Vol.
-
No.
- -
2013
Journal of Pain and Symptom Management 1
Brief Quality Improvement Report
A Single Institution’s Effort to Translate Codeine Knowledge Into Specific Clinical Practice Joel Jerome, PharmD, Jean C. Solodiuk, RN, PhD, Navil Sethna, MD, FAAP, Josh McHale, MPH, and Charles Berde, MD, PhD Boston Children’s Hospital (J.J., J.C.S., N.S., J.M., C.B.); Harvard Medical School (N.S., C.B.); and Northeastern University (J.J.), Boston, Massachusetts, USA
Abstract Background. Codeine is an unpredictable analgesic because of its variable pharmacokinetic, pharmacodynamic, and pharmacogenetic properties. This variability may lead to ineffective analgesia in some and respiratory depression in others. Despite this, codeine is still widely used. At a pediatric tertiary medical institution, codeine was prescribed despite efforts to inform prescribers of the potentially unpredictable analgesia and serious side effects. Measures. A retrospective/prospective metric was introduced to determine the frequency of codeine orders as compared with similar institutions using Pediatric Health Information Systems data. Intervention. Interventions included formal and informal education to prescribers, and replacing codeine with oxycodone for patients aged older than six months and an age-appropriate medication for those patients younger than six months within ordersets. Identifying and addressing the major barriers to change also was a key part of the process. Outcomes. Codeine use was reduced by 97% from the first quarter of 2008 through the third quarter of 2012. This was accomplished through orderset changes and education. Codeine was completely eliminated from the hospital formulary in January 2013. Conclusions/Lessons Learned. This quality improvement initiative was successful in eliminating codeine from the hospital formulary. Although education decreased codeine orders, understanding and addressing the barriers to change and directly changing the ordersets were the most effective and efficient for knowledge translation. J Pain Symptom Manage 2013;-:-e-. Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Quality improvement, pain, pediatrics, codeine, adverse effects, CYP 2D6, analgesics, opioid
Address correspondence to: Joel Jerome, PharmD, Department of Pharmacy, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. E-mail: [email protected] Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Accepted for publication: August 13, 2013.
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2013.08.011
2
Jerome et al.
Background Unfortunately, the translation of research findings to clinical practice is often slow. Although research findings are available, they do not always or readily get translated into clinical practice. Some of the reasons for this include: the lack of access to research and/or refusal to abandon outdated medical knowledge, lack of time to keep up with new research because of the sheer amount of research that is produced, and the inability to understand and translate the research. This is especially true in pain management because analgesics are often prescribed by a wide range of practitioners who may neither specialize in pain management nor be familiar with new developments in analgesic research. This article is an example of how electronic prescribing systems can be used to inform busy clinicians of the developing pharmacological knowledge that can affect prescribing habits and improve patient safety. Codeine or 3-methylmorphine has been used for many decades for the management of mildto-moderate pain. There is mounting evidence that codeine has both unpredictable efficacy and safety concerns.1,2 Codeine itself has little-to-no analgesic properties. It is a prodrug of morphine; therefore, the analgesic effect from codeine is predominantly reliant on the metabolism to active morphine. Codeine is metabolized via three major routes, namely glucuronidation to codeine-6-glucuronide (inactive), N-demethylation via the CYP3A4 enzyme to norcodeine (inactive), and O-demethylation via the CYP2D6 enzyme to morphine (active). The CYP2D6 enzyme responsible for the conversion of codeine to its active metabolite morphine is significantly affected by genetic polymorphism. The following breakdown of CYP2D6 metabolizers into four groups is a simplified way to look at a complex enzyme with many genetic variants. Individuals known as extensive metabolizers are those who display typical enzymatic activity and metabolize a predictable amount of codeine into active morphine. They represent the largest portion of the population. Those who carry two inactive alleles are known as poor metabolizers and do not form metabolites dependent on CYP2D6. The poor metabolizer, with the lack of 2D6 activity, produce no morphine from
Vol.
-
No.
- -
2013
codeine and, therefore, little-to-no analgesic effect. Individuals who have a duplication of the CYP2D6 gene are known as ultrarapid metabolizers and they display excessive metabolism. This group metabolizes a higher than predicted percentage of codeine into morphine. Therefore, these individuals are at an increased risk for the serious side effects of opioids, such as respiratory depression and, in severe cases, death.2e5 The final class of individuals is known as the intermediate metabolizers. This group does have some 2D6 enzyme activity, but less than the extensive metabolizers. These patients will get unpredictable analgesia and possibly no morphine from codeine. In one study, 36% of the patients had undetectable morphine levels after receiving codeine.6 The varying 2D6 activity throughout the population results in significant unpredictability in the analgesic effects of codeine. These genetic variations of codeine metabolism in the general population pose serious concerns to the use of codeine. Pretreatment genetic testing can identify the various polymorphisms; however, it is a costly test and not widely available. The variability of codeine is further complicated by the susceptibility of CYP2D6 and CYP3A4 to drug interactions. It has been estimated that approximately 50% of medications are metabolized by the CYP3A4 enzyme. The CYP2D6 enzyme is also responsible for approximately 25% of the metabolism of medications. There is an extensive list of medications that are considered CYP3A4 inhibitors.7 Because CYP3A4 is one of the major metabolic pathways for codeine, inhibiting it can lead to an increase in CYP2D6 enzymatic activity and, therefore, the potential for higher morphine levels and increased adverse effects. Alternatively, inhibiting CYP2D6 could decrease the percentage of codeine metabolized to morphine, thus decreasing pain control. A patient later found to be an ultrarapid metabolizer of CYP2D6 had life-threatening respiratory failure while taking a relatively small dose of codeine (25 mg) three times a day for cough. The patient also was taking clarithromycin and voriconazole (both CYP3A4 inhibitors) concomitantly. The higher percentage of codeine channeling through the CYP2D6 pathway resulted in a toxic level of morphine. The patient also had acute renal failure, which reduced the
Vol.
-
No.
- -
2013
Translating Codeine Knowledge Into Practice
clearance of the active glucuronide metabolite of morphine (morphine-6-glucuronide).1 This scenario illustrates the risk of drug interactions and genetic variances with codeine. In pediatrics, the variability is further complicated by differences in metabolic capacity, renal function, gastrointestinal function, and distribution sites. There are wide fluctuations in metabolic capacity, including CYP2D6 and CYP3A4 enzyme function, within the first few months of life. This can further complicate the already unpredictable pharmacokinetics of codeine.8 The aim of this quality improvement effort was to educate opioid prescribers and eliminate inpatient and outpatient orders for codeine to improve both the safety and efficacy of pain management.
Measures This quality improvement project was both a retrospective and prospective review of codeine orders before and after interventions. The first step in the process was to identify clinicians who frequently used codeine to enlist stakeholders and to understand their reasons for using codeine, and potential barriers to change. Meetings with stakeholders were arranged to educate clinicians and understand the prescriptive practices for the individual or the medical service regarding codeine. Data were pulled from the Pediatric Health Information System (PHIS), an administrative database that contains inpatient, emergency department, ambulatory surgery, and observation data from 43 not-for-profit, tertiary care pediatric hospitals in the U.S. These hospitals are affiliated with the Children’s Hospital Association (Overland Park, KS). Data quality and reliability are assured through a joint effort between the Children’s Hospital Association and participating hospitals. The data warehouse function for the PHIS database is managed by Truven Health Analytics (Ann Arbor, MI). For the purposes of external benchmarking, participating hospitals provide discharge/encounter data including demographics, diagnoses, and procedures. A total of 42 of these hospitals also submit resource utilization data (e.g., pharmaceuticals, imaging, and laboratory) into PHIS. Data are deidentified at the time of data submission,
3
and data are subjected to a number of reliability and validity checks before being included in the database. For this study, data from only Boston Children’s Hospital were used.
Interventions Over a period of three years, education and meetings with 12 different groups within the hospital were conducted. Education included Grand Rounds, an annual pain conference for staff members, and general in-services. Each discipline had a monthly staff meeting, for example, orthopedics. The pain treatment service pharmacist with or without one of the attending physicians on the pain treatment service requested to attend the meeting. At the meeting, the background information about codeine was presented and the physicians were able to respond with questions and concerns surrounding the possible elimination of this commonly used medication. Some of these concerns and the responses are listed in Table 1. As a result of these educational meetings with the medical and surgical groups, codeine was removed from 56 ordersets. Within these ordersets, codeine was substituted with oxycodone and/or appropriate alternatives for infants aged younger than six months. In most situations, the practice change was a simple substitution of oxycodone for codeine in the electronic orderset. This change reduced and in most cases eliminated use for that service. For services caring for patients aged younger than six months, finding an acceptable alternative was more challenging and required four months of meetings with directors and department chiefs (Pharmacy, Nephrology, Pain Treatment Service, and Nursing) and other clinicians to build consensus on safe and effective analgesics for infants younger than six months (Table 2). Once this algorithm for infant pain was developed and distributed throughout the hospital, the remaining services that needed options for infants were approached. Several other meetings were set up to see which analgesics worked for each of their ordersets/disease states. Some services decided to only use acetaminophen and ibuprofen and eliminate opioids from their orderset(s) completely. Others decided on lower doses of either morphine or oxycodone for
4
Jerome et al.
Vol.
-
No.
- -
2013
Table 1 Barriers to Eliminating Codeine Challenges
Quotations From Discussions
Response From Pain Team
Familiarity with prescribing codeine
‘‘I have been prescribing codeine to this population for 13 years and have not had any problems with codeine use.’’
Lack of knowledge of the literature describing the risks of codeine
‘‘I have not heard this before, could you send me the articles.’’
Lack of consensus regarding safe and effective analgesic dosing for infants
‘‘If I cannot give codeine, then what drugs can we use for our infants that are safe?’’ ‘‘It is not convenient because I can not call in oxycodone.’’
Although you may not have personally experienced any problems with codeine, there have been a number of deaths and near deaths associated with codeine use. There is also a substantial portion of the population that will not receive benefit from the drug. In this case, we supplied the physicians with multiple articles describing the variability of codeine. For this concern, we developed the infant analgesic algorithm (Table 1) to help support prescribers. Oxycodone is considered a CII, which is a stricter regulated class of controlled substance. There are stricter requirements including the need for a hard copy of the prescription and a limit of a 30 day supply. However, many patients with mild-to-moderate pain may only require acetaminophen and ibuprofen around the clock. If oxycodone is needed, then the stricter prescription requirements are in place for patient safety and to prevent diversion of controlled substances.
Convenience of prescribing codeine
The above four themes emerged from discussions with clinicians about codeine.
shorter durations of time as per the developed algorithm. The final intervention was to remove codeine completely from the hospital formulary. Once appropriate alternatives had been found for all patient age groups, the decision was made to bring the removal of codeine to the Pharmacy and Therapeutics (P&T) Committee for the hospital in October of 2012. The removal of all inpatient and outpatient prescribing of codeine was put into effect in January 2013. This gave the pain treatment service time to approach all remaining groups with codeine in their ordersets and discuss options for alternatives.
Outcomes Codeine use was reduced by 97% from the first quarter of 2008 through the third quarter of 2012. This was accomplished through education of stakeholders and replacing codeine with other analgesics within ordersets. Fig. 1 shows the decrease in codeine use between the first quarter of 2008, when the process of education and orderset changing began, and the first quarter of 2013 when codeine was
eliminated from the hospital formulary. There was a steady decrease in use over that time period. Most importantly, there were no observed increases in respiratory depression or in calls to the intensive care unit for evaluations or transfers from the floor as a result of these changes during the three years and thereafter.
Conclusions/Lessons Learned Providing the most recent information and orderset changes after key stakeholder meetings was most effective for reducing codeine use because the prescriber was directed to use whatever pain treatment regimen was available on their particular orderset. Although codeine was still available within the hospital until January 2013, changes to the ordersets and education of stakeholders reduced inpatient codeine medication orders by 97%. Four main challenges emerged from conversations with the 12 different services that prescribed most of the codeine in the hospital. Many codeine prescribers were familiar with prescribing codeine and were not aware of any serious adverse events related to codeine use in their patients. Many codeine prescribers
Vol.
-
No.
- -
2013
Translating Codeine Knowledge Into Practice
5
Table 2 Inpatient Infant Analgesic Algorithm #1
Acetaminophen - Ensure well hydrated - Ensure no liver dysfunction - Consider ATC dosing for ongoing management and opioid-sparing effect - Consider rectal or IV dosing when PO is unavailable Age Drug and dosages
-
No.
- -
2013
Journal of Pain and Symptom Management 1
Brief Quality Improvement Report
A Single Institution’s Effort to Translate Codeine Knowledge Into Specific Clinical Practice Joel Jerome, PharmD, Jean C. Solodiuk, RN, PhD, Navil Sethna, MD, FAAP, Josh McHale, MPH, and Charles Berde, MD, PhD Boston Children’s Hospital (J.J., J.C.S., N.S., J.M., C.B.); Harvard Medical School (N.S., C.B.); and Northeastern University (J.J.), Boston, Massachusetts, USA
Abstract Background. Codeine is an unpredictable analgesic because of its variable pharmacokinetic, pharmacodynamic, and pharmacogenetic properties. This variability may lead to ineffective analgesia in some and respiratory depression in others. Despite this, codeine is still widely used. At a pediatric tertiary medical institution, codeine was prescribed despite efforts to inform prescribers of the potentially unpredictable analgesia and serious side effects. Measures. A retrospective/prospective metric was introduced to determine the frequency of codeine orders as compared with similar institutions using Pediatric Health Information Systems data. Intervention. Interventions included formal and informal education to prescribers, and replacing codeine with oxycodone for patients aged older than six months and an age-appropriate medication for those patients younger than six months within ordersets. Identifying and addressing the major barriers to change also was a key part of the process. Outcomes. Codeine use was reduced by 97% from the first quarter of 2008 through the third quarter of 2012. This was accomplished through orderset changes and education. Codeine was completely eliminated from the hospital formulary in January 2013. Conclusions/Lessons Learned. This quality improvement initiative was successful in eliminating codeine from the hospital formulary. Although education decreased codeine orders, understanding and addressing the barriers to change and directly changing the ordersets were the most effective and efficient for knowledge translation. J Pain Symptom Manage 2013;-:-e-. Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved. Key Words Quality improvement, pain, pediatrics, codeine, adverse effects, CYP 2D6, analgesics, opioid
Address correspondence to: Joel Jerome, PharmD, Department of Pharmacy, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA. E-mail: [email protected] Ó 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.
Accepted for publication: August 13, 2013.
0885-3924/$ - see front matter http://dx.doi.org/10.1016/j.jpainsymman.2013.08.011
2
Jerome et al.
Background Unfortunately, the translation of research findings to clinical practice is often slow. Although research findings are available, they do not always or readily get translated into clinical practice. Some of the reasons for this include: the lack of access to research and/or refusal to abandon outdated medical knowledge, lack of time to keep up with new research because of the sheer amount of research that is produced, and the inability to understand and translate the research. This is especially true in pain management because analgesics are often prescribed by a wide range of practitioners who may neither specialize in pain management nor be familiar with new developments in analgesic research. This article is an example of how electronic prescribing systems can be used to inform busy clinicians of the developing pharmacological knowledge that can affect prescribing habits and improve patient safety. Codeine or 3-methylmorphine has been used for many decades for the management of mildto-moderate pain. There is mounting evidence that codeine has both unpredictable efficacy and safety concerns.1,2 Codeine itself has little-to-no analgesic properties. It is a prodrug of morphine; therefore, the analgesic effect from codeine is predominantly reliant on the metabolism to active morphine. Codeine is metabolized via three major routes, namely glucuronidation to codeine-6-glucuronide (inactive), N-demethylation via the CYP3A4 enzyme to norcodeine (inactive), and O-demethylation via the CYP2D6 enzyme to morphine (active). The CYP2D6 enzyme responsible for the conversion of codeine to its active metabolite morphine is significantly affected by genetic polymorphism. The following breakdown of CYP2D6 metabolizers into four groups is a simplified way to look at a complex enzyme with many genetic variants. Individuals known as extensive metabolizers are those who display typical enzymatic activity and metabolize a predictable amount of codeine into active morphine. They represent the largest portion of the population. Those who carry two inactive alleles are known as poor metabolizers and do not form metabolites dependent on CYP2D6. The poor metabolizer, with the lack of 2D6 activity, produce no morphine from
Vol.
-
No.
- -
2013
codeine and, therefore, little-to-no analgesic effect. Individuals who have a duplication of the CYP2D6 gene are known as ultrarapid metabolizers and they display excessive metabolism. This group metabolizes a higher than predicted percentage of codeine into morphine. Therefore, these individuals are at an increased risk for the serious side effects of opioids, such as respiratory depression and, in severe cases, death.2e5 The final class of individuals is known as the intermediate metabolizers. This group does have some 2D6 enzyme activity, but less than the extensive metabolizers. These patients will get unpredictable analgesia and possibly no morphine from codeine. In one study, 36% of the patients had undetectable morphine levels after receiving codeine.6 The varying 2D6 activity throughout the population results in significant unpredictability in the analgesic effects of codeine. These genetic variations of codeine metabolism in the general population pose serious concerns to the use of codeine. Pretreatment genetic testing can identify the various polymorphisms; however, it is a costly test and not widely available. The variability of codeine is further complicated by the susceptibility of CYP2D6 and CYP3A4 to drug interactions. It has been estimated that approximately 50% of medications are metabolized by the CYP3A4 enzyme. The CYP2D6 enzyme is also responsible for approximately 25% of the metabolism of medications. There is an extensive list of medications that are considered CYP3A4 inhibitors.7 Because CYP3A4 is one of the major metabolic pathways for codeine, inhibiting it can lead to an increase in CYP2D6 enzymatic activity and, therefore, the potential for higher morphine levels and increased adverse effects. Alternatively, inhibiting CYP2D6 could decrease the percentage of codeine metabolized to morphine, thus decreasing pain control. A patient later found to be an ultrarapid metabolizer of CYP2D6 had life-threatening respiratory failure while taking a relatively small dose of codeine (25 mg) three times a day for cough. The patient also was taking clarithromycin and voriconazole (both CYP3A4 inhibitors) concomitantly. The higher percentage of codeine channeling through the CYP2D6 pathway resulted in a toxic level of morphine. The patient also had acute renal failure, which reduced the
Vol.
-
No.
- -
2013
Translating Codeine Knowledge Into Practice
clearance of the active glucuronide metabolite of morphine (morphine-6-glucuronide).1 This scenario illustrates the risk of drug interactions and genetic variances with codeine. In pediatrics, the variability is further complicated by differences in metabolic capacity, renal function, gastrointestinal function, and distribution sites. There are wide fluctuations in metabolic capacity, including CYP2D6 and CYP3A4 enzyme function, within the first few months of life. This can further complicate the already unpredictable pharmacokinetics of codeine.8 The aim of this quality improvement effort was to educate opioid prescribers and eliminate inpatient and outpatient orders for codeine to improve both the safety and efficacy of pain management.
Measures This quality improvement project was both a retrospective and prospective review of codeine orders before and after interventions. The first step in the process was to identify clinicians who frequently used codeine to enlist stakeholders and to understand their reasons for using codeine, and potential barriers to change. Meetings with stakeholders were arranged to educate clinicians and understand the prescriptive practices for the individual or the medical service regarding codeine. Data were pulled from the Pediatric Health Information System (PHIS), an administrative database that contains inpatient, emergency department, ambulatory surgery, and observation data from 43 not-for-profit, tertiary care pediatric hospitals in the U.S. These hospitals are affiliated with the Children’s Hospital Association (Overland Park, KS). Data quality and reliability are assured through a joint effort between the Children’s Hospital Association and participating hospitals. The data warehouse function for the PHIS database is managed by Truven Health Analytics (Ann Arbor, MI). For the purposes of external benchmarking, participating hospitals provide discharge/encounter data including demographics, diagnoses, and procedures. A total of 42 of these hospitals also submit resource utilization data (e.g., pharmaceuticals, imaging, and laboratory) into PHIS. Data are deidentified at the time of data submission,
3
and data are subjected to a number of reliability and validity checks before being included in the database. For this study, data from only Boston Children’s Hospital were used.
Interventions Over a period of three years, education and meetings with 12 different groups within the hospital were conducted. Education included Grand Rounds, an annual pain conference for staff members, and general in-services. Each discipline had a monthly staff meeting, for example, orthopedics. The pain treatment service pharmacist with or without one of the attending physicians on the pain treatment service requested to attend the meeting. At the meeting, the background information about codeine was presented and the physicians were able to respond with questions and concerns surrounding the possible elimination of this commonly used medication. Some of these concerns and the responses are listed in Table 1. As a result of these educational meetings with the medical and surgical groups, codeine was removed from 56 ordersets. Within these ordersets, codeine was substituted with oxycodone and/or appropriate alternatives for infants aged younger than six months. In most situations, the practice change was a simple substitution of oxycodone for codeine in the electronic orderset. This change reduced and in most cases eliminated use for that service. For services caring for patients aged younger than six months, finding an acceptable alternative was more challenging and required four months of meetings with directors and department chiefs (Pharmacy, Nephrology, Pain Treatment Service, and Nursing) and other clinicians to build consensus on safe and effective analgesics for infants younger than six months (Table 2). Once this algorithm for infant pain was developed and distributed throughout the hospital, the remaining services that needed options for infants were approached. Several other meetings were set up to see which analgesics worked for each of their ordersets/disease states. Some services decided to only use acetaminophen and ibuprofen and eliminate opioids from their orderset(s) completely. Others decided on lower doses of either morphine or oxycodone for
4
Jerome et al.
Vol.
-
No.
- -
2013
Table 1 Barriers to Eliminating Codeine Challenges
Quotations From Discussions
Response From Pain Team
Familiarity with prescribing codeine
‘‘I have been prescribing codeine to this population for 13 years and have not had any problems with codeine use.’’
Lack of knowledge of the literature describing the risks of codeine
‘‘I have not heard this before, could you send me the articles.’’
Lack of consensus regarding safe and effective analgesic dosing for infants
‘‘If I cannot give codeine, then what drugs can we use for our infants that are safe?’’ ‘‘It is not convenient because I can not call in oxycodone.’’
Although you may not have personally experienced any problems with codeine, there have been a number of deaths and near deaths associated with codeine use. There is also a substantial portion of the population that will not receive benefit from the drug. In this case, we supplied the physicians with multiple articles describing the variability of codeine. For this concern, we developed the infant analgesic algorithm (Table 1) to help support prescribers. Oxycodone is considered a CII, which is a stricter regulated class of controlled substance. There are stricter requirements including the need for a hard copy of the prescription and a limit of a 30 day supply. However, many patients with mild-to-moderate pain may only require acetaminophen and ibuprofen around the clock. If oxycodone is needed, then the stricter prescription requirements are in place for patient safety and to prevent diversion of controlled substances.
Convenience of prescribing codeine
The above four themes emerged from discussions with clinicians about codeine.
shorter durations of time as per the developed algorithm. The final intervention was to remove codeine completely from the hospital formulary. Once appropriate alternatives had been found for all patient age groups, the decision was made to bring the removal of codeine to the Pharmacy and Therapeutics (P&T) Committee for the hospital in October of 2012. The removal of all inpatient and outpatient prescribing of codeine was put into effect in January 2013. This gave the pain treatment service time to approach all remaining groups with codeine in their ordersets and discuss options for alternatives.
Outcomes Codeine use was reduced by 97% from the first quarter of 2008 through the third quarter of 2012. This was accomplished through education of stakeholders and replacing codeine with other analgesics within ordersets. Fig. 1 shows the decrease in codeine use between the first quarter of 2008, when the process of education and orderset changing began, and the first quarter of 2013 when codeine was
eliminated from the hospital formulary. There was a steady decrease in use over that time period. Most importantly, there were no observed increases in respiratory depression or in calls to the intensive care unit for evaluations or transfers from the floor as a result of these changes during the three years and thereafter.
Conclusions/Lessons Learned Providing the most recent information and orderset changes after key stakeholder meetings was most effective for reducing codeine use because the prescriber was directed to use whatever pain treatment regimen was available on their particular orderset. Although codeine was still available within the hospital until January 2013, changes to the ordersets and education of stakeholders reduced inpatient codeine medication orders by 97%. Four main challenges emerged from conversations with the 12 different services that prescribed most of the codeine in the hospital. Many codeine prescribers were familiar with prescribing codeine and were not aware of any serious adverse events related to codeine use in their patients. Many codeine prescribers
Vol.
-
No.
- -
2013
Translating Codeine Knowledge Into Practice
5
Table 2 Inpatient Infant Analgesic Algorithm #1
Acetaminophen - Ensure well hydrated - Ensure no liver dysfunction - Consider ATC dosing for ongoing management and opioid-sparing effect - Consider rectal or IV dosing when PO is unavailable Age Drug and dosages
