Is codeine safe?

[joda]

Anyone whose read my posts will know all about bad back, etc. Well physio has me on crutches now, and suggested going back to gp to see if any pain relief could take to take edge off pain. Did this morn and gp said cocodamol. Everything been told before says shouldn't take codeine through pregnancy, but she said should be fine if use as and when rather than all time and is lowest dose. Also prescribed amitriptyline even though its not nerve pain. Both basically just to try and see if one works. Was reassured at time, but now after getting home and speaking to OH not sure if should try cocodamol or not, mostly to help me get more than an hours sleep at night x

[DrFluffy]

Codeine is perfectly safe in pregnancy - much safer than the negative effects of a stresses out and in pain mummy to be. If your doctor thinks you need it (it's much safer than amitriptyline!!!!!)

[joda in reply to DrFluffy]

thank you, that puts mind at ease. what are the probs with amitriptyline? Second gp to suggest. first I refused wanting to see if physio and paracetamol would be enough, this time tbh I'm at end of tether and willing try as even my very active baby fed up of me hitching all the time, and generally sleeps in the morning when I get up. The gp was trying to see side effects of amitriptyline but just said only prescribe if need outweighs risk. Didn't explain what risk was. and did say is up to me with either if use or not. I do know used to be used as anti depressant, other than that not much x

[DrFluffy in reply to joda]

Amitriptyline (a tricyclic antidepressant; used off licence for neuropathic pain, migraine and insomnia among other things) is an old drug, and therefore not very specific (acts on lots of different cell receptors), it therefore has a lot of unwelcome side effects. IIRC, if started in third trimester/later in pregnancy, baby can have a nasty amitriptyline withdrawal too. If you end up needing a c-section with anaesthesia, amitryptyline can interact with the drugs used.

On going pain is always associated with a degree of depression (a so called yellow flag symptom), so I guess that's why GP has suggested it? 10mg at night?

This is a decision between you and your GP, but I really think that if it were me being asked to take it (as a patient with medical knowledge, rather than with my doctor hat on), I would be trying the codeine before hitting the nasties...

[joda in reply to DrFluffy]

Hmm, maybe will be leaving the amitriptyline then. I know they keep saying safe, but said I would stop being sick by 16 weeks too and still waiting for that to happen. Hoping won't need C-section but at moment is a possibility if can't get my pelvis more mobile. all the ligaments etc done what supposed to, but the right hand side just not opening up, solid, because I just had to be awkward didn't I lol. But while I've been suffering the baby been doing really really well and don't want to jeopardise that, esp now with only five weeks to go. Not sure dosage etc yet, pharmacy was waiting for delivery so OH picking up later and gp didn't say, with either, and unlike my normal careful self didn't read prescription before handed it over. Could be i'm starting with depression symptoms, hard to tell after two weeks with an hours sleep a night if having a good night. Oh well, soon have my monster out here, safe and causing me trouble thanks for the advice x

[DrFluffy]

... The other thing to bear in mind is that it takes 3-6 weeks for ami to fully kick in. How far through are you? X

[kellydrage]

I had a spinal tumour removed in June 2010 and am 17 weeks pregnant. I am prescribed codeine and amitriptyline for mechanical and nerve pain. I am under the care of an OB and she is satisfied with those meds for the moment but I am getting extra growth scans just to be sure (even though she says it shouldn't be an issue) and she is writing to my GP to let her know the options for additional pain relief when the need arises (I get bad episodes of spasms). Hope that helps. The ideal is none of anything and I have tried and only take when absolutely necessary but that is becoming more frequent.

[joda in reply to kellydrage]

thanks. she did say as and when need, would rather take nothing but that just no longer an option. going to try cocodamol first and see how we do x

[joda]

Ha, I'm 35 weeks tomorrow. And been suffering low bp too so have been told baby might want to make an early appearance, but midwife thinks shouldn't be a problem as long as stays as is just now x

[kellydrage in reply to joda]

Good luck with it all - bad backs are the pitts x

[joda in reply to kellydrage]

Def, spinal tumour sounds much more painful than fractured vertebrae mind. Hope your doing ok pain wise. What we put ourselves through for babies x

[Hidden]

Both amitriptyline and codeine have not been studied fully for their effects during pregnancy. Interestingly both substances are associated with withdrawal symptoms, including respiratory depression in neonates (this is just a coincidence; it doesn't mean that they work in the same way).

There is the impression that codeine is a "milder" opioid but this is not true. The impression only exists because codeine in combination with other substances like paracetamol can be bought over the counter while other opioids require prescription. The US Food and Drug Administration places codeine in the same risk category as morphine for its high addiction potential.

Now with regards to the treatment of nerve pain: this is a condition that is often treated badly by GPs due to lack of education or awareness of the latest data. Chronic low back pain responds very poorly to amitriptyline (compared to e.g. diabetic neuropathic pain). This type of pain responds better to pregabalin or Cox2 inhibitors, both of which are not permitted during pregnancy. Saying all that, you mentioned that you have clear diagnosis you do not have nerve pain therefore you don't need to consider the above (including amitriptyline). However your doctor may have given you amitriptyline for another reason: often tricyclic antidepressants are prescribed in combination with lower dose of opioids in order to reduce opioid exposure.

Going back to codeine: it is true that if you take it in "as needed" basis you can minimise the risk of addiction to you and the baby and the risk for the baby to develop neonatal abstinence syndrome. The American Congress of Obstetricians and Gynaecologists have issued a warning against the use of codeine in the 1st trimester because of risk of congenital heart defects. The FDA has issued a warning against the use of codeine by breast feeding mothers, so please keep that in mind.

[Hidden in reply to Hidden]

Joda, I just had an epiphany: there is also something else you could ask your GP for: the lidocaine patches (brand name Versatis). These are patches that can be worn on the back and slowly release lidocaine (another opioid) locally to provide pain relief. The benefit of that is much lower opioid concentration running through your veins and much lower addiction potential. Data shows good results in patients with chronic low back pain. Good luck!

[Hidden in reply to Hidden]

Apologies for my pregnancy brain: lidocaine is an anaesthetic not an opioid. Again not widely studied during pregnancy but its metabolism is fast.

[Hidden in reply to Hidden]

The GP may be reluctant to prescribe the patch as it is expensive and also because it is primarily prescribed for a type of nerve pain. If that happens show him the following report that shows effectiveness in low back pain:

ncbi.nlm.nih.gov/pubmed/155...

[DrFluffy in reply to Hidden]

Lidocaine isn't an opioid - it's a sodium channel blocker that works by blocking the sodium channels in nerve cells slowing down or stopping nerve signal transmission. X

[Hidden in reply to DrFluffy]

Already corrected above

[DrFluffy in reply to Hidden]

Codeine IS a 'milder' opioid, as recognised by the WHO. It's metabolised to it's active form at around 1/10 of that of oral morphine sulphate - i.e 60mg of codeine = <6mg of oramorph/MST. X

[Hidden in reply to DrFluffy]

True; codeine in terms of equianalgesia is 1/10 that of morphine but it is also 90% bioavailable compared to 25% of morphine. In terms of potency some opioids are indeed "milder" however the relationship between potency and tolerability is not linear (thus rendering the word milder a misnomer). Therefore it doesn't mean that lower dose also means less side effects or addiction potential.

The opioid related symptom distress scale is currently only used as a clinical trial tool and not therapeutically. Pain KOLs like Nat Katz are pushing the FDA for its use in clinical practice but it will be a long time before it becomes reality. To my knowledge it has only been validated so far for use in surgery under general anaesthesia.

With regards to the relationship between benefit and safety (toxicity) all opioids are considered to be of narrow therapeutic index.

[DrFluffy]

You are comparing apples and pears - the bioavailability of codeine may be 90% - but that's codeine, which isn't the active metabolite... Active morphine has such a lower bioavailability as it undergoes rapid first pass metabolism (this is why rectal morphine has a bioavailability of nearer 80% and IV is nearer 100%.

It DOES NOT have a narrow therapeutic index - this is a very specific term used to describe drugs such as phenytoin, digoxin etc, where the difference between a therapeutic dose and a fatal dose is minimal. It also very much does have a linear relationship - it's just that some people are slow acetylators and others fast - I.e done break down morphine metabolised quickly and others slowly. It certainly does not display zero order kinetics (non-linear) - the two drugs that do are alcohol and warfarin.

Thankfully, in the UK, the FDA means sweet FA!

[Hidden in reply to DrFluffy]

Most opioids's TI is in the region of 30-100. The exceptions are sufentanil and remifentanil who have TIs in the order of thousands. I don't have a table handy, as at work we do the calculations by hand, but here is a quick reference:

ncbi.nlm.nih.gov/pubmed/859...

With regards to the relationship between potency and tolerability or addiction potential profile, if it was linear we would not have examples like the following:

-codeine is less potent than morphine but both are schedule 2 in terms of addiction risk

-buprenorphine is x4 more potent than morphine but it is schedule 3

-codeine has a worse GI side effect profile than oxycodone

-hydromorphone is five to seven times more potent than morphine but has an improved side effect profile

-Oxycodone is more potent and causes fewer severe adverse effects than morphine etc etc

Milder does not necessarily mean kinder..

And since you don't hold american experts in high regard, maybe you can give Prof Andre Moore (Oxford Regional Pain Relief Unit, Churchill Hospital), one of Britain's best pain experts, a call to ask him his opinion on the ORSD scale and the need to become a regulatory necessity so that people do not carry misconceptions about the benefit: risk profile of opioids.

[joda]

Thank you both. Didn't mean for a debate to start lol. Anyway, update, haven't tried the ami - haven't actually picked up from chemist yet. However have tried the cocodamol. Left until later because it's sleep I've been needing, and took one dose with dinner and then the next about an hour before bed, didn't rid me of pain, but did ease it enough to let me find a position to fall into a deeper sleep. Four hours of glorious sleep Gp had said cocodamol could make baby drowsy and would possibly be less active so be aware. But at mo think baby was as relieved as me to have some decent sleep as is back to wriggly morning movements. Has made me more stiff this morning and exercises a lot harder, and the pain is as strong as ever but feeling a lot better for some sleep. Not taken any this morn, going to take day as it comes.

Babymummy, gp did suggest patches of some kind, but after she double checked effects on pregnant women decided against them. Not sure what they were but she said no, didn't say why. Wasn't my usual gp either. She wondered why I hadn't been offered a tens machine by physio, and said could hire one through the surgery if need be, though buying one would probably be better. Haven't spoke to physio yet to ask why not. Think she's just being very cautious, so will be waiting to speak to physio before looking into tens x

[DrFluffy in reply to joda]

TENS was amazing through the early stages of my labour - as I was induced early, I couldn't get hold of a rental one, but the obstetric physio told me the company they used to hire had an offer on, and you could buy their standard machine for the same price as hiring it through the hospital...

This is it: still on offer!

babycaretens.com/acatalog/F...

After a 67 hour labour, I had lots of mechanical back pain after - this was also a god send, as I didn't want to take the NSAIDS I was repeatedly offered as I have a kidney problem and was on aspirin from 12/40 with heartburn (decided I'm unlucky enough to end up with acute kidney injury and a torrential upper GI bleed!!)

Glad you got 4 hours sleep

Xx

[Hidden in reply to joda]

She may have only checked opioid patches like fentanyl or buprenorphine patches. Not the lidocaine patches..

[joda]

I will ask about the patches and tens. Thank you both. Last night wasn't nearly so restful (though two hours still better than one), but that's cos decided to be clever and go for a day trip to Edinburgh (not that far from us) - only managed two hours of hobbling around on crutches (with lots of sitting down) before was completely shattered. Learned that hills are not my friend and I AM NOT superwoman, at least not anymore. Felt like a 1960s dalek, small gradients now defeat me... and yes think I may be going slightly insane. Was hardly able to move at all by time got home, and had the shakes - but know was my own fault trying to be to clever as usual, for once I've learned my lesson. My poor oh thought he'd killed me and kept apologising but was my idea as was fed up of being stuck in. Not one of my brighter ideas after all. There is a good upside which is that the baby seems much happier, and going to hopefully be able to get some more sleep today, so no doubt will be having my ribs kicked again shortly x

[oldermom]

Joda, I have a question for you regarding codiene use during pregnancy. I understand u were prescribed codiene during your pregnancy, did u use codiene throughout your pregnancy? How much did u take, did u take the pain meds right from the first trimester? Did it have any affects on your baby? I'm only 5 weeks along but I'm in constant pain and I'm the kind of person who can't tolerate pain. I was prescribed acetaminophen with codiene but I freak out everytime I take it. Anybody who can answer my question, please reply, I need to ease my mind. Thank u.

[joda in reply to oldermom]

Sorry, only just seen this. Was my last trimester mostly needed it. Have to say I tried my hardest not to take but by the end was taking as often as had been advised which was 4 times a day and this continued afterwards The best advice can give is trust your doctor. They'll keep you in hosp 24 hrs to keep an eye on baby as cocodamol can affect respiratory development but can tell you John is perfectly healthy. The doctors work out whats best for your baby. If you can't tolerate pain they'll give you what pain meds they can that will affect your baby as little as poss, but its a balance as a mum in pain and stressed out can be bad for baby so if you need the painkillers then best to follow docs advice and take. Don't know if this helps x

[oldermom]

A few days after I wrote this, I started spotting which lead to heavy bleeding and bad cramping The tests I took then were still positive but my hopes have died since there was a lot of blood loss which included big blood clots. I'm on my way to the doc this afternoon and they will be testing my hcg levels to see if I miscarried but I'm pretty sure I did. Such a heartbreaking experience for me and thought things would work out. I haven't had a child in like 16 years and was never on any birth control and when I found out I was pregnant, I was the happiest woman in the world! But now this, another sad ending A year ago, I had a molar pregnancy and now, another devastation.

[joda in reply to oldermom]

So sorry for your loss. Hope things get better and that the doctors can give you some advice that will help. Hope you are ok, wishing you the best x