Disclosure Statement. Learning Objectives. First Objective

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1 Ethics in Pediatric Pain: How do we treat children s pain without contributing to the opioid epidemic? Lonnie Zeltzer MD, Director Pediatric Pain & Palliative Care Program Distinguished Professor of Pediatrics, Anesthesiology, Psychiatry and Biobehavioral Sciences Disclosure Statement I have no actual or potential conflict of interest in relation to this program Ethics in Pediatric Pain: Learning Objectives 1. Provide an overview of acute vs chronic pain and implications for treatment 2. Discuss types of pain not well treated by opioids and how they should be treated 3. Discuss how opioid overuse/reliance/ hyperalgesia can be prevented. 4. Discuss economic impacts of poor treatment Ethics in Pediatric Pain: First Objective 1. To provide an overview of acute vs chronic pain and implications for treatment Scenario 1: Your daughter plays soccer, falls and hurts her knee Team is waiting, your daughter brushes off her injured knee and gets back into the game Parent Observation:Holds breath, waits to see what happens, notices her child gets up/continues to play Child Response:After game, daughter tells parents that her knee is bruised but she is fine now (and proud that her team won!) Parent Response:Talks about the game with daughter, doesn t mention knee, since daughter doesn t Scenario 2 Same daughter is in kitchen, trips, and hurts knee She remains on floor, holding knee and crying Parent Response: rushes over, worried that the knee might be injured, focuses on facial grimace, pain, continues to ask about knee Child Response: crying, now screaming that knee hurts badly Parent Response: worried and takes child to emergency room to see if knee is broken ER: nothing broken, child given oxycodone for pain. The example is set 1

2 How can acute pain become chronic? Many factors contribute to development & continuation of chronic pain in children While child neurobiology and genetics are contributors, parental role modeling and response to child pain is a significant factor in shaping child pain responses and behaviors Above 2 scenarios: potential outcome pathways for parental shaping of child s responses to acute pain Key role of primary care provider is to help shape parental responses to child acute pain Common Causes Abdominal pain Constipation Viral gastroenteritis Acute Pain Non-specific viral illness Injuries Dysmenorrhea Medical procedures Strep pharyngitis UTI Appendicitis Pneumonia Less Common Causes DKA IBD SCD HS Purpura Toxic ingestion Cholelithiasis Testicular torsion, Ovarian Cyst, renal colic, PID, ectopic pregnancy Biopsychosocial Assessment: Medication alone is NOT the Answer! Key Messages re: chronic pain in childhood 1. Child s neurobiology, genetics, past trauma experiences all play roles in how child experiences/ responds to pain 2. Parents model how frightening pain can be by their pain behaviors & by their responses to their child 3. Acute pain can lead to chronic pain: Fear of pain, expectations that pain will get worse, feelings of inability to cope with acute pain 4. Biopsychosocial model requires biopsychosocial treatment and not just medication Types of pain not well treated by opioids Recurrent abdominal pain Chronic daily headaches/ tension headaches Fibromyalgia Chronic back pain and other chronic musculoskeletal pain Complex regional pain syndrome and other types of neuropathic pain Phantom limb pain Any acute pain that has become chronic Development of Chronic Pain Central pain processing involves connectivity among different brain areas Acute pain can become chronic when central neural pathways form and become established (a connectome ) Factors contributing to formation of a pain connectome: negative acute pain experiences, pain fear, anxiety, depression, sleep deprivation, learning disability, etc 2

3 WHY? Central Brain Connectome Chronic pain can be maintained even after primary stimuli are gone (e.g. IBS after acute GI viral infection) Anxiety, past pain memories, depression, insufficient sleep, depression, expectations, feelings of helplessness, and other cognitive factors contribute to development and maintenance of chronic pain When pain becomes central, it doesn t mean that it is not real or painful to the patient Strategies typically used for acute pain do not work for chronic pain: why these chronic pain kids are frustrating to treat in an acute care setting Treatment of Chronic Pain Rx Goal: reprogram child s central pain connectome Physical/psychological therapies, medications aimed at neuropathic pain and at anxiety/depression/sleep work better than meds used to treat acute pain (e.g. opioids) Chronic pain leads to musculoskeletal pain from inactivity: movement hurts, leads to more inactivity, more pain, feelings of helplessness, and obesity Need to address family factors that facilitate the child s pain and disability, social (e.g. trauma, school bullying), and developmental factors (learning disability, ASD) A good biopsychosocial history and physical exam allow multimodal individualized therapy Third Objective: opioid overuse, reliance, hyperalgesia can be prevented 1. Elicit a detailed biopsychosocial history and complete physical exam 2. Allow child/parents to tell their story (patient and parent narratives are therapeutic) 3. Biopsychosocial History: story of the pain and associated symptoms, sleep onset and maintenance, diet, impact of pain on school, social activities, physical activities, family relations, mood, anxiety; Talk alone with older child/adol: psychological assessment and HEADS 4. PE: tender points, muscle tension and strength, balance, flexibility, allodynia, gait How to prevent opioid overuse, reliance, & hyperalgesia 1. Don t use opioids unless good reason: post op pain, procedure pain, cancer pain, palliative care, acute injury, acute disease flare (e.g. lupus, IBD): if used appropriately, opioids allow enhanced function 2. Chronic opioids for conditions not requiring them can lead to opioid hyperalgesia, overuse and abuse (used to treat psychological issues rather than pain, used recreationally), can lead to opioid addiction 3. ER quick fix opioid: doesn t address underlying pain/stress that precipitated the ER visit SLEEP: First step in treating chronic pain Sleep hygiene: routines, white noise, dark room Phone/iPAD blue lights: impact =2 cups of coffee; discuss sleep habits; Melatonin: 2 hrs pre sleep Behavioral Rx s: breathing, relaxation techniques IF meds are needed to launch better sleep habits: Trazodone, Mirtazapine TCA s, Gabapentin, Clonidine SSRI s if anxiety/depression related to insomnia Benadryl can have paradoxical effect, tired next day; Benzodiazepines block stage IV sleep

4 Opioids are not the treatment of choice for neuropathic pain Treatment for functional abdominal pain If medications needed: Tricyclic antidepressants: amitriptyline Anticonvulsants: gabapentin, pregabalin SSNRI: duloxetine Alpha agonists: clonidine Lidoderm patches, capsaicin cream Alpha lipoic acid Acetyl L Carnitine Anti oxidants: C0 Q Opioids are not appropriate treatment for functional abdominal pain (FAP) Pharmacological Clinical Trials Anti depressants for treatmnt of FAP in children and adolescents (Kaminski et al, Cochrane Database Syst Rev. 2011) no evidence supporting their use for treatment of FAP in children and adolescents Existing RCT s limited to amitriptyline No significant difference between amitriptyline and placebo for most efficacy outcomes in children and adolescents 21 Non pharmacological treatment for FAP systematic review (Rutten et al, Pediatrics, 2015) High quality studies are lacking Some evidence shows efficacy of hypnotherapy, cognitive behavioral therapy, and probiotics (LGG and VSL#3) in pediatric AP FGIDs Data on fiber supplements are inconclusive Most evidence is for CBT efficacy, including parent focus (see studies from R Levy et al, T Palermo et al) IBS: a brain gut neurosignaling disorder (ca 1850) Treatment for recurrent abdominal pain Education about what IBS is A Brain gut neural signaling problem Psychological treatment strategies CBT (Levy R & Palermo T studies), Hypnotherapy Behavioral incentive plan to enhance function, especially re. return to school PT for reconditioning and reducing abdominal wall muscle tension Complementary therapies 4

5 Disease related chronic pain may require opioids for relief Sickle cell disease Arthritis Immune related diseases: Lupus, Crohn s disease, Ulcerative Colitis Cancer Genetic diseases Bone diseases Major Principles of Pain Treatment 1. Most chronic pain in children is not effectively treated using opioids 2. ALL chronic pain requires biopsychosocial treatment approach, not just medication 3. Some chronic pain can require opioids to enable child to function with quality of life 4. These children ALSO need a biopsychosocial approach to treatment, not just medication Drugs not always the answer: Beginning of acupuncture 27 Complementary Therapies Mindfulness Hypnotherapy Acupuncture Yoga Chiropractic Biofeedback Massage Therapy Relaxation Art Therapy Music, Dance Drama, Writing Pet Therapy 28 More of something isn t always the answer 29 Pediatric Pain Advocacy Poor pain management in childhood creates risk for continued impairment as future adults 73% of children with chronic pain are at risk to become adults with chronic pain and will likely develop new pain conditions (if not treated adequately) We know what works, saves money, makes money, and prevents further problems: So why is there still a problem? 5

6 Pain Advocacy for Children: Attitudes In the 1970 s: infants did NOT receive anesthesia for surgery. Why? It was believed infants did not feel pain or it didn t matter since they wouldn t remember Healthcare providers do not receive adequate training in pain management: Recent survey of 104 US med schools 4 schools required a pain course, 1 had pediatric pain in the curriculum, 1 31 hrs: Total pain teaching across schools Mezei L, Murinson BB. Pain Education in North American Medical Schools. J Pain. 2011;12(12): IOM report, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research, Pediatric Pain: Economic Burden Poorly treated chronic pain in children is associated with huge annual economic burden $19.5 billion Groenewald CB, et al, The economic costs of chronic pain among a cohort of treatment seeking adolescents in the United States. J Pain. 2014;15(9): $11.8 billion dollars in additional yearly costs, more than expenditures for obesity ($0.73 billion) and asthma ($9.23 billion) combined Groenewald CB, et al. Health care expenditures associated with pediatric pain related conditions in the United States. Pain. 2015;156(5):951 Pediatric Pain: Economic Burden Comprehensive treatment of pediatric chronic pain resulted in $58,000 reduction in family healthcare costs and reduction of $11,000 loss from caregivers missing work (Gouge N et al, Integrating Behavioral Health into Pediatric Primary Care: Implications for Provider Time and Cost. South Med J. 2016;109(12): ) Thank You Integrating behavioral health providers into pediatric clinics allows physicians to see 42% more patients and collect $1142 more revenue per day (Asarnow JR, et al, Integrated medical behavioral care compared with usual primary care for child and adolescent behavioral health: a meta analysis. JAMA Pediatr. 2015;169(10): ) Ethics in Pediatric Pain: How to treat children s pain without contributing to the opioid epidemic Question 1. How can opioid overuse/reliance/ hyperalgesia be prevented when treating pain in children and adolescents? A. Never use opioids in children for post operative pain B. Treat recurrent abdominal pain with opioids C. Reduce neuropathic pain by treating with opioids D. Use a biopsychosocial approach to treating chronic pain in children 35 6