Parents, please note! These commonly used cough suppressants are not suitable for use by adolescents and children under 18 years old

Traditional Chinese medicine plays an important role in the treatment of clinical diseases, and has been proven to be effective in preventing and treating the COVID-19 pandemic in the past three years. Cough is a clinical symptom of respiratory diseases, and there are many Chinese patent medicines for treating cough. Most Chinese patent medicines can be given to children at reduced doses, but some cough suppressants containing poppy and millet husks should be avoided by children. The idea that "Chinese medicine has little toxicity and side effects" has been deeply rooted in people's minds, and it is precisely this idea that sometimes causes parents to accidentally stray into "minefields" when using medicine.

Poppy husk is the dried mature fruit of the poppy plant of the poppy family. It tastes sour and astringent, is neutral in nature, and is poisonous. It is specially used to treat chronic cough, chronic diarrhea, rectal prolapse, and abdominal pain. Some Chinese patent medicine prescriptions currently on the market contain poppy husk. If used improperly, it is easy to become addicted and cause serious adverse reactions such as central inhibition, which not only affects the treatment of diseases, but also causes serious social problems. Poppy husk contains morphine and codeine. In addition to its strong analgesic effect, morphine can also reduce the motility of gastric and duodenal smooth muscles, reduce the propulsion and peristalsis of the colon, and has an antidiarrheal effect; codeine is a central antitussive drug that can directly inhibit the cough center of the medulla oblongata, and its antitussive effect is rapid and powerful. The Chinese Pharmacopoeia stipulates that the content of morphine in poppy husk slices should be 0.06% to 0.4%, and the daily usage and dosage should be 3 to 6g.

If 6g of poppy and millet husk is used daily in clinical treatment, after conversion to morphine, the daily dose of morphine intake is 3.6 to 24mg, with a median of 15.6mg. In addition, there are literature reports that the morphine content in poppy and millet husk in some areas is about 0.6%. If 6g of poppy and millet husk is used daily, the daily dose of morphine intake is 36mg. For the treatment of acute severe pain, the oral daily dose of Western medicine morphine is 15 to 60mg. The "Chinese Pharmacopoeia" has not yet made detection and limit requirements for the content of codeine in poppy and millet husk. There are literature reports that the content of codeine in poppy and millet husk medicinal materials of different grades is 0.14% to 0.47%. If 6g of poppy and millet husk is used daily, the daily dose of codeine intake is 8.4 to 28.2mg, with a median of 18.3mg. The daily dose of Western medicine codeine for cough and moderate or above pain is 30 to 90mg.

Through data conversion, we can see that if 6g of poppy husk is used daily, the amount of morphine ingested has reached the therapeutic dose for acute severe pain, and the amount of codeine ingested has reached half the therapeutic dose. Continuous use of morphine or codeine for one week may cause addiction hazards.

However, the instructions for Chinese patent medicines containing poppy and millet husks are often used in clinical practice, and the regulations in the instructions and the Chinese Pharmacopoeia are quite confusing. The instructions for some Chinese patent medicines do not make relevant instructions for the use of the medicines in children, pregnant women, and lactating women, and the Chinese Pharmacopoeia does not make any testing and limit requirements for the content of morphine and codeine. For example, the main ingredients of Yangshen Baofei Pills and Zhisou Huatan Pills are poppy and millet husks, but the Chinese Pharmacopoeia does not make any testing and limit requirements for the content of codeine and morphine in poppy and millet husks. Although the Chinese Pharmacopoeia does not make any requirements for the content of morphine and codeine in Yangshen Baofei Pills, we can still roughly estimate the daily intake of morphine and codeine through its preparation process.

Yangshen Baofei Pills

【prescription】

Poppy & millet husk 120g Schisandra chinensis (fried with vinegar) 30g

Fritillaria 60g Tangerine peel 60g

Amomum villosum 30g Citrus aurantium 60g

Ephedra 30g Bitter almond 60g

Gypsum 30g Licorice 60g

Scrophularia 60g American ginseng 45g

【Preparation method】

Of the above twelve ingredients, American ginseng is crushed into fine powder; the remaining eleven ingredients such as poppy and millet shell are crushed into fine powder, sieved, mixed, and ground with American ginseng powder, sieved, and mixed. For every 100g of powder, add 120-130g of refined honey to make large honey pills.

The total weight of the twelve herbs and refined honey in the prescription is 1451.25g. The Chinese Pharmacopoeia stipulates that each Yangshen Baofei Pill weighs 6g. The above prescription can produce about 240 pills (1451.25÷6=241.88 pills). The content of poppy and millet husk in the prescription is 120g, so each pill contains about 0.5g of poppy and millet husk (120÷240=0.5g), which is converted into 0.3-2mg/pill of morphine and 0.7-2.35mg/pill of cocaine. The median morphine content is 1.15mg/pill and the cocaine content is 1.53mg/pill. The dosage of Yangshen Baofei Pill is 2 pills at a time, 2-3 times a day, so the daily intake of morphine can reach 4.6-6.9mg, and the daily intake of cocaine can reach 6.12-9.18mg. Similarly, the daily dose of morphine taken from Zhisou Huatan Pills is about 0.92 mg, and the daily dose of codeine taken from Zhisou Huatan Pills is about 1.22 mg.

In addition, if the strong loquat juice is converted into codeine, the daily dose of codeine consumed according to the recommended usage and dosage in the instructions is 1.5 mg, but the instructions have clearly stated that it is forbidden for children, pregnant women, and breastfeeding women; if the Ermu Ansou Pills are converted into morphine, the daily dose of morphine consumed according to the recommended usage and dosage in the instructions can reach 5.32 mg, and morphine is more addictive than codeine, but the instructions still do not make relevant instructions for the use of the drug in children.

There are many news reports about the problem of addiction to Chinese patent medicines. Given that the addictive hazards of Chinese patent medicines containing poppy and millet husk are objective, and that Western medicines containing codeine are expressly prohibited for use by adolescents and children under the age of 18, it is recommended that children should not use such Chinese patent medicines. When treating coughs, other Chinese patent medicines or Western medicines that do not contain poppy and millet husks can be used instead.

There is a saying that "what is not prohibited by law is free". Some Chinese patent medicines containing poppy and millet husks do not state that they are prohibited for children in their instructions, and there are no relevant laws and regulations stipulating that children cannot use Chinese patent medicines containing poppy and millet husks. If a child is really harmed by using such Chinese patent medicines, it will be difficult for parents to protect their rights. However, the author believes that in the near future, relevant regulations will be issued to regulate the use of such Chinese patent medicines.

Currently, the Chinese patent medicines containing poppy and millet husk in the prescription composition on the market include: Xuanfei Zhisou mixture, Zhikebao tablets, Juhong Huatan tablets, Zhisou Huatan granules, Zhisou Huatan pills, Kechuanshu tablets, Yangshen Baofei pills, Guiling tablets, Yangshen Baofei oral liquid, Kechuanning oral liquid, Zhike capsules, Compound Jixiangcao lozenges, Xiefei Dingchuan tablets, Huangying Kechuan syrup, Keqing capsules, Kexuting capsules, Kexuting syrup, Zhisou Kechuanning syrup, Ermu Ansou pills, Ermu Ansou syrup, Ermu Ansou tablets, Keling capsules, Kechuan syrup, Kechuanning tablets, Lingbei cough syrup, loquat cough granules, strong loquat dew, Asthma Ning tablets, Asthma Pills (Asthma Golden Pill), Ansou Huatan Pills, Dingchuan Zhisou Pills, etc.

When using the above Chinese patent medicines, please note:

1. It is forbidden to use in children, pregnant women and breastfeeding women;

2. Athletes should use with caution to avoid positive urine test results;

3. It is not suitable for long-term use and overdose is strictly prohibited. If the symptoms do not improve after taking the medicine for 3 days, please consult a Chinese medicine doctor for syndrome differentiation and treatment;

4. Do not drink alcohol, drink alcoholic beverages or take alcoholic medicines when using Chinese patent medicines containing poppy and millet husks, otherwise it may lead to drug overdose;

5. Chinese patent medicines containing poppy and millet husk should not be used together with other drugs containing poppy and millet husk, morphine, codeine, opium poppy, etc. Compound licorice tablets/oral liquid contain opium, which should not be used together.

Author: Liu Yanping Chen Ye

Shanghai Pudong New Area People's Hospital