What cough syrup with codeine (opioid) is commonly prescribed?

Codeine-Containing Cough Syrups: Not Recommended as First-Line Treatment

Codeine-containing cough syrups should be avoided for routine cough management due to significant adverse effects without proven superiority over safer alternatives like dextromethorphan. 1, 2

Commonly Available Codeine Formulations

The most common prescription codeine cough syrup contains:

• Codeine phosphate 10 mg per 5 mL (teaspoonful) combined with guaifenesin 100 mg as an expectorant 3
• Typical dosing when prescribed is 30-60 mg four times daily for adults 2

Why Codeine Is Not Recommended

Lack of Efficacy Advantage

• Codeine has no greater efficacy than dextromethorphan for cough suppression but carries a substantially worse side effect profile 2, 4
• Research demonstrates codeine is no more effective than placebo or vehicle syrup for acute upper respiratory tract infection cough 5
• Clinical trials show codeine, dextromethorphan, and guaifenesin are equally effective in relieving cough symptoms 6

Significant Safety Concerns

• The FDA altered labeling in 2018 to limit prescription opioid cough medicines to adults ≥18 years only 1
• Adverse effects include drowsiness, nausea, constipation, physical dependence, and potential for respiratory distress 1, 2
• Deaths from toxicity have been reported in young children with OTC cough medications 1
• For children with acute cough, codeine-containing medications should be avoided because of potential for serious side effects including respiratory distress 1

Preferred Alternatives to Codeine

First-Line Non-Opioid Options

• Dextromethorphan 60 mg provides maximum cough reflex suppression with a superior safety profile compared to codeine 2, 7
• Most over-the-counter dextromethorphan preparations contain subtherapeutic doses (typically 10-15 mg); effective dosing requires 30-60 mg 2, 7
• Honey and lemon is the simplest, cheapest initial approach for acute viral cough 2, 7
• Menthol inhalation suppresses cough acutely when inhaled, providing short-term relief 2, 7
• Sedating antihistamines like chlorpheniramine suppress cough but cause drowsiness, making them suitable specifically for nocturnal cough 2, 7

Alternative Opioid Options (If Opioid Required)

• If an opioid antitussive is absolutely necessary, pholcodine, hydrocodone, or dihydrocodeine are preferred over codeine due to better side effect profiles 2, 8
• Hydrocodone liquid formulations typically start at 5 mg twice daily with dose titration as needed 8
• Morphine should be reserved only for cases where cough is not suppressed by other opioid derivatives 2

Clinical Algorithm for Cough Management

Step 1: Initial Approach

• Start with honey and lemon for benign viral cough 2, 7
• Consider voluntary cough suppression techniques 7

Step 2: Pharmacological Treatment

• Use dextromethorphan 30-60 mg (not subtherapeutic OTC doses) for additional relief 2, 7
• Add menthol inhalation for acute, short-term symptom relief if needed 2, 7

Step 3: Nocturnal Cough

• Use first-generation sedating antihistamines specifically for nighttime cough disrupting sleep 2, 7

Step 4: Refractory Cases Only

• Reserve opioids (preferably pholcodine, hydrocodone, or dihydrocodeine—NOT codeine) only when non-opioid options fail 2, 8
• Consider peripherally acting antitussives like levodropropizine for opioid-resistant cough 2

Important Clinical Caveats

Common Prescribing Pitfalls

• Avoid prescribing codeine as first-line therapy due to poor benefit-to-risk ratio 1, 2
• Do not use standard OTC dextromethorphan doses expecting therapeutic effect; ensure 30-60 mg dosing 2, 7
• Check combination dextromethorphan products carefully to avoid excessive acetaminophen or other ingredients when using higher doses 7
• Never use codeine or any antitussive for productive cough where secretion clearance is physiologically beneficial 2

Special Populations

• Codeine is absolutely contraindicated in children under 18 years for cough 1
• In palliative care or lung cancer patients with refractory cough, codeine 30-60 mg four times daily may be considered when other options have failed 2
• For postinfectious cough, try inhaled ipratropium before any central antitussive 7