WEBVTT - Is cough mixture addictive?

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<v Speaker 1>Now, Health Matters with Daniel Martin. It's Health Matters. Welcome in, everybody.

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<v Speaker 1>I'm Daniel Martin and I've got your health on my mind.

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<v Speaker 1>On today's edition, as you heard on the news here

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<v Speaker 1>on CNA 938, the Health Sciences Authority revealed the illegal

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<v Speaker 1>health products report from what was seized in 2024, and

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<v Speaker 1>a majority of the illegal health products were codeine cough syrup.

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<v Speaker 1>So in total about more than 970,000 units of illegal

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<v Speaker 1>health products were seized. Codeine cough syrup made up something

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<v Speaker 1>like 54% of those numbers right there, the 970,000. Some

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<v Speaker 1>of the other things on the list include things like

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<v Speaker 1>sexual enhancement medicines and sedatives making up 19% and 18%.

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<v Speaker 1>So you see the big discrepancy there, the big difference.

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<v Speaker 1>What a big chunk, a chunk of um those numbers.

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<v Speaker 1>Falling to codeine cough syrup. But why? I'm sure some

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<v Speaker 1>of you know, of course, about the potentially addictive nature

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<v Speaker 1>of it, but it's just cough mixture, right? Is cough

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<v Speaker 1>mixture really that addictive and really that in demand? Doctor

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<v Speaker 1>Kelvin Goh is joining us. Doctor Goh is medical director

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<v Speaker 1>and Leed United Primary Care Network. Doctor Goh, good to

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<v Speaker 1>talk to you again. Hello. Bottom line, let's just talk

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<v Speaker 1>about cough mixture first and foremost. What's the concept? What's

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<v Speaker 1>the idea? What is cough mixture used for? How is

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<v Speaker 1>it used in Singapore?

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<v Speaker 2>I mean, there are, there are common drugs that are

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<v Speaker 2>used to suppress cough, and they tend to have a

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<v Speaker 2>few common active ingredients. So, top of the list would

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<v Speaker 2>be codeine, which is, which is a class B controlled drug.

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<v Speaker 2>Then you have uh dextrometophan. Others include promethazine and pseudoephedrine

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<v Speaker 2>and graphennoin, and they tend to be mixed together sometimes.

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<v Speaker 1>So codeine cough syrup is not something illegal, it's regularly

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<v Speaker 1>prescribed in clinics in Singapore.

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<v Speaker 2>It's a codeine containing cough syrup is regularly prescribed in

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<v Speaker 2>clinic in Singapore, pure coding cough syrup is uh more

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<v Speaker 2>seldom seen prescribed.

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<v Speaker 1>Is codeine also that component that sometimes when you get painkillers,

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<v Speaker 1>you get panadine, which is a combination of Panadol and codeine.

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<v Speaker 1>Is that codeine as

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<v Speaker 2>well? So is actually um

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<v Speaker 2>Codeine is actually processed by the body, if you consume

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<v Speaker 2>the co mixture, codeine becomes, it's metabolized into um morphine

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<v Speaker 2>6 corronide and a bit of morphine, and we are

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<v Speaker 2>all familiar with morphine, which is an opioid. And therefore

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<v Speaker 2>you get the effects of morphine if you take it

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<v Speaker 2>in very high doses.

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<v Speaker 2>But, but that lies another issue with uh uh codeine

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<v Speaker 2>metabolism because codeine metabolism is quite unique in the sense

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<v Speaker 2>that some patients are rapid ultra-fast metabolizers, some are slow metabollizers.

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<v Speaker 2>So because the active ingredient is a poor drug, so

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<v Speaker 2>the active ingredient is the morphine and the morphine 6

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<v Speaker 2>to 9. So, if you take a prescribed dose of morphine,

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<v Speaker 2>one guy may have only one quarter of the morphine.

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<v Speaker 2>After taking the same dose of codeine, of the morphine

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<v Speaker 2>is blood, the other gentleman or lady may have 10

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<v Speaker 2>times the higher dose because we don't really test routinely

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<v Speaker 2>for the CYP 450 gene, so we don't know who

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<v Speaker 2>is the ultrafast metabolizer and who.

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<v Speaker 2>Who is not. So imagine if you overdose a cough

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<v Speaker 2>mixture by a quantum of 1020, 2030 times and you

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<v Speaker 2>are ultra-fast metabolizer, you multiply that by multiples, you're talking

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<v Speaker 2>about potential lethal dose.

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<v Speaker 1>Wow, that is shocking to hear. Actually. Have we had

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<v Speaker 1>cases like that in Singapore? Is that something that happens?

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<v Speaker 2>there are case reports worldwide, even in, in patients who

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<v Speaker 2>have breastfed child taking, taking high dose of codeine and

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<v Speaker 2>the mom is a rapid metabolizer.

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<v Speaker 2>With high dose of codeine, yeah, high dose of codeine

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<v Speaker 2>morphine will suppress your respiratory drive and people get sedated,

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<v Speaker 2>they don't breathe that well, and then their brain may

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<v Speaker 2>become hypoxic.

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<v Speaker 1>So is it safe or not to take cough mixture?

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<v Speaker 1>I think that's what the average listener is wondering

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<v Speaker 2>right

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<v Speaker 1>now

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<v Speaker 2>if

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<v Speaker 2>you cough mixture in the prescribed dose, it is generally safe.

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<v Speaker 2>Um, but you are not, obviously, if you overdose it,

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<v Speaker 2>if you mix it with alcohol or other drugs, you

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<v Speaker 2>got the whole bottle down, it's very, very unwise, and

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<v Speaker 2>it's basically abuse, right? Similarly for other cough cough uh

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<v Speaker 2>other common cough uh uh medications like, like dextromethyphen. It's

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<v Speaker 2>also a pro drug. The active ingredient is metabolized by

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<v Speaker 2>the body in the Dextrophan and dextrophan

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<v Speaker 2>It's uh what we call NDMA antagonist. So it's basically

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<v Speaker 2>similar to the effect to ketamine, which is like a

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<v Speaker 2>harder drug, right? So in high quantities, people get visual hallucinations.

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<v Speaker 2>So people abuse these drugs for, to feel some euphoria,

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<v Speaker 2>to feel um a bit more relaxed. Yeah, but basically,

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<v Speaker 2>these are abuse and if you, if you let people

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<v Speaker 2>abuse cough mixture as they move along, they may move

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<v Speaker 2>on to harder and harder drugs.

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<v Speaker 1>Interesting. So that's the thing. If you're sticking to the,

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<v Speaker 1>if you, if your cough mixture does contain the codeine,

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<v Speaker 1>if you're sticking to the regular dosage that you're supposed to,

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<v Speaker 1>for the most part, most people will be absolutely fine until, unless,

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<v Speaker 1>like you said, you might be that person who's metabolizing

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<v Speaker 1>it very differently, lah.

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<v Speaker 2>Correct, and you abuse it by taking a dose

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<v Speaker 1>quantities.

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<v Speaker 1>I'll be admit when you're prescribe it, sometimes it comes

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<v Speaker 1>with a little plastic spoon la. Then we're supposed to

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<v Speaker 1>use the little plastic spoon and take the doses, but

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<v Speaker 1>sometimes people lazy, they just open and just drink straight

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<v Speaker 1>away from the bottle. That's the problem.

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<v Speaker 2>I mean, the abusers usually drink the whole bottle. I don't.

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<v Speaker 1>It's more than big gulps, right? Are you surprised to see,

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<v Speaker 1>because we've had problems of the misuse of codeine cough

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<v Speaker 1>syrup before. We've had cases of people's misrepresenting their illness

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<v Speaker 1>and getting the prescription and passing it on to abusers,

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<v Speaker 1>for example, as well. When and how can cough mixture

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<v Speaker 1>be misused?

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<v Speaker 2>When and how, I mean, there are people who abuse

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<v Speaker 2>this cough mixtures for recreational purposes, for just for that

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<v Speaker 2>dopamine high, right? So maybe these people instead of abuse,

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<v Speaker 2>if they are stressed, they need to find healthier ways

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<v Speaker 2>to manage the stress rather than going for the cheap

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<v Speaker 2>dopamine high with, with the cough mixture of drugs, things

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<v Speaker 2>like exercising, um, having healthy relationships, and having not adequate sleep, or, or.

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<v Speaker 2>Doing something constructive,

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<v Speaker 1>yeah. And how in terms of basically it's consuming large quantities,

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<v Speaker 1>it's not about having to change it, the chemical composition

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<v Speaker 1>additives or anything like that, it's just large quantities of

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<v Speaker 1>that codeine cough syrup.

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<v Speaker 2>Yes,

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<v Speaker 2>it's quantitative takes a large quantity, but they tend to

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<v Speaker 2>mix it with like like soft drinks, soda, alcohol and

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<v Speaker 2>other other drugs, other sedatives.

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<v Speaker 2>And all this add together to form a more lethal

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<v Speaker 2>uh uh combination. And of course, the, I mean MW

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<v Speaker 2>regulates it quite strictly. It's not that easy to get

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<v Speaker 2>it from uh GP clinics because I mean we are

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<v Speaker 2>experienced we we see patients who will come to us.

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<v Speaker 2>Being super friendly, telling us that they, they have certain

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<v Speaker 2>symptoms to confabulate and when you give them treatment or

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<v Speaker 2>investigations relevant to the symptoms, they reject and they insist

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<v Speaker 2>on a particular brand of cough syrup, two bottles, but

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<v Speaker 2>they come back the next day that I've lost the bottle, my,

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<v Speaker 2>my dog drank it, uh, I left in MRT, uh, my,

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<v Speaker 2>my uh brother took it, whatever, what have you not?

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<v Speaker 2>So they find reasons to get more supply, but nowadays

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<v Speaker 2>because of strain enforcement by.

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<v Speaker 2>MOH for any uh any breaches in the regulations and

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<v Speaker 2>also with the national electronic health records, we can actually

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<v Speaker 2>see if someone has been hopping. So I think that

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<v Speaker 2>may have driven this uh codeine uh market more underground,

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<v Speaker 2>but stromatophan and the rest can be obtained from the pharmacy,

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<v Speaker 2>so these are harder to detect.

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<v Speaker 1>Are those equally as addictive?

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<v Speaker 1>Or

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<v Speaker 1>possibly

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<v Speaker 2>to be misused. So one of the major ones I

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<v Speaker 2>mentioned before the Dextroph which became the active active metabolican

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<v Speaker 2>which has psychedelic properties, right? So people take it they

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<v Speaker 2>get feel a bit high in some visual hallucinations. So

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<v Speaker 2>this is

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<v Speaker 2>Relatively easier to access.

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<v Speaker 2>Because it's available from the pharmacy, from the clinics, and

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<v Speaker 2>it doesn't have that bad image like codeine, you know.

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<v Speaker 2>So people will not suspect generally that someone is abusing

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<v Speaker 2>such medications. I mean, there are people abusing all sorts

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<v Speaker 2>of medications, even paracetamol, right? So some people will take

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<v Speaker 2>some cough mixture, they abuse a pseudo epirine, they get palpitations,

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<v Speaker 2>irregular heartbeat, they sweat and stuff.

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<v Speaker 1>Remind us again, when is it prescribed? For what medical

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<v Speaker 1>condition would it would it ordinarily be utilized?

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<v Speaker 2>Typically it's prescribed for a patient with a viral upper

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<v Speaker 2>respiratory tract infection, uh, to help manage the cough symptoms.

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<v Speaker 2>It's basically a cough suppressant.

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<v Speaker 1>And how serious does the health issue have to be

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<v Speaker 1>for this to be prescribed?

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<v Speaker 2>Actually, it's generally not for serious health problems, in fact,

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<v Speaker 2>the long term.

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<v Speaker 2>The evidence from the effectiveness of codeine containing cough syrup

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<v Speaker 2>for cough is not that, not that great. Yeah. So

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<v Speaker 2>basically for symptomatic relief.

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<v Speaker 1>OK.

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<v Speaker 1>So this brings up a good point. So now that

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<v Speaker 1>you brought up the idea that, you know, some people

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<v Speaker 1>metabolize it differently as well, when should you go back

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<v Speaker 1>to your doctor and say, oh, this is, it's, it's, I'm,

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<v Speaker 1>I'm too drowsy. It's like, when should you go back

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<v Speaker 1>and maybe try and seek an alternative if it's being

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<v Speaker 1>a bit too strong for you? Generally,

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<v Speaker 2>if you take the medications, right, if you are a

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<v Speaker 2>rapid metabolizer,

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<v Speaker 2>Probably feel a lot more drowsy than other patients. Then

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<v Speaker 2>it's fine. Let me just switch another uh cough medication

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<v Speaker 2>for you. But generally, if your cough is not better,

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<v Speaker 2>you have to investigate the cause of the cough. Could

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<v Speaker 2>you be having a lung cancer? Will you be having

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<v Speaker 2>uh tuberculosis? Are you having acute bronchitis? Are you having

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<v Speaker 2>acute uh bacterial, rhino sinusitis? So the cause of the coughs,

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<v Speaker 2>needs to be investigated. Is it because of reflux, rather

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<v Speaker 2>than keep on taking uh weeks of weeks after weeks

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<v Speaker 2>of cough medications? Yeah.

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<v Speaker 1>Got a WhatsApp coming in from one of our listeners

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<v Speaker 1>at 963-119-38. Is this present in children's cough mixture as well,

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<v Speaker 1>because those are different and I'm assuming they are less potent.

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<v Speaker 2>Are these children's cough mixtures. 12 years of age.

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<v Speaker 2>And we are extremely careful with kids, yeah.

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<v Speaker 1>So that's a good point. So children's cough mixture is different,

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<v Speaker 1>generally don't contain this, and this is why it's another example.

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<v Speaker 1>Don't try and self-medicate, you know, parents might be like, oh,

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<v Speaker 1>got a cough, no, no, no, take the cough mixture

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<v Speaker 1>that doctor gave me, definitely not suitable.

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<v Speaker 2>Yes, always consult your family physician for the right dosage

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<v Speaker 2>and the right indications.

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<v Speaker 1>And you shouldn't be sharing medication anyway. It was prescribed

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<v Speaker 1>to you for a specific concern. It doesn't mean it's

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<v Speaker 1>universally applicable to everybody in the family as well. So,

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<v Speaker 1>the children's cough mixture is different. Good, good question. Thank

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<v Speaker 1>you so much for the WhatsApp. If this, is this

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<v Speaker 1>a true for people who are misusing this and consuming

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<v Speaker 1>it in very large quantities,

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<v Speaker 1>Is this a true addiction? Are we talking about addiction

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<v Speaker 1>management that has to happen here?

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<v Speaker 2>Yeah, so, so basically, if the patients and if those,

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<v Speaker 2>I mean, there's some are substance dependent, some is substance addiction.

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<v Speaker 2>So addiction, you have to, of course, fulfill the addiction criteria,

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<v Speaker 2>which actually means that in patients with substance abuse, basically,

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<v Speaker 2>They, they use the substance a lot longer and more

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<v Speaker 2>for what it's meant to, instead of maybe taking the medicine,

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<v Speaker 2>10 meals, they take 20, instead of taking it for

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<v Speaker 2>3 days until they are like.

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<v Speaker 2>Better, they take it for one week. And if they

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<v Speaker 2>try to cut down or stop using the substance, they're

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<v Speaker 2>not able to do so easily. So that's dependence. But for,

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<v Speaker 2>for addiction, there's a specific clinical criteria. There's usually a

0:11:35.690 --> 0:11:39.309
<v Speaker 2>lot of clinically significant impair and distress and it affects

0:11:39.309 --> 0:11:43.289
<v Speaker 2>them both socially in their work, their relationships, uh, it

0:11:43.289 --> 0:11:47.809
<v Speaker 2>affects everything and it's quite destructive to their lives. So, generally,

0:11:48.830 --> 0:11:52.440
<v Speaker 2>Seek help from your family physician. If necessary, we'll refer

0:11:52.750 --> 0:11:56.750
<v Speaker 2>the patient uh to the National Addiction Management Center. Many

0:11:56.750 --> 0:11:59.710
<v Speaker 2>family physicians are also trained in uh mental health in

0:11:59.710 --> 0:12:02.080
<v Speaker 2>the undergrad days, and many of us, including myself, we

0:12:02.080 --> 0:12:04.210
<v Speaker 2>have a graduate diploma in mental health too. So some

0:12:04.210 --> 0:12:06.718
<v Speaker 2>of us do have an interest in, in mental health

0:12:06.979 --> 0:12:10.190
<v Speaker 2>and and can help, uh, help you manage if you

0:12:10.190 --> 0:12:13.108
<v Speaker 2>have loved ones that are have addiction or dependency to

0:12:13.109 --> 0:12:15.510
<v Speaker 2>cough syrup. But the simplest thing to do is simply

0:12:15.510 --> 0:12:15.619
<v Speaker 2>just

0:12:16.335 --> 0:12:18.973
<v Speaker 2>you know, just go push that your loved ones or

0:12:18.974 --> 0:12:21.494
<v Speaker 2>your friend who is dependent, show some concern. Hey, what

0:12:21.494 --> 0:12:25.215
<v Speaker 2>happened to you in a non-judgmental, non-threatening way. Uh, why

0:12:25.215 --> 0:12:27.094
<v Speaker 2>are you doing this? I see two bottles of empty

0:12:27.094 --> 0:12:30.645
<v Speaker 2>cough syrup in the dustbin. Let them talk, let them,

0:12:30.695 --> 0:12:33.534
<v Speaker 2>let them express what happened. This may be a part

0:12:33.534 --> 0:12:36.575
<v Speaker 2>of a very unhealthy coping mechanism that they are using

0:12:36.575 --> 0:12:39.335
<v Speaker 2>to cope with certain stressors in life, and all they

0:12:39.335 --> 0:12:40.905
<v Speaker 2>need is some love and concern. So you don't have

0:12:40.905 --> 0:12:42.525
<v Speaker 2>to overmedicalize everything.

0:12:42.969 --> 0:12:46.409
<v Speaker 2>But uh do listen and uh to your kids and

0:12:46.409 --> 0:12:47.770
<v Speaker 2>to your, to your friends and loved

0:12:47.770 --> 0:12:48.189
<v Speaker 2>ones.

0:12:48.450 --> 0:12:52.070
<v Speaker 1>Yeah, that can be a great first step. Exactly. And also,

0:12:52.090 --> 0:12:54.169
<v Speaker 1>it's also very good to know that sometimes another first

0:12:54.169 --> 0:12:56.089
<v Speaker 1>step can be a family physician that you don't have

0:12:56.090 --> 0:12:58.718
<v Speaker 1>to necessarily get a specialist recommendation or go straight to NAMS,

0:12:59.090 --> 0:13:01.640
<v Speaker 1>but you can start with your family physician in many cases.

0:13:02.090 --> 0:13:04.630
<v Speaker 2>All the family physicians are trained in mental health, uh, they,

0:13:04.770 --> 0:13:07.449
<v Speaker 2>they are undergoing a psychiatry modules and attachment and a

0:13:07.450 --> 0:13:10.319
<v Speaker 2>group of us have also done further postgraduate training in

0:13:10.320 --> 0:13:10.929
<v Speaker 2>mental health.

0:13:11.630 --> 0:13:15.739
<v Speaker 1>Another WhatsApp coming in, 963-11938. This person says, bottom line,

0:13:15.859 --> 0:13:18.500
<v Speaker 1>should I decline cough mixture is it's prescribed? Can I

0:13:18.500 --> 0:13:20.130
<v Speaker 1>rely on Los Angeles instead?

0:13:20.929 --> 0:13:24.609
<v Speaker 2>No, you shouldn't decline if it's prescribed at the appropriate

0:13:24.609 --> 0:13:28.530
<v Speaker 2>dose and you follow the the prescribed dosage

0:13:28.530 --> 0:13:29.250
<v Speaker 1>in most cases,

0:13:30.130 --> 0:13:32.890
<v Speaker 2>it's a fairly good therapeutic index. But here we're talking

0:13:32.890 --> 0:13:35.130
<v Speaker 2>about here is about people who abuse it.

0:13:35.719 --> 0:13:38.848
<v Speaker 2>And, and you know, this guy, this gentleman may be abusing,

0:13:38.890 --> 0:13:41.380
<v Speaker 2>drinking one bottle and he gets a high, he passes

0:13:41.380 --> 0:13:44.010
<v Speaker 2>to his friends, a rabbing metabolizer, then we kill his

0:13:44.010 --> 0:13:48.119
<v Speaker 2>friend and also that that all these addictions also start

0:13:48.369 --> 0:13:50.380
<v Speaker 2>to a cascade, right? You start with softer drugs and

0:13:50.380 --> 0:13:52.530
<v Speaker 2>other harder drugs, you don't want, you don't want that

0:13:52.530 --> 0:13:56.400
<v Speaker 2>to happen. Um, if you take it as prescribed, as needed,

0:13:56.770 --> 0:13:59.848
<v Speaker 2>right dosage, and you follow instructions, it is all right.

0:14:00.530 --> 0:14:02.590
<v Speaker 1>But going to the point of the substitution, whether the

0:14:02.590 --> 0:14:05.630
<v Speaker 1>Los Angeles can serve good enough because I, I get

0:14:05.630 --> 0:14:07.070
<v Speaker 1>it sometimes like if I've just got a cough or

0:14:07.070 --> 0:14:09.099
<v Speaker 1>sore throat and let's say I've been prescribed the cough mixture,

0:14:09.179 --> 0:14:10.989
<v Speaker 1>I'll be like, I don't want to experience the drowsy

0:14:10.989 --> 0:14:12.429
<v Speaker 1>side effects. I got work to do. I know I

0:14:12.429 --> 0:14:14.429
<v Speaker 1>shouldn't be working when I'm on MC la, but sometimes

0:14:14.429 --> 0:14:16.219
<v Speaker 1>you have to and answer the phones and things like that.

0:14:16.390 --> 0:14:18.979
<v Speaker 1>Could I, can you substitute is the lozenges good enough

0:14:18.979 --> 0:14:20.789
<v Speaker 1>or is the coding cough mixture doing something? Los Angeles,

0:14:20.809 --> 0:14:20.830
<v Speaker 1>it is

0:14:20.830 --> 0:14:20.840
<v Speaker 2>the

0:14:24.469 --> 0:14:27.440
<v Speaker 2>the amount of the active ingredient or active metabolite in

0:14:27.440 --> 0:14:28.250
<v Speaker 2>your bloodstream.

0:14:28.710 --> 0:14:31.469
<v Speaker 2>So it's a lot harder to titrate the dosage of

0:14:31.469 --> 0:14:34.130
<v Speaker 2>a Los Angeles versus a syrup or tablet.

0:14:34.750 --> 0:14:37.109
<v Speaker 1>Good points, great questions as well. Dr. Goh, thank you

0:14:37.109 --> 0:14:38.859
<v Speaker 1>so much for your time today. Great to talk to you.

0:14:39.880 --> 0:14:40.479
<v Speaker 2>Have a good night,

0:14:40.590 --> 0:14:42.880
<v Speaker 1>bye. Our guest on the program helping us understand whether

0:14:42.880 --> 0:14:46.039
<v Speaker 1>or not cough mixture is addictive. Doctor Kelvin Go is

0:14:46.039 --> 0:14:49.640
<v Speaker 1>medical director and lead United Primary Care Network. This has

0:14:49.640 --> 0:14:52.520
<v Speaker 1>been Health Matters right here on CNA 938. I'm Daniel Martin.

0:14:57.830 --> 0:15:01.280
<v Speaker 1>Before making any decisions based on the information in our program,

0:15:01.409 --> 0:15:03.330
<v Speaker 1>please consult a medical professional.