Friday, February 6, 2009

Cough and Hydrocodone or Codeine Products

Today, I am going to write about a delicate topic: use of narcotic medications. As a specialist, I tend to see patients with more severe symptoms and signs. One that is particularly distressing is cough. This is the second most common reason to visit doctors, according to a US government survey. The average length of time between the onset of coughing and the doctor visit is 7 days. The various causes of cough have been described here. The treatment of last resort may be a cough medication containing either the narcotic medication hydrocodone or codeine. The goal is to quiet the cough, not to treat the cause. Patients should know that generally the effectiveness is low in my experience, the taste is fairly bitter, the addiction potential is there, and the cost is even higher. I won't prescribe this unless I have seen the patient for several visits and the objective intensity of the cough is severe. Many physicians I know, even Emergency Department physicians, absolutely refuse to prescribe these medications. Our office, like virtually every medical office I know of, has a policy of not calling in narcotic medications on call.

For health care providers, there is a lot of confusion concerning their use for cough. I can not find any literature to support which narcotic is more effective or safer on the other hand. There is also minimal literature supporting use of the other compounds added. I can't even find out how we started using them. Thus, if I have to prescribe something, I use the most dilute of the 7 hydrocodone + 3 codeine preparations available. I also always print the prescriptions on special paper that can not be copied. If there are repeated requests, then we call the pharmacist to check on the patient's prescription records and to alert them. Regretfully, this practice is necessary and actually advised by the state. I have met our district's physician in charge of monitoring and once been called about a patient's prescription. It turns out she was addicted. I learned that every state and the U.S. government tracks all physicians, pharmacies, and patients filling narcotic medications to watch for trends.

HC = hydrocodone, PE = phenylephrine, a decongestant (for nasal-sinus congestion); G = guaifenesin (to make mucus less sticky). All numbers are in mg/5ml unless noted.

Duratuss HD: HC 2.5, PE 10, G 225
Entex HC: HC 5.0, PE 7.5, G100
Histussin HC: HC 2.5, PE 5.0, dexbrompheniramine 1
Hycodan: HC 5.0, homatropine 1.5 * tabs only
Hycotuss: HC 5.0, G 100.
Protex DH: HC 4.5, G 300
Tussionex: HC 10, Chlorpheniramine 4.5 *extended release, only every 12 hours

Brontex: C 10, G 300 * tabs
Promethazine: C 10, promethazine 6.25 * several manufacturers
Tussi-Organidin NR: C 10, G 300

If you have a severe cough, try to focus on diagnosing and treating the cause of the cough. Use of narcotic medications should be normally a last and temporary step.

Addendum facts:
1. Hydrocodone was approved by the FDA for its antitussive effects in 1943. Homatropine was added to many preparations to prevent abuse or intentional overdose.

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