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April 30, 2014
EDs Still Writing Pediatric Codeine Prescriptions Despite Harmful Effects
San Francisco—Pediatric prescriptions for codeine continued to be issued at U.S. emergency departments despite potentially harmful effects in children, according to a new study. Researchers from the University of California San Francisco suggest in a report published recently in the journal Pediatrics that better alternatives such as ibuprofen or hydrocodone should be used instead. “Despite strong evidence against the use of codeine in children, the drug continues to be prescribed to large numbers of them each year,” said lead author Sunitha Kaiser, MD, assistant clinical professor of pediatrics at UCSF’s Benioff Children’s Hospital. “It can be prescribed in any clinical setting, so it is important to decrease codeine prescription to children in other settings such as clinics and hospitals, in addition to emergency rooms.” The study points out that, because of variability in how children process codeine, about a third receive no symptom relief from taking the opioid, while up to one in 12 can accumulate toxic amounts, causing possibly fatal slow breathing. Use of the drug in children is opposed by several national and international organizations. Guidelines from the American Academy of Pediatrics (AAP), issued in 1997 and reaffirmed in 2006, warn of codeine’s potential dangers and lack of documented effectiveness in children with coughs and colds. The American College of Chest Physicians 2006 guideline on treatment of pediatric cough also advises against use of the drug. For the study, researchers used the National Hospital and Ambulatory Medical Care Survey to determine the frequency of codeine prescriptions from 2001 to 2010 for children ages 3 to 17 presenting with cough or upper respiratory infection (URI). While the rates of codeine prescriptions decreased from 3.7% to 2.9% during the 10-year study period, 559,000 to 877,000 prescriptions still were written for children each year. Interestingly, no decline in prescriptions appeared to be associated with the reaffirmed guidelines in 2006. The study finds that codeine prescriptions were higher in children ages 8 to 12 and in regions outside the Northeast and lower for non-Hispanic black children or those with Medicaid. “Further research is needed to determine the reasons for these lower rates so we can reduce codeine prescriptions to all children,” Kaiser said, adding, “Many children are at risk of not getting any benefit from codeine, and we know there are safer, more effective alternatives available. A small portion of children are at risk of fatal toxicity from codeine, mainly in situations that make them more vulnerable to the effects of high drug levels such as after a tonsillectomy.” Last year, the FDA added a new Boxed Warning, FDA’s strongest warning, to the drug label of codeine-containing products about the risk of codeine in postoperative pain management in children following tonsillectomy and/or adenoidectomy. The action followed deaths of children who apparently were ultra-rapid metabolizers of codeine—a genetic trait that causes the liver to convert codeine into life-threatening or fatal amounts of morphine in the body. Kaiser maintained that ibuprofen is equal or better than codeine for treating injury pain, and that hydrocodone is also a safer, more effective opiate alternative. For cough, dark honey has been shown to be better than over-the-counter medicines for cough and is recommended by the AAP for children over age 1, the study notes. “Although there was a small decline in codeine prescriptions over 10 years, use for cough or URI did not decline after national guidelines recommended against its use,” the authors conclude. “More effective interventions are needed to prevent codeine prescription in children.” Ways to change codeine-prescribing patterns, according to the authors, could be removing the opioid from hospital formularies or insurance plan reimbursement policies. They also suggest that electronic medical record-based decision support could lead to safer prescribing.
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