Posted tagged ‘addiction’

Codeine is not for children

October 31, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Codeine is a terrible choice for treating children’s pain and cough, and we ought to just stop using it. It’s like an old yogurt container, way at the back of your fridge — sure, it was once tasty, and then for a while you held on to it for sentimental reasons. “Remember that yogurt?” you’d say to your spouse. But it’s well past time to throw that stinky stuff away.

For a long time, codeine was thought to be safer than other opiate-based pain medications. It’s a naturally occurring form of morphine with good oral bioavailability (that means you can swallow it in pill or liquid form.) But codeine, the molecule itself, has no biologic activity or drug effect on its own. It has to be converted, in the liver, to an active “metabolite” to have any effect on your body. And that’s the problem: the “activation” step. It turns out that different people have a huge variability in how quickly they activate codeine, which can lead to all kinds of problems.

Some people are “fast metabolizers” — meaning they very rapidly activate codeine. If you’re one of these people, the effects and side effects of codeine will be much higher than expected. There have been about 64 cases of severe respiratory depression reported in children taking “normal” doses of codeine, and many of these children died.

On the other hand, some people are “slow metabolizers”. They can take a dose of codeine, and their liver just sits there, twiddling its liver thumbs. Nothing happens. There’s no therapeutic effect of even very high codeine doses in these people, because their bodies don’t activate the drug.

A slew of international smart-guys has already begun to limit the use of codeine, especially in children. The US FDA slapped a black box warning against its use in post-op children, the Europeans issued a report suggesting that we stop using codeine entirely in children less than 12, and Health Canada even joined the fun, calling codeine “a big hoser of a mistake, eh?”

So, if not codeine, what else can we safely use to treat serious pain in children? Oxycodone (found in Percocet and other products), should have much less variability, though there will still be some added risk to fast metabolizers. The best option, really, might be to go back to using straight-up morphine, but there aren’t great studies looking at its absorption in children.

Non-opiate pain medicines work well, too — in many cases, as well as opiates, if used correctly. These medications, including acetaminophen and ibuprofen, can very effectively relieve even serious, post-op pain, if they’re given in advance and on schedule. Even if they can’t relieve pain completely, they can be used to reduce the doses of opiates needed. There are also IV preparations of acetaminophen and some NSAIDs.

We also need to be very careful about the kind of pain we’re treating. Acute serious pain, from surgery or a broken bone, can and should be safely treated with a combination approach that often includes opiates in the short run. But chronic or recurrent pain (including backaches and migraines) should not be treated with opiates. In the long run, these medicines actually increase the body’s sensitivity to pain, potentially leading to a cycle of dependence and addiction.

Sometimes, codeine is also used as a cough suppressant. The same risks for high- or low- metabolizers are there, and in fact there are no studies showing that codeine is even effective for cough in children. You’ve got all the risk for potentially zero benefit.

Codeine is an old medicine that’s way past its prime. We’ve got better drugs to choose from. If your doc offers a codeine prescription for your child, it’s time to say “no.”

Mmm codeine

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You and I are your child’s drug dealers

July 7, 2014

The Pediatric Insider

© 2014 Roy Benaroch, MD

Doing drugs no longer requires a dealer on the street corner.

Between the late 1990’s and 2010 sales of narcotic pain medicines quadrupled in the United States. Hydrocodone use increased by 280%, methadone by 1300%, and oxycodone by 900%. As the consumption of these medicines increased, so did ER visits and deaths from overdose– up by about 500%.

A whole lot of these medicines are not going to medical use. And a lot of the abuse is by our children.

And our kids, they know where to get these medicines. 10% of 8th graders and 45% of 12th graders believe they’re easy to obtain. Pain medicines are kept unsecured and unmonitored in about 75% of homes with teenagers. And over 50% of teens who abused narcotic prescription drugs say they got them from their own friends or family, just by opening a pill bottle, usually in their own homes.

Doctors and parents are both to blame. They get the drugs from us. We need to do a better job protecting our own children.

Doctors need to prescribe carefully, and keep track of refills. Pain has to be treated with more than just narcotics (though narcotics have to be part of the treatment of almost all serious pain.) We need to be careful to look for the early signs of dependence, which can develop into addiction and abuse.

Parents, grandparents, and neighbors need to lock up and keep track of these medications. Pain meds, ADHD meds, any kind of meds– they all can be abused. Set a good example by always using medications as directed.

“Leftovers” should be safely discarded, never hoarded. The best way to discard most medications is in your household trash, mixing the pills or liquid into something unpalatable, like coffee grounds or kitty litter. The FDA advises that some medications are best flushed down the toilet, including most narcotics. Alternatively, some pharmacies and doctors are happy to take back unused medicines to put with medical trash for incineration. (We may not legally be allowed to collect “controlled subtances,” including painkillers and ADHD medications.)

Medications, especially narcotics used for pain relief, are a crucial part of the relief of real suffering for many people. But there’s no doubt that a lot of the narcotics prescribed in the US are being abused. You owe it to your kids– don’t become their drug dealer. Keep those medicines safe.