Health Care

Doctors Still Prescribing Risky Codeine To Kids After Tonsillectomy

Doctors Still Prescribing Risky Codeine To Kids After Tonsillectomy”

"Codeine in general for children ought to be a zero event".

Codeine, an opioid pain reliever, came under scrutiny due to its adverse effects on children. According to the FDA, it led to serious breathing troubles, including 24 deaths, in children from January 1969 to May 2015. Chua said he does not think it's lack of awareness, because black box warnings are clear.

"The residual codeine prescribing is concerning since this should be a zero event", says lead author Kao-Ping Chua, M.D., Ph.D., a researcher and pediatrician at University of MI C.S. Mott Children's Hospital who conducted the study with colleagues at the University of Chicago and Harvard Medical School. In 2013, the U.S. Food and Drug Administration issued a "black box" warning, advising doctors against prescribing codeine to children to control tonsillectomy pain. According to Chua, who worked at UChicago Medicine while conducting the research, codeine has historically been among the most common drugs used to treat pain in children following these childhood surgeries.

"Five percent may not sound like a huge number, but you have to remember that the tonsillectomy and adenoid removal is the second most common surgery in children", said Chua, assistant professor of pediatrics and communicable diseases at the University of MI and C.S. Mott Children's Hospital. It is converted to morphine by a liver enzyme, and the speed of this conversion varies from person to person.

"Approximately 1-2% of people are "ultra-metabolizers" who convert codeine to morphine extremely quickly, causing a rapid spike in blood morphine levels and a resulting risk of overdose", he added. As a result, the FDA initiated a safety investigation in August 2012 and ultimately issued a "black box warning" that specifically prohibited the use of codeine for children undergoing these surgeries.

"This is an unacceptable gamble given that there are better alternatives", he added.

The researchers analyzed prescription data from Truven MarketScan Commercial Claims and Encounters database for over 360,000 privately insured children from all across the US who had tonsillectomies, adenoidectomies, or both.

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Codeine prescribing to children has declined further since 2015, says Dr. Kris Jatana, an otolaryngologist at Nationwide Children's Hospital who was not involved in the Pediatrics study.

The study was conducted to find out who well the doctors in the USA were heeding the warning issued by the FDA.

"There has been a shift away from the codeine prescriptions because of the black box warning". However, Chua said these drugs also have side effects and are prone to abuse, so the best strategy to manage post-surgical pain in children is to start with over-the-counter painkillers and only rely on opioids when absolutely necessary.

"The default position should be, 'let's avoid opioids, ' " Chua said.

"The problem is we don't how each patient metabolizes codeine. Plus, there are alternatives - like Tylenol [acetaminophen] and ibuprofen". "We shouldn't be using codeine for any reason in children".

It's not clear why some doctors continued to prescribe the drug. This trend deserves further study, Chua notes. "Over- the-counter agents like that actually have been proven to be quite effective in managing pain after tonsillectomies and adenoidectomies", he says.

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