Speaker 1: Now, Health Matters with Daniel Martin. It's Health Matters. Welcome in, everybody.
Speaker 1: I'm Daniel Martin and I've got your health on my mind.
Speaker 1: On today's edition, as you heard on the news here
Speaker 1: on CNA 938, the Health Sciences Authority revealed the illegal
Speaker 1: health products report from what was seized in 2024, and
Speaker 1: a majority of the illegal health products were codeine cough syrup.
Speaker 1: So in total about more than 970,000 units of illegal
Speaker 1: health products were seized. Codeine cough syrup made up something
Speaker 1: like 54% of those numbers right there, the 970,000. Some
Speaker 1: of the other things on the list include things like
Speaker 1: sexual enhancement medicines and sedatives making up 19% and 18%.
Speaker 1: So you see the big discrepancy there, the big difference.
Speaker 1: What a big chunk, a chunk of um those numbers.
Speaker 1: Falling to codeine cough syrup. But why? I'm sure some
Speaker 1: of you know, of course, about the potentially addictive nature
Speaker 1: of it, but it's just cough mixture, right? Is cough
Speaker 1: mixture really that addictive and really that in demand? Doctor
Speaker 1: Kelvin Goh is joining us. Doctor Goh is medical director
Speaker 1: and Leed United Primary Care Network. Doctor Goh, good to
Speaker 1: talk to you again. Hello. Bottom line, let's just talk
Speaker 1: about cough mixture first and foremost. What's the concept? What's
Speaker 1: the idea? What is cough mixture used for? How is
Speaker 1: it used in Singapore?
Speaker 2: I mean, there are, there are common drugs that are
Speaker 2: used to suppress cough, and they tend to have a
Speaker 2: few common active ingredients. So, top of the list would
Speaker 2: be codeine, which is, which is a class B controlled drug.
Speaker 2: Then you have uh dextrometophan. Others include promethazine and pseudoephedrine
Speaker 2: and graphennoin, and they tend to be mixed together sometimes.
Speaker 1: So codeine cough syrup is not something illegal, it's regularly
Speaker 1: prescribed in clinics in Singapore.
Speaker 2: It's a codeine containing cough syrup is regularly prescribed in
Speaker 2: clinic in Singapore, pure coding cough syrup is uh more
Speaker 2: seldom seen prescribed.
Speaker 1: Is codeine also that component that sometimes when you get painkillers,
Speaker 1: you get panadine, which is a combination of Panadol and codeine.
Speaker 1: Is that codeine as
Speaker 2: well? So is actually um
Speaker 2: Codeine is actually processed by the body, if you consume
Speaker 2: the co mixture, codeine becomes, it's metabolized into um morphine
Speaker 2: 6 corronide and a bit of morphine, and we are
Speaker 2: all familiar with morphine, which is an opioid. And therefore
Speaker 2: you get the effects of morphine if you take it
Speaker 2: in very high doses.
Speaker 2: But, but that lies another issue with uh uh codeine
Speaker 2: metabolism because codeine metabolism is quite unique in the sense
Speaker 2: that some patients are rapid ultra-fast metabolizers, some are slow metabollizers.
Speaker 2: So because the active ingredient is a poor drug, so
Speaker 2: the active ingredient is the morphine and the morphine 6
Speaker 2: to 9. So, if you take a prescribed dose of morphine,
Speaker 2: one guy may have only one quarter of the morphine.
Speaker 2: After taking the same dose of codeine, of the morphine
Speaker 2: is blood, the other gentleman or lady may have 10
Speaker 2: times the higher dose because we don't really test routinely
Speaker 2: for the CYP 450 gene, so we don't know who
Speaker 2: is the ultrafast metabolizer and who.
Speaker 2: Who is not. So imagine if you overdose a cough
Speaker 2: mixture by a quantum of 1020, 2030 times and you
Speaker 2: are ultra-fast metabolizer, you multiply that by multiples, you're talking
Speaker 2: about potential lethal dose.
Speaker 1: Wow, that is shocking to hear. Actually. Have we had
Speaker 1: cases like that in Singapore? Is that something that happens?
Speaker 2: there are case reports worldwide, even in, in patients who
Speaker 2: have breastfed child taking, taking high dose of codeine and
Speaker 2: the mom is a rapid metabolizer.
Speaker 2: With high dose of codeine, yeah, high dose of codeine
Speaker 2: morphine will suppress your respiratory drive and people get sedated,
Speaker 2: they don't breathe that well, and then their brain may
Speaker 2: become hypoxic.
Speaker 1: So is it safe or not to take cough mixture?
Speaker 1: I think that's what the average listener is wondering
Speaker 2: right
Speaker 1: now
Speaker 2: if
Speaker 2: you cough mixture in the prescribed dose, it is generally safe.
Speaker 2: Um, but you are not, obviously, if you overdose it,
Speaker 2: if you mix it with alcohol or other drugs, you
Speaker 2: got the whole bottle down, it's very, very unwise, and
Speaker 2: it's basically abuse, right? Similarly for other cough cough uh
Speaker 2: other common cough uh uh medications like, like dextromethyphen. It's
Speaker 2: also a pro drug. The active ingredient is metabolized by
Speaker 2: the body in the Dextrophan and dextrophan
Speaker 2: It's uh what we call NDMA antagonist. So it's basically
Speaker 2: similar to the effect to ketamine, which is like a
Speaker 2: harder drug, right? So in high quantities, people get visual hallucinations.
Speaker 2: So people abuse these drugs for, to feel some euphoria,
Speaker 2: to feel um a bit more relaxed. Yeah, but basically,
Speaker 2: these are abuse and if you, if you let people
Speaker 2: abuse cough mixture as they move along, they may move
Speaker 2: on to harder and harder drugs.
Speaker 1: Interesting. So that's the thing. If you're sticking to the,
Speaker 1: if you, if your cough mixture does contain the codeine,
Speaker 1: if you're sticking to the regular dosage that you're supposed to,
Speaker 1: for the most part, most people will be absolutely fine until, unless,
Speaker 1: like you said, you might be that person who's metabolizing
Speaker 1: it very differently, lah.
Speaker 2: Correct, and you abuse it by taking a dose
Speaker 1: quantities.
Speaker 1: I'll be admit when you're prescribe it, sometimes it comes
Speaker 1: with a little plastic spoon la. Then we're supposed to
Speaker 1: use the little plastic spoon and take the doses, but
Speaker 1: sometimes people lazy, they just open and just drink straight
Speaker 1: away from the bottle. That's the problem.
Speaker 2: I mean, the abusers usually drink the whole bottle. I don't.
Speaker 1: It's more than big gulps, right? Are you surprised to see,
Speaker 1: because we've had problems of the misuse of codeine cough
Speaker 1: syrup before. We've had cases of people's misrepresenting their illness
Speaker 1: and getting the prescription and passing it on to abusers,
Speaker 1: for example, as well. When and how can cough mixture
Speaker 1: be misused?
Speaker 2: When and how, I mean, there are people who abuse
Speaker 2: this cough mixtures for recreational purposes, for just for that
Speaker 2: dopamine high, right? So maybe these people instead of abuse,
Speaker 2: if they are stressed, they need to find healthier ways
Speaker 2: to manage the stress rather than going for the cheap
Speaker 2: dopamine high with, with the cough mixture of drugs, things
Speaker 2: like exercising, um, having healthy relationships, and having not adequate sleep, or, or.
Speaker 2: Doing something constructive,
Speaker 1: yeah. And how in terms of basically it's consuming large quantities,
Speaker 1: it's not about having to change it, the chemical composition
Speaker 1: additives or anything like that, it's just large quantities of
Speaker 1: that codeine cough syrup.
Speaker 2: Yes,
Speaker 2: it's quantitative takes a large quantity, but they tend to
Speaker 2: mix it with like like soft drinks, soda, alcohol and
Speaker 2: other other drugs, other sedatives.
Speaker 2: And all this add together to form a more lethal
Speaker 2: uh uh combination. And of course, the, I mean MW
Speaker 2: regulates it quite strictly. It's not that easy to get
Speaker 2: it from uh GP clinics because I mean we are
Speaker 2: experienced we we see patients who will come to us.
Speaker 2: Being super friendly, telling us that they, they have certain
Speaker 2: symptoms to confabulate and when you give them treatment or
Speaker 2: investigations relevant to the symptoms, they reject and they insist
Speaker 2: on a particular brand of cough syrup, two bottles, but
Speaker 2: they come back the next day that I've lost the bottle, my,
Speaker 2: my dog drank it, uh, I left in MRT, uh, my,
Speaker 2: my uh brother took it, whatever, what have you not?
Speaker 2: So they find reasons to get more supply, but nowadays
Speaker 2: because of strain enforcement by.
Speaker 2: MOH for any uh any breaches in the regulations and
Speaker 2: also with the national electronic health records, we can actually
Speaker 2: see if someone has been hopping. So I think that
Speaker 2: may have driven this uh codeine uh market more underground,
Speaker 2: but stromatophan and the rest can be obtained from the pharmacy,
Speaker 2: so these are harder to detect.
Speaker 1: Are those equally as addictive?
Speaker 1: Or
Speaker 1: possibly
Speaker 2: to be misused. So one of the major ones I
Speaker 2: mentioned before the Dextroph which became the active active metabolican
Speaker 2: which has psychedelic properties, right? So people take it they
Speaker 2: get feel a bit high in some visual hallucinations. So
Speaker 2: this is
Speaker 2: Relatively easier to access.
Speaker 2: Because it's available from the pharmacy, from the clinics, and
Speaker 2: it doesn't have that bad image like codeine, you know.
Speaker 2: So people will not suspect generally that someone is abusing
Speaker 2: such medications. I mean, there are people abusing all sorts
Speaker 2: of medications, even paracetamol, right? So some people will take
Speaker 2: some cough mixture, they abuse a pseudo epirine, they get palpitations,
Speaker 2: irregular heartbeat, they sweat and stuff.
Speaker 1: Remind us again, when is it prescribed? For what medical
Speaker 1: condition would it would it ordinarily be utilized?
Speaker 2: Typically it's prescribed for a patient with a viral upper
Speaker 2: respiratory tract infection, uh, to help manage the cough symptoms.
Speaker 2: It's basically a cough suppressant.
Speaker 1: And how serious does the health issue have to be
Speaker 1: for this to be prescribed?
Speaker 2: Actually, it's generally not for serious health problems, in fact,
Speaker 2: the long term.
Speaker 2: The evidence from the effectiveness of codeine containing cough syrup
Speaker 2: for cough is not that, not that great. Yeah. So
Speaker 2: basically for symptomatic relief.
Speaker 1: OK.
Speaker 1: So this brings up a good point. So now that
Speaker 1: you brought up the idea that, you know, some people
Speaker 1: metabolize it differently as well, when should you go back
Speaker 1: to your doctor and say, oh, this is, it's, it's, I'm,
Speaker 1: I'm too drowsy. It's like, when should you go back
Speaker 1: and maybe try and seek an alternative if it's being
Speaker 1: a bit too strong for you? Generally,
Speaker 2: if you take the medications, right, if you are a
Speaker 2: rapid metabolizer,
Speaker 2: Probably feel a lot more drowsy than other patients. Then
Speaker 2: it's fine. Let me just switch another uh cough medication
Speaker 2: for you. But generally, if your cough is not better,
Speaker 2: you have to investigate the cause of the cough. Could
Speaker 2: you be having a lung cancer? Will you be having
Speaker 2: uh tuberculosis? Are you having acute bronchitis? Are you having
Speaker 2: acute uh bacterial, rhino sinusitis? So the cause of the coughs,
Speaker 2: needs to be investigated. Is it because of reflux, rather
Speaker 2: than keep on taking uh weeks of weeks after weeks
Speaker 2: of cough medications? Yeah.
Speaker 1: Got a WhatsApp coming in from one of our listeners
Speaker 1: at 963-119-38. Is this present in children's cough mixture as well,
Speaker 1: because those are different and I'm assuming they are less potent.
Speaker 2: Are these children's cough mixtures. 12 years of age.
Speaker 2: And we are extremely careful with kids, yeah.
Speaker 1: So that's a good point. So children's cough mixture is different,
Speaker 1: generally don't contain this, and this is why it's another example.
Speaker 1: Don't try and self-medicate, you know, parents might be like, oh,
Speaker 1: got a cough, no, no, no, take the cough mixture
Speaker 1: that doctor gave me, definitely not suitable.
Speaker 2: Yes, always consult your family physician for the right dosage
Speaker 2: and the right indications.
Speaker 1: And you shouldn't be sharing medication anyway. It was prescribed
Speaker 1: to you for a specific concern. It doesn't mean it's
Speaker 1: universally applicable to everybody in the family as well. So,
Speaker 1: the children's cough mixture is different. Good, good question. Thank
Speaker 1: you so much for the WhatsApp. If this, is this
Speaker 1: a true for people who are misusing this and consuming
Speaker 1: it in very large quantities,
Speaker 1: Is this a true addiction? Are we talking about addiction
Speaker 1: management that has to happen here?
Speaker 2: Yeah, so, so basically, if the patients and if those,
Speaker 2: I mean, there's some are substance dependent, some is substance addiction.
Speaker 2: So addiction, you have to, of course, fulfill the addiction criteria,
Speaker 2: which actually means that in patients with substance abuse, basically,
Speaker 2: They, they use the substance a lot longer and more
Speaker 2: for what it's meant to, instead of maybe taking the medicine,
Speaker 2: 10 meals, they take 20, instead of taking it for
Speaker 2: 3 days until they are like.
Speaker 2: Better, they take it for one week. And if they
Speaker 2: try to cut down or stop using the substance, they're
Speaker 2: not able to do so easily. So that's dependence. But for,
Speaker 2: for addiction, there's a specific clinical criteria. There's usually a
Speaker 2: lot of clinically significant impair and distress and it affects
Speaker 2: them both socially in their work, their relationships, uh, it
Speaker 2: affects everything and it's quite destructive to their lives. So, generally,
Speaker 2: Seek help from your family physician. If necessary, we'll refer
Speaker 2: the patient uh to the National Addiction Management Center. Many
Speaker 2: family physicians are also trained in uh mental health in
Speaker 2: the undergrad days, and many of us, including myself, we
Speaker 2: have a graduate diploma in mental health too. So some
Speaker 2: of us do have an interest in, in mental health
Speaker 2: and and can help, uh, help you manage if you
Speaker 2: have loved ones that are have addiction or dependency to
Speaker 2: cough syrup. But the simplest thing to do is simply
Speaker 2: just
Speaker 2: you know, just go push that your loved ones or
Speaker 2: your friend who is dependent, show some concern. Hey, what
Speaker 2: happened to you in a non-judgmental, non-threatening way. Uh, why
Speaker 2: are you doing this? I see two bottles of empty
Speaker 2: cough syrup in the dustbin. Let them talk, let them,
Speaker 2: let them express what happened. This may be a part
Speaker 2: of a very unhealthy coping mechanism that they are using
Speaker 2: to cope with certain stressors in life, and all they
Speaker 2: need is some love and concern. So you don't have
Speaker 2: to overmedicalize everything.
Speaker 2: But uh do listen and uh to your kids and
Speaker 2: to your, to your friends and loved
Speaker 2: ones.
Speaker 1: Yeah, that can be a great first step. Exactly. And also,
Speaker 1: it's also very good to know that sometimes another first
Speaker 1: step can be a family physician that you don't have
Speaker 1: to necessarily get a specialist recommendation or go straight to NAMS,
Speaker 1: but you can start with your family physician in many cases.
Speaker 2: All the family physicians are trained in mental health, uh, they,
Speaker 2: they are undergoing a psychiatry modules and attachment and a
Speaker 2: group of us have also done further postgraduate training in
Speaker 2: mental health.
Speaker 1: Another WhatsApp coming in, 963-11938. This person says, bottom line,
Speaker 1: should I decline cough mixture is it's prescribed? Can I
Speaker 1: rely on Los Angeles instead?
Speaker 2: No, you shouldn't decline if it's prescribed at the appropriate
Speaker 2: dose and you follow the the prescribed dosage
Speaker 1: in most cases,
Speaker 2: it's a fairly good therapeutic index. But here we're talking
Speaker 2: about here is about people who abuse it.
Speaker 2: And, and you know, this guy, this gentleman may be abusing,
Speaker 2: drinking one bottle and he gets a high, he passes
Speaker 2: to his friends, a rabbing metabolizer, then we kill his
Speaker 2: friend and also that that all these addictions also start
Speaker 2: to a cascade, right? You start with softer drugs and
Speaker 2: other harder drugs, you don't want, you don't want that
Speaker 2: to happen. Um, if you take it as prescribed, as needed,
Speaker 2: right dosage, and you follow instructions, it is all right.
Speaker 1: But going to the point of the substitution, whether the
Speaker 1: Los Angeles can serve good enough because I, I get
Speaker 1: it sometimes like if I've just got a cough or
Speaker 1: sore throat and let's say I've been prescribed the cough mixture,
Speaker 1: I'll be like, I don't want to experience the drowsy
Speaker 1: side effects. I got work to do. I know I
Speaker 1: shouldn't be working when I'm on MC la, but sometimes
Speaker 1: you have to and answer the phones and things like that.
Speaker 1: Could I, can you substitute is the lozenges good enough
Speaker 1: or is the coding cough mixture doing something? Los Angeles,
Speaker 1: it is
Speaker 2: the
Speaker 2: the amount of the active ingredient or active metabolite in
Speaker 2: your bloodstream.
Speaker 2: So it's a lot harder to titrate the dosage of
Speaker 2: a Los Angeles versus a syrup or tablet.
Speaker 1: Good points, great questions as well. Dr. Goh, thank you
Speaker 1: so much for your time today. Great to talk to you.
Speaker 2: Have a good night,
Speaker 1: bye. Our guest on the program helping us understand whether
Speaker 1: or not cough mixture is addictive. Doctor Kelvin Go is
Speaker 1: medical director and lead United Primary Care Network. This has
Speaker 1: been Health Matters right here on CNA 938. I'm Daniel Martin.
Speaker 1: Before making any decisions based on the information in our program,
Speaker 1: please consult a medical professional.