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Honey Boo Boo

My son has been coughing for several weeks, and the cough will probably persist for another 2 or 3 weeks. Coughs last a long time. Patients think a cough will go away in less than a week but in reality they are likely to last several weeks.

Coughs are a pain for the patient and an annoyance for the people around them. You never really know if the cougher in the row behind you has asthma,  a post infectious cough or  is actively spewing TB or influenza all over the airplane.  I learned from Clinton the importance of not inhaling, especially on airplanes.

I tend to leave most symptoms alone if the they are not life threatening or otherwise unbearable for the patient. Codeine is the only really good cough suppressant and none of the over the counter cough medications are effective.  I assume that coughing with infection, like diarrhea, is beneficial. Key to treating all infections is to physically remove it. Undrained pus doesn’t heal, and a good cough is the most efficient way I know to remove potential pathogens from the lungs.

If there are benefits to suppressing the cough associated with acute respiratory infections I can’t find any and we have all seen people who, because of inability to cough secondary to rib fractures, develop severe pneumonia.  As a resident I had an elderly male die of just such a series of unfortunate events.

I suffer from a mild form the the naturalistic fallacy. I tend to let normal physiologic processes run their course unimpeded as long as they pose no harm to the patient.  So I do not treat infectious coughs, in part because medications are not effective, in part there is no benefit  and in part because the medications that are effective, and those that are not, have side effects. 

Not only has my son been coughing, but, thanks to flu-like illness season, almost everyone around me is coughing as well and someone asked me about honey as a cough treatment, pointing to a recent article in Pediatrics.

I like honey. Of the roughly 40,000 PB&J sandwiches I estimate I have consumed in my life, I bet half have been made with honey. For a variety of reasons I occasionally recommend honey for wounds. But as a cough therapy? Why would honey have an effect on cough? Whatever the active ingredient, it would have to survive gastric acid and pancreatic enzymes, be absorbed and have sufficient half life to have an effect.

Given that honey is >95% water and sugar there is little room for any ‘active’ ingredients. I went looking for a coherent, plausible mechanism for how honey might suppress cough but failed. Much was written about the complexity of honey, its antioxidant and antibacterial effects:

Honey is a remarkably complex natural liquid that is reported to contain at least 181 substances. It has well-established antioxidant and antimicrobial effects.

True and interesting, but it has little to with suppressing cough. The link between antioxidants and cough is tenuous at best, most of my Google-fu found references to asthma. It was also suggested that the sweetness of the honey is key:

Because of the close anatomic relationship between the sensory nerve fibers that initiate cough and the gustatory nerve fibers that taste sweetness, an interaction between these fibers may produce an antitussive effect of sweet substances via a central nervous system mechanism.

Neither seem particularly likely to me as a mechanism for cough suppressant.

There is a strong placebo effect when treating cough:

Placebo treatment has been reported to improve subjective and objective measures of disease in up to 30-40% of patients with a wide range of clinical conditions. A review of 8 clinical trials on the effects of antitussive medicines on cough associated with acute upper respiratory tract infection shows that 85% of the reduction in cough is related to treatment with placebo, and only 15% attributable to the active ingredient.

Although any author who routinly uses the word ‘powerful’ in conjunction with placebo, as Dr. Eccles does, probably has a stronger bias in favor of placebo effects than I. Coughs improve with time. Because of the favorable natural history of cough, a “positive” response in medication trials should not be assumed to be due to the medication.

The ever questionable Cochrane Reviews had evaluated honey as an anti-cough therapy and concluded

We included two RCTs of high risk of bias involving 265 children. The studies compared the effect of honey with dextromethorphan, diphenhydramine and ‘no treatment’ on symptomatic relief of cough using the 7-point Likert scale. Honey was better than ‘no treatment’ in reducing frequency of cough (mean difference (MD) -1.07; 95% confidence interval (CI) -1.53 to -0.60; two studies; 154 participants). Moderate quality evidence suggests honey did not differ significantly from dextromethorphan in reducing cough frequency (MD -0.07; 95% CI -1.07 to 0.94; two studies; 149 participants). Low quality evidence suggests honey may be slightly better than diphenhydramine in reducing cough frequency (MD -0.57; 95% CI -0.90 to -0.24; one study; 80 participants). Adverse events included mild reactions (nervousness, insomnia and hyperactivity) experienced by seven children (9.3%) from the honey group and two (2.7%) from the dextromethorphan group; the difference was not significant (risk ratio (RR) 2.94; 95% Cl 0.74 to 11.71; two studies; 149 participants). Three children (7.5%) in the diphenhydramine group experienced somnolence (RR 0.14; 95% Cl 0.01 to 2.68; one study; 80 participants) but there was no significant difference between honey versus dextromethorphan or honey versus diphenhydramine.

Since all over the counter medications for cough are essentially worthless, if honey is equal to dextromethorphan and dextromethorphan does nothing, then honey does nothing. Or does it?

Enter Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study, which received a lot of press, most of it favorable.

The study was simple and really, really flawed. Really.

First, it was partially funded by Big Honey (sounds like a New Orleans madame), and we know the Honey Board of Israel has their hooks into every aspect of honey-related therapies and has corrupted medicine in pursuit of good outcomes in clinical trials.  I am sure they are suppressing the negative studies and side effects, information they do not want you to know.

They enrolled children 1-5 years old with uncomplicated upper respiratory infection. Children with asthma, pneumonia, sinusitis, or allergic rhinitis were excluded. There were pre- and post intervention questionnaires with 5 items that evaluated the child’s cough and degree of sleep difficulty the night before and the night of the intervention.

Three types of honey were used: eucalyptus honey, labiatae honey, and citrus honey. The placebo was Silan, a syrup made from dates, because it was brown and sweet like honey. The children received 10 g (10 ml) of the honey or placebo 30 minutes before going to sleep. The next day the parents were called and completed the post intervention questionnaire. Parents were asked the following:

Screen Shot 2013-02-03 at 9.14.47 PM

 

 

 

 

 

 

So parents were asked about cough before enrollment, given the therapy, then quizzed the next day. Like veterinary medicine the researchers relied on second hand information as to efficacy and there is ample opportunity for bias. I would say, and this is without data, people tend to play up the symptoms at the beginning and play down their symptoms after the intervention.

But the data was impressive, despite the fact it seems like a minor intervention. Cough was better in all four groups and the honey outperformed the placebo:

 

Screen Shot 2013-02-03 at 9.19.16 PM

 

 

 

 

 

 

 

 

 

 

 

 

There were  big flaws in the study. First, of course, is they relied on the parents’ impression of efficacy. Not a reliable technique. There has been some interesting work with cough recognition software that, for example, can determine if the cough is likely due to pertussis. It would have been nice to have an objective measure of the cough severity before and after.  Just a recorder in the child’s room would have been sufficient.  It is also possible that they were seeing the natural history of cough, but I doubt it was a significant component of the response. Coughs do not get better that fast on their own.

And think about the parents. Your kid is ill. Is it serious? You are hyper-alert to your kids every cough and wheeze and are up all night. When my kids had fevers I would check them every 10 minutes for purpura, Meningococcal infection was always my worst infectious fear.  Being up all night with the kid you are tired. The next day you find out the child has a trivial, self limited disease, nothing to worry about. Reassured,  the next night you are not going to pay as much attention to the child’s cough and you need, and get, a better night’s sleep as a result.  You will be paying less attention.  It would have been so much better to get a baseline after the assessment, preferably with cough recognition software as back up, then the next night do the intervention.

But the big question they did not ask, and should have, is what did you think your child received? Could the parents tell if the kids were getting honey or Silan date extract? I expect they could.

The article says “The parents, the physicians, and the study coordinator did not know the content of the preparation that was dispensed.”

I like to cook and honey is a royal pain. It is thick and sticks to the measuring cup and spoon. I always end up some honey on my finger from trying to scrape it off the cup or the spoon or the spatula and that finger goes in the mouth. The honey was

packed in small plastic containers of 10 g each and marked with the letters A, B, C, or D. The study preparations were distributed to the pediatric community clinics in blocks of 4. Parents were instructed to administer 10 g of their child’s treatment product within 30 minutes of the child going to sleep. The parents were instructed that the preparation could be given undiluted or together with a noncaffeinated beverage.

You are going to squirt something in your ill fussy kids mouth, and being honey it almost certainly would have to be milked out of the container and in the process get it on the fingers. What parent would not smell it, taste it or otherwise check it out? No one. There is no way almost every parent, unless blind and anosmiac, would not know if their child received honey.  The question is whether they would know if they had the date extract.

It wasn’t an o-ring in ice water moment, but I went hunting and found 2 different date extracts. It wasn’t easy. Only one store in Portland sold the product and I had to get the other from Amazon. The date syrup I could find is darker than honey, looks more like molasses, is not as viscous as honey and tastes good but nothing like honey.  It tasted like sweet dates. No way did the products I found resemble honey. Too much datey goodness. To say the date syrup was a reasonable placebo for honey because it was sweet and brown is like saying my bicycle could be a mistaken for my car because it has wheels and is red.

As I read the paper, there is no way for the parents to have not known what their kids were receiving, honey or date extract, especially as the study was done in Israel where use of date syrup is common. There is the caveat that I do not know for sure if the products I sampled were equivalent to the ones in the study, but I strongly suspect it would be simple enough to know if you child received honey or date.

As they note in the final paragraph

The dropout rate was higher for children receiving citrus and eucalyptus honey. The exact reason for the higher dropout rate in these groups is not known. Because these types of honey are more aromatic, it is possible that some children disliked the honey taste.

For placebo to be a valid control it has to be indistinguishable from the active therapy, and, after tasting some date syrup, I call horsefeathers. The parents were almost certainly aware of whether their children were getting honey or date extract and that would render the conclusions of the paper fatally flawed.  The key characteristic in most studies of implausible or impossible therapies that demonstrate benefit is there is no placebo.  People know what they are getting and respond accordingly.  Bias central.  As in this study. Calling something a placebo does not make it so.  Placebo.  You keep using that word, I do not think it means what you think it means.

So did the paper demonstrate honey is better than placebo? I suspect not. I suspect the parents knew very well what their children were taking and bias flooded in. Someone, and I can’t find the quote, suggested I thought the placebo effect was the patient lying to themselves and/or to their doctors. Not quite. People will convince themselves that they are better when they are not and report the imagined improvement to their doctors. Humans are most expert at convincing themselves that what is not real is real. I always think the archetype is the Penn and Teller show with the the gutter downspout bent and painted to look like a giant magnet and the person telling the man in the white coat her arthritis was better (13:30 in). The same effect is probably occurring in this study.

Does the study demonstrate that honey is better than date extract? Yes.  But in a study to compare honey and placebo where the patients almost certainly know what they are getting.  Like acupuncture, it is effective only when the patient knows they are getting needles.

Does it demonstrate when you do not have an adequate placebo and make it simple for someone to break the blinding that it renders a study nearly worthless? Yes.

Does it suggest that neither the editors and reviewers of Pediatrics nor those reporting the study took the time to think about the validity of the study?  Yes. It is the new peer review. Peer: to appear partially or dimly.

Posted in: Clinical Trials, Herbs & Supplements, Science and Medicine

Leave a Comment (52) ↓

52 thoughts on “Honey Boo Boo

  1. lizz says:

    “I tend to let normal physiologic processes run their course unimpeded as long as they pose to harm to the patient.”

    I’m wondering if you’ve missed out the word “no” ?

  2. The Eventual Doc says:

    Couldn’t an equally valid interpretation of their “data”, such as it is, be that date extract worsens cough?

  3. Alia says:

    Over here a popular home treatment for colds, sore throat and cough is so-called “lemonade” – you take a spooful of honey, add juice from a quarter of lemon and a glass of warm water, stir and drink. Well, I do not think it can cure anything, but it does make you feel better – the drink tastes nice and you feel cared for (especially when it’s your mother who brings it to you, saying “drink it, it will make you feel better”).

    Anyway, I have pretty bad experience with coughs. For several years my every wintertime infection looked lik this – a few days of typical cold (slightly elevated temperature, runny nose, nothing serious and resolving on its own) and then three-four weeks of cough. Especially at night. So I did take codeine – it’s available OTC here, in small doses. Otherwise I would be unable to get a good night’s sleep, not to mention my poor husband. And then, for some reason, a few years ago it all changed and I do not get this cough. Don’t know the reason, but sure I’m glad.

  4. cervantes says:

    Yes, eventual doc, there should have been a no treatment arm.

    I once had a roommate make me a very strong ginger tea with lemon. (You boil the living excrement out of fresh ginger, basically.) It certainly seemed to open up the respiratory passages and calm the cough. Anyway, there’s something to be said for subjective relief.

  5. windriven says:

    ” I assume that coughing with infection, like diarrhea, is beneficial. Key to treating all infections is to physically remove it. ”

    So what does one do about the wee beasties ejected during the cough? Small children can’t manage and ignorant morons can’t be bothered to cover their blowholes when they succumb to a paroxysm of hacking. I understand the ‘out with the bad air’ thing but wish to maintain my own ‘in with the good air’. And while walking the streets wearing a surgical mask might be haute couture in Guangdong, in, say, Murfreesboro it might invite the ridicule of one’s neighbors and the attention of a fat sheriff with the IQ of a zipper pull.

    What is one to do?

  6. toffer99 says:

    “The ever questionable Cochrane Reviews” What did you mean by that, please? Perhaps I got hold of the wrong end of the stick, not being a medical professional, but I though Cochrane was the gold standard, the ever-reliable UNQUESTIONABLE upholder of evidence-based medicine?
    Please enlighten the ignorant.

  7. windriven says:

    toffer99

    The Cochrane Reviews are notoriously wishy-washy, often calling for more research on even the most obvious quackery.

    Faced with a bloody body Cochrane might give equal weight to the theories that the deceased was stabbed to death … or that he backed into a knife nine times.

  8. Troyota says:

    Interesting! This information has implications for my favorite cold remedy, “Gram’s Formula”:

    Place the following in a mug or heavy, heat-proof drinking glass (proportions and quantity per individual taste and needs):

    Bourbon
    Honey
    Lemon juice

    Fill with boiling water and mix; administer in bed or comfortable recliner. No driving!

    I guess I can substitute other sweeteners for the honey, not that I want to….

    Thanks much, this is a great site!

  9. Janet says:

    I raised my kids in Washington and Oregon–Washington when they were little, where you could get codeine cough syrup at the drugstore by signing your name in a big, important-looking book with a very stern pharmacist glaring at you very paternally. One bottle a year of this stuff (enough for a family of five in a bad cold/flu season), administered at bedtime, gave the kids the chance to sleep, rest, and get well–perhaps faster than without the codeine (due to the rest, not the codeine!)

    Last time I asked my doc here (Wisconsin) for codeine cough syrup, she looked at me like I had just asked her for heroin, and told me how effective the OTC crap is! I will be sure she sees this post and the links.

    I cough all the time because I have allergic asthma. I’m used to people backing away and staring at me with looks that could kill, so now I try to follow my coughs with a chirpy, “it’s just asthma”. I used to treat bad colds with the beverage recommended by Troyota above. It works! How do I know? I ask myself how I feel after I drink it! Myself always says, “better”. Who needs RCT’s? The thing is I really don’t get colds, so Im going to try it (what’s the harm?) for the cough. :-)

  10. stanmrak says:

    Methinks you may have too much time on your hands. Spending this much time and effort trying to prove that honey works or not proves nothing at all, and never will. Honey is not a drug, for crissake, and you can’t design any legitimate study that examines it in that way and get any reliable conclusion about its benefits. Next time you get a cough, just try it. Some of those things work whether you believe in them or not.

  11. dbe says:

    @Alia, I had the same thing, but younger. Used to get coughs as a child that were horrible and could get no sleep. Then around 16-17 it all stopped, after that even when sick my cough isn’t bad at all. No idea what changed, other than puberty.

  12. NSC says:

    Troyota’s treatment works well for me, too. Although in my experience the honey is optional. As is the lemon juice. And the hot water.

  13. windriven says:

    @stanmrak

    You just don’t get it, do you? Belief doesn’t enter into the skeptical view except as something to be disdained. There are hypotheses that cannot be tested. The efficacy of honey in the management of coughs in children can.

    “Some of those things work whether you believe in them or not.”

    I have no idea whether or not you meant this ironically. I doubt it as you don’t seem that reflective. So let’s work this through: excision of a ‘hot’ appendix cures appendicitis whether you believe in appendectomy or not. Reiki does not cure appendicitis though it may offer temporary relief if you believe that it will.

    NOTE TO PETER MORAN: stan here is living proof that that sCAM isn’t just a girl thing :-)

  14. @toffer99

    “Perhaps I got hold of the wrong end of the stick, not being a medical professional, but I though Cochrane was the gold standard, the ever-reliable UNQUESTIONABLE upholder of evidence-based medicine?
    Please enlighten the ignorant.”

    One of the resident bloggers can probably put this better but, here goes:

    That phrasing of your question seems a little over the top, so it causes me to pause to consider the sincerity, but giving you the benefit of the doubt: One of the main differences between Evidence Based Medicine and Science Based Medicine is that EBM doesn’t account for prior plausibility and use Bayesian analysis. For instance, the prior plausibility for homeopathy is incredibly low. For homeopathy to work as advertized, huge swaths of established science regarding physics, chemistry, biology, physiology, etc would have to be wrong. Therefore there is a higher burden of proof to overcome to support claims of efficacy for homeopathy.

    Chocrane frequently refuses to either conclude that a treatment has no evidence for efficacy and its use is therefore not recommended and/or that no further research is warranted. They often point out likely statistical anomalies or signals that fail to achieve statistical significance in the results or even methodological problems as reasons further research is warranted or needed. I had a discussion with someone last year at TAM where they mentioned that a Chochrane review had concluded something was not recommended and no further research was warranted and I remarked that for Chocranne to make such a conclusion, the data must have been historically, overwhelmingly negative, and He agreed.

    Also meta-analyses and systematic reviews are only as good as the studies they include. The meta of crap is not gold.

    To me (and I’m neither a medical professional or a researcher) systematic reviews are best used as a tool to determine what the consensus of available quality research is on a particular topic, while meta-analyses are best used to pool together the data of numerous smaller studies to look for weaker signals that the individual studies were too underpowered to detect. Both require high quality underlying studies, and metas really need very similar methodologies (almost reproduction level studies) in the underlying studies to be able to legitimately pool the data.

  15. … a little more on systematic and meta reviews:

    They’re not supposed to be the Facts of Life theme song:

    You take the good, you take the bad,
    you take them both and there you have
    a systematic review.

  16. DevoutCatalyst says:

    NOTE TO WINDRIVEN: Unless Stanleyetta shortened it to stan to avoid getting hit on by skeptics…

  17. DevoutCatalyst says:

    Smiley fail…

  18. RUN says:

    A question: There has been a lot of ‘buzz’ in the media about more benefits using raw honey vs the processed honey we buy in the stores. Is there research comparing the two, are there significant differences? The studies that were mentioned in this article, did they use raw or processed?

  19. elburto says:

    “Some of those things work whether you believe in them or not.”

    Stan there, missing the point of research by so much that if the point is in Glasgow, he’s in Kazakhstan.

    Science isn’t god, or the tooth fairy, or the magical levitating three-toed sloth of Costa Rica. It’s not a question of believing whatever you want to without evidence, relying solely on happy thoughts and warm fuzzies,

    Cold hard facts, statistics, research and results that can be reproduced and replicated. Science there. Not a man in black invoking a sky fairy, or someone in tie-dye preaching the virtues of crystals and otter eyelashes, or whatever the current fad is.

    If you’re impersonating a stunted wooligan, then bravo! You’re at the top of your game. If you really believe that clicking your ruby slippers together three times will cure all that ails you, well, you’ve been failed by society and whatever education system turned you out.

  20. mousethatroared says:

    When I’ve taken the kids into the doctor for cold/flulike/persistant cough symptoms, after they’ve ruled out concerning infections, they usually make comfort recommendations. Those are; nasal saline washes if the child will tolerate them, lots of liquids, warm lemon/honey drinks, humidifier in room at night. I believe the idea is preventing the mucus membranes from getting too dry and irritated, thus cutting down on coughing. Just anecdotally, the humidifier seems most helpful. Can’t really say about the other recommendations.

    I occassionally get the asthma post virus coughing fits. Besides using the emergency inhaler, any drinks that clear and moisten my throat seem to help. Cabonated drinks, hot citrus teas, ginger syrup drinks, chicken soup, etc. Also anything that relieves nasal congestion helps my cough as well…cuts down on mouth breathing and dryness/irritation, I’d guess.

  21. windriven says:

    @elburto

    What the world needs is an emoticon for a ‘high five’! Nicely stated.

    @DevoutCatalyst

    Smiley not required :-)

    @Karl

    ” The meta of crap is not gold.” !!!

    All in all, a fabulous Friday at SBM.

  22. LovleAnjel says:

    I’m pleased hear I am not the only person who regularly enjoys PB&H sandwiches.

  23. Xplodyncow says:

    Spending this much time and effort trying to prove that honey works or not proves nothing at all, and never will. [. . .] Some of those things work whether you believe in them or not.

    Because, see, it’s my own perception that matters. Not reality. I mean, duh.

  24. DugganSC says:

    I haven’t found honey to be an especially effective cough suppressant, but it does tend to coat the throat, making my coughs less painful.

  25. WilliamLawrenceUtridge says:

    Methinks you may have too much time on your hands. Spending this much time and effort trying to prove that honey works or not proves nothing at all, and never will. Honey is not a drug, for crissake, and you can’t design any legitimate study that examines it in that way and get any reliable conclusion about its benefits. Next time you get a cough, just try it. Some of those things work whether you believe in them or not.

    Thus missing the point that interpretation of scientific literature is a skeptical and intellecutal exercise capable of illustrating broader points than the mere topic-specific empirical one.

    Honey also carries risks, in the form of anaphylaxis, contamination, botulism and general risk of infectious disease (honey is pasteurized for a reason, though primarily to kill yeast).

    The irony of posting a comment criticizing a blog post for wasting time is truly a source of delight :) It goes beyond irony, into ununoctiumy.

  26. Calli Arcale says:

    There is no way almost every parent, unless blind and anosmiac, would not know if their child received honey.

    I disagree. Given the widespread adulteration of honey with corn syrup (in a surprising number of cases, 100% corn syrup), I’d say that there must be an awful lot of people who can’t tell they’ve been given something that isn’t honey, or else the lid would’ve been blown off of that scam a long time ago. That’s not to say you can’t tell the difference; just that most people don’t seem to be aware of the differences or at least are easily fooled.

    I do have to agree that if honey is no better than dextromethorphan, that means it’s no use at all as a cough suppressant. Some have talked about its bacteriostatic properties, though. Are those of any use?

  27. lilady says:

    @ Troyota: “Grams Formula”? Isn’t that the same as a “Hot Toddy”?

    http://www.sippitysup.com/hot-toddy-cocktail-cold-flu-season

    ` Five years ago I contracted pertussis and it was not *women’s intuition* that propelled me into my doctor’s office for a nasopharyngeal swab to “confirm” my diagnosis. Even before the results were available, I was put on a short course of an antibiotic, to decrease the chance that I would infect anyone else.

    I suffered through 8 weeks of rib-cracking painful coughing spells. A bronchodilator and two huge bottles of prescribed codeine cough syrup, enabled me (and my husband), to get some sleep.

    Windriven…”The Cochrane Reviews are notoriously wishy-washy, often calling for more research on even the most obvious quackery.

    Faced with a bloody body Cochrane might give equal weight to the theories that the deceased was stabbed to death … or that he backed into a knife nine times.”

    Heh, heh, I just might steal that one.

  28. Janet says:

    @Calli

    Yeah, but they didn’t give the kids corn syrup–they gave them some horrible-sounding brown date syrupy stuff. I like date, but date syrup doesn’t sound so good, maybe I’m wrong, though and it’s yummy. o_o

  29. Our pediatrician’s website hosts a panicked parent window where sleep-deprived, panicked parents can click in the dead of night (the exact time that very small babies suddenly become worryingly ill in my experience) for general advice about when to chill out until the next business day and when to wake up the doc on call. The host of this service is called Pediatric Web, and recommends honey for cough. I can attest to the power of the placebo and throat-coating effects of this sweet, sleepytime nectar.

  30. pmoran says:

    Someone, and I can’t find the quote, suggested I thought the placebo effect was the patient lying to themselves and/or to their doctors. Not quite. People will convince themselves that they are better when they are not and report the imagined improvement to their doctors.

    Here is the quote, from me. ” Nybgrus and Mark Crislip are trying to claim that placebo responses are entirely due to biased reporting (or as close that it doesn’t matter), essentially patients lying about how they now feel in order to please the doctors, and Steve Novella is not far from the same position.” (If any of you doubt that these positions were advanced I DO have the relevant quotes)

    It is true that patients can convince themselves they are better “when they are not”. Even obviously declining cancer patients can do this, but that merely demonstrates the power of the human mind where perceptions are concerned, as often displayed in demonstrations of human suggestibility. It in no way undermines placebo theory as usually conceived. The placebo IS about perceptions, and the focus of the mind, and the “endorphogenic” sensation of having done something useful, and other matters.

    So this study raises two quite separate questions. Does honey have a specific effect on cough? Probably not, unless, possibly (still) as a lingering distraction from a ticklish throat.

    The other question is “might this, even so, be a useful thing for a parent or patient to do for an annoying cough?”

    These are both legitimate scientific questions, but looking at quite different aspects of medicine.

    (Note to Windriven, Stanmrak may be trying to clumsily get across a similar “girly” point :-)

  31. Lytrigian says:

    Hot toddies were my grandma’s formula too.

    I don’t know if they help my coughs or not, but after 2 or 3 of them I don’t really care.

  32. windriven says:

    @pmoran

    “Stanmrak may be trying to clumsily get across a similar “girly” point :-)”

    Possibly, but I’ve never known him to show subtlety or nuance. Still, we can hope.

  33. Harriet Hall says:

    Mark makes the CAM apologists look silly. The ones who claim doctors only treat the symptoms and insist on writing prescriptions for everything. No shill for Big Pharma would say the things he has said about fever and cough.

  34. Quill says:

    “Hot toddies were my grandma’s formula too.
    I don’t know if they help my coughs or not, but after 2 or 3 of them I don’t really care.”

    Exactly so and I won’t care a bit what a well-done study says, unless it confirms my Toddy Bias. :-) I shall also start paying serious attention to Cochrane Reviews when they get jiggy with bourbon studies.

  35. lilady says:

    Honey for an infant’s cough? That’s a major no-no…

    http://www.mayoclinic.com/health/infant-botulism/HQ00854

    Poor babies can’t even have a hot toddy. :-)

  36. @ lilady: re botulism in honey. You’re right, of course. I should have clarified. Pediatric Web does mention not to give it to kids under 1 year. I do think they should include a hot toddy recipe for panicked parents!

  37. RobLL says:

    Cough 16 hours a day as needed (on the likelihood that coughing is functional)

    Enough codeine (I use C-3s, and a portion thereof as cough lessens) to get enough sleep at night.

    C-3s (300 mg acet. and 30 mg codeine) are the cheapest and likely most effective. The syrup is mostly sugary crap.

  38. pharmavixen says:

    I helped write the formulary for our organization, and we excluded dextromethorphan because of its dubious efficacy and its (tiny) potential for abuse – at high doses, it has ketamine-type effects, probably by the same mechanism as ketamine; ie, agonism @ the NMDA receptor. Our catchement area includes many people with substance abuse problems. Also, we treat many major mental illnesses, and DM has a (tiny) risk of serotonin syndrome when taken with SSRIs. And we hand out SSRIs like candy around here.

    But this current cough-cold-flu season has brought us a flurry of non-formulary drug request forms from physicians asking us to include DM syrup in the formulary. I have suggested guaeifenesin (Robitussin) syrup instead, with the rationale that at least we are giving our patients a placebo that is entirely harmless.

    As the point person for drug information, I am getting innundated with requests to justify the exclusion of DM. Like Mark’s research found, the evidence for its worthlessness is solid. But some of the other pharmacists are pressuring me to cave to the physicians and include DM as the path of least resistance. After all, DM is cheap, and its risks are tiny enough to be almost theoretical.

    It hasn’t been settled yet, but when evidence-based medicine comes up against institutional politics, I don’t think it’s the patients who win.

  39. Thank you, pharmavixen! I knew DM is off my list because of SSRI use, but I had no idea *why*! Thanks for shedding some light. Then I googled “serotonin syndrome” and found it indistinguishable from “a day in the life of a freelancer,” and think I’m going to have some of Gram’s Remedy and go to bed now! ;)

    windriven– Murfreesboro? Are you in Tennessee, by chance?

    Also, even though I have a botany background and am over the age of twelve, I maintain no one should ever, ever call it “labiatae honey”. Because… just because.

  40. dandover says:

    If there are benefits to suppressing the cough associated with acute respiratory infections I can’t find any …

    My wife has definitely found the benefit to suppressing my cough when she is trying to sleep next to me :)

  41. Calli Arcale says:

    lilady:
    It’s only raw honey that is a problem with respect to botulism. In the US, honey is mostly sold raw, but I understand that in other countries it is often pasteurized, which should kill the little nasties. I’ve often wondered why it’s seen as better to stick a label on it that says “don’t give to babies” rather than to pasteurize it. They’re heating it anyway to make it easier to bottle; they might as well heat it a little more and actually kill the germs. It’s not like the flavor’s going to change as long as you’re not getting it hot enough to start cooking the sugar. Of course, someone is bound to object that this would destroy its natural healthful magic….

  42. pmoran says:

    It hasn’t been settled yet, but when evidence-based medicine comes up against institutional politics, I don’t think it’s the patients who win.

    “Institutional politics”? Why blame this? I suspect, since you go on to suggest “a safer placebo”, you know that these doctors are responding to the very simplest of medical pressures, the “unmet medical needs” that I have been suggesting should be contributing more to our understanding of why people (and some doctors) turn to CAM.

    The advent of of evidence-based medicine has not been all sweetness and light for medical practice. This much-lauded facet of modern medicine has no ability in and of itself to produce new and better treatments of anything. It “merely” helps test them out.

    Yet it has had the effect of seriously reducing prescribing options for many symptoms. It has become so strongly prohibitive of non-EBM-prescribing, that we now see fit to frown upon the use of honey for a child’s cough through it not being shown to work clearly better than placebo..

    Cough is also just one of many instances where we have gone so far as to very extensively prescribe certain treatments, only to then either take them away, or made them very hard to get for one reason or another. This has happened with anxiolytics and other mood-modifying drugs (e.g. opiates and cocaine ), sleeping pills, stimulants such as amphetamines, the once ubiquitous “tonics”, and also recently a variety of appetite suppressants.

    It took us most of a century to discover that there are few free lunches in pharmacology, but all the while we were unwittingly holding out the promise of much nicer and more trouble-free lives for everyone just around the corner. “All your ills will have an answer” it seemed.

    So, we have limited right to get grumpy obout unreasonable public expectations when we ourselves have been permitting them to be aroused. These are one of many factors making the public receptive to less than honest medical claims .

    As some other commenters have hinted, there is a desperate need for an effective cough suppressant. It does not need to work as well as a rib fracture does, and thereby increase the risk of pneumonia — if that was ever a serious concern with the usual outpatient use of cough suppressants.

    I am not pretending there is an easy or correct answer to this. But it surely helps if we fully understand the terrain in which we are working.

  43. David Gorski says:

    The advent of of evidence-based medicine has not been all sweetness and light for medical practice. This much-lauded facet of modern medicine has no ability in and of itself to produce new and better treatments of anything. It “merely” helps test them out.

    Nonsense, Peter. There’s no “merely” about it, and remember that EBM (even more so SBM) includes the whole gamut from preclinical research to randomized clinical trials to meta-analyses. We at SBM quibble about the emphasis placed on basic science considerations, but to imply that the EBM infrastructure is incapable of producing new or better treatments is just plain wrong. It is now the primary scientific framework through which new and better treatments make their way from idea to clinical trials.

  44. pmoran says:

    Well, I suppose you can define anything in any way you want, David, but SBM itself came into existence to try and divert the emphasis of EBM away from clinical studies, specifically the placebo-controlled RCT, which we ourselves were up until then referring to as the “gold standard” of evidence.

    .About the only relevance of the distinction is in relation to the positive studies now appearing for unlikely CAM methods, although rarely SBM looks to soften the very strong prohibitive aspects of EBM and allow for some small practitioner discretion.

    My comments referred to pharmacology where EBM can mean little else other than clinical studies. The quotation marks around “merely” were clearly intended to be ironic, allowing for the importance of clinical studies in optimising medical treatment even if they cannot, as is quite obvious but rarely stated, generate new therapeutic ideas.

  45. Narad says:

    I helped write the formulary for our organization, and we excluded dextromethorphan because of its dubious efficacy and its (tiny) potential for abuse – at high doses, it has ketamine-type effects, probably by the same mechanism as ketamine; ie, agonism @ the NMDA receptor.

    While I’ve never had ketamine, I’ve tried high-dose dextromethorphan way back when it could be obtained in gelcaps. The (quite unpleasant) experience did not jibe with any accounts of ketamine use that I’ve encountered, perhaps due to activity at PCP-2 and σ-1. Ketamine and DXM’s metabolite, dextrorphan, are NMDA antagonists, BTW.

  46. pharmavixen says:

    “The (quite unpleasant) experience did not jibe with any accounts of ketamine use that I’ve encountered, perhaps due to activity at PCP-2 and σ-1. Ketamine and DXM’s metabolite, dextrorphan, are NMDA antagonists, BTW.”

    Yes. Typo. And yes. All the accounts of DM intoxication I have heard/read make it sound like it has about the same abuse potential as nutmeg.

    @pmoran: while SBM is our platonic ideal, we all work in reality-based medicine, or all the limitations of our practice settings. In the specific case of cough, codeine works well, but my pts are inmates in a jail, with a propensity for drug abuse. If we started handing out codeine for coughs, everybody would have a permanent cold (except for the gangsters, who sell drugs but take pride in not using them).

    Kinda o/t, but does anybody have experience with treating the coughs caused by smoking crack? I did a lit search and found nothing. Our dr treats it like asthma – steroid inhalers + short-acting beta agonist inhaler (or sometimes Symbicort).

  47. BlueJean says:

    Your mechanism of action search is a little underwhelming… My understanding is that honey is supposed to soothe a cough and a sore throat as a demulcent. I can’t imagine the effect lasts very long, if there is a significant effect, but maybe long enough to get to sleep after a long day.

  48. kathy says:

    Perky – “I maintain no one should ever, ever call it “labiatae honey”. Because… just because.”

    “A taste of honey.
    Tasting much sweeter than wine.
    I dream of your first kiss …”

    LOL! So you know what “labiate” means.

  49. mousethatroared says:

    @ Pharmavixen – In your original post, I thought the demands for dextrorphan were patient driven (doctor’s giving in to patient demands) but given your patients that seems less likely. I don’t get it. Are the doctors convinced it actually works? Is it a ‘if it ain’t broke don’t fix it’ unwillingness to change? Does the dextrorphan have some other benefit, like making people sleepy, which could help with a cough?

  50. Mark Crislip says:

    Infectious coughs are generated in the airway, not the throat.
    Sure hope honey isn’t getting in the airway.

  51. mousethatroared says:

    Mark Crislip
    ‘Infectious coughs are generated in the airway, not the throat.
    Sure hope honey isn’t getting in the airway.’

    I’m confused. Are those coughs that hang on for 2 or 3 weeks after the cold or flu, infectious coughs? I thought they were just due to general post infection irritation of the throat and airway. If it was only airway generated, then a drink of water would do nothing to sooth that dry/hacky cough I get at bedtime after a cold. But it really does and really, I’m not inhaling the water.

    Also, I thought that those post infection coughs weren’t communicable…at least that’s what our pediatrician said. When you say infectious, do you mean that it still spreads virus/bacteria? Or are we only talking about coughs that one gets at the beginning of an infection?

    Sorry to be a pain. but it really does seem like things that sooth the throat (hard candy, etc) cut down on that dry coughing reflex thingy.

  52. Alia says:

    @mousethatroared “Sorry to be a pain. but it really does seem like things that sooth the throat (hard candy, etc) cut down on that dry coughing reflex thingy.”

    I agree, they seem to be helping me, too. Not as good as codeine, but very useful if I got a coughing fit in the cinema or while lecturing my students, for example.

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