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.
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.
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.
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.
Dear Editor,
In the article "National patterns of codeine prescriptions for children in the emergency department" Kaiser et al found a small decline in the overall number of codeine prescriptions for children in U.S. emergency departments.(1) These findings are of particular relevance given the significant safety concerns regarding codeine use in the pediatric population; however, it is also critical to identify the potential unintended consequences of using therapeutic alternatives to codeine in this vulnerable population.
The authors investigated codeine prescriptions for pediatric upper respiratory infections (URIs) and cold symptoms and did not find a significant decrease in utilization. Based on these findings, more effective interventions to curb codeine prescribing were recommended.(1) While we agree that codeine use in children to treat URI symptoms should be avoided, providers must also be cognizant of the dangers of the therapeutic alternatives. One potential concern is that there would be an increase in the use of over-the-counter (OTC) and non-codeine-based prescription cough and cold medications to provide children with symptomatic relief. Like codeine, these medications have limited safety and efficacy data in the pediatric population and their use is also not recommended by the American Academy of Pediatrics' consensus guidelines and the Food and Drug Administration (FDA).(2,3) Providers caring for pediatric patients should be aware of these recommendations as they consider alternatives to codeine-based cough preparations to treat URIs and cold symptoms.
The study also examined trends in codeine utilization in pediatric patients for pain-related indications and recommended hydrocodone as a potential substitute when an opioid analgesic is indicated.(1) Although hydrocodone is an effective alternative to codeine with less potential for adverse drug events related to CYP2D6 polymorphisms, there is also concern regarding nonmedical hydrocodone use in the adolescent population.(4) Rates of opioid analgesic prescribing in adolescents has increased significantly over the past decade, which has paralleled increases in misuse, abuse, addiction, and fatalities.(4,5) In fact, opioid-related fatalities have more than doubled in adolescents over the past two decades.(5) Another important trend is that codeine alternatives, such as hydrocodone and oxycodone have been more commonly implicated in the nonmedical use of opioid analgesics among adolescents compared to codeine itself.(4,5) As such, shifting away from codeine prescribing in favor of drugs such as hydrocodone, may unintentionally increase access to drugs more commonly used for nonmedical purposes in this population. To mitigate nonmedical use, prescribers should evaluate whether there is an indication for an opioid analgesic, and if necessary, prescribe the shortest duration possible, with close follow up.(5)
In summary, the author's conclusions highlight the need for increased vigilance in reducing pediatric codeine prescribing; however, providers should also be aware of the potential harm that may result from the inappropriate prescribing of non-codeine alternatives. Additional initiatives will be required not only to curb pediatric codeine prescribing, but also to ensure the safe and effective use of evidenced- based alternative therapies.
References:
1. Kaiser SV, Asteria-Penaloza R, Vittinghoff E, Rosenbluth G, Cabana MD, Bardach NS. National patterns of codeine prescriptions for children in the emergency department. Pediatrics 2014 Apr 21. [Epub ahead of print].
2. Kelly L. Pediatric cough and cold preparations. Pedatr Rev 2004; 25(4):115-123.
3. American Academy of Pediatrics 2012. Withdrawal of cold medicines: addressing parent concerns. Available at: http://www.aap.org/enus/professional-resources/practice- support/Pages/Withdrawal-of-Cold-Medicines-Addressing-Parent- Concerns.aspx. Accessed April 24, 2014.
4. McCabe SE, West BT, Teter CJ, et al. Medical and nonmedical use of prescription opioids among high school seniors in the United States. Arch Pediatr Adolesc Med 2012; 166(9): 797-802.
5. Mazer-Amirshahi M, Mullins PR, Rasooly IR, van den Anker J, Pines JM. Trends in prescription opioid use in pediatric emergency department patients. Pediatr Emerg Care 2014; 30(4):230-5.
Conflict of Interest:
None declared