A case report of over-the-counter codeine dependence as consequence of self-medication for premature ejaculation.

Over-the-counter (OTC) opioid abuse, including codeine, has been a growing problem around the world. Although the majority of the abusers use it for recreational purposes, many become dependent on it after having used it a medication for pain or cough. We present a case of codeine dependence where the initial prescribed use had been as a cough medication, but the subsequent abuse of it occurred the following self-medication for premature ejaculation. There is growing need for awareness among doctors and pharmacists of OTC abuse of opioids and for preventive interventions such as restricting supply, audit of pharmacies, training pharmacists, and counter staff and dispensing knowledge about proper use of opioid-containing medications to patients.

Introduction

Opium (Papaver somniferum) has been historically known to be used as an aphrodisiac.[1] Codeine, a derivative of opium, is considered less potent in term of analgesic and sedative effects than opium. It has been used for treating cough, diarrhea, and pain but has addictive potential too. We present a case of over-the-counter (OTC) use of codeine which was consumed as self-medication for premature ejaculation.

Case Report

Mr. A is a 33-year-old married male, a pharmaceutical sales executive, presented with a history of consuming 200–300 ml/day of cough syrup containing codeine (10 mg/100 ml) for the past 28 months. Our patient reports having been married for the past 2 years and reports having ejaculation occurring with 5 min of penetration and difficulty controlling it during intercourse with his wife. He reports of not having problems with erection or pain during ejaculation and says he did not have this issue before marriage while masturbating. Three months after marriage, Mr. A suffered from acute bronchitis for which he was prescribed a codeine-containing cough syrup. He noticed his ejaculatory response after consumption of the syrup and started consuming 100 ml of the cough syrup (one bottle) each day after purchasing it OTC from different medical shops. Over the past 25 months, Mr. A found he had to increase the amount of cough syrup consumed to improve his time to ejaculation and consumed up to 200–300 ml/day (2-3 bottles). He would also have a craving for the syrup and would have episodes of headaches, nausea, and sweating upon abrupt cessation and subsided upon consumption of the syrup. Mr. A and his spouse did not report on any mood changes, increased sedation, or any other problems at work or family due to his cough syrup consumption. He decided to seek treatment for his problem after attempts by himself to abstain from consumption of the cough syrup were unfruitful during the past 3 months.

There was neither any history or family history of mental illness nor any conflicts with wife, other family members, and at workplace. There is no history of any medical illness, use of other medications, or other substance use disorders.

On mental status examination, he was adequately groomed with normal psychomotor activity. He was conscious with euthymic mood, and there were no ideas of guilt, depressive ideas/death wishes, formal thought disorders, psychotic symptoms, or cognitive impairment. As per the 10th revision of International Statistical Classification of Diseases and Health Related Problems, a diagnosis of mental and behavioral disorders due to use of opioids, dependence syndrome, continuous use, and premature ejaculation was made.

His physical examination and vital signs revealed no abnormalities, including normal pupil size and respiratory rate. He was admitted and laboratory investigations on the day of admission, including, hemoglobin, total and differential count, serum sodium and potassium, erythrocyte sedimentation rate, routine urine examination, renal and liver function tests, and random blood sugar were within the normal limits. No physical abnormalities of the genitourinary system were found upon consultation by a urologist.

Mr. A was started on oral clonidine of 0.1 mg three times a day and oral lorazepam 2 mg at night. The next day the patient reported having sweating, rigor, and mild muscle cramps of his legs following which he was given intravenous lorazepam and clonidine dosage was increased to 0.2 mg, three times a day. His symptoms gradually subsided and he did not report any withdrawal symptoms the next day. Oral naltrexone of 50 mg/day was started on the 4th day. He was discharged on the 14th day of admission after gradual tapering and stopping of oral clonidine and lorazepam tablets and motivational enhancement therapy sessions during his hospital stay. Liver function tests were normal on discharge. He was maintained on oral naltrexone of 50 mg/day over the next 3 months along with monthly monitoring of liver function tests. Sensate focus exercises along with stop and squeeze technique for practice were taught to Mr. A and his spouse following which Mr. A's premature ejaculation improved. After being abstinent from opioids for 6 months (confirmed by urine opiate screening test), oral naltrexone was stopped.

Discussion

Opioid addiction is considered a growing epidemic with prescription opioids considered a major cause for the problem.[2] Opioids are considered to be used in 0.4%–26% of substance abusers in India.[3]

OTC abuse of drug including codeine-containing cough syrups has been rising in India.[4] Studies in India have shown that majority of the abuses were initiated through friends for recreational purposes with those who initiated consumption of codeine following chest/cough ailments to be the least.[56]

The reason for codeine abuse in our patient had been due to possible delayed ejaculation as side effect of codeine although the correct mechanism of action is not known.[7] Historically, opioids have been considered an aphrodisiac due to prolongation of the sexual act by delaying ejaculation.[18] However, opioids have not been indicated in the treatment of premature ejaculation. Tramadol, a derivative of codeine, has been used to treat premature ejaculation which is understood to be due to its mu receptor agonist action leading to central and peripheral nervous system depressant effects leading to peripheral anesthetic action and decline in ejaculation.[9]

We would like to conclude with the need for regulation is dispensing medications from pharmacies to prevent the OTC substance abuse, especially medications with addictive potential like opioids. There is a need for increasing the awareness of the misuse of OTC codeine abuse among doctors and pharmacists alike. Restricting the supply of OTC codeine medications, auditing of pharmacies, training pharmacists, and counter staff on knowledge of codeine abuse and advising proper use of codeine use to the consumer are some of the measures described in countering OTC codeine abuse.[10] It is a high time, our country rises itself up to this menace before it grows to epidemic proportions.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.