets. However, Solpadine Max soluble contain caffeine.

  • Active ingredients (per tablet): codeine phosphate (12.8mg), paracetamol (500mg) and caffeine (30mg).
  • Codeine content12.8mg per tablet.  The highest amount of codeine phosphate available over the counter in the form of codeine & paracetamol combination.  

11. Solpadeine Plus soluble

Soluble Solpadeine Plus

Solpadeine Plus soluble tablets have the same composition of active ingredients as Solpadine Plus tablets (non-effervescent):

  • Active ingredients (per tablet): codeine phosphate (8mg), paracetamol (500mg) and caffeine (30mg)
  • Codeine content8mg per tablet.  The same amount of codeine phosphate as in standard -co-codamol or generic co-codamol effervescent (next paragraph).

12. Co-codamol effervescent (‘generic’)

Generic, including, cheap(er) supermarket and pharmacy version of co-codamol effervescent usually contain 8mg of codeine and 500mg of paracetamol per tablets.

There are many generic and branded versions of co-codamol effervescent (with or without caffeine), for example, Ultramol soluble tablets, Paracodol tablets. Their availability varies between pharmacies.

Combination of codeine and ibuprofen

In the last part of this post, I will list the most common combination medicines which contain ibuprofen and codeine as an active ingredient. Ibuprofen belongs to a group of drugs called Nonsteroidal anti-inflammatory drugs (NSAIDs) and unlike paracetamol, can be taken to help with inflammation in addition to its properties as a painkiller.

13. Nurofen Plus

Nurofen Plus - Ibuprofen & Codeine OTC

Nurofen Plus is probably the best-known brand of codeine and ibuprofen combination medicine.

  • Active ingredients (per tablet): codeine phosphate (12.8mg) and ibuprofen (200mg).
  • Codeine content: 12.8mg per tablet. The highest amount of codeine phosphate available over the counter.  
  • Similarly to paracetamol-codeine medicines, Nurofen Plus can be taken by adults and children over 12 years of age.

14. Solpadeine Migraine Ibuprofen & Codeine Tablets

Solpadeine for migraines

Solpadeine Migraine Ibuprofen & Codeine tablets have the same active ingredients as Nurofen Plus:  

  • Active ingredients (per tablet): codeine phosphate (12.8mg) and ibuprofen (200mg).
  • Codeine content: 12.8mg per tablet. The highest amount of codeine phosphate available over the counter.  

 15. Boots ibuprofen and codeine tablets

Boots ibuprofen and codeine tablets represent the same combination of active ingredients as Nurofen Plus tablets, namely ibuprofen 200mg per tablet and codeine phosphate 12.8mg per tablet.

Combination of codeine and aspirin

Aspirin belongs to the same class of drugs as ibuprofen – NSAIDs. At higher doses (more than 300mg daily), aspirin is usually taken to help with pain (headache, toothache etc.), to reduce temperature (antipyretic effect) and to reduce inflammation. A lower dose aspirin, baby aspirin (75mg) may be recommended by a GP as secondary prevention of cardiovascular disease, for example, in patients who had a heart attack or stroke.  

16. Codis 500 soluble tablets

Codis 500 contains two active ingredients:

  • Aspirin: 500mg per tablet
  • Codeine content: 8mg per tablet

As with other codeine products, Codis 500 is recommended for short term management of pain, which is not relieved by other analgesics such as paracetamol alone. Codis 500, aspirin, and other aspirin-containing products should not be used in children under the age of 16.

Codis 500 are soluble tablets and needs to be dissolved in the water before administration.

17. Boots aspirin & codeine tablets

Boots aspirin and codeine tablets are licensed for adults and children over 16 years of age. Two main active ingredients found:

  • Codeine content: 8mg per tablet
  • Aspirin: 400mg per tablet

The licensed use for Boots and aspirin and codeine tablets is the same as previously discussed codeine products.

Prescription-only codeine

Codeine available on prescription can be prescribed on its own or in combination with paracetamol. When prescribed, there are no restrictions in terms of quantity that can be prescribed by GP.

Codeine is usually available in a pack of 28 tablets. Prescription-only co-codamol exists in a pack sizes of up to 100 tablets or capsules. POM versions of codeine & co-codamol medicines include:

  • Codeine 15mg tablets
  • Codeine 30mg tablets
  • Codeine 60mg tablets
  • Codeine & paracetamol (co-codamol) is available in the form of tablets and capsules with 500mg of paracetamol per tablet/capsule, and either 8mg, 15mg, 30mg of codeine.

Conclusion

With the exception of codeine linctus, codeine over the counter can only be purchased as a combination product with paracetamol, ibuprofen or aspirin. Some evidence exists to support better analgesic effectiveness of codeine & paracetamol when compared to paracetamol alone. A number of restriction are in place to control over the counter supply of codeine-containing products. Use of codeine is associated with a number of common side effects and addiction.

References:

de Craen AJ, Di Giulio G, Lampe-Schoenmaeckers JE, Kessels AG, Kleijnen J. Analgesic efficacy and safety of paracetamol-codeine combinations versus paracetamol alone: a systematic review. BMJ. 1996 Aug 10;313(7053):321-5. doi: 10.1136/BMJ.313.7053.321. PMID: 8760737; PMCID: PMC2351742. Available at: https://doi.org/10.1136/bmj.313.7053.321 Accessed on 17/12/2020

Wiffen PJ, Knaggs R, Derry S, Cole 

P, Phillips T, Moore RA. Paracetamol (acetaminophen) with or without codeine or dihydrocodeine for neuropathic pain in adults. Cochrane Database of Systematic Reviews 2016, Issue 12. Art. No.: CD012227. DOI: 10.1002/14651858.CD012227.pub2. Accessed 17 December 2020. Available at: https://doi.org/10.1002/14651858.CD012227.pub2 Accessed on 17/12/2020

 

I am a community pharmacist working in UK. I blog about drugs, health and pharmacy.

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