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PAIN AND SYMPTOM MANAGEMENT IN CHILDREN

PAIN AND SYMPTOM MANAGEMENT IN CHILDREN . Pamela M. Sutton, M.D. October 2012 OBJECTIVES

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PAIN AND SYMPTOM MANAGEMENT IN CHILDREN

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  1. PAIN AND SYMPTOM MANAGEMENT IN CHILDREN Pamela M. Sutton, M.D. October 2012 OBJECTIVES The listener will: • Develop insight into pain and symptom challenges in children • Review pain assessment • Understand the role of NSAIDS in bone and joint pain • Understand the relative strengths and appropriate use of opioids • Learn the role of adjuvant analgesics • Consider symptom management in various cases

  2. PAIN AND SYMPTOM MANAGEMENT IN CHILDREN Pamela M. Sutton, M.D. October 2012 OUTLINE I. GOALS OF CARE II. PAIN ASSESSMENT III. TREATMENT OF PHYSICAL PAIN A. Analgesic Ladder B. NSAIDS C. Opioids D. Adjuvants (Co-analgesics) IV. NON-PAIN SYMPTOMS V. CASES  

  3. PALLIATIVE CARE TO CURE SOMETIMES TO RELIEVE OFTEN TO COMFORT ALWAYS 15th Century Folk Saying

  4. IDEAL GOALS OF CARE • CARE AND CURE • CURATIVE ATTEMPTS MADE MORE COMFORTABLE WITH ACTIVE SYMPTOM MANAGEMENT AND EMOTIONAL, SOCIAL, and SPIRITUAL SUPPORT.

  5. PAIN

  6. CANCER PAIN IS TOTAL PAIN • “EVERYTHINGHURTS” • PHYSICAL PAIN FAMILY PAIN • EMOTIONAL PAIN CAREGIVER PAIN • SOCIAL PAIN DOCTOR/STAFF PAIN • SPIRITUAL PAIN • FINANCIAL PAIN

  7. OBSTACLESTO PAIN RELIEF • LACK OF EDUCATION ABOUT TREATMENT • LACK OF AVAILABILITY OF MEDICATION DUE TO LAWS AND/OR EXPENSE • WORRIES ABOUT SIDE EFFECTS INCLUDING ADDICTION AND ABUSE

  8. OBSTACLES TO PAIN RELIEF Inability of child to communicate due to age, language, illness, anxiety, lack of awareness. A child may fear treatments and not ask for help.

  9. PAIN ASSESSMENT • HISTORY FROMPATIENT(AND/OR FAMILY IF PATIENT TOO YOUNG OR UNABLE TO COMMUNICATE WELL) • BELIEVE THE PATIENT! • PAIN IS WHAT THE PATIENT SAYS IT IS!

  10. PAIN ASSESSMENT YOUNG CHILD • FLACC SCALE (INFANT OR UNRESPONSIVE PATIENT) • FACES SCALE

  11. PAIN ASSESSMENTOLDER CHILD • ASK SEVERITY OF PAIN ON A SCALE OF ZERO TO TEN

  12. PAIN ASSESSMENTOLDER CHILD • ASK: • LOCATION • QUALITY (ACHING, BURNING, • SHOOTING) • DURATION (INTERMITTENT OR • CONTINUOUS) • WHAT MAKES PAIN BETTER • WHAT MAKES IT WORSE

  13. PAIN ASSESSMENT • ASSESS EMOTIONAL STATE Emotional pain may cause ongoing suffering despite appropriate physical measures • PHYSICAL EXAM(There may not be any objective physical finding.) • Consider tests. • REASSESS PAIN FREQUENTLY

  14. NOCICEPTIVE PAIN(tissue injury)vs NEUROPATHIC PAIN(nerve injury) PHYSICAL PAIN

  15. TREATMENT OF PHYSICAL PAIN • PERSISTENT PAIN SHOULD BE TREATED ON A REGULAR BASIS (NOT PRN) TO PREVENT RETURN OF PAIN AND TO HELP NORMALIZE THE PATIENT’S LIFE.

  16. TREATMENT OF PHYSICAL PAIN • PROPER USE OF MEDICATIONS CAN SUCCESSFULLY TREAT PAIN IN 90% OR MORE OF CANCER PATIENTS

  17. TREATMENT OF PHYSICAL PAIN • ORAL MEDICATION IS PREFERRED BECAUSE OF EASE OF ADMINISTRATION, STEADY BLOOD LEVELS, SAFETY.

  18. TREATMENT OF PHYSICAL PAIN • MEDICATION • BY LADDER • BY CLOCK • BY APPROPRIATE ROUTE • BY THE CHILD

  19. WORLD HEALTH ORGANIZATION 3 STEP METHOD FOR CANCER PAIN RELIEF(“Analgesic Ladder”) • STEP 1. NON-OPIOID +/- ADJUVANT If pain persists or worsens, go to: STEP 2. MILD OPIOID + NON-OPIOID +/- ADJUVANT If pain persists or worsens, go to: STEP 3. STRONG OPIOID +/- NON-OPIOID+/-ADJUVANT

  20. ANALGESIC LADDER W.H.O. PREFERRED ORAL MEDICATIONS(1986) • STEP 1: ASPIRIN (ACETAMINOPHEN) • STEP 2: CODEINE(DEXTROPROPOXYPHENE) • STEP 3: MORPHINE (METHADONE)

  21. PREFERRED ANALGESICS STEP ONE: ASPIRIN • Advantages: Widely available, cheap, • effective for pain of inflammation. • Disadvantages: Potential GI/renal toxicity. • Interferes with platelet function. • (increased bleeding) • Possible association with Reyes • Syndrome.

  22. PREFERRED ANALGESICS STEP ONE: ACETAMINOPHEN • Advantages: Widely available, cheap, • effective for mild pain. • Disadvantages: Potential liver toxicity. • Not an anti-inflammatory • medication. Not the best • choice for bone pain.

  23. PREFERRED ANALGESICS STEP ONE ALTERNATIVE(USA): NSAID’S (eg. Ibuprofen, Naproxen) • Advantages: Anti-inflammatory effects • especially helpful for bone pain. • Dosage may be less frequent • than aspirin or acetaminophen. • Disadvantages: Costly. Potential GI side effects • and/or possible interference with • platelet function.

  24. PREFERRED ANALGESICS POSSIBLE STEP TWO MEDICATIONS (USA) a.Tylenol with Codeine (Tabs or Elixir) codeine/acetaminophen BUT: CODEINE must be converted to morphine in body to give analgesia and ineffective in many children. b. Lortab (Tabs or Elixir) hydrocodone/acetaminophen

  25. PREFERRED ANALGESICS STEP 3--IMMEDIATE-RELEASE ORAL MORPHINE Oral morphine is one third as potent as parenteral morphine when given on a regular basis. In other words, a patient receiving 10 mg of morphine sulfate IV every 4 hours who is switched to oral dose would need 30 mg morphine sulfate orally every 4 hours. Titrate dose as needed to control pain. The correct dose is that which relieves pain!

  26. PREFERRED ANALGESICS • STEP THREE ALTERNATIVE: LONG-ACTING MORPHINE PREPARATIONS • Add up the dose of oral morphine in 24 hours • and divide by 2. Example: If the patient is • taking 10 mg of immediate-release morphine • every 4 hours around the clock, the 24 hour total • is 60 mg. This patient would take 30 mg of a • long-acting preparation every 12 hours.

  27. ALTERNATIVE STEP THREE OPIOIDS a. Oxycodone Percocet-5 Percocet-10 Roxicet Oral Solution Oxycodone Tablets 5 mg; 15 mg; 30 mg Roxicodone Oral Solution. Roxicodone Intensol. Oxycontin Long acting tablets which usually last 12 hours. b. Hydromorphone(Dilaudid) Tablets Oral Liquid Suppositories IV/Subcutaneously c. Fentanyl (Should not be used if opioid naïve) IV Patches BEWARE of buccal preparations. Potent and potentially dangerous. d. Methadone BEWARE titration difficulties. May accumulate. IV/Subcutaneously but may cause nodules subq Oral Liquid Oral Intensol Tablets

  28. CONCERNS ABOUT OPIOIDS • 1. ADDICTION • Physical Dependence and Psychological Craving is • necessary for addiction. • 2. TOLERANCE • Rarely a practical problem. Dose can be increased if • tolerance occurs. • 3. RESPIRATORY DEPRESSION • Rarely a problem when appropriate dose of oral • narcotic is titrated to level of pain.

  29. CONCERNS ABOUT OPIOIDS 4. LETHARGY • Sleepiness may occur in first few hours/days but • usually improves. Dose may need to be adjusted. • 5. NAUSEA • Occurs in less than half of patients. May resolve, • but if not, patient can be given anti-emetic or an • alternative opioid. • 6. CONSTIPATION • Frequent problem--should be anticipated with stool • softener/laxative. Avoid bulk laxatives.

  30. POSSIBLE ROUTES OF ADMINISTRATION OF OPIOIDS RECTAL BUCCAL SUBCUTANEOUS INTRAMUSCULAR INTRAVENOUS TRANSDERMAL EPIDURAL,INTRATHECAL

  31. ADJUVANT ANALGESICS a. ANTIDEPRESSANTS b. ANTICONVULSANTS C. ANESTHETIC AGENTS D. CORTICOSTEROIDS

  32. OTHER TREATMENTS OF PAIN • SUPPORTIVE-- FAMILY/FRIENDS/STAFF/PLAY • BEHAVIORAL--DEEP BREATHING/PROGRESSIVE RELAXATION • PHYSICAL--TOUCH/HEAT,COLD/ETHYL CHLORIDE/ EMLA / TENS • COGNITIVE--DISTRACTION,IMAGERY

  33. NON-PAIN SYMPTOMS

  34. NAUSEA/VOMITING: a. Phenothiazines--act on chemoreceptor trigger zone Chlorpromazine (sedating) Prochlorperazine b. Promethazine--phenothiazine with antihistaminic effect. Mildly sedating. c. Haloperidol--acts on chemoreceptor trigger zone d. Ondansetron—serotonin antagonist e. Scopolamine--anticholinergic f. Antihistamines: Hydroxizine Diphenhydramine g. Lorazepam h. Corticosteroids

  35. CONSTIPATION Constipation likely if taking opioids. Treat with fluids and combination of fecal softener and large bowel stimulant if possible. -Docusate, senna, bisacodyl, cascara sagrada. -Milk of magnesia may be useful if other methods unsuccessful. -Glycerin or bisacodyl suppositories or small tap water enema may be helpful.

  36. PALLIATIVE CARE PEDIATRIC CASES

  37. CASE 1 TWO YEAR OLD WITH NEUROBLASTOMA TRANSFERED FROM SLOAN KETTERING TO DIE AT HOMELOGISTICAL PROBLEMSSYMPTOM MANAGEMENTEMOTIONAL SUPPORT

  38. CASE 1 FIVE YEAR OLD BOY WITH LEUKEMIA DYING AT HOME FEAR OF INJECTIONSBONE PAINHEADACHEFAMILY DISTRESS AT TIME AND AFTER DEATH

  39. SEVEN YEAR OLD DYING WTH END STAGE AIDS AT HOMETWELVE YEAR OLD WITH HIV ENCEPHALOPATHY IN HOSPITAL

  40. 35 year old survivor of Ewing’s Sarcoma at age 7. Chronic pain and treatment challenges for life.

  41. USEFUL REFERENCES • CANCER PAIN RELIEF, WORLD HEALTH ORGANIZATION, GENEVA, 1986. • CANCER PAIN RELIEF AND PALLIATIVE CARE IN CHILDREN, WHO, 1998. • CARING FOR PEDIATRIC PATIENTS; UNIPAC EIGHT, AAHPM, 2012. • PEDIATRIC CANCER PAIN; NCCN CLINICAL PRACTICE GUIDELINES IN ONCOLOGY; V.I.2007 • PRIMER OF PALLIATIVE CARE, 5th Edition; AAHPM, 2010.

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