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