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From Health Law Daily, April 21, 2014

Children’s codeine prescriptions remain high despite warnings

By Patricia K. Ruiz, JD

Despite a decline in the prescription of codeine for children in the past 10 years, and despite warnings against the use of codeine in children who have a cough or upper respiratory infection (URI), a study published in the journal Pediatrics has shown that a substantial number of codeine prescriptions are still being given to children. According to the study, titled “National Patterns of Codeine Prescriptions for Children in the Emergency Department,” more effective interventions are necessary “to prevent prescription of this potentially hazardous drug to children.”

Background. According to the study, there are serious safety concerns about the use of codeine in children because of the risk of toxicity compared to the inadequate relief the drug provides to many children. “Because of the unreliable effect of the drug and its associated risk for death,” the researchers wrote, “national and international guidelines have recommended against codeine use in children for both of its common indications, analgesia and cough suppression.” Specifically, guidelines issued by the American Academy of Pediatrics (AAP) in 2006 warned about the potential dangers of the drug, as well as its lack of efficacy in children with cough or URI.

Slight decrease in codeine prescriptions. The researchers analyzed the 10 most recent years of data available from the National Hospital and Ambulatory Medical Care Survey (NHAMCS) of emergency department (ED) visits for patients aged three to 17. The sample of data showed 56,375 ED visits by children in this age group, which, when weighted, represented a total of 189,028,628 ED visits between 2001 and 2010. Over this time period, the rate of codeine prescription fell from 3.7 percent to 2.9 percent, with total prescriptions ranging from 558,805 to 876,729 per year. According to the researchers, children between eight and 12 were prescribed codeine more frequently, and there was no statistically significant change in prescription rates for this age group. For ages three to seven, the researchers did find a decline in codeine prescription, which, according to the study, “is reassuring, as these children are at greatest risk for potential toxicity. There was also a decline in prescription for non-Hispanic black children, but the researchers noted that “[d]ecreased prescribing of codeine in these children . . . may reflect general opioid prescription avoidance rather than provider knowledge that poor codeine metabolizers are more common among non-Hispanic blacks.”

Codeine for treatment of URI. Despite guidance by the AAP warning of the risks of codeine use in children for the treatment of cough and URI, the researchers found no changes in prescription patterns. Between 69,057 and 145,857 children are being prescribed codeine every year for URI and cough. “This suggests that cough and URI prescribing may be an important focus for interventions to change provider behavior,” wrote the researchers. The researchers suggested switching from acetaminophen-codeine to acetaminophen-hydrocodone as an alternative, as hydrocodone “has demonstrated efficacy as an analgesic agent with good safety profile in children.” The removal of codeine from hospital formularies and electronic medical record-based decision support for providers was also suggested by the researchers.

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