Posted tagged ‘narcotics’

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

Dispose of unused medications safely

September 26, 2016

The Pediatric Insider

© 2016 Roy Benaroch, MD

Al wrote in, asking what she ought to do with unused medications, including some psychiatric drugs and controlled substances. It’s good to get those out of the house, safely—but how?

Parents should make sure to keep their homes free of unused medications. The misuse of prescription medications (usually narcotic painkillers) has surpassed motor vehicle accidents as the leading accidental cause of death in the US. A lot of these medicines, especially the ones that come into teenage hands, come from unused supplies lifted from parents. Teenagers don’t necessarily know what all of those pills do, and at least some of them are willing to gulp down handfuls just to see what will happen.

Toddlers, too, can find their way to unused, colorful vials in the medicine cabinet – some of which can kill with a single pill. And even adults really shouldn’t hoard antibiotics or other prescription meds. The risks are too high.

But what to do with all of these medicines? Tossing them down the a sink drain or flushing them down the toilet aren’t ideal. Water in municipal drains contributes to their accumulation in our drinking water (though even if we never flushed ‘em down, many are excreted in urine. There’s a pleasant thought.) The FDA does keep a list of “drugs you should flush,” consisting mostly of narcotics and similar medications that are just too dangerous to toss out any other way.

For most medicines, it’s safer to get them to a landfill rather than adding them to our water supplies. You can toss them into your household trash after mixing them with something disgusting, like cat litter, coffee grounds, or dirt. Alternatively, drugs can be incinerated along with other biomedical waste. I don’t know if most docs would agree to do this, but if my patients and families bring me leftover medications, I just add them to my “biohazard” box for transport and incineration. Doesn’t cost me much of anything to add a few vials now and then.

I’ve also seen drug stores selling mailing bags to return medications for destruction. The operative word, there, is ‘selling’—I think $4 for a bag. Not much, but 4 beans that you probably want to spend on something else!

What are you doing with that thing that we don't even know what it does?