This season, as we all suffer the agonies of watching our children cough all night for days on end, with no relief in sight, it is sobering to recall a very sad story, the valiant attempt to create a medicine we can give our children to get rid of the cough.

The Urgency of Cough

In many ways, cough is the worst problem a healthy child can experience.  Sneezing and runny noses are awful, as are vomiting and diarrhea.  But runny noses are misery, and coughs are agonizing.  Vomiting typically lasts 1-3 days with a stomach flu, but it takes 25 days for 95% of a group of kids with a cold to see their cough finally leave all together.

Cough is often described as convulsive.  Jags of coughs can go on for an hour causing a child to really suffer and parents to really get upset.

And, in today’s day and age it simply seems impossible that nothing at Rite Aide or CVS can stop, at the very least, soothe a cough.

The story of opium and cough dramatizes how that desperation led to decades of use of two drugs that turned out to be useless at best, and caused great harm to children over the years.

The Origins of the Relation of Opium to Cough

Opium is the dried white rubbery material from the head of the opium poppy.  In that white fluid can be found two closely related chemicals, morphine and codeine.  In fact, the word codeine comes from the Greek word of head of the poppy, kodeia.

Opium has been a popular material for deep into pre-history.  But by the 1700’s preparations of opium had been turned into popular medications in the British Empire, the most famous being paregoric.  Paregoric was used up until the 1970’s in the US for use to stop cough and diarrhea.

Sometime during the centuries of human use of opium, the idea that people using opium did not cough so much became part of popular imagination and common sense.

This concept was so dearly held that when codeine and morphine were finally chemically purified from raw opium in the early 1800’s, it was assumed that codeine would be the cure for a cough.

This assumption was so deeply believed that in medical schools we were all taught that there was a special receptor in the part of the brainstem that managed the cough reflex that codeine blocked.  The point was the if you have a cough, and you take codeine, the cough will cease because codeine directly operates on the brain to stop people from coughing.

What’s the problem with codeine?

Well, the problem with codeine is found in its chemical name, it is really 3-methyl-morphine, and like morphine and heroin, people get addicted to it.

Even with no addiction, codeine, like all opiates, can make you stop wanting to breathe, which is a fatal side effect.   It is a serious enough hazard that the FDA has issued warning that use of codeine can be fatal in children.  Sadly, many children have died after taking doctor-prescribed tylenol with codeine after tonsillectomies.

Why not change codeine into something that stops cough but is safe?

In the 1940’s the drug industry made this a priority, and in 1954, a new drug was created called dextro-methorphan.   Dextro-methorphan, as the name suggests, is a right handed (most drugs and many sugars come in right and left handed versions) type of codeine.

It was hoped it would stop coughing without being addictive of cause fatal cessation of breathing.

The good news is that dextro-methorphan is definitely not addictive, and it does not stop interest in breathing.

The bad news is that it does nothing to stop coughing either.

So, do codeine and dextro-methorphan work?

Many, many decades of published studies have tried to find evidence that these two drugs actually help cough.

How is that measured?  Easy, just count how many coughs per hour a child coughs, and how many days the cough goes on.

If the medicine works, kids taking it will cough at least a few less coughs per hour, and/or cough for a few less days.

Bad news- the studies are united in finding that kids who take codeine cough as many times an hour and for as many days as kids who take water.  Same for dextro-methorphan.

Should I give me child codeine or dextro-methorphan for a cough?

No.

First, they do not work.

Second, in the case of codeine, it is a dangerous drug.

I took decades, but in the fall of 2016, the American Academy of Pediatrics finally came out and made the answer the official answer of our profession of pediatrics:  kids should not be prescribed codeine, period.

https://www.aap.org/en-us/about-the-aap/aap-press-room/Pages/AAP-Report-Says-Codeine-Too-Risky-For-Kids-Urges-Restrictions-on-Use.aspx

Which drugs have codeine and dextro-methorphan in them?

Well, the most commonly prescribed source of codeine is in Tylenol with codeine.

Dextro-methorphan is found in nearly any over the counter preparation that has the word “cough,” on it, including the now red-hot, highly popular Mucinex.

It is of interest that if you look at the recently marketed Mucinex and the very old Robitussin, you will find they are the same set of drugs.

BOTTOM LINES

1. My goodness, do we ever need a drug to stop us and our children from suffering the agonies of cough.   I would support the use of such a remedy.
2. The problem is that no such remedy actually exists.
3. Codeine- an ingredient found in raw opium, long taught to suppress cough, has no impact on cough, and has cost many children’s lives over the years.  The AAP has now made it official, it should no longer be prescribed or used.  It does not work for cough, it is dangerous to use for a breathing problem.
4. Dextro-methorphan.  The wonder drug of 1954 turns out to be a big flop.  It nicely fails to addict and to stop breathing, but it sadly also fails to stop coughing in any way.
5. The story of Codeine and Dextro-methorphan dramatize the power of our urge to believe that there must be a drug to stop a cough, or at least make it milder.  This hope even reached the curricula of medical schools who taught it was so.   But it does not good to our kids to give them drugs that we know do not work.  Right now about 500 over the counter cough and cold remedies are under investigation for fraud by the FDA, fraud.
6. So, tonight, when our children suffer and agonize with cough for weeks, let them sip some tea, soup, milk, let them suck on something.  For swallowing actually does interrupt breathing and cough, while you swallow, and will actually give some relief.  And let them you know you are there for them, and that the cough will go one day.

To your health,
Dr. Arthur Lavin