Codeine and Tramadol Overused for Pediatric Pain Management Despite Recommendations

Despite warnings from the United States Food and Drug Administration (FDA) 7 years ago, clinicians continue to prescribe perioperative opioids for children undergoing tonsillectomy and adenoidectomy.^1-3 The FDA warned clinicians in 2012 that codeine posed a higher risk than other analgesics in causing respiratory depression in children.²

In addition to prescribing codeine for analgesia, clinicians used it as an off-label cough suppressant.^2,4 Two years ago, the FDA added tramadol to the list of contraindicated drugs for children 12 years old and younger.^2,5

The warnings come as understanding of the metabolism of these opioids in children has evolved. While most children metabolize codeine through the UGT2B7 pathway, about 10% metabolize the opioid through the CYP2D6 pathway, converting the codeine into high-dose morphine.² Likewise, in some children who metabolize via the CYP2D6 pathway, tramadol converts to O-desmethyltramadol, which can also lead to oversedation, respiratory depression, and death.²

Particularly troubling in pediatric patients undergoing a tonsillectomy is that the surgery already compromises the airways.² In addition, children are more susceptible to respiratory depression than adults.

Despite Warnings, Clinician Inertia

In a retrospective chart study of more than 362,000 children, pediatric researcher Kao-Ping Chua, MD, PhD, from the University of Michigan, Ann Arbor, and colleagues found that 1 in 20 clinicians continued to prescribe perioperative codeine for children undergoing tonsillectomy and adenoidectomy from 2010 to 2015.³ The 5-year study examined the prescribing patterns for privately insured children (49.9% aged 0-5 years; 48.7% girls).

While codeine prescribing declined from 31% to 5% during the study period, more concerning is that 3% of children with obstructive sleep apnea were still prescribed codeine, even though obstructive sleep apnea is a known risk for inducing respiratory depression.³ When clinicians substituted alternatives, they were most often hydrocodone or oxycodone.³