The Codeine Controversy

Codeine. It’s been around for a long time. It was prescribed 1.7 million times in 2011 for kids under the age of 18 for pain and cough. It wouldn’t have lasted this long and been used that often if it wasn’t a good medication…right?

Maybe, maybe not. Codeine’s risks and questionable effectiveness have been reported in the news lately. Here is the issue: codeine needs to be broken down in our bodies to form morphine, which does the job of relieving pain and cough (maybe, see below). But what if our bodies couldn’t make codeine into morphine? Or what if they made too much morphine?

For almost 1 in 10 people, one of those two situations occurs on a genetic basis. Some people have too many copies of the gene that codes for the enzyme which turns codeine into morphine. In this situation, their bodies will create an overdose of morphine.

In fact, there have been several deaths in children after tonsillectomy and adenoidectomy procedures, which led the Food and Drug Administration (FDA) to place a “boxed warning” in 2012 stating that codeine should not be used for pain relief following a tonsillectomy and adenoidectomy in kids under six years of age. A “boxed warning” is the FDA’s strongest warning about a medication, so they clearly felt that codeine posed safety issues in young children following this surgery. Another problem is for nursing mothers who have the excess genes (called “ultra-rapid metabolizers”). The overproduction of morphine leads to higher levels of morphine in breast milk, which has led to overdoses in the babies.

The opposite scenario can happen, too. The enzyme can be missing or defective and the person taking codeine gets little to no pain relief, so they suffer needlessly. I can tell you I have had lots of parents tell me in our pain management clinic that “codeine didn’t do anything” for their child. Then after a pause, they sometimes will add, “it never did anything for me, either.” It’s genetic, so it can run in families. There are also a number of medications that affect this enzyme, and lead to either overproduction or underproduction of morphine from codeine. That is why it is important to let your doctor, dentist or pharmacist know what medications and herbal supplements you are taking.

There are tests for the gene, but for now it is too expensive to test everyone who might need a pain medicine. So, what is the best thing to do?

For one thing, codeine has never been shown to be better than placebo for cough. So why take a chance on it, if it does not work better than a sugar pill? A typical cough is pretty short-lived. If it is related to a cold, then lots of fluids, honey and humidified air can be helpful. The old-fashioned treatments chicken soup and tea with honey have been favorites in my household. The cough caused by a virus will get better. If the cough is from something more serious that a cold, then treating the cause of the cough is better than just trying to stifle the cough. For instance, if your child is coughing due to asthma problems, treating the asthma first is the best thing to do to get rid of the cough.

What about for pain? There are plenty of safer alternatives. Oxycodone is also broken down by the same enzyme, but not much. The body has other ways to deal with it, so it has not had the same problems as codeine. Morphine comes in pill and liquid forms, and does not have the same issues, either. Same for hydromorphone. Hydrocodone (in Vicodin and Norco, among others), tramadol and tapentadol are handled by the same enzyme as codeine is, although with slightly different issues. While they have not had the same problems as codeine, they should be used cautiously.

In the end, talking with your doctor or dentist is the best thing to do. There are safer and more effective alternatives to codeine, and prescriptions for all of them can be adjusted to give the proper dose for all sizes of children. Here at Cincinnati Children’s, we used codeine for many years, but we no longer prescribe it after a tonsillectomy and adenoidectomy.

For other types of pain relief, we prescribe it only when a patient has already had it before coming to our medical center and got lucky (that is, it worked without side effects). Based on what we know about codeine and its genetic relationship, if it’s worked safely in a patient before, it will most likely again, all things being equal. We use other options when starting a patient on pain medication with no history of taking codeine.

Codeine has been a long-used and trusted pain medicine. But as the field of medicine evolves, we learn more and more about the best ways to care for folks. All I can say, after reviewing the evidence and recommendations, is that I will not prescribe it for my patients if they have not had it before.