Kids still getting codeine despite harmful effects
Even though research suggests that codeine should generally not be given to children, plenty of emergency providers are still prescribing the drug to pediatric patients, according to a new study in the journal Pediatrics.1 According to a serial cross-sectional analysis of ED visits for children aged 3 to 17, culled from the National Hospital and Ambulatory Medical Care Survey, prescriptions for codeine declined only slightly, from 3.7% to 2.9%, between 2001 and 2010. This is despite recommendations by several national and international organizations advising providers to opt for safer alternatives rather than codeine in children.
For instance, the American Academy of Pediatrics issued guidelines in 1997 and 2006 warning of potentially harmful effects from codeine in children. The guidelines also pointed out the drug’s lack of documented effectiveness in treating coughs and colds in young people. Similarly, the American College of Chest Physicians released guidelines in 2006, advising against the use of codeine in children.
Interestingly, while prescriptions for codeine in children declined slightly during the study period, they did not decline for use in the case of cough or upper respiratory infections. The authors, led by Sunitha Kaiser, MD, an assistant clinical professor of pediatrics at the University of California, San Francisco, Benioff Children’s Hospital, say the findings underscore the need for solutions to change provider prescription behaviors. They suggest alternatives to codeine, such as ibuprofen and hydrocodone, are better options for children who present with a cough or cold.
The problem with codeine is that because of variability in the way children process the drug, roughly one-third receive no benefit from the drug. Further, a small percentage of children taking codeine can accumulate toxic amounts of the drug, causing their breathing to slow down, and potentially causing serious consequences, including death.
In their analysis of the data, the authors found that codeine prescriptions tended to be higher in children aged 8 to 12, and in regions outside of the Northeast. Prescriptions of the drug were lower for non-Hispanic black children and for children on Medicaid. The authors suggest more research is needed to figure out the reasons behind these figures so that codeine prescriptions can be further reduced in children.
In response to the guidance against the use of codeine in children, some pediatric hospitals have removed the drug from their formularies while others have taken strong steps to curb its use. For instance, ED-based clinical pharmacists at Children’s Medical Center (CMC) in Dallas, TX, speak with any provider in the department who writes a prescription for codeine. "We let them know about the potential risks and benefits and suggest another alternative therapy that may be just as efficacious for pain control, but has a better safety profile for the patient," explains Stephanie Weightman, RpH, PharmD, BCPS, a clinical pharmacist in the ED. "Most of the time we are able to make that appropriate switch in therapy for the patient."
Study authors note hospital administrators might also want to consider beefing up decision support mechanisms within their electronic medical records so that prescribers are alerted to the potential risks associated with codeine in children, and they would also like to see insurance companies change their reimbursement policies with respect to codeine.
- Kaiser S, Asteria-Penaloza R, Vittinghoff E, et al. National patterns of codeine prescriptions for children in the emergency department. Pediatrics 2014;133:e1139-e1147.