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Codeine still prescribed for children despite harmful effects
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Codeine is continually prescribed to children in the United States despite potential harmful effects, according to recent study findings published in Pediatrics.
“Despite strong evidence against the use of codeine in children, the drug continues to be prescribed to large numbers of them each year,” Sunitha Kaiser, MD, who is assistant clinical professor at UCSF Benioff Children’s Hospital San Francisco, said in a press release. “It can be prescribed in any clinical setting, so it is important to decrease codeine prescription to children in all settings including clinics and hospitals, in addition to emergency rooms.”
Sunitha Kaiser
Kaiser and colleagues evaluated 189 million ED visits by children aged 3 to 17 years from 2001 to 2010 to determine changes in pediatric codeine prescription rates over time. Over that period, there were several reports of deaths in children due to codeine and the AAP reaffirmed its 1997 guidelines in 2006 that warned of dangers and lack of documented effectiveness of codeine in treatment of cough in children.
At the beginning of the study period, the rate of codeine prescriptions was 3.7% compared with 2.9% at the end of the study. Approximately 500,000 to 800,000 codeine prescriptions were given to children each year. No significant changes were found in codeine prescriptions for injury visits during the study period (P=.70).
During the study, codeine prescriptions decreased from 3.8% to 3% (P=.007) among patients aged 3 to 7 years. There was no significant change in codeine prescriptions for cough and colds associated with the release of the AAP guideline.
Patients aged 8 to 13 years were more likely to be prescribed codeine compared with patients aged 3 to 7 years (OR=1.42; 9% CI, 1.21-1.67). Non-Hispanic black patients were less likely to be prescribed codeine compared with non-Hispanic white patients (OR=0.67; 95% CI, 0.56-0.8). Patients with Medicaid were also less likely to be prescribed codeine compared with patients on private insurance (OR=0.84; 95% CI, 0.71-0.98).
“Further research is needed to determine the reasons for these lower rates so we can reduce codeine prescriptions to all children,” Kaiser said.
Among 37 million ED visits among patients aged 3 to 17 years diagnosed with upper respiratory infection or cough, 2.8% received a codeine prescription. Albuterol (12.7%) was the most common prescription among visits for upper respiratory infection or cough without a codeine prescription, followed by acetaminophen (12.4%) and ibuprofen (11.5%). Overall, 12.5% of visits resulted in no prescriptions. Ibuprofen (21.8%) was the most common prescription among visits for injuries without a codeine prescription, followed by acetaminophen (10%) and acetaminophen-hydrocodone (3.9%), whereas 36.2% of those visits resulted in no prescriptions.
“Due to wide variability in how codeine is metabolized, about one in three children get no therapeutic benefit and about one in 12 may be at risk of fatal side effects,” Kaiser told Infectious Diseases in Children. “Despite growing knowledge of this, hundreds of thousands of codeine prescriptions are occurring every year; so it is important that we find effective interventions to decrease codeine prescription to children and encourage use of safer, more effective alternatives.”
In an accompanying editorial, Alan D. Woolf, MD, MPH, FAAP, and Christine Greco, MD, FAAP, both of Harvard Medical School, wrote that the study suggests removal of codeine-containing products.
“Removing the products from routine Medicaid and private health insurer reimbursement schedules may be effective in reducing the drug’s everyday use in children,” they wrote. “Professional continuing education and resident and student curricular content initiatives are also needed to inform present and future pediatric health care providers.”
Sunitha Kaiser, MD, can be reached at sunithavemula1@gmail.com.
For more information:
Kaiser SV. Pediatrics. 2014;doi:10.1542/peds.2013-3171.
Woolf AD. Pediatrics. 2014;doi:10.1542/peds.2013-4057.
Disclosure: See the studies for a full list of disclosures.
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Edward A. Bell, PharmD, BCPS
Kaiser and colleagues have evaluated data from the National Hospital Ambulatory Medical Survey (NHAMS) over the 10-year period, 2001-2010, for emergency department (ED) visits, and assessed national prescribing of codeine for children 3 to 17 years of age. The primary outcome measure was the annual number and percent of all pediatric ED visits with codeine prescriptions. The percentage of ED visits with codeine prescriptions decreased from 3.7% to 2.9% during this study period, which was statistically significant. Extrapolating this percentage use to the population, codeine continues to be prescribed to a large number of children annually, ranging from 558,805 to 876,729.
The authors additionally evaluated why codeine was prescribed, and found that 2.8% of children diagnosed with an upper respiratory tract infection (URI) or cough were given codeine. This prescribing rate did not change when national guidelines on the treatment of pediatric cough were published in 2006-2007. These guidelines, from the American College of Chest Physicians and the AAP (reaffirmation of its 1997 recommendations), state that, due to a lack of controlled efficacy data, and concern over adverse effects, codeine is not recommended for routine treatment of pediatric cough. More recently published data on the propensity of codeine to demonstrate genetic variations in metabolism to its active form (morphine), potentially resulting in toxicity to rapid metabolizers, including death, reveal its decreasing therapeutic role.
This study illustrates that more needs to be done to highlight the decreasing benefit-risk ratio of codeine use in children. Prescribing habits for codeine for post-tonsillectomy pain are changing. Hurdles remain in the treatment of pediatric cough, as there is little to choose from, and old habits are hard to break. No controlled data support the use of dextromethorphan or antihistamines for cough, although recent data do support the use of honey. Honey may be easier to swallow than codeine, in more ways than one.
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