Hazards of codeine plus paracetamol compounds.

Sir, Codeine phosphate is a popular drug of abuse and is commonly taken in preparations combined with either aspirin or paracetamol. Preparations containing larger amounts of codeine (30 mg) are especially popular. Opiate tolerance may result in dependent individuals needing to ingest large amounts of these drugs, thus risking potentially fatal paracetamol or aspirin toxicity. A 37-year-old woman recently attended the drug clinic at the Southern General Hospital, Glasgow as a result of dependence on Tylex® (Cilag) (containing codeine 30 mg and paracetamol 500 mg). She had initially been prescribed this for sciatica but she found that in addition to providing analgesia it also improved her mood. Her consumption increased and she supplemented her prescription by buying the preparation from 'street sources', taking up to 30 tablets daily and experiencing opiate withdrawal symptoms if unable to obtain them. Despite being warned of the dangers of this, she admitted at a subsequent appointment to having consumed 100 of these tablets over the previous week, 35 having been taken in the previous 24 hours, in order to improve her mood. A serum paracetamol level of 328 mg 1-1 was detected seven hours after the last dose and she was admitted for treatment with acetylcysteine. Her liver enzymes were elevated (alanine aminotransferase 48 IU 1-1 and gamma glutamyl transpeptidase 235 IU 1-l) but fortunately her coagulation indices remained normal and she was well enough to be discharged after two days. We have also had anecdotal reports from other drug abusers attending the drug dependency clinic of increasing availability of Tylex on the street. It has previously been reported that opiate addicts abuse combinations of codeine and aspirin and are apparently able to remove some of the latter;' with preparations such as Distalgesic® (Dista) (coproxamol dextropropoxyphene hydrochloride and paracetamol) concern has largely been focused on the opiate component2 and there has been a resultant alteration in prescribing habits.3 The increasing popularity of codeine and paracetamol preparations urges us to warn prescribers to be mindful, not only of the addiction potential and street value of codeine, but also of the potential toxicity of paracetamol in combination analgesics.