Saturday, November 27, 2010

Corex Cough Syrup - Opioid Addiction Over-the-Counter

Codeine is methyl-morphine
Corex Cough Syrup contains codeine – an addiction causing opioid. One 100ml bottle of codeine containing Corex cough syrup has the same effect as a 30mg tablet of morphine. The drug belongs to the same class of substances as heroin. Medicines are routinely purchased over-the-counter at most pharmacies in Pune and cough syrups very frequently so. Always read the fine print.

Codeine suppresses the cough reflex through a direct effect on the cough centre in the brain stem. However, there is little evidence in the medical literature to support its use as a cough suppressant. Several studies show that codeine does not reduce cough frequency, intensity, or duration (Herbert & Brewster, 2000).

Patients who are prescribed Corex cough syrup or those who buy it over-the-counter are not warned of its addiction potential. They subsequently continue using it as they 'feel restless and anxious' without it. These feelings are part of the spectrum of withdrawal symptoms associated with all opioids, and are another sign of addiction. A 36 year old woman who came to me for treatment of lethargy and lack of interest was consuming a bottle of Corex cough syrup every day for more than two years. Patients and parents should be educated about the lack of benefit and the addiction risk of codeine cough syrups (American Academy of Pediatrics, 1997).

Pharmacists dispensing Corex cough syrup know its potential for addiction. They have their 'regulars' who buy litres of Corex cough syrup over the month. The bottles are handed over in a paper bag without the exchange of a word, leave alone a prescription.

Corex is the top selling medication in India earning Pfizer, the drug manufacturer, Rs 1,820,000,000 during the year 2009. U.S.-based Pfizer and Abbott Laboratories are leading players in India's $103-million market for codeine-based cough syrups. The ministry of finance is now pressuring the companies to enable tracking of each batch produced. The sheer malevolence of this entire chain is brought home by the patient who relapses repeatedly during treatment. Every time he tries to fill his prescription for deaddiction the pharmacist takes advantage of his craving cues to resupply him with codeine containing Corex cough syrup.

So it was with a certain joy that I read
That was the Indian FDA (Food and Drug Administration) in action in Pune. Their sting on a reputed chain of pharmacies gives us new hope for control of over-the-counter codeine opioid addiction. 

Codeine prescription restrictions - Update

Ministry of Health (2016)
Bans codeine containing cough syrups. Ban upheld by Drugs Technical Advisory Board in July 2018

EMA-CMDh (2015)
(European Medicines Agency – Coordination Group for Mutual Recognition and Decentralised Procedures - Human)
Use of codeine for cough and cold
  • contraindicated in children below 12 years. This means it must not be used in this patient group.
  • not recommended in children and adolescents between 12 and 18 years who have breathing problems
Govt of India Notification 2014
References
  1. Committee on Drugs, American Academy of Pediatrics. Use of codeine-and dextromethorphan-containing cough remedies in children. Pediatrics 1997;99:918-20
  2. EMA-CMDh. Codeine Article-31 referral - Codeine not to be used in children below 12 years for cough and cold. EMA/249413/2015. 24 April 2015
  3. Herbert ME, Brewster GS. Myth: codeine is an effective cough suppressant for upper respiratory tract infections. West J Med 2000;173:283.

21 comments:

  1. OTC abuse of codeine based preparations is not the only thing to worry about.there are other combinations contains drugs like dextromethorphen thta are also abused.likewise there are typical markets like the NE of india where codeine bae brands like Phensedyl are sold in huge quantities.we need a policy regarding refilling of prescriptions also at the MCI level

    Regards,
    Ravishankar

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  2. This is a pbs documentary which is a real eye opener...
    OXY - WHAT YOUR KIDS AREN'T TELLING YOU

    What's scary is that in India from what I know, you can get prescription medicines without prescriptions....

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  3. Ravi, yes, there are other opioids out there. Codeine containing Corex cough syrup is unique in that there is a large section of abusers who are addicted without initially seeking out the drug. We prescribe it without thinking, and often without knowing what's in it. The MCI is acting to regulate refills, but for some other medications.

    The other aspect that really interested me is the successful way the drug is manufactured and distributed. To gain the status of India's number one cash earning drug is not a mean achievement. It's been among the top two or three best sellers for some time now. The manufacturer is proud of it.

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  4. Hi Cyn. Its scary alright. (BTW congrats!) However, there's probably a workaround the legal system everywhere. My spam box has regular offers selling Hydrocodone (dihydrocodeine) for $4.40, prescription not required, and free shipping in the US and Canada.

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  5. Hi Neville!
    Well all is fair and fare in the pharmaceutical business! The office which monitors all manufacturing process and side effects of a single drug or with combinations of compounds do know of the consequences, So why allow for production ? Well Iam sure the drugs contol department is fully aware of not only codeine but many others including "fevicol".
    I think the answere will lie in educating addicts themselves or friends and families who know of such victims (that includes the family doctor) should find ways of safe medications.Iam sure the pharma company would change formulas to do justice to their revenues and patrons. why is not under scheduled drugs? After all we need to know that there could be avery small percentage of individuals who are really addicted , may be a few thousands! India any way has no developed welfare measure for its citizens in any which way you want to think. So who cares! only a few concerned like us! God help the rest. even he is far to reach for anybody in suffering, where do we draw aline? ONLY BRINGING AWARENESS THOUGH ITS THE LONG ROUTE.
    SRINIVAS NAIDU

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  6. Hi Srinivas. Increasing awareness and educating people will take time to have an effect, but it’s time well spent.

    There are other effective cough syrups available. The pharma companies continue to manufacture codeine containing cough syrups because it earns them money. Its been known since more than a decade that codeine is not effective for cough. That fact has not stopped them from selling it as such.

    Placing it under scheduled drugs would be effective. Methylphenidate is under schedule and its still almost impossible for a child to get it continuously when needed.

    A National Survey showed that 0.2% of Indian males abuse opioids and of these 22% satisfy the WHO definition of addiction. Given the size of our population that works out to a lot of opioid addicts in absolute terms! Its worth acting on.

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  7. There is a huge problem in the US with teens getting high on OTC medications, including cough syrup. So now, no full-strength (non-prescription) cough syrups can be purchased without getting it from a pharmacist, who takes your driver's license info and enters it into a computer database, so one cannot go to multiple pharmacies to purchase more of the meds. And anything really strong, like codeine cough meds, must be gotten with a doctor's prescription. These addictive meds are considered to be gateway drugs to more serious illegal drugs.

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  8. The US FDA has gone further and banned propoxyphene (another OTC opioid) on 19-Nov-2010. The reason - its adverse effects on heart rhythm.

    Codeine was recently shown to have an even more malignant effect on the heart, and on overall mortality (Solomon et al, 2010). So maybe its next on the ban list.

    The addiction potential of these opioids apparently excites only the end user.

    Daniel H. Solomon, Jeremy A. Rassen, Robert J. Glynn, Katie Garneau, Raisa Levin, Joy Lee, BA; Sebastian Schneeweiss. The Comparative Safety of Opioids for Nonmalignant Pain in Older Adults. Arch Intern Med. 2010;170(22):1979-1986. doi:10.1001/archinternmed.2010.450

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  9. Dear Doctor,
    My brother is taking 'Corex' for more than 8 years. It has affected his nervous system badly. Need your help urgently. Please share your contact number.

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  10. 'About Me' in the right sidebar of this blog provides all my contact details at http://www.pathfinderclinic.com/providers/neville-misquitta-psychiatrist

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  11. Dear Doctor,

    I have just found out that my partner is addicted to Corex for about 6 years (or at least, he is taking it on a regular basis). He tried to hide this from me - a behaviour which worries me even more. He does not know that I have found out, and I am worried if I talk about it with him, he will deny it, or worse: choose his addiction over our marriage. How to approach this issue and is there any person in Delhi I can contact for more informtion?

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  12. Any approach you use will generate anxiety and some stress. The habit needs to be discussed with your partner non-confrontationally and with a show of support.

    He is going to deny his habit, so you need to be sure of your facts - start from how you found out in the first place.

    It would be best for your relationship if you are the person who brings this up with your partner. If he is unable to deny the habit he will give assurances that he is now going to stop. Accept that at face value, but take a commitment from him that in case the behaviour recurs he will accompany you to a psychiatrist. When that happens be firm and follow-through don't give a third chance.

    In case you don't feel confident, the above could be done by some other person he trusts and listens to; a brother or close friend. You could also read http://blog.pathfinderclinic.com/2010/11/how-to-get-somebody-to-consult.html to get an idea of what other people have tried.

    Stopping Corex will take some time with initial regular visits to the psychiatrist, so you need to be prepared to support your partner through that. Logistically it will be best to find a psychiatrist near you, your GP or family doctor would be the person to approach for that. The Delhi Psychiatric Society website (http://www.delhipsychiatricsociety.com/index.asp) also gives addresses of psychiatrists near you.

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  13. Dear Doctor,

    Can you please recommend anyone who can treat my brother who is addicted to corex for past 10 years in Hyderabad. He is in a very bad shape and we do not know how to tackle him. Waiting for your reply eagerly. Thanking you in advance

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  14. HI, Is corex still available in india?? Is it still abused??

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    Replies
    1. Definitely to both. Corex is still one of the top three revenue earners for Pfizer. I am still having to treat new cases of Corex dependence on a regular basis.

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  15. Dear Sir,
    Pls mention names of some Doctors practicing in Delhi/NCR,for treatment of problem of cough syrup addiction.

    ReplyDelete
    Replies
    1. it will be best to find a psychiatrist near you, your GP or family doctor would be the person to approach for that. The Delhi Psychiatric Society website www.delhipsychiatricsociety.com/index also gives addresses of psychiatrists near you.

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  16. is corex new product cough syrup alcohol and codeine free banned in india?????????????????

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    Replies
    1. Don't use corex for intoxication. It is one of the most addictive drugs known to mankind. But personally I feel tobacco and alcohol are the worst because of their availability and a general acceptable use in society.

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  17. what will hapepn if a person consume one full bottle (100ml) of corex cyrup in one shot?

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    Replies
    1. Drowsiness would be the the first effect. 100ml of Corex has 200mg of Codeine + 80mg of Chlorpheniramine. The equivalent oral dose of morphine is about 30mg.
      Respiratory depression leading to death could also occur depending on usage pattern, time since last dose, body weight, and use of alcohol/other substances.

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