Continued Prescribing of Periprocedural Codeine and Tramadol to Children after a Black Box Warning

• Published in: The Journal of surgical research Vol. 256; pp. 131 - 135
• Main Authors: Kohler, Jonathan E., Cartmill, Randi S., Kalbfell, Elle, Schumacher, Jessica
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.12.2020
• Subjects: Administrative Claims, Healthcare - statistics & numerical data; Adolescent; Ambulatory Surgical Procedures - adverse effects; Child; Child, Preschool; Codeine; Codeine - therapeutic use; Drug contraindications; Drug Labeling; Drug Prescriptions - standards; Drug Prescriptions - statistics & numerical data; Female; Humans; Inappropriate Prescribing - prevention & control; Inappropriate Prescribing - statistics & numerical data; Infant; Male; Pain, Postoperative - drug therapy; Pain, Postoperative - etiology; Pediatric surgery; Perioperative Care - standards; Perioperative Care - statistics & numerical data; Postoperative pain; Practice Patterns, Physicians' - standards; Practice Patterns, Physicians' - statistics & numerical data; Retrospective Studies; Tramadol; Tramadol - therapeutic use; Wisconsin; Wisconsin; Postoperative pain; Pediatric surgery; Tramadol; Drug contraindications; Codeine
• ISSN: 0022-4804; 1095-8673; 1095-8673
• DOI: 10.1016/j.jss.2020.06.023

Codeine and tramadol are commonly used analgesics in surgery. In 2013, the Food and Drug Administration (FDA) issued a contraindication to the use of codeine in tonsillectomy and adenoidectomy patients aged below 18 y. This warning was expanded in April 2017 to include tramadol and all children aged below 12 y. We sought to describe the prescribing of codeine and tramadol to contraindicated populations in Wisconsin before and after the release of the expanded FDA warning. Using a statewide Wisconsin claims database, we identified common pediatric ambulatory surgical procedures across the specialties of otolaryngology, urology, general surgery, orthopedics, and ophthalmology. For these procedures, we examined the rates of perioperative codeine and tramadol prescription fills and change in prescribing after the FDA contraindication. Surgeons in all of the specialties studied continued to prescribe codeine to pediatric patients after the contraindication, but tramadol was rarely prescribed. Procedures with relatively high rates of codeine fills were strabismus repair (65% of opioid fills), circumcision >1 yo (22%), and laparoscopic appendectomy (15%). Codeine fills significantly declined after the contraindication to 6% for circumcision >1 yo and 5% for orchiopexy and inguinal hernia repair. Otolaryngology, which was subject to the 2013 codeine contraindication, has low rates of codeine fills (under 2.5%) for the whole period studied. Codeine prescribing for strabismus repair showed no significant decline. Codeine, and to a lesser extent tramadol, continue to be prescribed to contraindicated populations of children. This represents a target for future de-implementation interventions.