A new medication that is sure to succeed

As a doctor I’ve been trained to recognize patterns, but that same skill can lead to prejudicial thinking. Maybe I’ll fail to recognize an old, disheveled man as the brilliant engineer he is, or the brilliant young physician as an alcoholic. I try to see beyond my own prejudices but one that’s hard to break is my suspicion of drug-seeking patients.

Prescription drug abuse has become a massive problem in the U.S.. Around 30,000 Americans die each year from the misuse of prescription drugs. Most of these deaths involve opioids such as oxycodone, or combinations of prescription drugs and alcohol. It’s a clinical conundrum. We want to treat severe pain, but the tools we have can be dangerous.It takes knowledge and vigilance to treat pain using opioids, given the risk of substance use disorders and their high street value.

Enter into this picture a new medication, Rezira, marketed as a syrup to treat cough and congestion. Presumably, this would be used for patients with the common cold, the usual cause of these symptoms.

This is an accident waiting to happen. The main ingredients are hydrocodone, the opioid present in vicodin, and pseudoephedrine, a decongestant and potential stimulant sometimes used in the manufacture of methamphetamine. When sold as vicodin, hydrocodone is mixed with tylenol, which if overused can cause liver failure. This drug removes that risk, perhaps protecting users from accidental tylenol doses. It offers a winning combination, a drug causing euphoria and central nervous system depression, plus a stimulant. Opioids and stimulants are a popular combination, for example when cocaine and heroin are mixed in “speedballing”.

This drug is a setup for diversion and abuse. It’s sure to develop a high street value. Given that the evidence for the use of opioids for cough is pretty meager, and the potential for misuse is high, I see no place for this drug in our pharmacopeia.

27 Comments

  1. Brian

     /  October 7, 2012

    Hi Pal,

    I gotta disagree with you on this one. As you know, codeine and analog syrups are already available (e.g. Vi-Q-Tuss, Tussi-Organidin) and this adds a useful component that is already available OTC. By looping the psuedoephedrine into the Rx shelf, it actually makes things safer.

    There will always be a potential for abuse. I think the practice of binding hydrocodone to acetaminophen — basically to ensure liver failure before opiate toxicity — is really cruel. Liver failure is a horrible way to go, and we’re basically making it preffered to someone getting a high.

    I’m not saying that drug use is OK, but I look at it in the spirit of needle exchanges: it is incumbent on medicine to do the most good and the least harm. This looks like a good combination that offers greater physician control than someone going to a corner drugstore and buying Sudafed…

    I guess what I’m getting at is that if it’s gonna happen, it’s gonna happen. We can try to regulate, but the alternative — to nix it because we hink it *might* be bad — is just burying our heads in the sand. This is a valuable therapy for things like post-nasal drip that interferes with sleep.

  2. DLC

     /  October 7, 2012

    Why not market it directly to street level drug dealers and cut out the middle man ?
    Brian : why not market a hydrocodone without the tylenol ? it’s already being done.
    There are better cough suppressants than this, that can’t be used as the primary ingredient in methamphetamine. This stuff just seems tailor-made for drug seekers.

    • Brian

       /  October 7, 2012

      Codeine and hydrocodone are probably the two most effective cough suppressants on the market today. The ingredient in Rezira that could be used in meth production is not the hydrocodone, but the pseudoephedrine… which is available at your local Walmart right now without a prescription. I guess my point is that it’s better to try to regulate than not regulate. A cold has many symptoms, and the drugs to treat them have some side effects that can go haywire in combination, just as Pal alluded to. But I’d feel better with a controlled Rx form a physician than a consumer making his own OTC cocktail… Some Codiclear, some Sudafed, some Bendaryl…

      • DLC

         /  October 9, 2012

        My post was unclear, but I was referring to the pseudoephedrine , not the hydrocodone, as the primary ingredient in methamphetamine. I also disagree that pain meds are better cough suppressants. synthetic opioids are good, but the potential for abuse is huge. My comment regarding hydrocodone was directed at your statement regarding hydrocodone and tylenol and liver damage, that it’s possible to offer the opioid without the acetaminophen. (although personally I think the combination has advantages for pain, and I’m not really concerned with catering to drug abusers)

  3. I join Brian’s disagreement but for different reasons as I’m not a clinician and am not familiar with what’s available. Instead I’m going to take this from a risk-benefit standpoint by asking this question: should we suppress the availability of new prescription drugs simply because they might have abuse potential? If so, why should drugs with potential benefits be suppressed due to the risk of abuse? Should we defer to the risk of abuse in determining whether a drug should be introduced?

    I mean we have “backyard chemists” creating new crap all the time simply to have something that’ll get them high but not be found in drug screenings. Never underestimate what human ingenuity can produce, but at the same time, have a little more faith that in general most patients can be and are responsible with prescription drugs.

  4. A. Marina Fournier

     /  October 8, 2012

    I am allergic to codeine and to vicodin. This drug has no chance of helping me. DLC, what are these better cough suppressants? The decongestant/expectorant combo does very little to help, and 8 oz of even inexpensive scotch doesn’t always put me out (CNSD, not really for me, it isn’t)

    In heavy pollen seasons, other allergen exposure, and with my rare colds (when *did* I last have the flu–a dozen years or so ago?), I have severe coughs that resemble those of either whooping cough or walking pneumonia. Wheezing, continuing unproductive for about two minutes, sometimes leading to vomiting (in my case, in my sister’s, cracking/fracturing ribs) if I can’t stop the trend by immediate liquid intake, so as to force the muscles to change direction, and I’ve had the blood pressure in my head alone crank up to near black-out during episodes.

    What can *I* do, what can *I* use or take?

    Even attempting to sleep sitting up, and I do mean attempting to sleep, helps very little, as the post-nasal drip, or reactive, coughs every few minutes keep me from settling to sleep, and if I should sleep, it will be light and broken. Rest when I have a cold? Get more sleep? HOW? Should I mention I’m a lifelong insomniac?

    My sister, for whom I am conservator physical and estate, recently moved up here from So. Calif. A physician who makes house calls to care homes visited her, and while looking at her list of meds, saw hydrocodone at bedtime, as a sleep aid. I expressed concern to the doctor of its inappropriate use, not mentioning the addiction factor, and he agreed, changing that for something more appropriate for sleep difficulty. I don’t know what the other conservator, who probably knows more than I do about medications, was thinking, allowing that scrip. She seems to be sleeping better now, too.

    I think of the policy of keeping certain OTC meds behind the counter, and requiring ID and all, is made by the same sort of people who felt that if we eliminate 10% of molesters in schools (who happen, in their minds, to have been any gay or lesbian), we’re ahead of the game at least that much, overlooking the vast number they’re not even considering. Getting OTC pills to make meth with is for the small-timer: the big mfr/dealer has access to the unadulterated chemicals, and in far greater quantities.

    The policy of not prescribing opiates to the terminally ill in substantial pain, because they might get addicted to it–excuse me, they’re going to die soon, and the use of opiates will suddenly stop. They aren’t going to mugging or burglarizing anyone.

    So, the terminally ill, by this policy, are left in that pain, instead of making their last days/weeks/months more comfortable. When I explained this to my seven year old son, along with why the City Council of Santa Cruz were dispensing medical marijuana on the steps of City Hall that day, and the government opposition to “death with dignity” (re: the OR law, voted in recently then, but opposed by the Feds), he said, it seems as if the government wants people to suffer.

    • Brian

       /  October 8, 2012

      Ask your doctor about Tessalon or Pipazethate. Can’t guarantee that they’ll work, but they’re not related to codeine and are stronger than the dextromethorphan you’d find OTC. Good luck.

      • saffronrose

         /  October 10, 2012

        The Tessalon also proved too weak to be effective, and my web searches don’t show Pipazethate being in the US. I will ask my internist about it.

    • Chris

       /  October 9, 2012

      My family doctor suggested Benadryl (diphenhydramine) and just generic cough syrup. The Benadryl helps you get to sleep and kind of relaxes the coughing. I found it helps.

      And I am also among the 10% of the population who cannot take opiates/narcotics as they make sick to my stomach. It was very unpleasant after breaking my ankle when the pain meds made it so I had to keep hobbling to the bathroom with crutches to vomit.

      • saffronrose

         /  October 10, 2012

        Lifelong insomniac here has never slept due to the ingestion of benadryl, more’s the pity. I don’t know about other opiods/opiates, but yes, codeine makes me lose the contents of my stomach. Not very helpful for cough supressant, eh?

        • Brian

           /  October 10, 2012

          Another option for you might be a hydrocodone syrup (not quite the same as codeine, so you might tolerate it better) + Phenergan (stops nausea, etc., and also has a sedative effect).

          • saffronrose

             /  October 12, 2012

            I’ll check with my internist and see what she says–I’ve heard of this before, but haven’t been sure it would work for me.

          • Personally, I’m allergic to Phenergan, so that one’s right out for me. Benadryl puts me to sleep nicely when I’m not coughing and vomiting every five minutes, but is only slightly better than a sugar pill when I am.

            I’ve tried Tessalon and it didn’t work. The only thing that works for me is the codeine cough syrup, but my doctor’s office won’t prescribe it for me, no matter what. I’m not sure if my asking for cough syrup once every few years when I haven’t slept properly in weeks is drug-seeking behavior, but whatever the reason, I’m out of luck.

            On the occasions when the cough goes to my chest, I just don’t sleep for several weeks. Too bad I also have to drive places during that period. I’m grateful I’ve never crashed my car or killed anyone due to lack of sleep.

    • DLC

       /  October 9, 2012

      A. Marina Fournier : I’m not your doctor. for all that, I’m merely an amateur stating an opinion formed by my own studies into the subject and my own personal experiences, having suffered for years from chronic bronchitis*. I know cold meds pretty well, at least for myself. But what works for me might not work for you, so I try to rely on the science to form a general rule. You and your doctor may have to work together, trying various alternatives, in order to find a combination that works.

      (in my case, chronic bronchitis ceased after I quit smoking. 30 years worth of tobacco smoke was killing me. )

      • saffronrose

         /  October 10, 2012

        DLC, I do appreciate the one datum about the Pipazethate, of which I have never heard. It is often, in forums like this, that I find something useful of which I was previously unaware!

        My annual springtime bronchitis disappeared when I stopped burning the candle at both ends between March and May. Husband seems to have stopped getting strep throat at the drop of a hat. I’d only get it once every fifth one of his. When my son went through the development of his immune system, mine seems to have received a booster. I can’t recall the last time I had flu, and I *might* get one cold a year. I was miserable then, but I’m thankful for the benefits now.

  5. I’m not a doctor or health care professional of any kind, but I thought the trend these days was towards not using cough suppressants except when the coughing is problematically severe or causing problems with sleeping.

    • saffronrose

       /  October 10, 2012

      The problematically severe coughing has indeed been interfering with my sleeping since my sophomore year in college. Haven’t a clue what changed then.

  6. Vicki

     /  October 9, 2012

    I wouldn’t call it “making my own over-the-counter cocktail.” I’d call it taking the minimum number of medications, which is not the same as the minimum number of pills or syrups. I had trouble finding a plain cough suppressant, without either acetominophen or an expectorant mixed in last winter, until someone told me I’d likely find it with other medicines intended to be given to children/adolescents. Do the marketers think that no adult, even those who buy such things for their children, will want to treat only one symptom?

  7. Karen

     /  October 9, 2012

    I HATE multi-symptom medicines. I’ve never had a multi-symptom (at the same time) cold or flu. For me, colds invariably start with a killer sore throat, followed by some days of runny nose/ running down my throat, followed by days of horrible congestion. At some point in all of this the asthma kicks in, and sends me reeling with evil, deep coughs.

    I’ve benefited from a few nights of codeine-based cough syrup, because it disrupts the productive cough that leads to the asthma cough that can keep me coughing ALL NIGHT. I appreciate the value of a productive cough, but one must sleep sometime.

    In the last few years I’ve avoided (because of circumstances not related to illness avoidance) most contagious people, and I’ve had very few colds. I also get a flu shot every year. Not getting sick in the first place is worth all the codeine in the world.

  8. As someone who has worked in the medical field (Army Combat Medic, basically paramedic jack of all trades) and has spent time around opiate addiction i can definitely say it is a bit naive of Brian to assume that the benefits of having this drug on the market outweigh the very real risk of patient abuse. Honestly, it blows my mind that FDA even let this onto the market. As for the codeine headache based medicines, we may end up like russia if those become prevalant; http://www.youtube.com/watch?v=mxPXxos_BNw

    • Brian

       /  October 10, 2012

      I will always err on the side of helping someone rather then denying them relief on the basis of “what ifs.” Codeine is addictive. Alprazolam is addictive. But both are effective medications when used properly. By following your philosophy, any medication with any addiction risk shouldn’t prescribed?

  9. Also, the thing about Opiate addiction is that is does not discriminate. If you take it long enough you WILL become addicted, regardless of personality which is the nature of physical addiction. It’s also a reason why many of the people who do become addicted do not necessarily fit the regular markers. (young, male, whatever.) I know it’s ridiculously hard to tell a patient “no” (when there telling you nsaids/tylenol/physical therapy aren’t working) but as a doctor you should be able to have that tough love.

  10. I read “hydrocodone” and that’s all I needed to know. It will be very popular no doubt. Almost a dual market for drugs now. You have “legitimate” whatevercodones that you can abuse (even if I seriously doubt that sixteen-year-old is a licensed pharmacist). Or you can go for more “natural” opium, cocaine, and cannabis for your high. (Note: The methheads will also say their drug is “natural”.) You now have choices in how to screw up your body.

    Drug culture is complicated, with many, many subcultures. Users of powder cocaine tend to view crackheads with contempt, for instance.

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