Removal of Codeine in Pediatric Oncology: A Qualitative Evaluation of Success and Attitudes

Abstract

Background: Codeine is an opioid analgesic requiring hepatic conversion to morphine via CYP2D6 to provide analgesic effect. CYP2D6 population polymorphisms cause unpredictable conversion to morphine. Multiple reports of death or adverse events in children receiving codeine has led to increased calls for discontinuation of use in children. Our Pediatric Oncology Program volunteered to pilot codeine removal. When looking for implementation strategies for this practice change, neither successful implementation nor barriers to change had been reported. Objectives: To evaluate whether prescription of codeine was reduced, assess the attitudes of health professionals at different points during practice change, determine if our educational tools were successful in aiding this change. Methods: An electronic survey was created and distributed to all Pediatric Oncology Team members prior to implementation, and 3 and 6 months after. In our hospital, all opioids are dispensed from automated cabinets. Reports assessing the number of codeine doses dispensed in a 2 month period prior to and following implementation were obtained. Results: Survey response rate was 55%. In the assessment points prior and post implementation, 249 codeine doses were administered to 35 patients, 7 doses were administered to 3 patients respectively. Major concerns about provincial triplicate prescription barriers and utilization of other opioids were minimal (22%) but still decreased 6 months after implementation (8%). Barriers to successful implementation initially rated significant were attitudes of other health professionals (42%) and perceptions of parents/families (60%). Both showed marked improvement 6 months after implementation (25%). Education strategies for implementation were well-utilized and rated by participants as beneficial. Eighty-two percent of respondents rated the practice change as easy. Conclusion: Removal of codeine was successful using a diverse, planned education program. Initially identified barriers did not hinder implementation. Our intent is to use these results to implement a similar practice change within the entire children's hospital.