How much codeine cough syrup

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Try out PMC Labs and tell us what you think. Learn More. We describe the first reported case of acute confusional state in a ly healthy year-old girl ultimately attributed to inappropriate codeine use. The usage of codeine in the paediatric setting has been highlighted in recent years with many reported deaths—mostly due to respiratory depression. The risks associated with codeine usage may be particularly unnecessary with OTC cough suppressants as evidence of efficacy is absent.

Finally, codeine dependence is a common problem among adults and has been reported locally and internationally among adolescents. The combination of lack of efficacy, risk of acute intoxication and dependence, suggests that the use of OTC codeine preparations may be unwarranted. This case provides an invaluable example of the importance in maintaining an open mind in the assessment of patients with acute confusion. In addition to its clinical ificance, it explores efficacy, toxicity and dependence on a drug with an overestimated safety profile in the paediatric population.

Finally, the recent publication of guidelines from the European Medicines Agency EMA regarding codeine usage in paediatrics, provides an interesting backdrop and highlights these new guidelines to unaware readers. A ly well year-old girl presented to the Emergency Department of a General Regional Hospital in Ireland, with a 5-day history of fluctuating confusion and anterograde amnesia. The amnesia and confusion fluctuated throughout the day and the symptomatology was unusual.

The patient falsely How much codeine cough syrup completing tasks, for example, she claimed to have showered when it was apparent to her mother that she had not showered. Additionally, she was noted to be How much codeine cough syrup languages during her homework. There were no concerns raised by school, and the patient was otherwise asymptomatic.

There was no history of head injury or other ificant medical history. The patient denied illicit drug use; she had a history of well-controlled asthma. She was afebrile, there were no abnormalities on general examination and, specifically, there was an entirely normal neurological examination.

A urine toxicology screen was reported positive for codeine quantity not specifiedno other drugs or metabolites were present. This medication is available over the counter OTC in Ireland. Baseline laboratory investigations included full blood count, C reactive protein, liver function tests, renal profile and electrolytes—all reported normal. MRI of the brain was entirely normal. Genotyping for the CYP2D6 mutation ultrafast metabolisers was not sought as symptoms only developed after exceeding the maximum recommended dosage.

The causes of acute confusion in the adolescent setting are wide-ranging including infective, metabolic, psychiatric, vascular and malignant, and, as in this case, toxin-induced. The patient's fluctuating and somewhat unusual symptoms initiated a request for a psychiatry review. Despite these initial assumptions, the symptoms were attributable to codeine intoxication.

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Five days following admission, the symptoms abated; urine codeine was negative at this time point. Paediatric presentations of codeine intoxication often include central nervous system depression, respiratory depression, pruritus and flushing. Confusion is a relatively unusual complaint. Patients with respiratory depression present with noisy breathing, slow breathing, sighing or even s of cyanosis.

On physical examination, findings of meiosis, hyporeflexia, hypothermia and bradycardia may be reported, however, in this case, they were absent. Codeine phosphate is an OTC cough suppressant. This is in spite of a lack of evidence for efficacy.

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Additionally, codeine is associated with a complex side effect profile, which includes dizziness, nausea, vomiting, abdominal pain and constipation. However, the availability of codeine phosphate OTC, and the rare polymorphism associated with ultra-rapid metabolisers, means that risks remain. The risks of respiratory depression associated with the use of codeine in the paediatric setting are becoming increasingly clear. A recent review highlighted seven fatalities among 27 cases of codeine intoxication.

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ificantly, the report highlighted children predisposed to risk—children with renal failure, children undergoing adenotonsillectomy and those with a CYP2D6 gene polymorphism. Physical complications of prolonged usage of codeine include perforated peptic ulcers, hepatotoxicity and gastrointestinal bleeding. While these complications are relatively unusual, common psychiatric sequelae include impulsivity, depression, compulsive behaviour and anxiety. Although there was no suggestion of addiction in this case, a local newspaper recently reported problems of dependence among adolescents—a common theme in the Irish media in recent years.

The likelihood of misuse was shown to be ificantly increased in those from lower socioeconomic classes, females, those who reported poor health and those with a history of a depressive episode. This study also showed higher abuse among the more vulnerable members of our society, including minority ethnic groups; lesbian, gay, bisexual and transgender individuals; and those from urban areas.

In the context of these prevalence data, the physical and psychiatric sequelae of long-term usage may contribute to ificant morbidity. Additionally, codeine has been associated with volumetric changes in dopaminergic white matter, which is of particular concern in the developing brain of adolescents.

This evidence of dependence compounds the many problems associated with codeine cough suppressant. It lacks efficacy, may cause acute toxicity and can lead to dependence in both, the How much codeine cough syrup and adult populations. Parents, pharmacists and medical personnel need to remain vigilant to the potential adverse effects of codeine in this vulnerable patient group. Careful exclusion of organic causes is required even in the presence of unusual symptomatology.

There How much codeine cough syrup little evidence for the use of oral codeine phosphate for the treatment of cough. Codeine dependence predisposes and is associated with physical and psychiatric illness, highlighting the ificant reductions in morbidity and mortality that are achievable with addressing issues of dependence. Codeine dependence compounds the many other problems associated with the use of oral codeine phosphate. The authors would like to extend their sincere appreciation to the patient and her family for their consent.

Contributors: DOR interviewed the patient for the purpose of the case report, and drafted the report. MT provided his clinical experience of the case. Additionally, he provided guidance on the structure of the report and advice on the most pertinent information. EM reviewed various drafts in the production of the final report. Competing interests: None declared.

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Patient consent: Obtained. Provenance and peer review: Not commissioned; externally peer reviewed. National Center for Biotechnology InformationU. BMJ Case Rep. Published online Dec 7. Author information Article notes Copyright and information Disclaimer. Correspondence to David O Reilly, ei. Accepted Nov 9. This article has been cited by other articles in PMC. Background This case provides an invaluable example of the importance in maintaining an open mind in the assessment of patients with acute confusion. Case presentation A ly well year-old girl presented to the Emergency Department of a General Regional Hospital in Ireland, with a 5-day history of fluctuating confusion and anterograde amnesia.

Investigations Baseline laboratory investigations included full blood count, C reactive protein, liver function tests, renal profile and electrolytes—all reported normal. Differential diagnosis The causes of acute confusion in the adolescent setting are wide-ranging including infective, metabolic, psychiatric, vascular and malignant, and, as in this case, toxin-induced.

Outcome and follow-up Five days following admission, the symptoms How much codeine cough syrup urine codeine was negative at this time point.

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Discussion Paediatric presentations of codeine intoxication often include central nervous system depression, respiratory depression, pruritus and flushing. Learning points. Acknowledgments The authors would like to extend their sincere appreciation to the patient and her family for their consent.

Footnotes Contributors: DOR interviewed the patient for the purpose of the case report, and drafted the report. References 1. Opioid-induced respiratory depression in paediatrics: a review of case reports. Br J Anaesth ; — Smith S, Schroeder K. Over-the-counter medications for acute cough in children and adults in community settings. Health Products Information Leaflet. Patient Information Leaflet—Codinex.

Dublin, Pharmacovigilance Assessment Committee. London: The European Medicines Agency, The survey on the state of mental health of cases of cough mixture addicts.

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Chin J Soc Med ; 28 —2. Use of codeine-containing medicines by Irish psychiatric inpatients before and after regulatory limitations on their supply. Ir J Psychol Med ; 30 :7— Ford J. Misuse of over-the-counter cough or cold medications among adolescents: prevalence and correlates in a national sample. J Adolesc Health ; 44 —7. Purple drank prevalence and characteristics of misusers of codeine cough syrup mixtures. Addict Behav ; 38 —9.

Monitoring the future national survey on drug use, —, vol. Bethesda: National Institute of Drug Abuse, Decreased striatal dopamine transporters in codeine-containing cough How much codeine cough syrup abusers. Drug Alcohol Depend ; — Manaboriboon B, Chomchai C. Dextrometorphan abuse in Thai adolescents: a report of two cases and review of literature. J Med Assoc Thai ; 88 —5. Five deaths resulting from abuse of dextromethorphan sold over the internet.

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"Purple Drank" (Codeine and Promethazine Cough Syrup): A Systematic Review of a Social Phenomenon with Medical Implications