0% of Caucasians Showing Little or No Benefit from Its Use. Declaration of Interest Reply from the Authors Declaration of Interest

This therefore makes it difficult to explain the prescription of a pro-drug, where we can so poorly predict the response without genetically testing each individual patient. The rationale given for using codeine in paediatrics is reported to include familiarity with the drug, the lack of controlled drug status, and ease of prescribing. It is administered in day surgery settings and prescribed for use in the community. However, recommendations for codeine in the postoperative setting have declined and the evidence for its use as an antitussive is lacking. We propose that codeine is popular in the paediatric population because healthcare professionals perceive it to be a ‘safer’ choice than morphine. To investigate this further, we completed a snapshot survey in two local district general hospitals, examining staff views on the safety profile of codeine in paediatrics, with respect to other commonly used analgesics. Fifty-nine doctors and 25 nurses (n1⁄484), spanning a wide range of specialities and levels of experience, completed a short questionnaire; 100% identified morphine as a drug they would worry about causing respiratory depression, yet only 42% felt the same about codeine (a pro-drug for morphine). Moreover, when asked about relative overall drug safety, 92% ranked codeine as safer than morphine and notably 88% ranked it safer than tramadol and 15% ranked it safer than ibuprofen. Moderate pain should never be left untreated either in hospital or in the community and codeine has traditionally been used in this setting. Nevertheless, in the light of Niesters and colleagues’ paper, we need to question our practice with respect to the use of codeine in paediatric patients. Whether this should involve genetically testing patients before its prescription, treating codeine as a controlled drug, giving clear warnings of risk related to its use, and training to ensure adverse events are identified early or all of the above, remains to be debated. However, until a consensus is agreed, we as clinicians need to consider the use of this ‘safe’ analgesic very carefully.