The term "100-Day Cough" has its origins about five centuries ago in either China or Japan, depending on whom you believe. Although there is no universal definition, it is generally accepted that the malady in question is actually pertussis, aka, whooping cough. This is something you really don't want to get. People who catch this highly contagious bacterial infection suffer coughing fits that are severe enough to cause (among other symptoms) vomiting, cracked ribs, and seizures. Fortunately, several vaccines are effective against the infection.
What the hell is going around?
Do you know anyone at the moment who isn't coughing? There is a nasty bronchitis all over the place. Although in England, there has been a 230% rise in genuine whooping cough infections compared to 2022, the term "100-day cough" is being informally used in the press to refer to the nasty bronchitis cases in the US, some of which can last a very long time:
“We have been seeing an unusually large number of patients who had typical viral upper respiratory infections, but have had a lingering cough that has lasted weeks to months,”
Dr. Scott Braunstein, national medical director of Sollis Health, interviewed in the HuffPost.
He ain't kidding. I had it. And my wife waited until vacation week – a splendid time to get sick by any measure – to follow suit. My cough was merely annoying and is now gone. Hers, which has been going on non-stop for 10 days and counting, sounds more like a dyspeptic Rottweiler dry-heaving into a karaoke mic. It was keeping both of us awake.
Off to the urgent care center, where we ran into the same situation that I had previously experienced in 2016 while in an identical similar situation It was anti-opioid madness, of course. Despite some sporadic progress in dethroning the government-backed anti-opioid fascism, don't kid yourself. When it comes to controlled substances, the DEA still runs the show, not the physician.
Image: Picryl
Let's take a trip to the urgent care center!
The nurse practitioner (NP), who looked about 12 years old, did everything right (1): Scripts for azithromycin and prednisone. But when I heard the name "benzonatate" – a supposedly effective cough suppressant – I knew what was coming next. Let's review.
But first...
Benzonatate sucks
I know this from personal experience but don't take my word for it. On the website Drugs.com, it receives a putrid rating of 3.9/10 based on 758 patient reviews. How bad is this score? For some perspective, take a look at "4 Prescription Drugs People Hate," By comparison, Flagyl – a nasty antibiotic, Tamiflu – a marginally effective flu antiviral but superb vomit inducer, and Lyrica (pregabalin), an epilepsy drug now used off-label for pain except it doesn't work most of the time, get considerably higher ratings.
If you read "4 Prescription Drugs," you'll see some horrible and often hilarious quotes about the three drugs above. Given the ratings on both Drugs.com and AskAPatient.com, it is hard to imagine what it would take to get a lower score than any in this trio, let alone one much lower, yet benzonatate pulled it off and not by a little. Of the four in the article, only Fosamax– a stomach-mangling osteoporosis drug with a list of side effects longer than your thigh bone somehow manages to "top" benzonatate with a gruesome rating of 2.6/10. The lesson here is that no matter how bad something is, someone or something else is worse – something Yankees fans have learned in recent years watching the hitters seemingly perplexed about which end of the bat to hold.
Back to the urgent care center
The salient part of my conversation with the NP went something like this:
JB: I don't suppose there's any point in asking about codeine-promethazine cough syrup, right?
NP: No, we don't prescribe that here.
JB: She's been up coughing for three straight nights. The only thing that helped was a sub-therapeutic dose of oxycodone. The syrup would be a lot better.
NP: Was the oxycodone yours?
JB: Yes (but possibly no – see below)
NP: You know that's illegal, right?
JB: Yes, I do, and my wife suffering for no good reason is immoral.
NP: Thanks for telling me.
HUH? Thanks for telling me?? What does that even mean? Is she gonna rat me out?
It's been nice while it lasted. A little harsh for 2.5 mg of oxycodone, no?
Disclaimer time
My memory sucks. Not only that, my memory sucks. So it's quite possible that the real dialogue at urgent care was actually this:
JB: She's been up coughing for three straight nights. The only thing other thing that might help would be a sub-therapeutic dose of oxycodone, but I prefer the codeine syrup.
NP: Is the oxycodone yours?
JB: What oxycodone?
NP: You know that would be illegal, right?
JB: Of course, I'd never do anything like that. No, ma'am. I dispose of my unused opioids just like any other idiot law-abiding citizen would by dropping them off at Walgreens because the morons at the DEA told me to do so.
Back to medicine
Let's get this out of the way.
Opioids are the only clearly effective centrally-acting anti-tussive drugs and are thought to work by suppressing the brainstem cough center through mu and kappa opioid receptor agonism. They are the first-line symptomatic treatment for severe, distressing cough.
While benzonatate is rated 3.9/10 (758 reviews), codeine-promethazine does a bit better: 7.1 (60 reviews). Gee, that sounds like it's twice as good as benzonatate, right? Selected quotes (2) about the latter back this up. And, for some perspective, I chose the following commonly-used drugs off the top of my head and looked up the ratings: Pepcid (6.0), Ambien, (7.0), Zoloft (7.3), Naproxen (6.9), and Benadryl (7.2). Codeine-promethazine clearly falls within the patient approval range of commonly used drugs, while benzonatate does not (3).
Finally, here are some telling quotes that describe how sick people are forced to use what is, at best, a second-rate drug rather than something that actually works. Pay special attention to the last one.
"Tessalon Perles (brand name for benzonatate) are useless for cough might you as well swallow a tic tac it would have the same effect for a cough."
"What bothers me most is the hesitancy by most doctors to give me something that works when I tell them benzonatate does not touch my deep cough. Everyone is treated like a drug addict when you ask for something a little stronger even when you don't have a problem."
"I can't imagine a doctor actually prescribing this for an adult, this is a child-level drug. I actually had an Urgent Care refuse to prescribe something stronger after 3 days of coughing and congestion on this medication. Now, in 10-degree weather, I have to go to my car after sitting in the urgent care for an hour and getting bad medical advice from 20-year-old unlicensed medical staff."
"This medication is absolutely useless!! It doesn’t help with coughing whatsoever. The only medicine that has ever helped for extreme coughing (a cough that literally keeps you awake the entire night) is codeine cough syrup. Of course, doctors no longer prescribe that cough syrup because they fear you’ll get addicted to a three-day supply of medication! Now I get to spend the next 12 hours sitting in an emergency room with my daughter because she has chest pain from continually coughing."
How many people have found themselves in a similar situation where a bottle of syrup for a cough or a few days' worth of oxycodone after a tooth extraction could make all the difference in the world? It's a damn good thing that I may have had some oxycodone on hand to give to my very ill wife to allow her to get some sleep.
So, let me post the same question I often ask when I write about controlled substances, especially any opiate: Who is in charge of medicine, and how did we let this happen?
NOTES:
(1) She did everything right that she was allowed to do.
(2) To be fair, in the hundreds of patient reviews of benzonatate, it is not difficult to find people who liked the drug and found it quite effective. A number even rated it 10/10. Still, it's hard to argue that this drug is generally helpful. Its average rating is appallingly low. I have chosen not to include the positive reviews because I didn't feel like it.
(3) I looked up another ten absolutely random drugs, some of which I've never even heard of, and nine were in the 6-7 range and one 5.9. I did not find anything that had a patient rating that was even remotely close to that of benzonatate, although if you spend the time, you'll almost certainly come across some.
Josh Bloom
Director of Chemical and Pharmaceutical Science
Dr. Josh Bloom, the Director of Chemical and Pharmaceutical Science, comes from the world of drug discovery, where he did research for more than 20 years. He holds a Ph.D. in chemistry.
