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A Rational Approach to Managing Acute Pain in Children

Pain is one of the most common reasons for a parent or caregiver to seek medical attention for their child. Children experience pain for a wide variety of reasons, many that are similar to if not exactly the same as causes of adult pain, but historically pediatric patients have been grossly undertreated. I am 37-years-old and, sadly, if I had undergone a surgical procedure as an infant there would have been a significant chance that I would have received no analgesia at all. Things are better now, but there remains a large gap between what is recommended and how pediatric pain management is practiced in the real world.

The appropriate management of a child’s pain is a vital aspect of compassionate and high quality care, and it is simply the right thing to do. Failing to treat pain effectively is ethically no different than purposefully causing pain in a child, and it can have serious repercussions. Poorly controlled pain can interfere with a child’s recovery because of the negative impact of catecholamine surges and other stress-related chemicals, and impair the ability to take part in physical or occupational therapy. It can also make future encounters with health care professionals more challenging because of anxiety and mistrust.

Untreated pain can interfere with deep breathing, potentially leading to prolonged need for supplemental oxygen and increased risk of pneumonia. It can prevent restful sleep, which has myriad health consequences beyond just cognitive impairment. Pain can interfere with the family unit by significantly increasing parental or caregiver anxiety, which can lead to neglect, abuse, and increased utilization of healthcare resources. Poorly-managed acute pain can increase the likelihood of a patient, even a child, developing chronic pain. There is even good evidence in neonates (my next post I think), that poorly managed acute pain can lead to increased sensitivity and an increased pain response to future occurrences of procedural pain, such as routine immunizations.

Multiple reports throughout the 1970′s and 1980′s revealed that pediatric patients received substantially less pain treatment compared to adults for equivalent conditions, such as broken bones and hernia repair. Despite steady improvement in pain management in kids over the past few decades, we still have a long way to go. Though appropriate anesthesia is now standard of care in children of all ages, many physicians are uncomfortable with evaluating and treating acute pain (chronic pain is another topic) in children. And many parents are resistant to the use of safe and effective pain medications.

Even with physicians that might profess their comfort with recognizing and treating pediatric pain, my admittedly personal experience is that many still allow kids to be in pain at times for a variety of reasons. However, it isn’t that these physicians and caregivers are heartless or enjoy watching their patients, or their children if it is a parent putting up a roadblock, suffer. Even knowing a child is in pain can sometimes be challenging. And there are many misconceptions regarding pain in children that interfere with appropriate treatment. The bulk of these misconceptions involve the use of opioids. All of these misconceptions and false beliefs should be amenable to education and increased awareness of science-based guidelines.

Pediatric pain is a challenging entity. So much so that many institutions have pediatric pain teams. My wife is an expert on pediatric pain and spends her days, and often nights, as a palliative care pediatrician helping to manage pain and other symptoms in children who are approaching the end of life. Her insights and expertise on this topic have been invaluable in my own encounters with pain as a pediatric hospitalist. Her experience, like mine, is that even at major academic institutions pain management is regularly not approached systematically, nor based on the best available evidence.

So what is pain exactly, and how is it assessed in kids?

A brief primer on pain

At its core, pain is an unpleasant sensation or emotional experience that can occur when there is tissue injury, when we expect tissue injury to occur, or when we think there has already been tissue injury. It is entirely subjective and personalized. Each individual learns over time, through their own personal experiences, what sensations and emotions to label as pain and how to express the severity of that pain verbally once they have achieved that stage of cognitive development. There are many ways that this process can get tripped up, leading to chronic pain even after any tissue injury has healed, but that deserves its own discussion so I will stick to acute pain. Of course children with chronic pain can have acute pain as well. It’s complicated.

We generally break pain down into two categories, nociceptive and neuropathic, and nociceptive is further broken down into somatic and visceral pain. The label nociceptive pain is given to pain initiated by otherwise-healthy pain receptors present in injured or inflamed tissue. Somatic describes pain associated with skin, soft tissue, muscle and bone while pain from our internal organs is visceral. The difference clinically is that with visceral pain it is hard for patients to describe a specific location of their dull- or cramping-type pain, while somatic pain is sharp, throbbing and they can point right to it. Neuropathic pain involves damaged sensory nerves rather than specific pain receptors and is typically more of a burning, tingling, or shooting pain.

Pediatric pain assessment basics

The key to appropriately managing pain in a child involves deciphering the clues obtained from a thorough history taking and physical exam, in order to assess the type of pain, where it is coming from and the severity. We use self-reporting methods when we can, but obviously it often isn’t as simple as just asking the patient to rate their pain on a 1 to 10 scale. There are behavioral observational scales validated on pediatric patients, such as young infants and toddlers, who are unable to self-report but we must frequently rely on details provided by caregivers. These caregivers, no different than the rest of us, can fall prey to stress and cognitive biases that alter their memory and perception. Also, there is always concern that observational assessment may underestimate pain compared to self-report.

We must also frequently deal with adolescent patients whose ability to reliably rate their own pain using a numerical scale is suspect because of psychiatric conditions, maladaptive responses to stress, and even malingering, though this isn’t common. In general, it is considered best practice to take the patient’s word for their pain severity, at least until you have a good relationship with them and ample evidence that their pain reporting is unreliable. Not treating pain is unacceptable and I would rather treat a thousand kids for pain unnecessarily, but safely, than allow one child to suffer needlessly.

As in the adult world, we are called upon to assess neurologically impaired patients that might be in pain or may simply be agitated for some other reason. These children, who are unable to communicate because of neurological impairment, are particularly challenging. The best practice is to make use of observational clues and to trust the caregiver, who is usually quite familiar with the patient’s typical patterns of behaviors and vocalizations when facing regular day-to-day stresses. They are best able to point out when these patterns have changed or are inconsistent with other possible etiologies for the concerning changes. The parent of a severely cognitively impaired 15-year-old boy may be able to tell us, for instance, that a particular period of moaning, grunting, change in muscle tone or posture, or other behavior is not what is typical for him when he is merely hungry or has a cold. That being said, this population of pediatric patients still are often victims of untreated pain.

Pediatric pain management pearls

Compared to when I was an infant in the late 1970′s, the options for treating pain in children have only improved a little. There are few new pharmaceutical agents and there has been an expansion of adult approaches to pain into the pediatric sphere. These improvements, whether talking about the use of an old drug in a new way like methadone for pain in kids or transdermal fentanyl patches, are typically only used by experts like my wife. It is not even entirely clear that these newer approaches are better.

The bulk of the improvement in pediatric pain management, and again there is plenty of room for improvement, is that we somewhat more reliably treat kids who are in pain that would have suffered through it in the past. A physician doesn’t need to be an expert, and to be comfortable using every drug in the book, to be able to provide good care for most children with pain. The key for managing pediatric pain effectively is to become familiar with the use of just a few drugs, to not be afraid to use them when appropriate, to make use of non-pharmaceutical methods of pain control and to be consistent and systematic in our approach. Our goal should always be to control and prevent acute pain.

Decades ago, the World Health Organization (WHO) developed guidelines for treating pain and an analgesic ladder of pain management that has now been adjusted for use in pediatric patients. It entails a stepwise approach to pain based on the severity and response to any intervention. I’ll give you the quick and dirty version of the WHO guidelines:

  1. Assess for pain, and severity of pain, regularly in injured or sick kids.
  2. Use non-pharmaceutical methods like massage, play therapy, distraction techniques and cognitive psychotherapy in addition to drugs, especially with painful procedures like blood draws and abscess drainage if not sedated. (Please don’t get me started on acupuncture.)
  3. With anything more than minor pain, schedule pain medication around the clock instead of waiting until they are hurting.
  4. Use oral pain medications whenever possible and avoid uncomfortable intramuscular or rectal administration.
  5. Anticipate and treat side effects.
  6. Use non-analgesic medications when appropriate to treat neuropathic pain, anxiety, or swelling that might be adding to the perception of pain.

The 2-step pediatric analgesic ladder essentially amounts to using big drugs for big pain and little drugs for little pain, as my wife likes to say. We generally use non-opioid medications like acetaminophen and ibuprofen on step one (little pain) and opioids on step two (big pain) or when little pain doesn’t respond to the step one approach. Non-analgesic medications can be given on any step depending on the circumstances, and non-pharmaceutical measures should always be put into use.

I like the QUEST approach as a framework for a physician learning about pain management to build on:

Question the child
Use a pain scale
Evaluate behavior
Secure parent involvement
Take cause of pain into account
Take action and evaluate results

Comfortable children or: How you should learn to stop worrying (too much) and love morphine

No pharmaceutical intervention is risk free. But, as has been pointed out time and time again on SBM, the poison is typically in the dose. Dosed appropriately based on a child’s weight, and used appropriately based on science-based guidelines, opioid medications are extremely safe and effective in the treatment of pain in children of any age. They are just one piece of the puzzle, but unfortunately they are most often the missing piece.

First off, with rare exception, non-opioid medications like acetaminophen and ibuprofen should always be used for mild pain and in conjunction with opioids for more severe pain. They are safe when dosed right and very effective. For some causes of pain, ibuprofen is preferred over acetaminophen because of its anti-inflammatory properties. And because I’m a pediatrician, I’m compelled to mention that aspirin should never be given to a child less than 19 years of age unless directed to do so by a physician because of the association with Reye syndrome, a sometimes deadly encephalopathy that can injure multiple organs systems.

Now the good stuff. There are many options for using opioid medications and they can be given by the IV, oral, transmucosal (fentanyl lollypops), and transdermal (fentanyl patch) route. Generally IV morphine is the first-line opioid for severe pain, but hydromorphone (dilaudid) is also commonly used in kids, as is fentanyl, although it is used mostly when sedation is desired along with pain control during an invasive procedure. Children with moderate acute pain are typically given oral agents such as oxycodone or tramadol, at least they should be, but are often given combination products containing acetaminophen and codeine or hydrocodone (lortab). I’ll explain why this is not a good idea.

Historically combination drugs like acetaminophen and codeine, or acetaminophen and hydrocodone, have been given to people of all ages for moderate pain, often after surgical procedures for use at home while recovering. In the pediatric population, which is all I can really speak for, we have been trying to move away from their use, and especially the use of codeine, for years. Unfortunately it is still commonplace to see these drugs prescribed by non-pediatric surgeons and dentists, and I do still see them used by some pediatricians.

What’s the problem with these medications? Why should codeine in particular be wiped from the minds of anyone with the ability to prescribe it? Because the potential risks far outweigh the potential benefit. Here’s why.

In August of 2012 the FDA, which had been made aware of 3 pediatric deaths in children receiving standard doses of codeine for analgesia after having their tonsils and/or adenoids surgically removed, and one case of severe respiratory suppression, issued a warning. A few months later they issued a stronger “boxed warning” for inclusion on product labeling. Many pediatricians stopped using it and pediatric hospitals began removing it from their formularies in droves.

It shouldn’t have taken these deaths to get to this point though, because we have better options available. But codeine had developed a reputation as a good choice when a weak opioid was needed. People thought it was safer than just giving lower doses of what are commonly thought of as stronger drugs like oxycodone and morphine. It isn’t.

The way codeine provides analgesia is by its conversion to morphine in our bodies. The problem is that in some people, around 1-2%, this conversion is more robust than would be expected. In these hyper-metabolizers, the body doesn’t have to time to return to baseline before the next dose is given. So over multiple doses, this can lead to a stacking of adverse effects, primarily respiratory suppression and sedation, without an improvement in analgesia.

Another problem with codeine is that a larger percentage of the population doesn’t metabolize it much at all. They won’t stop breathing, assuming an appropriate dose is given, but they aren’t protected from the side effects. And they will get no analgesia except from the added acetaminophen if there is any. There are also a number of medications that interfere with the conversion to morphine, thus limiting its ability to provide pain relief. Remember this the next time a physician tries to prescribe codeine for you or your child for pain or cough, which it doesn’t work for either!

Why don’t we like combination pain medications that don’t include codeine? They aren’t a good option either in most situations, but it’s because of the acetaminophen, not the weak opioid. With combination products, we lose the ability to safely change dosing on the fly, such as taking two pills when the pain is worse instead of the prescribed single pill. In some circumstance, the acetaminophen can accumulate and lead to potentially-fatal toxicity. We also lose the ability to give acetaminophen if there is an associated fever. Finally, many people take OTC products that contain acetaminophen without even realizing it. Again, we have better options, so why take the risk in kids.

Speaking of risks

Naturally it isn’t all sunshine and daisies with opioids. There are risks and side effects. But when dosing is done with care and based on the child’s weight, the risk of serious adverse events is very low and far outweighed by the benefits. And when side effects are anticipated, they can almost always be managed safely and effectively when they arise. These include sedation, respiratory depression, constipation, nausea, urinary retention, itching, and rarely, repetitive involuntary twitching of some muscle groups. Tolerance to these effects tends to occur within a couple of days so most patients can get by with symptomatic treatment (medication for nausea or itching) but not with constipation. This is why it is a good idea for anyone on an opioid to also be on a stool softener.

Sometimes the side effects, like itching or nausea, or simply not tolerable to the patient. We will typically try a different opioid when this occurs, and in many cases that does the trick. Another drug to add to the list of opioids best forgotten is meperidine (demerol). Reasonable increases in the dose of most opioids in response to poorly controlled pain do not tend to lead to an increased risk of adverse effects if a patient is tolerating the drug. Meperidine is an exception because of unique products of its metabolization, which can lead to severe toxicity with dose increases. It’s a bad drug.

Pediatric pain misconceptions and some counterarguments

So what are the many barriers to effective management of pain, which includes the appropriate use of opioid medications? There are a lot of them unfortunately, and the patient, their caregivers, and the treating nurses and physicians can all fall prey to them. Patients may be reluctant to report their pain for fear of being labelled a drug seeker, concern over poorly-managed side effects, or because of social issues at home. What happens when mom needs to sell them to pay the light bill, or is taking them herself because she is addicted? The patient or caregiver may be afraid of the development of an addiction, or physical dependency on the medication.

Medical professionals may be afraid of harming their patient, or worried about the development of addiction or misuse. They may be concerned about prescribing controlled substances. Many physicians are uncomfortable with children nearing the end of life, and the possibility of contributing to their death by prescribing an opioid. The most common barrier is simply inadequate training in pain management and the lack of skills needed to assess pain in children however.

These barriers are, for the most part, understandable but unfounded. The key to removing them is education and developing a good approach to pain management. As stated above, severe side effects are uncommon when doses are appropriate and the others are generally able to be dealt with or subside after a few days. There is no difference between lower dosing of a stronger opioid and a weaker opioid when it comes to side effects. Dependence on opioids is rare as well. So is drug-seeking. Pediatric patients seeking a higher dose are considerably more likely to be doing so because of undertreatment or the development of tolerance than to be drug seeking. And the use of opioids in a patient that is receiving end-of-life care does not contribute to their death when used appropriately.

There are a number of misconceptions regarding pain in children that are not so understandable, but still should respond to education. Children do not always scream or cry when they are in pain. Sometimes they just shut down. This is where a thorough history and physical should come in very handy. If a 15-month-old who just had a hernia repair is clingy, or curled up with their eyes closed refusing to interact with anyone, they are likely in pain even if there are no tears. This is especially true after a lengthy period of undertreated pain. Think of it as learned helplessness.

Children who would be expected to have significant pain because of an injury, illness, or surgical procedure should be treated for pain. A common issue I have with nursing is when scheduled pain medications are not given because the child is asleep. A child who just had a broken femur screwed back together is sleeping because the pain management has thus far been effective. Waiting until they are awoken by pain is cruel. The point of scheduling pain medications rather than giving them as needed is to prevent pain, which is every bit as important as treating pain once it occurs. As my brilliant wife likes to say, PRN = Patient Receives Nothing.

Pain is never good for kids. There is never a benefit to pain, no lesson to be learned from it. Treating pain will not impair a physician’s ability to do a physical exam, it will only improve it. A common misconception that I’ve personally encountered a number of times, although not typically when a pediatric surgeon is involved, is that a child’s pain should not be treated if there is suspicion of a surgical process, typically appendicitis, until the surgeons arrive to assess them. This is cruel and simply untrue.

Conclusion

This discussion is far from comprehensive. Pain management in kids is complex and this just scratches the surface. There are even plenty of misconceptions about pediatric pain management that I left out so this wouldn’t drag on too much. But I believe that this is a good overview, perhaps more of a deep scratch or gouge into the surface of the thing that I hope will lead to better pain management should a reader find themselves in need of it for their own child or for the child of a friend or family member. If you don’t think that a child is being treated appropriately, speak up.

It can’t be said enough that the best way to approach pediatric pain is consistently and systematically. Pain is one of the few instances where kids and adults should be thought of as equivalent. We all feel pain, even premature infants, and we all deserve to be treated for it. There are adult patients with neurological impairment that are non-communicative just as there are in pediatrics. Both populations have psychiatric issues that increase the complexity of treatment. Both adult and pediatric practitioners must rely on caregiver report at times. The drugs used to manage acute pain are the same, though the doses sure are different, and we all can be helped with non-pharmaceutical interventions. Although an adult is perhaps less likely to respond to a bubble machine and a Dora the Explorer video in quite the same way as a young child.

Posted in: Science and Medicine

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43 thoughts on “A Rational Approach to Managing Acute Pain in Children

  1. mousethatroared says:

    Thanks for an excellent overview of a current approach to pain management in kids! My son’s last surgery (bone graft for cleft palate) was in 2011 and he was given tylenol 3 to management pain at home. I wonder if our surgeon has switched medications, now. Hopefully, I won’t find out for quite a while, as my son isn’t due for another surgery until his teens.

    One thing that I thought was interesting was the device they used to control pain at the donor site were the bone for the graft was taken (hip). Typically, we’re told, that is where kids experience the most pain after this surgery. The surgeon threaded a very small tube (looks like a wire) under the skin at the hip that washed the site in local anesthesia periodically. The tube was hooked to a canister/pump that my son carried on a strap. This contraption was used for several days, the length of time that the pain from the hip typically peaks, then the tube was removed at home. Because of this, my son experienced very little hip pain…The tube removal did kinda freak him out though, I guess that’s the downside. :(

    After my son’s second surgery, he experience significant nausea and vomiting…they did give him anti-nausea medication, but it didn’t seem they could get ahead of it. I let the anesthesiologist and anesthetist know about this for his most recent surgery and they were able to give anti-nausea medication earlier. He seems much more comfortable.

    Thanks again for an informative article. It good for folks to know that there are safe and effective ways to control kid’s pain, when needed.

    1. mousethatroared says:

      I said – “My son’s last surgery (bone graft for cleft palate) was in 2011 and he was given tylenol 3 to management pain at home. ”

      Actually, now I wondering if I’m recalling that right…I’m pretty sure we were sent home with some oral medication that was more powerful than tylenol. But I can’t quite remember what it was. Memories from a sleep deprived period are not always accurate. ;)

  2. goodnightirene says:

    Oh dear! I always request codeine because of intense itching from the synthetics (all of the ones I’ve tried).

    But this is about kids–sorry.

    I was so very lucky to raise four with no hospitalizations or illness beyond colds and a few ear infections. We did use codeine cough syrup and I was somewhat horrified to read your data on this practice. We always used it for coughing that kept the child awake at night. If nothing else, it seemed to allow him or her to sleep, thus improving recovery. I have passed that “wisdom” on to the family and I think I must now retract it–if the offspring’s doctors have not already done so.

    Thanks for these insights into pediatrics. I am interested even (especially?) though I seem to have stumbled through it all with some very inferior knowledge.

    1. mousethatroared says:

      Jeez Irene – Not even any broken bones, concussions or stitches required? How’d you manage that?

      1. Alia says:

        Well, some parents are lucky enough to have children like me – no broken bones, no stitches (well, once I stepped on a broken glass and the wound was pretty deep but still it healed well without stitches), no typical childhood illnesses (which means I had chicken pox at the age of 21, no fun at all), no hospital stays or ER visits ever. Well, there’s this deadly allergy to wasp and bee stings but it can be easily managed (meaning: my parents had to kill every bee and wasp that appeared in our place).

        1. mousethatroared says:

          Alia “Well, some parents are lucky enough to have children like me – no broken bones, no stitches” etc

          Clearly, some are that lucky. I just had to rib Irene a little on her luck of having more than one child like that. I actually got off with no injuries that required medication stronger than tylenol (well, I did get a finger slammed in a locker door and that kept me up a couple of nights with the throbbing, but it wasn’t that bad an injury really) But, between the five kids, we had a few broken bones, two concussions, two poisonings (do they usually administer a sedative when they pump a child’s stomache, now?)… surprisingly (luckily) nothing that required stitches.

          I will add, the part of the article about how you can’t assume that a child will cry when they are in pain struck home. My sister got her arm broken playing launch with my older siblings. My dad (my mom was gone for the day) thought because she wasn’t crying and hollering she must be fine. When my mom got home that evening and found my sister in bed before bedtime, pale and quiet, she immediately took her to the E.R.

  3. TwistBarbie says:

    I broke my arm when I was 11. I knew right away it was broken but for some reason my parents insisted it was “just a bruise” and took me to the walk-in clinic first . The doctor took one look and said “Get her to the hospital” 45 minutes later we arrived and I guess it was too late in the evening, or they were too busy to do the surgery (it was around 8pm) so they kept me there and I had surgery in the morning. They must have given me something for pain when I arrived, but I remember lying in the hospital bed in agony all night, with no offer of pain relief from anyone. I hope nothing like that ever happens to my kids, or anyone else’s for that matter! Thank you for this excellent article.

  4. Harriet Hall says:

    Thanks for the excellent article. I certainly agree that under-treatment of pain should be avoided, but I suspect that sometimes doctors tend to over-treat pain because of their own biases.

    You mentioned a child in pain from hernia repair. When I was an intern, we did hernia repairs on a toddler and an adult the same day. On the afternoon of the day of surgery, the toddler was standing up begging to be taken out of the crib and someone who didn’t know he had had surgery lifted him out and he was happily running about the ward with no evidence of discomfort. Three days later, the adult was still complaining and grimacing in pain when he turned over in bed. I always thought the toddler was in less pain than the adult because (1) his tissues were younger and more flexible, so the surgery was less traumatic, and (2) there is a broad spectrum of suffering with the same pain sensations; some adults report more pain because they expect to hurt and are hyperaware of every sensation, and if kids haven’t learned that it’s “supposed” to hurt, they suffer less. I thought the toddler probably had similar pain sensations but was able to disregard them because he was distracted by his strong motivation to get out of the crib and play. How would you interpret their different responses? Don’t the same “pain” sensations tend to cause less “suffering” in a child? We all know that kissing a child’s owies results in fewer pain complaints than encouraging an adult to pay attention to how bad he feels.

    My own anecdotal experience: I have had two excisional breast biopsies with nothing but local anesthesia (no sedatives or other drugs), and never needed to take any of the pills I was given for post-op pain (I felt “pulling” sensations and mild discomfort that I didn’t interpret as “pain”). As a doctor, I was not anxious about the procedure, and I was not afraid of cancer because I expected the surgery to eliminate it even if it was present. I think a patient who was unfamiliar with surgery and the OR and was scared to death about the experience and the prognosis would have experienced a lot more pain than I did.

    Another anecdote: I have seen babies undergoing circumcision without any anesthesia who cried loudly during the preparations, particularly when their arms and legs were tied down; but who calmed down and happily sucked on their pacifier and then showed little evidence of distress during the procedure itself and afterwards. They had no understanding of what was happening; compare that to an adult who thinks “They’re going to cut off part of the most sensitive, treasured part of my anatomy?”

    Sometimes in suturing a tiny laceration, we thought the distress caused by a needle infiltrating the area with lidocaine would be just as bad as the distress caused by taking a single stitch or two without anesthesia, so we would omit the lidocaine. Adults who could give consent almost always preferred that approach. Were we wrong to do that?

    I guess what I’m getting at is that pain and suffering are two different things, and it would behoove us to give more emphasis to those non-pharmaceutical interventions you mentioned. Reassurance, suggestion, distraction, TLC, time, attention, and bedside manner are things CAM providers often do better than the average MD. I think we can learn something from them.

    1. Max says:

      Forget biopsies. Many people are even terrified of flu shots, even though the shot itself doesn’t hurt, and there’s only a dull ache afterwards, unless the nurse screws up and injects into the bursa. Distraction helps there.

      Dan Ariely said that his interest in irrational behavior started when he was in a hospital with severe burns. His nurses were ripping off his bandages quickly, when it would’ve been better to rip them off slowly and allow time to recuperate. Time and attention would’ve helped there.

      Julia Galef wrote that the pain of having bandages removed from her burn wounds didn’t bother her as much after the nurse said that she was just pulling the edges off normal skin, not the wound itself. Reassurance and suggestion helped there.

      Patients with pain asymbolia can feel pain and describe its quality and intensity, but they don’t consider it unpleasant.

  5. Young CC Prof says:

    “Children do not always scream or cry when they are in pain. Sometimes they just shut down.”

    Not only children, disoriented adults do this too. This is partly why I had such lousy pain control after my surgery a couple years ago. No one asked me whether I was in pain, only told me it “wasn’t that bad, right?” My natural reaction to pain IS to shut down, to go very still and quiet and just endure.

    I was confused from the anesthesia, and too busy trying to get through from moment to moment to figure out that I should be demanding help. (I also suffer from mild chronic pain which usually isn’t treated, so I get used to putting on a happy face and ignoring it.) By the time I was clearheaded enough to express my needs, the surgeon had gone home, the script he left proved entirely inadequate, and there wasn’t a darned thing the nurses could do until morning.

    My previous surgeries involved little or no postop pain and lots of attentive nurses offering drugs that I really didn’t need at all, so it really hadn’t occurred to me that that might happen, that I’d wake up in severe pain and not get relief for like 16 hours.

  6. ERKamloops says:

    Thanks for the great post, Clay. I have seen all too much oligoanalgesia in children. I completely agree with your stance on getting rid of codeine. In my juristriction, it is the easiest narcotic to prescribe and therefore, the overwhelming favorite.

    There was an editorial in the CMAJ on this subject several years ago: http://www.cmaj.ca/content/182/17/1825.full

    I would also suggest that a stool softener alone is not going to cut it in most patients with narcotic induced constipation. A tip to deal with this in the emergency department is to give the patient a dose of 2 mg naloxone (adult dose). It has only about 2% oral bioavailability, so there is usually minimal or only transient disturbance in analgesia.
    For anyone interested in the master class in dealing with constipation in the emergency department, check out Rob Orman’s The Constipation Manifesto on ERCast. http://blog.ercast.org/2012/02/the-constipation-manifesto/

    1. Kathy says:

      now there’s a subject that could do with some attention … constipation. The woomeisters of today maybe don’t pay it as much attention as the woomeisters of yesterday, but it’s bound to come back into fashion.

      1. windriven says:

        Kathy, it may have already come back into fashion. A Google search for ‘colon health’ returns 37 million hits!

        I clicked on one youtube (http://www.youtube.com/watch?v=1DYSGPeDCTc) for, if you’ll pardon the expression, shits and grins and found a presentation by, I kid you not, The Herbal Alternative Research Team with commentary by one Keith Davenport, ND (not doctor).

        In it I was amazed to learn, among other things, that my immune system is directly related to the condition of my intestines and that “toxemia is the cause of all disease.” At 44 seconds this ass-clown intones that, “United States Health and Human Services (does he mean DHHS?) admitted several years ago that ‘over 90% of Americans are walking around with (dramatic pause) clogged colons.’ No citation of course.

        I stopped at 1:25 as I couldn’t take another picture of ugly malformed turds. It is 6:19am here and I just finished breakfast.

        Anyone who thinks that naturopathy is remotely related to medicine (they claim equivalent or better training than MDs) should watch this idiocy. Just be sure to watch it in the evening after you’ve had three fingers of Scotch.

        1. Nashira says:

          The woomeisters freaking love poo and crazy ideas for constipation especially, although diarrhea pops up sometimes. I’m pretty sure that the perennially awful Gillian McKeith is their patron goddess. She is, incidentally, someone whom I’d quite love to see sacrificed to a volcano, but I’m afraid she’d give it the runs and that could be pretty disastrous for any neighboring critters.

          I’m still frustrated at how difficult it is to find reasonable, science-based info on things like IBD… Even reading SBM and RI and other skeptical medical blogs hadn’t quite prepared me for just how much wooful nonsense was out there, when I was trying to learn about my shiny new ulcerative colitis diagnosis. Apparently it’s quite common for people to pull the same thing they do in the SCAM cancer treatment testimonials that Dr. Gorski dissects, namely have curative surgery (colectomy) and then swear up and down that it was this whacked out diet or special homeopathic preparation that really solved all their problems. Ugh!

  7. LDoBe says:

    I remember a few occasions of not having any pain management when I was a kid.
    When I was about 6 years old, my brother managed to bash me in the back of the head with a piece of asphalt. We went to the emergency room at the nearby teaching hospital where a student sterilized the wound, and asked the overseeing doctor whether he should give me a local anesthetic. The 70 year old doctor said (I remember this distinctly) “Don’t bother, it builds character.” And then I was given a baker’s dozen stitches, in the back of my head by a student while I kicked and screamed. I still have a big lumpy scar two decades later that probably wouldn’t exist if I was given the proper anesthetic so I could sit still.

    Then there was the time I was hospitalized with cluster headaches when I was twelve, and just given a barf bucket. That was pretty bad. I swear it physically hurts all over again when I think about that time.

    I remember being in pain a lot as a child. And I was surprised at the adequate pain management I received when I had my wisdom teeth taken out at 17. It was the first time I hadn’t been told to “just bite on a stick, you pussy” by my doctors.

  8. Alia says:

    I remember from my childhood in the 1980s that dentists would almost generally use no analgesia when treating children (whether removing baby teeth or drilling). What we have as a result is a whole generation of adults who are so afraid of dentists that they would go there only when their pain gets too hard to bear.

    1. Max says:

      My dentist didn’t use any anesthesia when removing baby teeth, big deal, I got over it.
      What we have now is a whole generation of adults who want to be knocked out for the smallest procedures, and take painkillers for the slightest temporary pain.
      Earlier this year, 24-year-old Marek Lapinski died after he was injected with propofol while getting his wisdom teeth pulled.
      What we have now is more Americans dying each year from drug overdoses than car crashes, and 80% of heroin users having previously abused prescription painkillers.

      1. Nashira says:

        There is no. good. reason. to not offer people adequate pain control, and many excellent reasons to make certain that children (and adults with communication problems) especially have their pain managed. One might suggest you try reading this post again. It isn’t without risks, but nothing is. Leaving the pain untreated isn’t without risk. The longer pain is poorly controlled, the worse the pain can become, the more difficult it is to bring it under control without whale-sized doses of meds, and the more upsetting and emotionally difficult it is. If you think that it’s weak to want pain management, that just makes me think you’ve never been in severe pain and that you’ve never seen what living in pain does to people.

        You’re probably too busy chilling out on your high horse, looking down your nose at the straw addicts.

      2. mousethatroared says:

        @Max – Has it occurred to you that getting wisdom teeth out may sometimes be a bit more painful and involved than getting your baby teeth pulled. I had five impacted wisdom teeth, some of them had to be broken before they could be removed. My mouth was so full of stitches afterwards that I could only open it a very small amount. I am very glad that I had a local and a sedative. One anecdote of one death (out of the many, many people who do well) without any comparison of the risks of trying to do oral surgery without a local and a sedative is not very compelling.

        Also, getting a flu shot (which generally doesn’t require pain medication) is not like …say appendicitis. So the fact that a flu shot doesn’t hurt very much is pointless. The number of people who die from drug overdoses is also unrelated to the decision to use pain management in children, unless you have some actual evidence that shows a causal relationship between the two.

        I’m appalled that you would actually suggesting that people should not treat children’s pain based on some groundless speculation that the results are people who can’t tolerate pain or might become drug addicts later in life. That is just pointless cruelty.

        1. Alia says:

          I can understand your pain very well – I had two of my wisdom teeth (impacted) excised surgically, one of them was so big and complicated that the dental surgeon later asked me if she could take it to show it to her students. And then there were stitches, a few days on liquid diet and high doses of ketoprofenum. I had the procedure done on holidays both times or I would have to go on sick leave.
          On the other hand, my husband had his wisdom tooth pulled out without any problems and virtually no pain afterwards.

        2. Max says:

          You had a local and a sedative, which is appropriate for five impacted wisdom teeth. That’s relatively safe. I don’t know if the teeth had to come out in the first place, but that’s another story.
          Marek Lapinski received a sedative (midazolam), an opioid (fentanyl), a barbiturate (methohexital ), and ketamine. During the procedure, he woke up coughing and was knocked out with propofol, after which he died.
          http://www.kevinmd.com/blog/2013/04/minor-anesthesia.html

          I didn’t see any evidence in the above post that a lack of analgesia when treating children in the 1980s has resulted in a whole generation of adults who are afraid of dentists. Are children no longer afraid of dentists?

          1. mousethatroared says:

            Max – “I didn’t see any evidence in the above post that a lack of analgesia when treating children in the 1980s has resulted in a whole generation of adults who are afraid of dentists. Are children no longer afraid of dentists?”

            See, to me, it’s rather obvious that, ethically, one doesn’t preform painful procedures on children without pain medication unless there is good evidence that the risks/ downsides of the pain medications are greater than the benefits. Which means you are the one who has to provide evidence for any risk/downsides.

            1. Max says:

              No, one doesn’t administer potentially harmful drugs to children unless there is good evidence that the benefits are greater than the risks/ downsides. First, do no harm.

              1. mousethatroared says:

                Did you read the article? Are you just ignoring the risks that it outlined for not administering appropriate pain management in pediatric acute pain? Are you just ignoring that Dr. Jones outlined how to minimize the risks of pain medication?

                Why don’t you actually stick to the content of the article, which is about acute pain, rather than dwelling on your strawman of baby tooth pulling and flu shots?

                Oh, and I invite you to have someone cut open your mouth and a few layers of muscle, then sew it all back together in a different formation without pain medication during surgery and recovery. Then you can tell me about how “harmless” that is.

              2. Nashira says:

                Leaving them in untreated pain is harming them. It is cruel and wrong to leave someone to suffer when you can relieve their pain safely. And whaddayaknow, in most times and places, we *can* treat pain safely and appropriately. I cannot fathom this position in which the slightest risk of harm from meds or other interventions, somehow means that the only ethical option is to throw your hands into the air and insist it’s better to suffer than risk becoming a drug addict.

                Your sense of proportion is seriously jacked up, and I cannot help but suspect that your tune would be different if you were the one being refused pain management. Mostly because I have run into folks like you before, and what’s good for the goose is never good for the gander.

              3. mousethatroared says:

                Nashira “I cannot fathom this position in which the slightest risk of harm from meds or other interventions, somehow means that the only ethical option is to throw your hands into the air and insist it’s better to suffer than risk becoming a drug addict.”

                Not to mention that the belief that offering pain medication to a child with acute pain may lead to drug addiction is complete speculation. For all we know, allowing infants or children to experience acute pain may lead to neurological/pain sensitivity issues that increase the likelihood of chronic pain latter in life and lead to higher risk of drug abuse in adulthood.

                In short, his concerns are just B.S. just so stories.

              4. Max says:

                This thread started with a just-so story that a lack of analgesia when treating children in the 1980s (“whether removing baby teeth or drilling”) has resulted in a whole generation of adults who are afraid of dentists. That comment brought up removing baby teeth, so it’s not my strawman. Your strawman is that I’m against all pain medication during surgery, after I said that a local and sedation is appropriate for extraction of impacted wisdom teeth.

                Anyway, in response to the original just-so story, I said that for all we know, getting children accustomed to taking painkillers whenever they feel pain has resulted in a disturbing rise of painkiller abuse.
                So it’s funny to see more “for all we know” responses to my response instead of evidence to support the claims in the original comment.

              5. Alia says:

                Well, Max, the thing is, I’m not American. And while I could provide you with data that supports what I said, you simply would not be able to understand it as it is not in English, sorry. And OK, I should add that I was not speaking about the centre of the modern world, the US, in my previous comment.

              6. mouethatroared says:

                Oh, due to your other references to flu shots and burn treatment, I thought that you were suggesting a medical culture of controlling pediatric pain was leading to the high rates of opioid addiction that we are seeing today.

                You were actually proposing the idea that the practice of local anesthesia and nitrous oxide in tooth extractions and drilling in pediatric dental care is the cause of the high rates of opioid addiction that we see today.

                Really…that seems plausible to you? Because, I’ll be honest, it seems utterly ridiculous to me and I have two close family member who have opioid abuse problems.

          2. windriven says:

            Max, you really are something.

            “which is appropriate for five impacted wisdom teeth.” Alia said two. I suppose five is within the realm of possibility but I think four is the maximum compliment of wisdom teeth that would fall in the confines of ‘normal’.

            “I don’t know if the teeth had to come out in the first place” No, you don’t. And why bring that up? She and her dentist clearly did. You find it appropriate to second guess people whom you don’t know? Question the medical judgment of someone because they practice mainstream medicine? What are we to make of you?

            “During the procedure, he woke up coughing and was knocked out with propofol, after which he died.” Yes, it would have been far better to have given him a bullet to bite, wouldn’t it? Then the procedure could have been performed on a writhing, struggling man – no danger there. The report you linked was based on early and incomplete information as TsuDoNimh described below.

            So what’s your real beef Max? You pop up from time to time spraying bile. Are you seeking redress for some real or imagined failure of medicine? Are you promoting some variety of quackery? Or are you just a pointless troll popping up from time to time to spray bile? Just wondering…

            1. mousethatroared says:

              Just to be fair, Alia mentioned she had two wisdom teeth removed. I mentioned above that I had five removed (I’m some sort of throwback, but better an extra wisdom tooth than a tail).

              But, no, Max’s point is not very clear.

            2. Max says:

              mousethatroared set the record straight about the 5 wisdom teeth, thanks for that.

              Why bring up extraction of impacted wisdom teeth? Because that’s another procedure that’s often done unnecessarily.
              http://www.webmd.com/oral-health/news/20050505/wisdom-teeth-removal-often-unnecessary

              “Yes, it would have been far better to have given him a bullet to bite, wouldn’t it?”
              It wouldn’t have killed him, so yes, it would’ve been better than killing him. But I already said twice that a local and sedation is appropriate. It would’ve been better to figure out why he woke up coughing instead of knocking him out with propofol.

              Do you see me promoting quackery anywhere? Obviously not, or you wouldn’t ask. Seeking redress for failure of medicine is more like it, since I’ve seen enough people harmed by such failures, Marek Lapinski being one of them.

              1. windriven says:

                Max,
                I went back and retread each of your comments in this thread and I read some of the stories reporting the circumstances of Lapinski’s death which was according to the coroner’s report* accidental. I was not able to determine if any action was taken by the board or if any civil litigation was instituted or that the ensuing trial shed additional light on the circumstances of his death.

                Unless you have inside information undiscoverable through routine means, there is nothing I could find indicating that the extractions were unnecessary or that the oral surgeon mishandled the anesthetic. I will say that IMHO, it would be prudent in cases where considerable sedation will be used to have that monitored by an anesthesiologist or CRNA. But that sort of care is expensive.

                I am also left wondering what the point is that you wish to make. It seems to be that people shouldn’t expect routine analgesia and perhaps that people shouldn’t have wisdom teeth extracted unless they are abscessed or impacted.

                Do you think you could state your argument in a few sentences?

      3. Tsu Dho Nimh says:

        Lapibnski died, not because of the analgesic, but because of airway obstruction.

        “Eventually it was discovered the patient had surgical gauze in his airway as paramedics tried to revive him.”

        1. Max says:

          But he wouldn’t have died if he hadn’t been so drugged up. First, all the other drugs may have caused the airway obstruction in the first place. And then, instead of figuring out what caused the coughing, the oral surgeon administered propofol to knock him out and achieve good “patient compliance.” It stopped the coughing all right, but it masked the real problem.

    2. Kathy says:

      @Alia, I’m one of them. But in this case the injection for the anaesthetic caused more pain than the drilling. I’ve been afraid of needles ever since, which is awkward to say the least.

      Once when I had to have a blood test done I told this to the sister that was to draw the sample. She was more than merely sympathetic … she took a proper scientific interest and suggested we take my blood pressure before and after. I didn’t understand why but afterwards when I had stopped throwing up and was lying on her couch wiping the cold sweat off my face, she explained how interesting it was to see how drastically my blood pressure had dropped during the brief procedure. “Shock” she explained … I found it a comfort to know though I’m afraid the symptoms remain!

      1. mousethatroared says:

        I’m actually not bother by most shots or needles, I seem to have difficult veins and have had nurses have to take multiple attempts at IV insertion or blood draw, even had a blood donation nurse have wiggle the needle around in my arm quite a bite, mid donation, because I was clotting and the flow stopped and it didn’t really bug me much.

        But I really dislike dental locals. They just hurt…much more than most needle insertions.

        Luckily pediatric dentists today seem to work really hard on prevention, with sealents, flouride treatments, flouride washes, brushing, flossing, flouride in the water a child may never need a filling. Even with my son, who has very cavity prone teeth, the dentist can often catch the cavity and fill it before the drilling required is deep enough to be painful. That is excellent, in my book.

    3. Young CC Prof says:

      I’m told that when I was not quite a year old, I knocked out a tooth and had it re-implanted and later extracted again after it got abscessed. There was no anesthetic, the dentist just had his assistant and my parents hold me down.

      I have no memory of this, I just didn’t have a front tooth until I was seven, but my parents sure do.

  9. skipbidder says:

    Your points on codeine and combination opioids are well-made.

    I also appreciate the point that untreated or undertreated acute pain can lead to chronic (often neuropathic) pain. This is overlooked.

    1. skipbidder says:

      Have re-read the article at a more leisurely pace.

      I think you’ve done a pretty good job Dr. Jones. A nice post.

      I’ve got one little addition and then a nitpick.

      Morphine (and hydromorphone) can also both be given subcutaneously. (In adults at least.) This tends to be an inpatient hospice trick, but not reason why you can’t do it in other situations where you don’t don’t have a line but oral analgesia isn’t best choice. Morphine can also be used topically in nonhealing wounds. (It is too hydrophilic to be useful in intact skin, but we recruit peripheral opioid receptors in chronic wounds.)

      You point out that we don’t tend to develop a tolerance to constipation. This is certainly true, and important to point out. However, it takes something a little more than a stool softener for prophylaxis against this. What we tend to call a stool softener in the US is docusate sodium (Colace). It is probably more accurately described as a surface-wetting agent. In my own field, the phrase we use for Colace is “All mush, no push”. Recs are to include a stimulant laxative as well (senna or bisacodyl). Senna-S two tabs BID is the typical initial adult plan. Titrate to effect. Reasonable alternatives include lactulose or polyethylene glycol. (Although when I get my own horribly metastatic cancer, I think I’ll be using diabetic candy turtles with sorbitol for my own prophylaxis.) Using docusate alone is very common adult primary care doc mistake when writing for opioids.

      Your discussion points on the WHO ladder remind me of another palliative care mantra. I probably sound like a cultist. :)
      But here it is:
      By the ladder,
      By the clock,
      By the mouth,
      For the individual,
      With attention to detail.

  10. Hank says:

    I think dealing with acute pain issues is much much easier than chronic pain. You want to stir some feathers, start discussing the treatment of chronic pain with the tools we have now….and look at the evidence, side effects, dangers, patient perspective, PROP, regulators, etc…..

    1. windriven says:

      You know Hank, that is a great idea. A guest post by an anesthesiologist doing chronic pain management would be extremely useful. Chronic pain is a petri dish for woo. A concise backgrounder the IASP classification system for types of pain and a brief discussion of likely etiologies and treatments of the various major types would dispel a lot of misconceptions.

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