What is the recommended dosage and usage of cough medicine containing codeine (opioid) for adults and children over 12 years?

Codeine-Containing Cough Medicine Dosage and Usage Guidelines

Codeine-containing cough medicines should not be used in children under 12 years of age due to safety concerns, and adults should use no more than 30-60 mg every 4 hours, not exceeding 6 doses in 24 hours.

FDA-Approved Dosage for Adults and Children Over 12

For adults and children 12 years and older, the FDA-approved dosage for codeine-containing cough medicine is 1:

• 10 mL (2 teaspoons) every 4 hours
• Do not exceed 6 doses (60 mL) in 24 hours
• This typically provides 30-60 mg of codeine per dose

Safety Concerns and Contraindications

Children Under 12 Years

• Codeine is contraindicated in children under 12 years of age for cough treatment 2
• The FDA issued a boxed warning (their strongest warning) against codeine use in children under 12 years following reports of deaths and serious adverse events 2
• The contraindication was added in April 2017, explicitly warning that "codeine should not be used to treat pain or cough in children younger than 12 years" 2

Adolescents (12-18 years)

• Caution is advised for adolescents between 12-18 years who:
  • Are obese
  • Have obstructive sleep apnea (OSA)
  • Have other respiratory conditions 2

Genetic Considerations

• Some individuals are ultra-rapid metabolizers of codeine (due to CYP2D6 genetic polymorphisms)
• This can result in rapid conversion of codeine to morphine, causing potentially fatal respiratory depression 2
• Screening for these genetic variants is unreliable as normal metabolizers can be induced to become ultra-rapid metabolizers 2

Efficacy Considerations

The efficacy of codeine for cough suppression is limited:

• Provides less than 20% suppression of cough due to upper respiratory infections 3
• Studies comparing codeine to placebo for cough associated with common cold found no significant difference between treatments 4
• Dextromethorphan may be equally effective for cough frequency reduction and potentially better at reducing cough intensity compared to codeine 5

Appropriate Use Guidelines

Codeine cough suppressants should be used only for:

• Dry, non-productive cough that is bothersome and disruptive 3
• Short-term use (3-7 days) due to potential for physical dependence 3
• Situations where the cough is interfering with rest or recovery 3

When to Avoid Codeine

Avoid codeine-containing cough medicines when:

• Patient is coughing up significant amounts of sputum 3
• Clearance of secretions is needed for recovery 3
• Cough is serving a physiological purpose to clear mucus 3
• In pregnancy, especially third trimester 3
• In elderly patients (use lower doses if necessary) 3

Alternative Options

For those who cannot or should not use codeine, consider:

• Dextromethorphan: 10-15 mg three to four times daily 3
• Benzonatate: 100-200 mg four times daily 3
• Simple home remedies like honey and lemon for acute viral cough 3
• Ipratropium bromide inhaler for cough due to URI or bronchitis 3

Monitoring and Follow-up

• Assess response after 2-4 days and discontinue if no improvement is seen 3
• Monitor for adequate expectoration despite cough suppression 3
• Watch for signs of respiratory depression, especially in those with risk factors

Key Pitfalls to Avoid

1. Never use codeine-containing cough medicines in children under 12 years
2. Do not prescribe for prolonged periods (>7 days)
3. Avoid using when productive cough is beneficial for clearing secretions
4. Be cautious in patients with respiratory conditions or those taking other sedating medications
5. Do not exceed recommended dosages, as this increases risk without improving efficacy