I try to make a point of not criticizing other doctors’ decisions. When a patient of mine sees a provider outside of my practice and is cared for in a manner different from what I would have done, I generally try to give some deference to variations in perspective and training. Since I wasn’t present in these situations and may not have all the relevant information in assessing the care given, so long as it seems reasonably competent I don’t bad-mouth the other provider.
But dammit, recently someone went and prescribed codeine to one of my patients.
She was traveling with her family out of the state, and developed a fever and cough. A physician in that area saw her, diagnosed her with a sinus infection, and gave prescriptions for both an antibiotic and a codeine-acetaminophen combination—the latter to control her cough. (Some minor details have been changed out of respect for patient confidentiality.) Her parents brought her to see me for a follow-up upon their return.
Looking at her prescriptions, I couldn’t stop myself. The antibiotic for sinusitis was a judgment call (PDF), and fell into the “I wasn’t there” category of clinical decisions I wouldn’t second-guess. But the codeine? That was straight up bad medicine, and I said so.
Unfortunately, it appears that an appalling number of medical providers are practicing just this kind of bad medicine. According to a new study in the journal Pediatrics (PDF), from 2001 to 2010, hundreds of thousands of prescriptions for medications containing codeine were provided at emergency room visits in the United States. Extrapolating from a representative sample, the authors report that this staggering tally of inappropriate prescriptions were written for the management of pain or as a cough suppressant in children under 12.
Codeine should not have been prescribed for these patients because its metabolism in children varies widely from person to person. The medication is converted to morphine in the liver, and the efficiency of this process for any given patient is difficult to predict. Some metabolize codeine quite poorly and have inadequate pain control as a result. Others have the opposite problem and are “ultra-rapid” metabolizers at risk for potentially fatal overdose. There is no ready and reliable means of telling which category the child in front of you may fall into.
Because of the wide variability in codeine metabolism, its use as a cough suppressant is not recommended. This should not be news to any medical provider, given that these recommendations came out in 1997. In 2012, the Food and Drug Administration put a black box warning on its use as an analgesic following surgery to remove the tonsils or adenoids. In Europe, it is restricted outright to patients under 12.
Evidence-based medicine often involves changes in recommended practices, sometimes resulting in great controversy. Long-established guidelines can, over time, be shown to need revision. The recommendation to avoid peanuts and other “highly-allergenic” foods until children reached certain ages to lower the risk of allergy, for example, was established in 2000, vaguely reversed in 2008, and finally clarified last year. If medical providers don’t keep up, they can find themselves delivering care that is outdated at best and downright harmful at worst.
But to be so far behind the times that you are prescribing a medication despite recommendations to the contrary that have been around since Bill Clinton’s second term is disgraceful. There is no excuse for this kind of carelessness. The numbers reported in this new study are a shocking indictment of how out of touch some medical providers can be.
My patient should not have had a prescription for codeine, and if I’d been in a position to prevent it, I would have. It is not a benign medication, and it has no appropriate role as a cough suppressant in children. Every medical provider who cares for children should know this, and I would never trust my patients with one who doesn’t.