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Join us for an insightful podcast discussion with L. Joseph Parker, a research physician. In this episode, we delve into the fascinating world of promethazine with codeine cough syrup, its medical applications, diversion risks, and the legal complexities surrounding its prescription. Explore the history, metabolism, and cultural influences of this medication, and discover why it’s been a topic of interest in health care and the legal system.

L. Joseph Parker is a research physician.

He discusses the KevinMD article, “Codeine cough syrup: a controversial classification.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome back Joseph Parker. He’s a research physician. Today’s KevinMD article is titled “Codeine cough syrup: a controversial classification.” Joseph, welcome back to the show.

L. Joseph Parker: Thank you, sir.

Kevin Pho: Well, Joseph has been on multiple times. Just go to KevinMD.com/podcast, to the search icon in the upper right-hand corner, search for his past episodes, and hear his story. But today, let’s jump right into today’s article about codeine cough syrup. So how did this article come together?

L. Joseph Parker: I had been unaware that codeine cough syrup had become popular in a few segments of the population. I’d been using it for 30 years. It’s a very effective cough syrup. Codeine gets converted into morphine at a slow rate in the liver, and this allowed you to prescribe the codeine cough syrup and the patient would get a tiny dose of morphine, and morphine’s the best antitussive we have. So we had been using it for 30 years with no problem at all, and then all of a sudden you see physicians being prosecuted for prescribing it. When they’re prosecuted, the DEA claims in court that it has a high addiction potential and a high diversion potential. I have a big problem with that, because it’s classified as Schedule V when it’s codeine with promethazine cough syrup, which is what they’re upset about.

Kevin Pho: So tell me about some of these individuals that you’ve heard have been prosecuted for prescribing.

L. Joseph Parker: I’m one of them. I’m one of them. I was charged for prescribing. Over a two-year period, I had treated 29 people in total with this cough syrup. As a primary care physician, you see people with chronic cough, and it was my job in our primary care group practice to handle controlled medications, so that was part of my responsibility. I treated 29 people, half Black and half white, almost split perfectly 50-50, because that’s how our demographics are. I was charged for prescribing to four Black men, and nothing was said about any of the white patients, the same age group, everything the same.

When the pain committee in my state had reviewed this prescribing (and why the pain committee is reviewing cough treatment is interesting), they had underlined the word “Black”: “prescribed to Black men.” It became obvious to me that there is implicit or even explicit bias taking place here, where, depending on someone’s race, you can’t treat them with a certain medication without being perceived as a bad doctor, as enabling diversion or enabling addiction.

This is true in pain treatment in general. We’ve seen a case where an African American woman died in a hospital because after a C-section she was saying, “I’m in pain,” and they were saying, “She just wants pain medicine.” She ended up having a complication that ended her life. You are supposed to assume, based on the color of someone’s skin, how much pain they’re in. You see it with Native American treatment, too. They’ll say, “Well, Native Americans are stoic. They’re tough. They don’t need pain treatment.” All of humanity left on this planet, we don’t have any Neanderthals or Denisovans running around; we’re all the same in a lot of regards. We all have implicit biases. We all feel pain the same as a species, though each individual can feel it extremely differently. Being Native American, you might culturally not show your pain in public as much, but you feel it just the same. There’s no difference.

So there has become a kind of purge, or a crusade, to stop the prescribing of codeine with promethazine cough syrup. The problem I have with the way they’re going about it is, first, I think it’s racist. But even besides that, it’s still Schedule V. Now, Schedule V is defined, confusingly, as being below Schedule IV in risk of addiction and diversion. Well, then you have to read Schedule IV. Schedule IV says a low risk of diversion, a low risk of addiction. So one part of the federal government labels it as being a low risk of diversion and addiction, lower than low, actually, because Schedule IV is low and Schedule V is lower than that. And then you’ve got another branch of the federal government taking doctors into court and telling the jury that this medication has a high risk of diversion and a high risk of addiction.

So we go back to the problems with medical or scientific testimony to a lay jury. You can tell a jury that isn’t scientifically experienced almost anything, and they don’t know whether that’s true or false. They depend upon these government witnesses and experts to tell the truth. If we are prescribing it, and we’re looking it up in our manuals and our PDRs, and it says low risk, and we prescribe it as if it were low risk, we should not then be able to be prosecuted by a different branch of the federal government that says it’s high risk. It’s getting to be such a minefield in medical practice that almost any difference of opinion is seen as a criminal act by either local or federal law enforcement.

Kevin Pho: Give us a sense of how much codeine cough syrup you prescribed to get their attention.

L. Joseph Parker: OK, so here’s what they do. In my practice, I was sort of the complicated-patient person. All four of these young men had been treated by nurse practitioners. They had been to specialists, and none of the specialists said, “They don’t have anything wrong; stop their treatment.” So they came to me afterward with diagnoses of maybe chronic sinusitis, cough-variant asthma, things like that, and they’d each been on the medication for around six months. Past 90 days, they’re chronic.

The standard treatment is five cc’s every four to six hours. Well, if it’s every four hours, that’s six times a day. Six times five is 30 cc’s a day. If you’re treating them monthly, 30 times 30 is 900, so that’s 900 cc’s a month. Now, I prescribed less than that. I would usually do it in 600 cc’s; I think that was the most I prescribed.

The problem is, when you get into court, they will have an expert get up there and say, “This is usually prescribed in three- to five-day periods.” So five days of 30 cc’s is 150 cc’s. First off, the jury has no idea what 150 cc’s is, and if you want to hold up a little bottle and show them, you’re not allowed to do stuff like that. So the jury doesn’t know what the cc’s are, and the expert will get up and say, “It is usually prescribed in 150 cc’s. Less than 5 percent of patients are prescribed more than that.” Well, that’s all true, because chronic cough isn’t super common. We treat acute cough all the time in the ER. I would do the same thing in the ER: three to five days, then go see your family doctor. These patients have a chronic condition. So they are purposely confusing the definition of average with common or usual, so that you’re outside the usual practice of medicine, right? Everybody who sees the most serious patients is going to be on the extremes of treatment.

The nurse practitioners send these patients to an MD because they’ve said, “Hey, I’ve tried for six months. I can’t figure it out.” I would also give them six months. On every one of these patients, I had sent them to specialists, done chest X-rays, and looked for tuberculosis. One had spent some time incarcerated, so I looked for AIDS, stuff like that. And if I couldn’t solve it, I would tell them at the end of six months, “I’m referring you to a specialist,” either a pulmonologist, an allergist, an ENT doctor, whatever I thought was appropriate for what I thought their problem was. And I had said I would no longer prescribe this medication unless the specialist agreed that it was necessary. That was not enough. It was a criminal act to treat them for that period of time.

They didn’t go back and prosecute the people who treated them before me, but they prosecuted me because I treated them. The nurse practitioners before me were treating them five to seven days at a time, which meant the person had to go back four times a month, right? I don’t think that’s reasonable. To a degree, of course, they could hammer you for fraud on that, too. They would say, “Why are you treating a chronic problem that way?” If you had a patient with chronic pain and you had them come back every week, they’re going to accuse you of fraud, that you’re making them come back for too many visits. So I would treat 30 days at a time, sometimes three weeks at a time.

And the only thing that would work would be the codeine-based cough syrup. It’s really the only thing we’ve got. Dextromethorphan and codeine are kind of similar molecules; dextromethorphan is the right-handed enantiomer. Dextromethorphan doesn’t work as well, and it also can be abused. Large doses of dextromethorphan can be used as a hallucinogen, and that became popular for a while. So when you’re treating a medical problem chronically, you will prescribe a longer course, so the totals will be high.

But what has really irritated me is that, both in the medical boards and the review committees and everywhere, it is just assumed that if you’re prescribing something to a Black person, they don’t need it. They didn’t prove diversion. They didn’t even claim diversion. They say there is a risk of diversion; therefore you cannot prescribe it, and it is criminal to prescribe it. Just like they say there’s a risk of addiction in opiate treatment, therefore you can’t prescribe. But there’s a risk of addiction and diversion with everything you prescribe. There’s a risk of death with everything you prescribe.

So what they do is add up everything you prescribed to every patient over a two-year period, and they say in the newspapers and to the jury, “The doctor prescribed a gallon of cough syrup to this man.” Well, we don’t do that with any other medicine. We don’t take your blood pressure medicine and say, “This doctor prescribed 2,000 pills over a two-year period.” It’s numbers without context, and it seems like a lot. But put it in context: When they say 2,000, well, there was a science communicator who was talking about being on a jury, and they kept saying that the defendant had 2,000 milligrams of crack cocaine. Well, 2,000 milligrams is two grams. That’s less than the weight of a penny. But by saying 2,000 milligrams, it sounded like a big number to the jury, when we don’t deal with metric enough for it to give us a common sense of scale.

I started in the medical field 30 years ago, and implicit bias, and now explicit bias, because it’s politically popular to be explicit about your biases now, has not gotten better. In a lot of ways, it’s gotten worse. Now, I grew up in a former slave state, and when I say “former slave state,” actually all American states are still slave states, because the 13th Amendment said you can have slaves as long as they were convicted of a crime. A lot of people think that slavery is banned in America. It’s not. The 13th Amendment made an exception for convictions, and if you go down to Angola in Louisiana, it’s an old plantation being worked by Black people who are slaves today. They’re just slaves who were convicted of a crime.

I don’t want to have to practice medicine worrying about the color of my patient’s skin, except if it’s related to a condition they might have, like sickle cell or something. But you have to be cognizant of the fact that some of your colleagues will have implicit biases, and they will see you as a bad doctor for treating patients with darker-colored skin with pain medication or even cough medicine. Your colleagues will have that, your local law enforcement will have it, and federal law enforcement is clearly enforcing this. There should be some way to preclude them from doing it, but there’s really no one you can go to when you get targeted like this.

So I want to make sure that my colleagues out there practicing and treating cough understand this. Dextromethorphan is over the counter, and there are only two prescription cough medicines that are very effective. Tessalon Perles work a little bit. There’s Hycodan, which is hydrocodone cough syrup, but no one uses that; it really was never very effective. Hydrocodone gets converted into hydromorphone in the body, and hydromorphone is not a good antitussive. Codeine is the best prescription cough syrup, but you should use extreme caution prescribing it, or just not prescribe it. Send them to a pulmonologist, send them to an ENT doctor, and let them prescribe.

Kevin Pho: So what was the outcome of this case? When you presented these arguments, what was the response, and what was the eventual outcome of this particular case?

L. Joseph Parker: Well, I was convicted. It’s a misdemeanor to prescribe cough syrup to a patient, but I was convicted. If they can get an expert to sit up there and say, “This is the usual practice of medicine, and what he did was not usual,” then by definition the jury is going to sit there and look at that, and, not being medically savvy, they’re not going to understand the difference between acute and chronic and subacute and all this. A lot of it is emotional. They will throw out large numbers, and that will sound like a lot.

When you do the math, the average amount per month for all the patients I treated for cough over that two-year period was much lower than the maximum that could have been prescribed. If someone’s trying to make money off prescribing cough syrup, first, they’re not going to treat just 29 people in two years. They’re going to give everybody a maximum dose, and they’re going to charge more for the patients being treated with the cough syrup than they do for someone being treated for blood pressure. But that wasn’t the case. The charges were the same whatever you were being treated for, whether you came in with blood pressure or diabetes. But that slips right past the jury.

You don’t have enough time to educate them about these factors: about how you use three to five days of medication for someone with an acute problem in the ER, and then maybe a week to 10 days when you first start seeing them in a primary care clinic, but when they have a chronic problem, you treat them a month at a time. That’s standard of care, but not that many people have that problem. So you will never treat an average patient, and neither will I. There are no average patients; there are just averages within a group. Every patient you see is unique in different ways.

And some people can’t metabolize codeine, so they will actually use it up faster than they’re supposed to, because it’s not effective. In about 18 percent of the population, the cytochrome P450 2D6 enzyme does not convert the codeine into morphine, and codeine is not nearly as effective as morphine. So when they come back and say it doesn’t work, they’re not lying to you. They’re serious. It may not work.

Kevin Pho: Now, if you were to replay this case, or your prescription of codeine medicines, what would you do differently this time?

L. Joseph Parker: I think if they believe it’s a high risk of diversion and addiction, they need to move it from Schedule V to Schedule III, and that would immediately make all the doctors stop and notice and ask why, like they did with hydrocodone, right? They moved it from Schedule III to Schedule II, and all the doctors stopped and took a look and said, “OK, I guess it’s not safer than these other Schedule IIs.” So they need to change the scheduling.

But me personally, what I would do is not prescribe codeine cough syrup to any patient for any reason. I would either prescribe them Tessalon or recommend they use over-the-counter things, and send them to a specialist. The specialist will be an expert in that area. You, as a primary care doctor, will not be considered an expert in any area. So anyone they get to come speak against you will be accepted by the court, in front of the jury, as an expert, and the jury will be told that you’re not an expert. The jury will be wondering, “Why is a non-expert treating these people?”

Well, primary care physicians should be willing to continue the treatment started by other medical professionals as they make their evaluations and help guide the patient, hopefully, to some form of resolution of their problem, right? Sometimes you find out that they’re smoking. You have to do some checking, and you find out they’re smoking these cigar-like cigarettes, because they don’t think that’s really smoking since they do it once a week. That’s enough to irritate the throat. And sometimes the cough itself becomes irritating enough to continue the coughing. They get a respiratory infection, they start coughing, the coughing inflames their throat, and the inflammation makes them keep coughing. So you have to use something effective to get rid of the cough, to see if they’re just reflexively coughing from the inflammation caused by the coughing. You have to use something, or you’re not analyzing anything. It could be gastroesophageal reflux at night making them cough.

You don’t know when it’s starting out. It seems simple to someone reviewing it once you know the solution. It’s just like someone who comes into the ER with chest pain and ends up having an MI. Of course it seems clear to everybody reading about it later: “Well, he came in with chest pain; of course he had an MI.” It didn’t have to be. It could have been a dissecting aortic aneurysm. It could have been gastroesophageal reflux. It could have been esophageal spasm. It could have been a spontaneous pneumothorax. It could have been all these different things that you as a doctor have to evaluate and weigh. But when they Monday-morning quarterback it, they can go back and say, “Well, you should have immediately given him a blood thinner and done this.” Well, if he was having a dissecting aortic aneurysm and I gave him a blood thinner, I just killed him, right?

The medical boards are staffed by physicians. They may not be in your specialty, but they can understand the complications of the care. When you’re facing law enforcement, they do not understand anything about that, and to them it’s a simple cookbook thing. And the implicit bias puts you in danger with this cough medication.

Kevin Pho: We’re talking to L. Joseph Parker. He’s a research physician. Today’s KevinMD article is titled “Codeine cough syrup: a controversial classification.” Joseph, let’s end with some take-home messages that you want to leave with the KevinMD audience.

L. Joseph Parker: Get specialty consultations for any medication that they see as being high risk. So any opiate medication, including this cough syrup, because it is an opiate. So get specialty consultation, get backup, and make sure that you have verification and a second opinion on what you’re doing.

Kevin Pho: Joseph, once again, thank you so much for sharing your story, time, and insight, and thanks again for coming back on the show.

L. Joseph Parker: Thank you very much. I appreciate it.