National Patterns of Codeine Prescriptions for Children in the Emergency Department

Abstract

BACKGROUND AND OBJECTIVES: National guidelines have recommended against codeine use in children, but little is known about prescribing patterns in the United States. Our objectives were to assess changes over time in pediatric codeine prescription rates in emergency departments nationally and to determine factors associated with codeine prescription. METHODS: We performed a serial cross-sectional analysis (2001–2010) of emergency department visits for patients ages 3 to 17 years in the nationally representative National Hospital Ambulatory Medical Care Survey. We determined survey-weighted annual rates of codeine prescriptions and tested for linear trends over time. We used multivariate logistic regression to identify characteristics associated with codeine prescription and interrupted time-series analysis to assess changes in prescriptions for upper respiratory infection (URI) or cough associated with two 2006 national guidelines recommending against its use for these indications. RESULTS: The proportion of visits (N = 189 million) with codeine prescription decreased from 3.7% to 2.9% during the study period (P = .008). Odds of codeine prescription were higher for children ages 8 to 12 years (odds ratio [OR], 1.42; 95% confidence interval [1.21–1.67]) and among providers outside the northeast. Odds were lower for children who were non-Hispanic black (OR, 0.67 [0.56–0.8]) or with Medicaid (OR, 0.84 [0.71–0.98]). The 2006 guidelines were not associated with a decline in codeine prescriptions for cough or URI visits. CONCLUSIONS: Although there was a small decline in codeine prescription over 10 years, use for cough or URI did not decline after national guidelines recommending against its use. More effective interventions are needed to prevent codeine prescription to children.

Trends in opioid prescriptions among children and adolescents in the United States

“…Similarly, Richardson et al found increased rates of opioid prescriptions to adolescents with non-cancer pain from 2001 to 2005 in the USA [22]. In contrast to these studies Kaiser et al found that rates of opioid prescriptions did not increase among children and adolescents presenting to emergency departments in the USA between 2001 and 2010[9]. However, these studies did not provide critically important information on opioid prescriptions among family members to allow for understanding the context of opioid availability in the home to children and adolescents in the USA.…”

Pharmacogenetics for Safe Codeine Use in Sickle Cell Disease

“…1, 2 Citing its unpredictable pharmacokinetics and pharmacodynamics that could lead to deleterious outcomes, some have suggested ending all codeine use in children. 3,4 In response, several pediatric hospitals have removed codeine from their formularies. [5][6][7] Although these efforts may be a justifiable use of the formulary system to improve patient safety, it is a blunt approach that limits therapeutic options.…”

“…Although codeine is commonly prescribed (>18 million US outpatient prescriptions in 2013) 10 and largely well tolerated, the reports of severe adverse events and death in children ignited discussion about its risks and benefits. 3,4,[11][12][13] It is well established that some individuals may not experience any pain relief from codeine, likely a result of its poor metabolism, but both lack of efficacy and safety concerns may be reduced through preemptive CYP2D6 genotype testing. 9 Using this approach, clinicians know in advance of prescribing which patients may be at risk for a poor outcome with codeine and conversely, which patients are most likely to benefit from it.…”

The Use of a Pediatric Migraine Practice Guideline in an Emergency Department Setting

“…53 However, no studies specifically address codeine use in pediatric migraine patients, and current national guidelines recommend against its use in the ED. 54 Codeine was not part of our MCPG, due to concerns regarding opioid toxicity. Codeine is metabolized through the CYP3A4 subfamily and CYP2D6 subfamily of cytochrome P450 enzymes.…”