For years, my paraphrased messages from the experts have been: “Pediatricians under-treat pain in children.” “Just because they don’t complain in words doesn’t mean that they don’t feel pain.” “Effective pain management requires that physicians ‘stay ahead of the pain.'” “Treat pain early and aggressively in children.” With all this in mind, I was very interested to read this week that the FDA recently put out a warning about using one of the oldest pain medicines available in children: codeine.
Specifically, the four children they reported on were children who took codeine after having their tonsils and adenoids removed because of airway blockage called disordered breathing of sleep. Here is the way they think this happened: when a child takes a dose of codeine, his or her liver converts the codeine into morphine, which is the active drug that acts on the brain to block pain signals from the affected part of the body. If the child is a rapid converter (of codeine to morphine) and has taken multiple doses of a codeine, they can get a very high “morphine level” in the blood which can suppress their drive to breath.
You can see that the push to treat pain aggressively in children can, on rare instances, backfire. No pediatrician is going to know if the child who they are trying to treat for pain is a rapid metabolizer of codeine or not. To my knowledge, it is just not practical to test for this problem before a child needs a narcotic pain medicine. So, we doctors find ourselves once more between a rock and a hard place. Children need treatment for pain, but narcotics require great caution. Maybe we need to perfect methods of treating pain that don’t involve drugs!
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2. Marcia L. Buck, Pharm.D., FCCP, FPPAG
Nov 27, 2012
Pediatr Pharm. 2012;18(10) © 2012 Children’s Medical Center, University of Virginia