Codeine is a prescription medicine that belongs to a group of drugs called opioids. Codeine is a component of many prescription pain medicines used to treat mild to moderate pain. It is also classified as an “antitussive” due to its ability to suppress cough; therefore, codeine, usually in combination with other drugs, is one of the active ingredients in some cough medicines. In some states, codeine-containing medicines for cough suppression are available over-the-counter (OTC). Unlike prescription drugs, OTC medicines can be purchased at a pharmacy without the need for a doctor’s prescription. However, misuse of codeine cough and cold medicines can lead to increased risks of serious adverse effects.

Please continue reading to learn more about different codeine cough syrups, the risks associated with their use, and how often you can safely take these medicines. 

Which cough and cold medicines contain codeine?

Brand names Tuzistra (chlorpheniramine and codeine) and Phenergan with Codeine (promethazine and codeine) are some examples of codeine-containing medications that are used to relieve cough and cold symptoms, such as sneezing, stuffy or runny nose, and other allergy symptoms. 

Does DM cough syrup have codeine?

DM cough syrup does not have codeine. It contains dextromethorphan and is an OTC medication used to reduce coughing. 

How often can you take codeine cough medicine?

The recommended dose of promethazine and codeine syrup for cough in adults 18 years and older is 5 mL (1 teaspoon) every 4 to 6 hours as needed. You should not take more than 30 mL (6 doses) of this codeine cough medicine in 24 hours. 

The recommended dose of Tuzistra XR extended-release suspension in adults 18 years and older is 10 mL (2 teaspoons) every 12 hours as needed. You should not exceed 20 mL (2 doses) in 24 hours.

Read the product label and follow the prescription’s instructions carefully. Take the medicine exactly as instructed. You should use a medicine measuring device like an oral syringe instead of using household items like a kitchen spoon; an oral syringe will help you get the most accurate dosing. Do not take higher doses or more frequent doses without consulting your doctor. Talk to your health care professional if your cough symptoms are not controlled after several days of codeine use. 

What is the FDA drug safety communication regarding codeine cough medicine?

As of 2017, the U.S. Food and Drug Administration (FDA) restricts the use of prescription codeine pain medicines and tramadol in children. In the same FDA drug safety communication, the agency also recommends against the use of these prescription medicines in breastfeeding mothers due to possible harm to their infants. 

In 2018, the U.S. FDA announced that they will require safety labeling changes for prescription cough and cold medicines containing codeine or hydrocodone. The goal of this safety communication is to limit the use of these prescription medicines to adults 18 years and older because their risk outweighs the benefits in children younger than 18 years of age. The agency also requires the addition of safety information about the risks of misuse, abuse, overdose, slowed or difficult breathing, and even death to their Boxed Warnings.

What are the risks of codeine cough medicine?

The common side effects of codeine-containing medications include dizziness, drowsiness, headache, dry mouth, nausea, vomiting, constipation, and sweating. These medicines can also cause more side effects that are serious. Some of the serious side effects and risks of codeine-containing medicines are listed below.

Allergic Reactions

Some people can develop allergic reactions to codeine-containing cough medicines. Signs and symptoms of an allergic reaction include skin rash, hives, itching, swelling of the throat, tongue, lips, and face, chest tightness, and trouble breathing. Seek immediate medical attention if you develop any of these symptoms of drug allergies.

Habit-Forming

Cough syrups that contain opioids, for example, codeine, can be habit-forming. Opioid medications have the potential for abuse, misuse, and addiction. Inappropriate use of these medications can lead to opioid overdose and death. People with a history of substance abuse or mental illness are at greater risk of misuse and abuse. You should take codeine medicines at the prescribed dose as needed for the duration advised by your doctor. Discuss with your doctor if the medication does not reduce coughing or your symptoms worsen; for the first 24 to 48 hours, you should communicate the progress with them. 

Breathing Problems

Codeine medicine affects breathing and can lead to shallow breathing and difficulty breathing, which can be life-threatening. Once codeine enters the body, it is metabolized into morphine -- this process is faster in some people who are referred to as “ultra-rapid metabolizers of codeine.” The quick breakdown of codeine can result in a very high level of morphine in the blood, which, in turn, can intensify the side effects of morphine. Extreme sleepiness and shallow breathing may be signs that you are an ultra-rapid metabolizer of codeine. This risk is especially high in children under 18 years of age, as they are more sensitive to this effect. Therefore, pediatric codeine use can lead to serious health complications that can be fatal if not treated immediately. 

Taking medication that suppresses the central nervous (CNS) system while on codeine medicine can also put you at higher risks of respiratory depression, as CNS depressants and codeine both affect your breathing. Examples of CNS depressants are sleeping pills, other opioid pain medicines, medicines for anxiety like benzodiazepines (Valium, Xanax), seizure medications, and alcohol. 

People with health conditions like obstructive sleep apnea (OSA), asthma, or chronic obstructive pulmonary disease (COPD) are at higher risk of developing breathing problems. Go to the nearest emergency room and seek immediate medical attention if you develop breathing problems while on codeine-containing cough or pain medicine.

Extreme Drowsiness

Taking codeine-containing cough medicine can cause extreme sleepiness, which can be life-threatening. The risk is higher if you take it with other medicines like benzodiazepines (Valium, Xanax) or alcohol. Tell your doctor if you experience any unusual sleepiness while on codeine cough or pain medicine. You should not drive or perform any activities that require mental alertness until you know how this medication affects you.

Drug Interactions

Interactions between codeine and other medicines can cause life-threatening adverse reactions. Give your doctor and pharmacist a complete list of your medications, including prescription drugs, over-the-counter medicines, dietary supplements, and herbal remedies, to avoid dangerous drug interactions. 

Codeine may also interact with serotonergic drugs -- medications that affect the serotonin levels in the body. Serotonergic medications include antidepressants, antipsychotics, medication for nausea, and stimulant medicine. You should not take codeine medicine if you have taken a monoamine oxidase inhibitor (MAO inhibitor) within the past 14 days. Examples of the MAO inhibitors approved for depression treatment are isocarboxazid (Marplan), phenelzine (Nardil), selegiline (Emsam), and tranylcypromine (Parnate).

Opioid Withdrawal in Newborns

The use of codeine-containing cough medicines during pregnancy can lead to opioid withdrawal symptoms in newborn babies. These effects can be life-threatening for infants. Similarly, codeine use during breastfeeding is not warned against as codeine can get into breast milk leading to breathing problems and extreme sleepiness in infants. Pregnant and breastfeeding women should discuss with their doctors the risks and benefits of different treatment options for coughs and colds.

Ultra Rapid Metabolizers

Some people have a variation of an enzyme in their body that makes them convert codeine to morphine faster and more intensely than others. The risk of adverse events related to codeine can be higher in ultra-rapid metabolizers. 

References:

1. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-restricts-use-prescription-codeine-pain-and-cough-medicines-and
2. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2785985
3. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/use-codeine-and-tramadol-products-breastfeeding-women-questions-and-answer
4. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/207768s007lbl.pdf
5. https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/008306s034lbl.pdf
6. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-requires-labeling-changes-prescription-opioid-cough-and-cold