Tips for primary care clinicians assessing and managing pediatric chronic pain

Chronic pain is complex, with evidence of biological, psychological, and social factors that perpetuate the suffering. Many possible contributors to pain include micro-traumas, infections, genetic risk factors, early life stressors, acquired vulnerability, adverse childhood events, parental chronic pain, anxiety, depression, and stress sensitivity. [Denk: 2017] Alone or in combination, these components can lead to disordered pain processing and imprecise encoding of a threat or painful event. When pain is experienced longer than expected, or it is an incorrect physiologic response to pain, inflammatory signals can lead to primary pain disorders such as chronic pain or functional pain disorders.

Normal pain starts with an insult to the body. This insult stimulates sensory nerves that communicate with the brain that this insult is a manifestation of pain. Inhibitory descending and facilitatory ascending pathways calm or accentuate the pain experience, respectively. Our facilitatory ascending pathways can be enhanced by stress, anxiety, depression, perceived injustice, sleep disturbance, and other factors. Inhibitory descending pathways protect us from pain and can be stimulated by integrative modalities, rehabilitation, psychotherapy, social interaction, and other experiences. If facilitatory or inhibitory input is disrupted, there is a risk of central sensitization and chronic pain. 

Chronic pain can be defined as a disorder that cannot be explained by appropriate medical assessments, significantly disrupts everyday life for an individual, and affects their daily activities. Major categories of primary pain disorders include primary headaches, centrally mediated abdominal pain syndrome, widespread musculoskeletal pain such as fibromyalgia, orthostatic dysfunction, conversion disorders, and acute on chronic pain disorders. Chronic pain is complex and treatment for it must rely on multimodal therapies. 

Chronic pain
Chronic pain and recurrent pain syndromes are manifestations of underlying vulnerabilities rather than separate disorders.

Treatment of chronic pain
A holistic approach is needed for the successful assessment and management of pediatric chronic pain. Treatment of chronic pain is multimodal and relies heavily on the importance of rehabilitative, interdisciplinary teams, and addressing underlying stressors and/or vulnerabilities.

Medications for pain
Short-acting opioids are appropriate for treatment in an acute pain crisis when non-opioid options have been exhausted. The use of one opioid at a time is recommended when treating acute pain. Mixed analgesic medications (e.g., acetaminophen/oxycodone) have been shown to have poor outcomes in children.

Medications - not first-line treatment
Medications are not first-line treatment for chronic pain but rather an adjunct. Chronic pediatric pain without inflammation does not benefit from opioids.

Evidence-based treatment of chronic pain considers all aspects of the situation, looking for what is underneath the pain. Persistent failure to address the core components of dysregulation can hamper therapy and contribute to a sense that the issues are not being taken seriously. From the beginning of this challenging process, providers should acknowledge that a patient’s pain is real and highly complicated. Many families have not had their experience validated in this way, and the acknowledgment may be a bridge to helping the patient and family feel heard, respected, and supported in the journey of treatment.

Management of chronic pain should address the biological, psychological, and social components contributing to disrupting and sensitizing an individual’s pain pathway. Multimodal pain management has been shown to decrease chronic pain significantly through integrative therapies, parental coaching, and the 4 S’s (sports, social, sleep, and school).

These 4 S’s can help patients normalize their lives and introduce routines to decrease psychological distress: [Friedrichsdorf: 2016]

• Sports: physical therapy, daily activities, and exercise
• Social: strategies and tactics to maintain a social life, reassuring and supporting them that their pain is real
• Sleep: appropriate sleep hygiene, coaching them to assist waking in the morning, having breakfast, being on time, not napping or sleeping in 
• School: encouraging school attendance, allowing for breaks if needed, developing an IEP/504 plan

Current research and data suggest great potential for chronic pain treatment through integrative medicine. Such medical techniques include acupuncture/acupressure, massage, and active mind-body techniques (guided imagery, hypnosis, yoga, distraction, breathing strategies). Individual responses to these therapies may vary significantly. 

Medications

Medications are never first-line treatment for chronic pain, though often patients present to their provider after treatment with a wide variety of pharmacology. Chronic pediatric pain without inflammation cannot be ameliorated by opioids. Medications are best used as an adjunct for the treatment of chronic pediatric pain. If a patient is experiencing pain longer than the expected time for a given acute process, transitioning to addressing underlying vulnerabilities should be the next step in management. Some examples of adjuvant analgesics used with some success in chronic pain include tricyclic antidepressants, gabapentin, sodium channel blockers/local anesthetics, alpha-agonists, such as clonidine, acetaminophen, and melatonin.

Pediatric Integrative Medicine (see NM providers [0])
May be helpful to direct components of management, including traditional and complementary modalities in a safe and evidence-based manner.

• G89.2x, Chronic pain, specify site
• G89.29, Other chronic pain (when can’t further specify site)
• R52, Pain, unspecified (applies to generalized pain)