Codeine In Children Research Articles

Prescribing Patterns of Codeine and Alternative Medicines in Children in Europe.

IntroductionConcerns over serious respiratory depression in children led to two European Union (EU) referral procedures (in 2013 and 2015) to review the benefit–risk balance of codeine in this population when used for pain relief, cough or cold. Consequently, codeine should no longer be used in children aged < 12 years and restrictions were introduced for treatment in children ≥ 12 years.ObjectiveThis multinational collaborative study aimed to assess the effectiveness of these risk minimisation measures by evaluating changes in prescribing of codeine and alternative treatments.MethodChildren under 12 and 12–18 years old were followed between 2010 and 2017 to analyse quarterly trends in prescribing of codeine and alternative treatments in electronic health records from France, Germany, Norway, Spain and the United Kingdom using interrupted time series analysis.ResultsOverall prescribing of codeine in children decreased in all five countries, reaching near zero prevalence in children under 12 years of age. This was accompanied by an increase in use of other opioid analgesics in France (from 0.15 to 0.56 prevalence per 100 person-years immediately after the first referral), Norway (from 0.0006 to 0.0013 at the end of the study), the United Kingdom (from 0.018 to 0.05 at the end of the study), and an increase in non-opioid analgesics in Norway (from 0.045 to 0.075 at the end of the study) after the referral on pain relief indication. The referral on cough/cold indication led to a decrease in use of opioid and non-opioid antitussives in children aged < 12 years in France (from 10 to 7 and 20 to 16, respectively) and had no impact in other countries. Overall prescribing trends for codeine and alternatives were similar across both age groups within each country.ConclusionThe decrease in use of codeine shows that healthcare professionals followed the adopted measures and switched prescribing practices for pain management in children aged < 18 years towards opioid or non-opioid analgesics depending on national clinical and reimbursement settings. Whist the magnitude of the first referral on pain differed between countries, the second referral on cough/cold had only a minimal impact on the use of codeine and antitussives.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40264-022-01214-y.

Assessment of the Management of Post-Tonsillectomy Pain at the ENT-CFS Department of Ignace Deen National Hospital

Introduction: Tonsillectomy is described as one of the oldest surgical procedures according to the authors of the surgical treatise (Aulus Amida and Paul of Aegina in the 6th and 7th centuries) found in the Vatican library. The contraindication of codeine in children has changed the management of post tonsillectomy pain. The aim of this study was to assess the management of post tonsillectomy pain in our developing country context. Methods: This was a prospective, analytical study lasting 6 months (September 2019-February 2020), carried out in the ENT/CFS department of the Ignace Deen National Hospital. We included in this study all patients who underwent a tonsillectomy in the department during the study period and who agreed to participate in the survey. Results: 34 patients were included in our study, i.e. a frequency of 25% of surgical interventions. The mean age of our patients was 18.06 ± 12 years with extremes of 03 years and 45 years. Recurrent hypertrophic tonsillitis with sleep disturbances was the most frequent indication for surgery in our study, at 47.06% (n = 16). We performed an isolated tonsillectomy in 52.9% (n = 18) of cases. Analgesia was multimodal using the WHO Step I and II analgesics in 44.1% (n = 15) and 55.9% (n = 19), respectively. Pain control was satisfactory in all patients. Conclusion: The evaluation of post tonsillectomy pain is essential for optimal management. In this indication, multimodal analgesia, involving several levels I and II analgesics, provided satisfactory pain control.

Pharmacist and Pediatrician Knowledge of Codeine Use in Children.

In 2011, approximately 1.7 million pediatric patients had a codeine-containing prescription filled at a US retail pharmacy. Numerous cases involving serious adverse effects or fatalities have been reported in children who have been prescribed codeine. In 2013, the US Food and Drug Administration added a boxed warning to avoid codeine in children after a tonsillectomy. The purpose of this study is to determine pharmacists' and pediatricians' knowledge of the boxed warning for codeine in children. Two separate surveys were administered to community pharmacists in Maryland, pediatricians, and pediatric residents at a single institution in Maryland. Both surveys consisted of questions regarding knowledge of the boxed warning for codeine in children. There was no difference in the awareness of the boxed warning between pharmacists (48.9%, n = 43) and pediatricians (51.3%, n = 41, p = 0.88). More pharmacists knew that ultrarapid metabolizers have the risk for increased adverse events from codeine (39.5% pharmacists vs. 20% pediatricians, p = 0.01). In addition, 36% of pharmacists and 33% of pediatricians noted that it was never appropriate to use codeine in a child (p = 0.73). Only half of pharmacists and pediatricians surveyed were aware of the boxed warning for codeine. One third of pharmacists and pediatricians in this study would never use codeine in a child. Therefore, more education is needed for pharmacists and pediatricians regarding the dangers of using codeine in children.

Pain after tonsillectomy: effectiveness of current guidelines?

Tonsillectomy is one of the most common major surgical procedures performed in children. In 2013, the use of codeine in children was severely restricted. French guidelines for treating tonsillectomy's postoperative pain at home have been reconsidered OBJECTIVE: The aim of our study was to measure effectiveness and safety of two schedules: acetaminophen + ibuprofen (A + I) and acetaminophen + tramadol (A + T) in children who underwent tonsillectomy. We undertook a 1 year prospective and observational single-center study. All children who underwent tonsillectomy were eligible. The choice of the regimen, A + I group or A + T group, was left for the anesthesiologist in charge, done during the pre-anesthetic assessment. After hospital discharge, parents had to give systematically A + I or A + T, 4 times a day during 5days and then acetaminophen alone for the next 5days The primary endpoint was the home pain assessed using Parents' Postoperative Pain Measurement Short Form (PPPM-SF) scale. Secondary endpoints were the rate of further hospitalization and/or surgery due to tonsillectomy-related adverse events. Over the study period, 342 tonsillectomies were performed. The return rate of PPPM-SF scales was 58%. Two hundred patients were analyzed. The median age was 4 [3; 5.2] years and was lower in group A + I (4 [3; 5]; 5 [4; 7]; p < 0.0001). PPPM-SF scores were greater than or equal to 3 in both groups during the first 6 postoperative days. The mean decrease of PPPM-SF score over time was higher in group A + I than in group A + T (p = 0.007). Readmission rate was significantly higher in group A + T (A + I: 0; A + T: 7; p = 0.002) as the rate of reoperation for bleeding (A + I: 0; A + T: 3; p = 0.049). Home pain management after tonsillectomy should be improved. In clinical practice, A + I seems at least as effective as the combination A + T, without increasing readmission and/or additional surgery for bleeding.

Codeine use among children in the United States: a nationally representative study from 1996 to 2013.

Concerns regarding the safety of codeine have been raised. Cases of life-threatening respiratory depression and death in children have been attributed to codeine's polymorphic metabolic pathway. International health agencies recommend restricted use of codeine in children. Despite these recommendations, the epidemiology of codeine use among children remains unknown. Our objective was to examine patterns of codeine use in the US among children. A cross-sectional analysis of children of age 0-17 years from 1996 to 2013 in the US was performed. Data were extracted from MEPS, a nationally representative set of health care surveys. Prevalence rates of codeine use between 1996 and 2013 were examined. Multivariable logistic regression examined relationships between codeine use and patient demographics. Codeine use remained largely unchanged from 1996 to 2013 (1.08 vs 1.03 million children, respectively). Odds of codeine use was higher in ages 12-17 (OR, 1.40; [1.21-1.61]), outside of the Northeastern US, and among those with poor physical health status (OR, 3.29 [1.79-6.03]). Codeine use was lower in children whose ethnicity was not white and those uninsured (OR, 0.47 [0.34-0.63]). Codeine was most frequently prescribed by emergency physicians (18%) and dentists (14%). The most common condition associated with codeine use was trauma-related pain. Pediatric codeine use has declined since 1996; however, more than 1 million children still used codeine in 2013. Health care providers must be made aware of guidelines advising against the use of codeine in children. Codeine is potentially hazardous and safer alternatives to treat children's pain are available.

Codeine: Time to Say "No".

Codeine has been prescribed to pediatric patients for many decades as both an analgesic and an antitussive agent. Codeine is a prodrug with little inherent pharmacologic activity and must be metabolized in the liver into morphine, which is responsible for codeine's analgesic effects. However, there is substantial genetic variability in the activity of the responsible hepatic enzyme, CYP2D6, and, as a consequence, individual patient response to codeine varies from no effect to high sensitivity. Drug surveillance has documented the occurrence of unanticipated respiratory depression and death after receiving codeine in children, many of whom have been shown to be ultrarapid metabolizers. Patients with documented or suspected obstructive sleep apnea appear to be at particular risk because of opioid sensitivity, compounding the danger among rapid metabolizers in this group. Recently, various organizations and regulatory bodies, including the World Health Organization, the US Food and Drug Administration, and the European Medicines Agency, have promulgated stern warnings regarding the occurrence of adverse effects of codeine in children. These and other groups have or are considering a declaration of a contraindication for the use of codeine for children as either an analgesic or an antitussive. Additional clinical research must extend the understanding of the risks and benefits of both opioid and nonopioid alternatives for orally administered, effective agents for acute and chronic pain.

AAP: “Time to Say No” to Codeine for Children

Citing risk for respiratory depression or death, the American Academy of Pediatrics, in a clinical report, urges clinicians and parents to stop giving

CHANGING PRESCRIBING CULTURE – A FOCUS ON CODEINE POSTPARTUM

AimTo eliminate the prescribing of codeine and codeine combination products postpartum to improve safety in breast fed infants.Concerns have been raised over the use of codeine and codeine combination products...

Pain management in the acute care setting: Update and debates.

Pain management in the paediatric acute care setting is underutilised and can be improved. An awareness of the analgesic options available and their limitations is an important starting point. This article describes the evolving understanding of relevant pharmacogenomics and safety data of the various analgesic agents with a focus on agents available in Australia and New Zealand. It highlights the concerns with the use of codeine in children and discusses alternative oral opioids. Key features of oral, parenteral, inhaled and intranasal analgesic agents are discussed, as well as evidence supported use of sweet tasting solutions and non-pharmacological interventions. One of the biggest changes in acute care pain management has been the advent of intranasal fentanyl providing reliable potent analgesia without the need for intravenous access. The article will also address the issue of multimodal analgesia where a single agent is insufficient.

DTB Select: 6 | June 2015

Further restrictions on the use of codeine in children ● MHRA reminder on misleading medicine advertising ● A protocol for deprescribing ● Regulating herbal medicines: next steps ● Paracetamol ineffective...

WHAT DO DOCTORS WORKING IN PAEDIATRICS THINK ABOUT SWITCHING FROM CODEINE TO MORPHINE?

Purpose Following the publication of restrictions on the use of codeine in children by the Medicines and Healthcare Products Regulatory Agency (MHRA) in July 2013,1 many paediatric centres changed to using morphine in place of codeine. In our centre, the switch occurred in October 2013. Approximately six weeks later we asked all doctors working in paediatrics for their opinions on switching from codeine to morphine. Methods Six questions were developed to assess how doctors had found out about the safety concerns with codeine; their opinion on the information provided and the coordination of the switch within the Trust; whether they thought the switch to morphine was a positive or negative change and what they thought could be done to improve the way morphine is used. The questions were inputted into survey monkey software and the link generated was emailed to all consultants and junior doctors working in paediatrics (approximately 280 recipients). Two weeks after the survey was circulated the responses were collated and analysed using descriptive statistics and thematic analysis. Results Twenty nine doctors responded to the survey. They reported receiving information about the safety concerns with codeine from a variety of sources with emails from MHRA/outside the Trust being the most common. 83% were happy with the information they received from within the Trust about the planned switch from codeine to morphine and 88% were positive or neutral about how the switch was coordinated. Of the 64 comments made about using morphine instead of codeine, 77% were negative, 20% positive and 3% neutral with the most common concerns being increased risk of errors, abuse/ingestion potential in the community, lack of an intermediate analgesic and reduced availability due to controlled drug restrictions. Positive themes included improved pain management with morphine, simpler regimes and the variety of preparations giving greater flexibility. Ideas for improving the way morphine is used included audit, feedback, training and using a single strength of morphine solution or adding warnings to highlight the stronger preparation. Conclusions Although the response rate to the survey was poor, the results showed that the majority of those replying had negative opinions about the switch to using morphine instead of codeine. Most were concerned about the potential risks associated with increased use of morphine although there were positive comments about morphine improving pain management. The survey is due to be repeated in July 2014 to determine whether opinions have changed and a comparison between the quantities of morphine and codeine issued from pharmacy will be undertaken to see if overall oral opiate use has changed.

G412(P) To evaluate the management of acute painful crisis, outcomes of safety and efficacy of codeine in children with sickle cell disease

<h3>Method</h3> A retrospective audit was performed on all admissions with diagnosis of sickle cell pain from January to December 2013. Case notes of 54 patients were reviewed using pre-specified audit criteria. Types of analgesics administered at home and in hospital and pain scores were recorded where available from the case notes. <h3>Results</h3> Over the one-year period, 91 admissions were recorded. The average age was 6.6 years (±4.1), with the majority of children (45%) aged between 1 and 5 years. The most prevalent haemoglobinopathy was HbSS (82%). The majority of patients (61%) had a single painful crisis admission, 33% had 2–3 admissions, and the remainder presented with four or more admissions. Most patients (93%) received one or more analgesics prior to admission. The drug of choice varied, with paracetamol and ibuprofen been the most frequently utilised combination (43%), while 22% received opioids (20% had codeine). Similar to the pre-admission trends, a wide range of analgesics were utilised in hospital with the majority of patients receiving paracetamol and ibuprofen combination (43%). The doses utilised at home were considerably less than those given on admission, suggesting inadequate pain management at home. Codeine was given in 37% of the cases in and it was observed that patients who received codeine had significantly higher initial pain scores on admission compared with those who did not receive codeine. However the administration of codeine did not greatly improve the pain scores and additional step up analgesia was required in 10% of cases who received codeine in hospital. <h3>Conclusion</h3> Clear analgesic benefits could not be demonstrated for codeine use with regards to the outcome of efficacy. Although dihydrocodeine is now the weak opioid of choice at our unit added safety measures similar to those with codeine are in place. The audit was limited by poor documentation which have been addressed by the introduction of clearer updated local documents.

EMA recommends restrictions on codeine for children

EMA recommends restrictions on codeine for children

AUDIT OF THE PAEDIATRIC PAIN GUIDELINES

AimTo assess whether the trust's multidisciplinary guideline on pain management in children1 is being adhered to.MethodA data collection tool was designed, piloted on 4 patients, and then adapted for use...

Why Can’t We Retire Codeine?

Some remedies have long outlived their usefulness and have thankfully been relegated to historical archives, supplanted by safer, more effective drugs. We no longer prescribe mercury loop diuretics or antisyphilitic arsenicals. Yet, the use of codeine-containing products persists for cough relief and analgesia in children. As Kaiser et al1 report in their study “National Patterns of Codeine Prescriptions for Children in the Emergency Department” in this month’s issue, prescriptions for codeine-containing products barely edged down in frequency between 2001 and 2010, despite convincing studies documenting their lack of benefit and serious adverse effects. Using data from the National Hospital and Ambulatory Medical Care Survey database, they found codeine prescribed in the pediatric emergency department at the incredible rate of 558 805 to 876 729 prescriptions per year with only a small statistical decline over that period. Additionally, the US Food and Drug Administration reported that >1.7 million children aged 17 years and younger had a prescription for a codeine product filled at a pharmacy in 2011.2 These high numbers continue despite guidance from professional societies discouraging the use of codeine in children. Why do pediatric practitioners continue to write prescriptions for codeine? Kaiser et al … Address correspondence to Alan D. Woolf, MD, MPH, FAAP, Pediatric Environmental Health Center, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: alan.woolf{at}childrens.harvard.edu

Codeine for children

Codeine for children

A Comparison of Postoperative Tramadol versus Acetaminophen with Codeine in Children Undergoing Tonsillectomy

Objectives: 1) Evaluate the effectiveness of tramadol compared to codeine/acetaminophen for post-tonsillectomy pain management. 2) Describe the safety and side effects of tramadol compared to codeine/acetaminophen during the post-tonsillectomy recovery period. Methods: Prospective, double-blinded, randomized controlled clinical trial of children ages 4-15 who underwent routine tonsillectomy (with or without adenoidectomy) surgery at Children’s Hospitals and Clinics of Minnesota in 2011 and 2012. Children were randomized to receive scheduled—followed by PRN—dosing of either tramadol or codeine/acetaminophen. Primary outcomes were assessed during a 10-day postoperative follow-up period with parent diaries and chart review. Diaries captured the following domains: physical recovery; pain (multiple pain scales); sleep; side effects; need for medical attention; and global satisfaction with treatment. Results: The final sample of 74 children was mostly white (92%), female (65%), and 6 years of age (range 4-14). Most parents completed diaries for ≥ 4 days (92%). There were no significant differences between groups in terms of medication efficacy or overall experience with side effects. Groups did not differ in terms of days with a mean pain score &gt;4 ( P = 0.85) (tramadol = 1 day; codeine = 1.5 days). Conclusions: There were no differences between groups in terms of postoperative medication efficacy or safety in this small trial. Due to codeine’s declining acceptability for use in children and risks associated with its efficacy and safety, tramadol should be considered as a first line prescription for children undergoing this common procedure. Further evaluations of oral pain medications for post-tonsillectomy care should be conducted.

Wither codeine?

Wither codeine?

Pain Management in Children: Part 2 — A Transition from Codeine to Morphine for Moderate to Severe Pain in Children

Opioids remain the agent of choice for the treatment of moderate to severe pain in both adults and children. Codeine, an opioid analogue, is commonly used in the treatment of mild to moderate pain in both adults and children. However, there has been growing concern about the safety of codeine use in children. This second part of the article on pain management in children will focus on codeine's questionable efficacy and safety concerns about the use of codeine in children.

Pain Management in Children: Part 1 — Pain Assessment Tools and a Brief Review of Nonpharmacological and Pharmacological Treatment Options

If pain is not treated quickly and effectively in children, it can cause long-term physical and psychological sequelae. Therefore, it is important for all health care providers to understand the importance of effective pain control in children. This article is divided into 2 parts: Part 1 reviews the pharmacotherapy of pain management in children and Part 2 will review the problems relating to the use of codeine in children, and the rationale for recommending morphine as the opioid of choice in the treatment of moderate to severe pain. There has been growing concern about codeine's lack of efficacy and increased safety concerns in its use in children. Due to the variability of codeine metabolism and unpredictable effects on efficacy and safety, The Hospital for Sick Children in Toronto, Ontario, no longer includes codeine or codeine-containing products on the regular hospital formulary and now recommends oral morphine as the agent of choice for the treatment of moderate to severe pain in children. A knowledge translation (KT) strategy was developed and implemented by the hospital's Pain Task Force to support this practice change.