Running head: USE OF CODEINE ANALGESICS ON PEDIATRIC PATIENTS
Use of Codeine Analgesics on Pediatric Patients
Zachary Zwiernikowski
Ferris State University
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USE OF CODEINE ANALGESICS ON PEDIATRIC PATIENTS
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Abstract
Analgesics are medications that alleviate pain, and often go by the simple name of “painkillers.”
Analgesics are used by postoperative patients of every age on a regular basis. Previously thought
to be completely harmless, some of the analgesic compounds have recently been proven to cause
harmful side effects. The painkiller in question is Codeine, and the affected individuals are
children, specifically post-tonsillectomy adolescents. The primary reason for these adverse
reactions are due to the way Codeine is metabolized. Along with metabolism, obstructive sleep
apnea in children increases the risk of adverse effects of taking codeine postoperatively. The
FDA has released warnings and recommendations about the dosage and possible side effects of
pediatric codeine use.
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Use of Codeine Analgesics on Pediatric Patients
Codeine is an analgesic that is “marginally better than aspirin for most people” (Watt &
Arnstein, 2013). Primary health care providers are the largest group of practitioners prescribing
codeine, at 89.1% of providers asked in one general survey. Out of all practitioners surveyed,
39.6% of codeine prescribers have been in the practice for at least 20 years. Newer practitioners,
of 5 years or less, are cutting back on codeine prescription with only 19.4% of the codeine
prescribers in this category (Cartabuke, Tobias, Taghon, & Rice, 2013). Codeine use seems to
be on the downturn with younger practitioners, possibly due to the recent findings of pediatric
effects.
Analgesics In Everyday Use
Analgesics are used for postoperative patients as a method of pain relief. Many
analgesics can be obtained over-the-counter and used in daily life for headaches, toothaches, and
more. These analgesics do not have to be prescribed by a physician and are known throughout
the households by fairly recognizable names. Advil and Motrin are both brand names for
ibuprofen, found within most households. Acetaminophen, commonly branded as Tylenol, is as
similarly effective as ibuprofen, but is less likely to cause stomach irritation. Naproxen may be a
bit more effective at pain reduction for some people, but may cause more routine stomach
irritation. Aspirin is becoming increasingly more common due to observed benefits such as a
reduction and blood clots, and is the oldest analgesic on the market. These four analgesics can be
found in homes everywhere due to the ease obtaining them and the effectiveness to stop slight
pain that occurs on a regular basis (Columbia Health, 2012). Aside from over-the-counter
medication, physicians can prescribe other medications that often help to maximize pain
USE OF CODEINE ANALGESICS ON PEDIATRIC PATIENTS
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alleviation. One such prescribed medication has been under scrutiny due to its adverse effects on
pediatric postoperative patients. That drug is codeine.
Codeine’s Mechanism and Pediatric Patients
Codeine is prescribes to pediatric patients for post-tonsillectomy and/or adenoidectomies.
The way codeine takes effect is through the metabolizing of the drug. Watt and Arnstein (2013)
note that during metabolism, codeine metabolizes into morphine, providing the patient with pain
relief. They explain that most patients normally metabolize codeine, but a percentage of
individuals can be slow- or ultra-rapid metabolizers. Normal and slow metabolizing patients
have no issue with codeine, but ultra-rapid metabolizers are at risk for opioid toxicity and even
overdose at recommended dosages. Data shows that these ultra-rapid metabolizing pediatric
patients are more prevalent than one may expect with a range of 1%-10% among white
individuals, 3% among blacks, 1% among Hispanics and Asians, and 28% among North Africans
(Watt & Arnstein, 2013).
Obstructive Sleep Apnea
In addition to patients that are ultra-rapid metabolizers, patients with obstructive sleep
apnea (OSA) also run an increased risk of harm when taking codeine. Pre-existing breathing
problems already apparent with the presence of OSA combined with possible labored breathing
during codeine’s conversion into morphine put these patients are at greater risk than the average
post-tonsillectomy patient (U.S. Food and Drug Administration, 2013). FDA recommendations
for pediatric patients receiving codeine for post-tonsillectomy is to administer the medication at
the lowest possible dose while carefully monitoring the patient’s response (Watt & Arnstein,
2013).
Nursing Theory
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The recent findings of codeine’s adverse effects on pediatric patients ties into Margaret
A. Newman’s nursing theory for patient care. Her theory states that “Nursing interventions are
purposeful, using a total-person approach to patient care to help individuals, families, and groups
attain and maintain wellness” (Taylor, Lillis, LeMone, & Lynn, 2011, p. 74). Within the
clinical practice it is important for nurses to address the patient’s full self, including their current
conditions. This can be applied to codeine’s negative reactions by assessing the patient and
informing the physician of preexisting conditions, such as ultra-rapid metabolism or OSA.
Prescribing the correct minimum dose for these patients is detrimental to effectiveness and health
of the patient. Clinical application points to “reducing adverse conditions that increase the risk
for or actually affect optimal patient functions” (Taylor, Lillis, LeMone, & Lynn, 2011, p.
74). Teaching a patient and family of the side effects that could point to a negative reaction to
codeine can help to give directive to the family. Knowing what do to if a given situation arises
increases optimal patient understanding and function. Teaching is part of a nurses job, and
teaching is a great intervention that uses the total-person to help maintain his or her wellness.
Conclusion
Pediatric patients are at risk of adverse effects when using codeine if the patient is an
ultra-rapid metabolizer or has OSA. The primary reason is the conversion of codeine to
morphine. Ultra-rapid metabolizers may receive an overdose of morphine due to the excessive
metabolism of codeine even if the patient’s dose is the correctly prescribed amount. Patients
with OSA have a previous breathing condition in which the morphine metabolized may act
adversely with. The FDA has released warnings and recommendations of proper dosage. There
are many other analgesics that may work to alleviate postoperative pain if the risks while using
codeine are too great.
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References
Cartabuke, R. S., Tobias, J. D., Taghon, T., & Rice, J. (2013). Current practices regarding
codeine administration among pediatricians and pediatric subspecialists. Clinical
Pediatrics. doi: 10.1177/0009922813498151
Columbia Health. (2012, July 20). Aspirin vs. ibuprofen. Retrieved from
http://goaskalice.columbia.edu/aspirin-vs-ibuprofen
Taylor, C. R., Lillis, C., LeMone, P., & Lynn, P. (2011). Taylor's clinical nursing skills: A
nursing process approach (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
U.S. Food and Drug Administration. (2013, Feb 20). Safety announcement. Retrieved from
http://www.fda.gov/Drugs/DrugSafety/ucm339112.htm
Watt, L.D., & Arnstein, P. (2013). Codeine for children: Weighing the risks. Nursing, 43 (11),
62-63. doi: 10.1097/01.NURSE.0000435212.18895.d1