The approach the field of pediatrics has taken toward pain management in children has shifted dramatically over the last half century. Pediatric pain was woefully under-managed even up to the 1970s and 80s, with infants sometimes undergoing complex surgeries without perioperative or postoperative pain control.
Over the following two decades, as physicians and scientists learned more about the acute and long-term effects of pediatric pain, the pendulum swung in favor not only of pain management, but of the use of opioid medications for controlling both chronic and acute pain in both children and adults, regardless of the pain’s origin.
“With the recognition that pain had short- and long-term potential consequences, and the lack of data at the time suggesting downsides to opioids, there was a very dramatic shift,” says Neil Schechter, MD, of the Pain Treatment Service in Boston Children’s Hospital’s Department of Anesthesia, Perioperative and Pain Medicine. “We started asking, ‘If there’s no significant downside, why should children suffer unnecessarily?'”
But has the pendulum swung too far in favor of opioids? In a recent article in JAMA Pediatrics, Schechter notes that opioid drugs are not always prescribed in appropriate ways, and that these practices may contribute to population-level risks of both overdose and illicit use.
He argues for thoughtful approaches to opioid prescribing that reduce both risks.
Rational use for acute pain
“Opioids can play an important role for management of acute pain and in palliative care,” says Schechter, who has written about office-based pain management for minor procedures like vaccinations and was senior author on a major textbook on pediatric pain.
The amount prescribed for acute pain should be monitored appropriately. In general, he notes, “you should only expect two weeks to a month of discomfort requiring opioids from most procedures or acute illnesses.” If significant pain extends beyond that period, he adds, the child should probably be re-evaluated.
Schechter also suggests that families should have the appropriate controls in place to ensure proper access. For instance, Schechter says providers should encourage families to store prescribed opioids separate from other medications, ideally in a locked cabinet. This, he says, reduces the risk of accidental overdose and can also discourage diversion of opioids for illicit use.
Roles for chronic use?
When asked about opioids’ role in control of chronic pain, especially pain that does not stem from organic disease—for instance, for functional pain problems such as persistent headache, irritable bowel syndrome or musculoskeletal pain—Schechter answers that, in general, opioids have a very limited role, a view backed by multiple consensus panels.
He instead cites the value of a multimodal approach that combines pharmacologic and non-pharmacologic components, such as:
- Exercise. “Exercise is critical,” Schechter says. “There is a great deal of data on the value of exercise for persistent pain problems.”
- Cognitive behavioral therapy, which reframes the experience of pain and which takes a problem-solving approach to addressing the limitations of pain.
- Neuromodulating drugs, such as gabapentin or amitriptyline. “These help rewire the nervous system’s response to stimuli and pain threshold,” he explains. “They act like a dimmer switch, in that they do not eliminate pain but affect neurotransmission of pain signals”.
There are specific cases where chronic opioid use may be appropriate. For such cases, Schechter notes that his service has families sign an opioid contract stating that they will safely store the medication and that they will request the medications from a single provider.
And although caution is advised, Schechter emphasizes that it is essential that there be no significant barriers to opioid availability for patients receiving palliative care for life-threatening or -limiting conditions.
A partnership approach to pain care
When caring for patients who are experiencing chronic pain, or who have been prescribed a round of opioid medication but are still experiencing discomfort, Schechter advocates strongly for a partnership or medical home model that involves primary care providers, physical therapists, psychologists and pain specialists.
“Pain problems are often multidisciplinary,” he says. “PCPs should consider establishing their own virtual multidisciplinary pain teams, partnering with specialists in their community who have a comfort level with pediatric pain-related issues.”
He also cites the value of having a single provider coordinate the medication aspects of a patient’s care. “There should be a core person who knows all of the patient’s medications and who explains to the patient how to use those medications appropriately.”
Schechter adds that if a patient has an acute pain-related issue such as a fracture, but the pain persists more than a month, then referral back to an appropriate specialist (e.g., an orthopedist) should be considered. “The specialist might want to investigate more deeply to see if something has gone awry that might explain the continuing pain.”
The Pain Treatment Service has many resources, programs and services available for the care of children with chronic pain, such as the Mayo Family Pediatric Pain Rehabilitation Center and The Comfort Ability (workshop for youth with chronic pain). To discuss concerns about patients with acute or chronic pain, contact the service at 617-355-7040.