Experts push to ban OTC codeine as UK faces rising dependence

Health experts are calling for a ban on over-the-counter codeine in the United Kingdom, arguing that the drug provides limited relief for chronic pain and has become a driver of dependence across communities.

Abby Johnson, 35, of Gloucester, embodies the concerns about wide access to codeine. She was treated for gallstones and was prescribed 30mg tablets to take up to four times daily. Within a year, she used her month’s supply—240 tablets—in three days, then sought more from local and online pharmacies, accumulating debt in the process. Johnson recalls that she would experience crippling withdrawal symptoms within 12 hours without the drug, including severe anxiety, flu-like symptoms, abdominal pain and insomnia. The dependence went on to damage her health and employment: she lost weight to 7st 7lb, struggled to focus, and eventually resigned, then faced being sacked after prolonged illness. Now in a medically supervised withdrawal program, she says she is gradually reducing her dose and rebuilding her life.

Codeine is an opioid, part of a broader family that includes tramadol, oxycodone and fentanyl. Although it is often described as a weaker opioid, it remains highly addictive because it is converted to morphine in the body, producing euphoria and reinforcing use. Packets warn that codeine can become addictive within days, and medical guidance has long stressed that its value is greatest for short-term, acute pain—such as after surgery or in palliative care—not for chronic pain, which is defined as lasting more than three months. Beyond the risk of addiction, codeine can cause a range of adverse effects, including irregular heart rhythms, confusion, constipation, dizziness, abdominal cramps and drowsiness, and it can depress breathing in high doses or when mixed with other depressants.

Recent evaluations have placed the UK at the forefront of global OTC codeine availability. While tightening controls around codeine have been introduced—such as moving codeine-containing linctus to prescription-only status—over-the-counter sales remain among the highest in the world. Oxford University data published in Drug Safety in 2022 ranked the UK fourth in average OTC codeine sales among 31 countries, and a 2023 Oxford study estimated that 4.75 billion doses were sold over the counter between 2013 and 2019 through 83 products, equating to an average of about 17 doses per person.

Experts say the scale of use and the lack of systematic monitoring contribute to the problem. “The problem is GPs don’t know if a patient is buying large amounts of codeine,” said Professor Sir Sam Everington, a London-based GP and incoming president of the Royal College of GPs. He argued for a national database or other monitoring to alert clinicians when patients are purchasing large quantities, noting that informal sharing of information among pharmacists remains limited.

Data from King’s College London published last week show that opioid-related deaths rose by about 50 percent compared with official tallies between 2011 and 2022, underscoring the broader risks of opioid misuse, including misuse of medicines like codeine. Health researchers also point to recent declines in opioid prescribing overall, but stress that reductions have been modest and that long-term, non-cancer pain remains an area where opioids are still prescribed at high levels.

In the United Kingdom, tighter controls have already reduced access in some areas. Dr. Alison Cave, chief safety officer at the Medicines and Healthcare products Regulatory Agency (MHRA), cited changes such as restricting codeine linctus to prescription-only status as part of a broader effort to curb risk. Yet experts emphasize that the remaining supply, including combined products like co-codamol and other formulations, continues to be widely available.

“There has been a decrease in prescribing opioids, but it’s been relatively modest,” noted Roger Knaggs, a professor of pain medicine at the University of Nottingham and chair of the British Pain Society. He and others caution that long-term, non-cancer pain is often managed with strategies beyond opioids, including physical activity, adequate sleep, cognitive approaches such as CBT and mindfulness, and education that pain does not always correlate with tissue damage.

Sailesh Mishra, a consultant in pain management and anaesthesia at the Royal Victoria Infirmary in Newcastle, stresses that opioids have only a limited role in chronic non-cancer pain. When they are used, doses must be carefully weighed against risks, benefits, and the need for regular reassessment of effectiveness.

The attention to codeine is not limited to policy debate. Abby Johnson’s experience echoes a broader concern about dependence and the way patients may cycle through prescriptions and non-prescription sources. After a surgical removal of her gallbladder in late 2022, Johnson was re-prescribed codeine for post-operative pain and found herself unable to stop. She eventually sought help through a drug-dependency service and has been undergoing opioid substitution therapy, group therapy and counseling for nearly a year. She says she’s seen a dramatic life change since entering treatment and has launched an online petition urging a nationwide database to track OTC codeine sales, arguing that the scale of the problem requires systematic monitoring.

Public health researchers warn that codeine’s availability on the high street may contribute to the broader challenge of opioid dependence. Nottingham University’s Pain Reports study, featuring responses from general practices in the East Midlands, found that a significant share of patients on opioids experience adverse effects, and more than a third feared dependence or addiction. While the NHS has moved to reduce opioid prescribing, millions still receive such medications, highlighting the ongoing need for comprehensive strategies beyond pharmacologic treatment, including behavioral therapies and social prescribing approaches such as active lifestyle programs and community engagement.

The state of access to codeine, the evidence on its efficacy for chronic pain, and the human cost highlighted by Johnson and others have intensified calls for more drastic steps. Some clinicians argue that banning OTC codeine could reduce impulsive buying and non-prescribed use, while others contend that any policy must be coupled with robust patient support, safer alternatives for pain relief, and better clinician-patient communication. As policymakers weigh options, the conversation centers on balancing patient comfort with the imperative to curb misuse and protect vulnerable individuals from the life-altering consequences of dependence.